- Email: [email protected]
Biological plating for unstable sacral fracture
Biological plating for unstable sacral fracture
configuration was not very clear on this radiograph. The CT scan of the pelvis with 3 D reconstruction was obtained which showed Denis type 2 fractures on both the sides.4 The right hemipelvis had migrated upward in respect to left one (Figure 2). It also showed fracture of the coccyx (Figure 3). These fractures are unstable Tiles Type C fractures.5 Biological dual plating was done with reconstruction plates into posterior ilium on both sides by sliding the plates across the fracture without opening it. Open reduction of pubic symphysis was done by another reconstruction plate by anterior approach (Figure 4). The nursing care became easy and patient was able to sit upright on the 2nd postoperative day. She started full weight-bearing at 3 months, though foot drop is still persisting at 9 months and bladder function has not recovered. By proper stabilization, such patients can be made to move around pain-free. Major complications like bed sore, systemic infection and gross disability could be prevented, along with benefit of getting easy nursing care.
GK Aggarwal, MS* Arvind Aggarwal, MS** VK Sahni, MS** Manoj Garg, MS** Anil Kumar, D Orth***
INTRODUCTION Sacral fractures and lumbosacral dislocation constitute 1% of all spinal fractures. They frequently are associated with other injuries and hence are often missed. The most common causes of sacral fracture are motor vehicle accidents and fall. Direct severe blunt trauma results in comminuted sacral fractures. These fractures are also associated with pelvic fractures. Most of these are associated with nerve root dysfunction. A high index of suspicion is necessary. These patients should be examined for sacral root dysfunctions. Complex unstable fractures of the sacrum, such as Tile C fractures, which are unstable both rotationally and vertically, present specific surgical challenge and it is really difficult to make the patient move around pain free. Stability to the posterior sacroiliac complex is provided by the posterior ligamentous complex only. The sacroiliac joint itself has no inherent bony stability. So such fractures require posterior fixation to regain vertical stability.
DISCUSSION Sacral fractures are better treated with closed reduction and percutaneous iliosacral screw fixation which offers adequate stability with a lower risk of wound complication when compared with open reduction and internal fixation. But it is difficult, requiring multiple assistants, continuous traction, and control of the ilium to reduce the fracture. Watson-Jones in 1940 described ‘an unusual and instructive case’ of lumbosacral dislocation with a cauda equina lesion, in which the patient eventually died from ascending urinary tract infection. Evans in 1959 described another case associated with a fractured femur. The dislocation was missed at first and intractable bed sores drew attention to the cauda equina lesion. Simpson et al. reported excellent results with the use of the anterior retroperitoneal approach for anterior plating of the sacroiliac joint because it allowed direct observation of the joint.1
CASE REPORT A 39-year-old lady was admitted in unconscious state following suicidal jump from 30 ft height. She was in shock and had to be given multiple blood transfusions. After gaining consciousness, she was unable to sit upright in bed and nursing care was difficult. She had got unstable fracture of sacrum and right-sided radiculopathy at L5, S1 and S2 levels with foot drop on right side and bladder/bowel involved. There was no significant bony injury over other part of body. The anteroposterior radiograph of the pelvis showed fracture of the sacrum with pubic diastasis (Figure 1). Fracture
*Head of Department, **Senior Consultant, ***DNB Candidate Department of Orthopedics, Maharaja Agrasen Hospital, New Delhi. Correspondence: Dr. Anil Kumar, Flat No. 103, Block No. 2, Punjabi Bagh Enclave, DDA MIG Flat, Madipur, New Delhi – 110063. Ph/Fax: +91-11-25211681; Mob: +91-9891723710. E-mail: [email protected]
JCOT Vol 1 No 1
Figure 1 Anteroposterior radiograph showing sacral fracture. 54
© 2010 Elsevier India
Biological plating for unstable sacral fracture
A
B
Figure 2 (A, B) Denis type II fracture on both sides and widening of pubic symphysis.
Figure 3 3D CT showing coccygeal fracture.
Figure 4 Postoperative radiograph.
Kellam recommends anatomical reduction of the posterior injury and internal fixation with fusion of the sacroiliac joint.2,3 Denis, Davis and Comfort classified sacral fractures into three types: type I fractures occur lateral to the neural foramina through the sacral ala, type II are transformational, and type III occur medial/central to neural foramina, it includes transverse fractures of the sacrum.4 Tile has compared the relationship of the posterior pelvic ligamentous and bony structures to a suspension bridge with the sacrum suspended between the two posterior superior iliac spines.5–7 Tornetta and Matta used iliosacral screws for posterior fixation and reported that two thirds of patients returned to their preinjury occupations.8,9 Cole, Blum, and Ansel reported good results with percutaneous iliosacral screw fixation of Tile C fractures.10 Routt et al. described difficulty in obtaining closed reduction of pure sacroiliac joint dislocations; open reduction of the sacroiliac joint often was necessary before percutaneous screw placement. They emphasized that the surgeon must be familiar with the variations of upper sacral anatomy and that fluoroscopic
imaging, including the lateral sacral view, must be excellent. They also emphasized the fact that the normal sacral ala has an inclined anterosuperior surface, the sacral alar slope, which extends from proximal–posterior to distal–anterior.11 Use of the endoscope enables us to apply the concept of minimal invasive plate osteosynthesis in anterior pelvis fixation.12 Sommer Christopher fixed a low transverse fracture of the sacrum (S3–S4) in a 15-year-old girl, with Locking Compression Plate.13 Minimally invasive transiliac plate osteosynthesis for type C injuries of the pelvic ring has been described in literature. Dolati et al. stated that sacral fractures with a neurologic deficit are not a contraindication for minimally invasive procedure because they can be decompressed by distraction and stabilized in a neutral position by plate fixation.14 Krappinger et al. concluded that posterior plate osteosynthesis is a sufficiently stable method for the treatment of unstable pelvic ring injuries with a low risk of iatrogenic nervous tissue and vascular lesions. The disadvantages are limited reduction possibilities, the necessity of bilateral bridging of the sacroiliac
JCOT Vol 1 No 1
55
© 2010 Elsevier India
Aggarwal, et al
joint in a unilateral injury, as well as a higher rate of symptomatic hardware.15 In our case, sacral fixation was done through posterior approach by inserting two reconstruction plates across the sacrum without opening the fracture site, along with anterior fixation of the pubic symphysis for rotational stability. Computed tomography is an essential part of the evaluation of any significant pelvic injury, allowing evaluation of the posterior portion of the pelvic ring that may be poorly seen on standard roentgenograms. The proper stabilization helps by avoiding major complications associated with prolonged immobilization in such fractures.
5.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. ♦
11.
6. 7. 8. 9. 10.
12. REFERENCES 1. Simpson LA, Waddell JP, Leighton RK, Kellam JF, Tile M. Anterior approach and stabilization of the disrupted sacroiliac joint. J Trauma 1987;27:1332–9. 2. Kellam JF. The role of external fixation in pelvic disruptions. Clin Orthop Relat Res 1989;241:66–82. 3. Kellam JF, McMurtry RY, Paley D, Tile M. The unstable pelvic fracture: operative treatment. Orthop Clin North Am 1987;18:25–41. 4. Denis F, Davis S, Comfort T. Sacral fractures: an important problem— retrospective analysis of 236 cases. Clin Orthop Relat Res 1988; 227:67–81.
JCOT Vol 1 No 1
13.
14.
15.
56
Tile M. Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg 1996;4:143–51. Tile M. Acute pelvic fractures: II. Principles of Management. J Am Acad Orthop Surg 1996;4:152–61. Tile M. The management of unstable injuries of the pelvic ring. J Bone Joint Surg Br 1999;81:941–3. Matta JM, Tornetta P 3rd. Internal fixation of unstable pelvic ring injuries. Clin Orthop Relat Res 1996;329:129–40. Tornetta P 3rd, Matta JM. Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop Relat Res 1996;329:186–93. Cole JD, Blum DA, Ansel LJ. Outcome after fixation of unstable posterior pelvic ring injuries. Clin Orthop Relat Res 1996;329:160–79. Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma 1997; 11:584–9. Zobrist R, Messmer P, Levin LS, Regazzoni P. Endoscopic assisted, minimally invasive anterior pelvic ring stabilization: a new technique and case report. J Orthop Trauma 2002;16:515–9. Sommer C. Fixation of transverse fractures of the sternum and sacrum with the locking compression plate system: two case reports. J Orthop Trauma 2005;197:487–90. Dolati B, Larndorfer R, Krappinger D, Rosenberger RE. Stabilization of the posterior pelvic ring with a slide insertion plate. Oper Orthop Traumatol 2007;19:16–31. Krappinger D, Larndorfer R, Struve P, Rosenberger R, Arora R, Blauth M. Minimally invasive transiliac plate osteosynthesis for type C injuries of the pelvic ring: a clinical and radiological follow-up. J Orthop Trauma 2007;21:595–602.
© 2010 Elsevier India
configuration was not very clear on this radiograph. The CT scan of the pelvis with 3 D reconstruction was obtained which showed Denis type 2 fractures on both the sides.4 The right hemipelvis had migrated upward in respect to left one (Figure 2). It also showed fracture of the coccyx (Figure 3). These fractures are unstable Tiles Type C fractures.5 Biological dual plating was done with reconstruction plates into posterior ilium on both sides by sliding the plates across the fracture without opening it. Open reduction of pubic symphysis was done by another reconstruction plate by anterior approach (Figure 4). The nursing care became easy and patient was able to sit upright on the 2nd postoperative day. She started full weight-bearing at 3 months, though foot drop is still persisting at 9 months and bladder function has not recovered. By proper stabilization, such patients can be made to move around pain-free. Major complications like bed sore, systemic infection and gross disability could be prevented, along with benefit of getting easy nursing care.
GK Aggarwal, MS* Arvind Aggarwal, MS** VK Sahni, MS** Manoj Garg, MS** Anil Kumar, D Orth***
INTRODUCTION Sacral fractures and lumbosacral dislocation constitute 1% of all spinal fractures. They frequently are associated with other injuries and hence are often missed. The most common causes of sacral fracture are motor vehicle accidents and fall. Direct severe blunt trauma results in comminuted sacral fractures. These fractures are also associated with pelvic fractures. Most of these are associated with nerve root dysfunction. A high index of suspicion is necessary. These patients should be examined for sacral root dysfunctions. Complex unstable fractures of the sacrum, such as Tile C fractures, which are unstable both rotationally and vertically, present specific surgical challenge and it is really difficult to make the patient move around pain free. Stability to the posterior sacroiliac complex is provided by the posterior ligamentous complex only. The sacroiliac joint itself has no inherent bony stability. So such fractures require posterior fixation to regain vertical stability.
DISCUSSION Sacral fractures are better treated with closed reduction and percutaneous iliosacral screw fixation which offers adequate stability with a lower risk of wound complication when compared with open reduction and internal fixation. But it is difficult, requiring multiple assistants, continuous traction, and control of the ilium to reduce the fracture. Watson-Jones in 1940 described ‘an unusual and instructive case’ of lumbosacral dislocation with a cauda equina lesion, in which the patient eventually died from ascending urinary tract infection. Evans in 1959 described another case associated with a fractured femur. The dislocation was missed at first and intractable bed sores drew attention to the cauda equina lesion. Simpson et al. reported excellent results with the use of the anterior retroperitoneal approach for anterior plating of the sacroiliac joint because it allowed direct observation of the joint.1
CASE REPORT A 39-year-old lady was admitted in unconscious state following suicidal jump from 30 ft height. She was in shock and had to be given multiple blood transfusions. After gaining consciousness, she was unable to sit upright in bed and nursing care was difficult. She had got unstable fracture of sacrum and right-sided radiculopathy at L5, S1 and S2 levels with foot drop on right side and bladder/bowel involved. There was no significant bony injury over other part of body. The anteroposterior radiograph of the pelvis showed fracture of the sacrum with pubic diastasis (Figure 1). Fracture
*Head of Department, **Senior Consultant, ***DNB Candidate Department of Orthopedics, Maharaja Agrasen Hospital, New Delhi. Correspondence: Dr. Anil Kumar, Flat No. 103, Block No. 2, Punjabi Bagh Enclave, DDA MIG Flat, Madipur, New Delhi – 110063. Ph/Fax: +91-11-25211681; Mob: +91-9891723710. E-mail: [email protected]
JCOT Vol 1 No 1
Figure 1 Anteroposterior radiograph showing sacral fracture. 54
© 2010 Elsevier India
Biological plating for unstable sacral fracture
A
B
Figure 2 (A, B) Denis type II fracture on both sides and widening of pubic symphysis.
Figure 3 3D CT showing coccygeal fracture.
Figure 4 Postoperative radiograph.
Kellam recommends anatomical reduction of the posterior injury and internal fixation with fusion of the sacroiliac joint.2,3 Denis, Davis and Comfort classified sacral fractures into three types: type I fractures occur lateral to the neural foramina through the sacral ala, type II are transformational, and type III occur medial/central to neural foramina, it includes transverse fractures of the sacrum.4 Tile has compared the relationship of the posterior pelvic ligamentous and bony structures to a suspension bridge with the sacrum suspended between the two posterior superior iliac spines.5–7 Tornetta and Matta used iliosacral screws for posterior fixation and reported that two thirds of patients returned to their preinjury occupations.8,9 Cole, Blum, and Ansel reported good results with percutaneous iliosacral screw fixation of Tile C fractures.10 Routt et al. described difficulty in obtaining closed reduction of pure sacroiliac joint dislocations; open reduction of the sacroiliac joint often was necessary before percutaneous screw placement. They emphasized that the surgeon must be familiar with the variations of upper sacral anatomy and that fluoroscopic
imaging, including the lateral sacral view, must be excellent. They also emphasized the fact that the normal sacral ala has an inclined anterosuperior surface, the sacral alar slope, which extends from proximal–posterior to distal–anterior.11 Use of the endoscope enables us to apply the concept of minimal invasive plate osteosynthesis in anterior pelvis fixation.12 Sommer Christopher fixed a low transverse fracture of the sacrum (S3–S4) in a 15-year-old girl, with Locking Compression Plate.13 Minimally invasive transiliac plate osteosynthesis for type C injuries of the pelvic ring has been described in literature. Dolati et al. stated that sacral fractures with a neurologic deficit are not a contraindication for minimally invasive procedure because they can be decompressed by distraction and stabilized in a neutral position by plate fixation.14 Krappinger et al. concluded that posterior plate osteosynthesis is a sufficiently stable method for the treatment of unstable pelvic ring injuries with a low risk of iatrogenic nervous tissue and vascular lesions. The disadvantages are limited reduction possibilities, the necessity of bilateral bridging of the sacroiliac
JCOT Vol 1 No 1
55
© 2010 Elsevier India
Aggarwal, et al
joint in a unilateral injury, as well as a higher rate of symptomatic hardware.15 In our case, sacral fixation was done through posterior approach by inserting two reconstruction plates across the sacrum without opening the fracture site, along with anterior fixation of the pubic symphysis for rotational stability. Computed tomography is an essential part of the evaluation of any significant pelvic injury, allowing evaluation of the posterior portion of the pelvic ring that may be poorly seen on standard roentgenograms. The proper stabilization helps by avoiding major complications associated with prolonged immobilization in such fractures.
5.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. ♦
11.
6. 7. 8. 9. 10.
12. REFERENCES 1. Simpson LA, Waddell JP, Leighton RK, Kellam JF, Tile M. Anterior approach and stabilization of the disrupted sacroiliac joint. J Trauma 1987;27:1332–9. 2. Kellam JF. The role of external fixation in pelvic disruptions. Clin Orthop Relat Res 1989;241:66–82. 3. Kellam JF, McMurtry RY, Paley D, Tile M. The unstable pelvic fracture: operative treatment. Orthop Clin North Am 1987;18:25–41. 4. Denis F, Davis S, Comfort T. Sacral fractures: an important problem— retrospective analysis of 236 cases. Clin Orthop Relat Res 1988; 227:67–81.
JCOT Vol 1 No 1
13.
14.
15.
56
Tile M. Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg 1996;4:143–51. Tile M. Acute pelvic fractures: II. Principles of Management. J Am Acad Orthop Surg 1996;4:152–61. Tile M. The management of unstable injuries of the pelvic ring. J Bone Joint Surg Br 1999;81:941–3. Matta JM, Tornetta P 3rd. Internal fixation of unstable pelvic ring injuries. Clin Orthop Relat Res 1996;329:129–40. Tornetta P 3rd, Matta JM. Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop Relat Res 1996;329:186–93. Cole JD, Blum DA, Ansel LJ. Outcome after fixation of unstable posterior pelvic ring injuries. Clin Orthop Relat Res 1996;329:160–79. Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma 1997; 11:584–9. Zobrist R, Messmer P, Levin LS, Regazzoni P. Endoscopic assisted, minimally invasive anterior pelvic ring stabilization: a new technique and case report. J Orthop Trauma 2002;16:515–9. Sommer C. Fixation of transverse fractures of the sternum and sacrum with the locking compression plate system: two case reports. J Orthop Trauma 2005;197:487–90. Dolati B, Larndorfer R, Krappinger D, Rosenberger RE. Stabilization of the posterior pelvic ring with a slide insertion plate. Oper Orthop Traumatol 2007;19:16–31. Krappinger D, Larndorfer R, Struve P, Rosenberger R, Arora R, Blauth M. Minimally invasive transiliac plate osteosynthesis for type C injuries of the pelvic ring: a clinical and radiological follow-up. J Orthop Trauma 2007;21:595–602.
© 2010 Elsevier India