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TEMPORARY REMOVAL: Vertical shear pelvic ring injuries: Management algorithm
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Vertical Shear Pelvic Ring Injuries: Management Algorithm Clifford B. Jones MD, FAAOS, FAOA, FACS PII: DOI: Reference:
S0020-1383(20)30073-5 https://doi.org/10.1016/j.injury.2020.01.045 JINJ 8555
To appear in:
Injury
Received date: Revised date: Accepted date:
6 January 2020 26 January 2020 28 January 2020
Please cite this article as: Clifford B. Jones MD, FAAOS, FAOA, FACS , Vertical Shear Pelvic Ring Injuries: Management Algorithm, Injury (2020), doi: https://doi.org/10.1016/j.injury.2020.01.045
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
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Highlights The manuscript will describe the injury mechanism and pattern along with classifications and associated injuries. Initial treatment plan followed by stabilization of the polytrauma patient with a vertical shear injury will be described. The treatment algorithm will be discussed based upon location of posterior injury (SI joint vs Sacrum), ability to reduce via indirect methods, safe zone or osseous corridor for percutaneous screws, intraforaminal debris, spinopelvic dissociation, sacral comminution, patient comorbidities, and posterior skin quality will determine treatment options. Outcomes are based upon ability to obtain and maintain anatomic ring fixation, neural injury, associated injuries, and time to fixation.
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Vertical Shear Pelvic Ring Injuries: Management Algorithm
Clifford B. Jones, MD, FAAOS, FAOA, FACS Orthopaedic Surgery Division Chief, Dignity Health Medical Group, Phoenix AZ St Joseph’s Orthopaedic Surgery, McCauley Office Building, Suite 850, 500 West Thomas Road, Phoenix AZ 85013 Creighton Medical School – Phoenix C: 480-521-1614 [email protected]
Abstract Vertical shear pelvic ring injuries are multidirectionally unstable. Indirect pelvic reduction can be performed and can facilitate concurrent lifesaving interventions. Because of the inherent instability, fixation methods should be fortified with many methods to avoid loss of fixation and recurrence of deformity. Outcomes are related to final reduction quality, neural injury, and polytrauma. Key words: pelvic ring injury, treatment, vertical shear, lumbopelvic fixation, triangular fixation Introduction Pelvic ring injuries are common affecting all age groups. These injuries are the resultant of low energy falls in the elderly with osteoporotic bone or high energy forces in the younger population. Vertical shear pelvic ring injuries are by definition higher energy resulting in an unstable vertical displacement of the hemipelvis. Associated injuries locally and globally are common with increased morbidity and mortality [1 2]. The unstable nature of this injury necessitates surgical intervention to reduce and stabilize the pelvic ring. Imaging and Classification Initial imaging consists of the trauma scout anterior-posterior (AP) pelvis. Demonstrating injury and/or with the initial trauma evaluation, a CT will delineate the injury pattern, displacement, and associated injuries. Reformatted injury 3D CT is very helpful in evaluating the amount of displacement and type of deformity (rotational, vertical, posterior, cranial). Since X-rays are not averaged, true inlet and outlet images are better at defining injury but the quality can be variable. Without further movement or pain to the patient, reformatted 3D CT into inlet and outlet can provide better quality combined with Judet and views in between to further assess the injury and deformity. Injuries can be ligamentous (sacroiliac joint (SI), pubic symphysis (PS)), osseous (ramus, acetabulum, ilium, sacrum), and/or a combination of both. Classification can be descriptive (Judet) or based upon pattern. Vertical shear injuries are OTA/AO 61C with involvement of the ilium (61C1.1), SI joint (61C1.2) or sacrum (61C1.3) [3]. Tile also
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describes these injuries as a type C or vertically unstable [4 5]. Young and Burgess would classify as described vertical shear. Injuries can be subtle based upon initial presentation with minimal displacement [2 6].This can be especially true with patients intubated and paralyzed in the field before presentation or with associated spinal fractures and paralysis. Diagnosing a complete, non-impacted posterior ring injury and lumbar transverse process fractures can be pathognomonic for pelvic ring instability [7 8]. Further analysis of the lumbar-sacral articulation is also helpful in assessing the extent of posterior pelvic instability with injuries involving the L5S1 articulation such as Isler 2 (through the L5S1) and Isler 3 (medial to the L5S1 facet) [9 10]. Mechanism and Associated Injuries The mechanism is usually a vertically directed force to the hemi or complete pelvis such as a fall from height or sudden deceleration car accident or motorcycle accident [6 11 12]. A low energy fall onto a knee in an osteoporotic elderly patient can generate similar injury patterns. Secondary to these forces, associated injuries are common. Local injuries can consist of urological (urethral, bladder), pudendal nerve (erection, ejaculation), pelvic floor, vascular (pudendal, internal iliac, external iliac, common iliac, superior gluteal, venous plexus), and neurological (sciatic nerve, superior gluteal, lumbosacral plexus/nerve roots). Global injuries are bleeding (shock), visceral, spine, chest, and head. Expecting, preventing, and/or treating these other life threating injuries are paramount and performed in parallel with the trauma team. Initial Management Life saving measures for shock, chest, and head are initially based upon ATLS [6 11 12]. Orthopaedic intervention can proceed concurrently and support the life saving measures. Reducing a hip dislocation and pulling gentle traction to achieve length to the pelvis will assist reduction of pelvic volume. The pelvic volume can be reduced with application of a sheet, binder, or percutaneous clamp to the pelvis. I prefer a sheet or binder which can be can easily be adjusted and does not interfere with posterior fixation options [13].Reduce the widening manually before applying the device to avoid further shearing of the soft tissues. If sacral comminution and/or intraforaminal debris is present, be careful not to over compress and potentially create or worsening a nerve injury. Apply skeletal traction (20 lbs. or 12 kg, distal femur) to maintain length of the hemipelvis. Perform this as soon as possible in conjunction with the trauma team to facilitate resuscitation and pain control. If the surgeon is skilled and efficient and/or already in the operative suite for other procedures, a percutaneous “resuscitative” posterior sacro-iliac screw can be inserted for immediate pelvic volume reduction, improved stability, but with the potential for a non-anatomic reduction. Anatomic reduction is possible but is not the only goal at this stage of treatment. This temporary fixation lessens the need for binders but potentially may require staged additional anterior fixation and/or revision of posterior fixation if not anatomic [14]. Preoperative Planning Planning on operative intervention will be based upon patient stability, associated injuries, and pelvic treatment required to obtain and maintain pelvic ring stability. Secondary to patient instability and potentially extensive anterior and posterior surgery,
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patients need to be stabilized and monitored concerning hemoglobin, lactic acid, and ongoing resuscitation. Despite intervening with traction and binder, formal surgical intervention should be delayed until stable. Associated injuries such as bowel or bladder injury, may preclude open anterior fixation. Chest or spine injuries may preclude posterior, prone approaches. Timing, more than five days after injury, may preclude efficiency of percutaneous techniques. CT analysis will determine osseous corridors and sacral dysmorphism [15-17]. Multidirectional deformity may require open supine or prone approaches. Residual displacement should be assessed again intraoperatively to avoid displacement of greater than five millimeters to avoid inferior outcomes, increased fracture reduction stability, and smaller safe zone corridors to insert percutaneous screws. Perioperative Equipment Skilled and experienced trauma anesthesia is critical to safe and effective pelvic surgery. The anesthesiologist should be comfortable with polytrauma patients with chest and head trauma in both supine and prone positioning. Paralysis facilitates indirect and direct methods of deformity correction. A radiolucent table with the ability to apply traction improves fluoroscopy visualization. Traction weights up to 20 lbs (12 kg) should be available. A large fluoroscopy c-arm will improve visualization and lessen parallax. For supine cases, three folded radiolucent blankets placed under the patient from the pelvis proximally to the head allows for posterior percutaneous approaches in the supine position. To lessen brachial plexus injury, limit shoulder hyperextension shoulders during supine approaches. Fracture Reduction Fracture reduction can be accomplished with skeletal traction. Acceptable reduction should be scrutinized with imaging to assess symmetry. Intraoperative inlet assesses rotation and translation (anterior and posterior) reduction. Outlet assesses rotation and length (cranial and caudal) reduction. Lateral can determine the translation, rotation, and length with assessment of the iliac cortical density, sciatic notch, and acetabular overlay. Anterior reduction of PS and ramus injuries improves length, translation, and rotation of most hemipelvis injuries, therefore; anterior fixation will facilitate posterior pelvic reduction. Sacro-Iliac (SI) and Transsacral Transiliac (TSTI) Screws Sacro-Iliac (SI) and Transsacral Transiliac (TSTI) screws are best for reducible injuries, adequate safe zone size, sacroiliac joint dislocations, non-comminuted sacral injuries, hemipelvis injury without spinopelvic dissociation, transforaminal sacral fractures without compromising intraforaminal osseous debris or neural injury. Reduction quality is in the eye of the surgeon. Even though more percutaneous posterior fixation is being performed, posterior reduction quality should be within 5mm to improve screw fixation quality and safety and functional outcomes [18 19]. CT analysis will determine screw trajectory and safe zones of the osseous corridors. For SI injuries, a posterior to anterior, caudal to cranial screw will facilitate perpendicular screw insertion for symmetrical joint reduction and compression. For sacral injuries, a transiliac transsacral screw perpendicular to the fracture plane will facilitate reduction without translation. Comminuted sacral injuries can be compressed for osseous contact but should not be
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overcompressed and used judiciously with foraminal debris. Spinopelvic dissociation requires additional fixation. SI and TSTI screws can be inserted in the prone or supine position. I prefer the supine position because of familiarity with fluoroscopy, set up, traction, and polytrauma. Furthermore, anterior fixation can be performed with the same set up. Screws required are 6.5, 7.0, or 8.0 mm cannulated partial and fully threaded screws beginning at 75mm and ending at 180mm in length. If an adequate supine reduction is obtained, then I would compress the injury with a partially threaded screw until a symmetrical SI joint or sacral width is obtained at the sacral one level. I would then insert an additional fully threaded TSTI screw at the sacral two level. If possible, a sacral three fully threaded screw is inserted [20]. Depending on the comminution and safe zone geometry, the partially threaded zone one screw can be replaced with a fully threaded screw. If an adequate supine reduction cannot be obtained either with traction and/or percutaneous SI screw fixation, then I would abandon the supine percutaneous approach. For SI dislocations, I would reduce the SI joint via an open lateral window and perform an open reduction and compression of the SI joint with a clamp before SI screw insertion. For displaced sacral fractures, I would convert to an open prone parasacral approach [21]. Utilizing large point-to-point Weber clamps from the lateral posterior ilium to the midline sacral spine, the hemipelvis can be axially translated to obtain length and compressed. Like a “shoe horn”, a freer at the fracture site can facilitate anterior to posterior translation. Usually the caudal sacral fracture site will provide a good read for fracture reduction quality. With the clamp in position under compression, fully threaded sacral screws can then be inserted. If a good fracture site interdigitation can be achieved, then a minimum of two TSTI screws should be adequate (Figure 1). Lumbopelvic and Triangular Fixation Lumbopelvic (LP) fixation spans the fixation from the pelvis onto the lumbar spine unloading sacral fixation [22]. Triangular (TRI) fixation is lumbopelvic fixation with an additional transsacral transiliac screw which improves stability both axially and coronally [23 24]. With LP or TRI no anterior fixation is required and immediate weight bearing can begin [24 25]. Indications for LP or TRI are sacral dysmorphism precluding safe TSTI screw fixation, marked sacral comminution precluding stable sacral fixation, extension into the L5S1 facet (spinopelvic dissociation), sacral foraminal osseous intrusion with or without neural injury, and/or predicted patient noncompliance with weight bearing restrictions. Pelvic fixation is initiated with pedicle screw fixation into the sciatic buttress, which starts at the posterior inferior iliac spine, PIIS, and ends at the anterior inferior iliac spine (AIIS). TRI of the lumbar fixation is with pedicle screw fixation the lumbar 5 (L5) and possibly lumbar 4 (L4). Lumbopelvic fixation requires prone posterior approach. If an adequate indirect closed reduction is achieved, a percutaneous method of screw insertion can be performed. Severe degloving, skin friction burn, or posterior open wounds may be best treated with percutaneous methods. Inadequate reduction quality, neural injury with or without intraforaminal debris or osseous encroachment, or degloving requiring open debridement may benefit from a prone, open approach.
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The open approach is accomplished with a paramedian or a midline approach. If bilateral or requiring sacral neural decompression, the midline approach may be best [22]. If not requiring neural decompression, then the paramedian approach may be best. Upon the approach, avoid using Bovie electrocautery to avoid dural and/or neural injury. Dissect cranially to the L5 pedicle insertion site, laterally to the iliac crest, and caudally to the exit site of the sacral fracture site. Carefully remove and decompress intraforaminal debris. One adequate decompression is performed, translate, rotate, and compress the fracture with a spin down Weber clamp. Utilizing two clamps, one cranial and one caudal, will facilitate a symmetrical reduction. Insert the L5 pedicle screw. Create an inset area below the level of the posterior ilium to avoid screw head prominence. Insert the sciatic buttress pedicle screw (8.0mm, length 120-130 mm) utilizing iliac Judet (above the sciatic notch cranially and caudally) and role-over obturator Judet combine with outlet view (within the sciatic buttress medially and laterally). Flexion/extension and internal/external rotation can be corrected with the appropriate manual movement of the sciatic buttress insertion device. If rotational movement of the hemipelvis occurs with screw insertion, tap the screw before inserting to avoid loss of reduction. Insert the connecting rod and tighten the construct (Figure 2). Insert one or two TSTI screws above the sciatic buttress for sacral one and below the for sacral two screws. In patterns that reduce adequately with indirect traction methods and not requiring foraminal decompression, percutaneous LP and TRI fixation can be performed effectively [26]. This may be an effective method to reduce incisional complications in the setting of concomitant Morel-Lavalle’ degloving injuries. Treatment Algorithm Treatment should be based upon posterior injury (SI vs Sacral fracture), adequate posterior fixation with closed indirect method and/or anterior fixation, adequate safe zone and/or osseous fixation pathway, comminution, foraminal debris, and spinopelvic dissociation (Figure 3 and 4). Other variables are polytrauma, co-morbidities, degloving injury, surgeon skill, and time from injury. Postoperative Management Since these injuries are unstable, limited weight bearing and physical therapy directed range of motion or strengthening should be avoided for six to 12 weeks. Postoperative CT determination of injury reduction quality and minimal fracture site comminution may expedite weight bearing and therapy. Triangular fixation may allow for immediate weight bearing but should be individualized for each patient and injury pattern. Complications Complications include wound healing problems, inadequate fracture reduction, neural injury, and/or loss of fixation. With layered closure over a drain, modern posterior fixation constructs should be minimal [21]. In the setting of a large Morel-Lavalle’ degloving injury, percutaneous rather than open methods may optimize results [26 27]. Inadequate fixation should be determined based upon adequacy of reduction, amount of comminution, anticipated noncompliance, and/or amount of fixation. With unstable vertical shear with comminution, a minimum of two TSTI screws should be inserted
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(Figure 5). Neural injury can occur with inadequate reduction, intraforaminal debris, and/or over compression (Figure 6). Outcomes Quality of the posterior pelvic reduction within five millimeters is optimal and should not be more than one centimeter [19 28]. LP and TRI fixation may provide extra stability to avoid loss of fixation and recurrence of deformity. Vertical shear, pelvic ring injury, outcomes are related to associated injuries, especially neurological injuries [29 30]. Early operative fixation with open or percutaneous methods can improve outcomes [31]. Despite obtaining injury reduction and maintaining unstable injuries with rigid fixation, long term impairments can be expected [32]. Conclusion Vertical shear pelvic ring injuries are multidirectionally unstable injuries that are associated with a plethora of other injuries expected in polytrauma patients. Indirect pelvic reduction can be performed and can facilitate concurrent lifesaving interventions. Pelvic deformity can be reduced with indirect and direct methods. Because of the inherent instability, fixation methods should be fortified with many methods to avoid loss of fixation and recurrence of deformity. Outcomes are related to final reduction quality, neural injury, and polytrauma. CB Jones Conflict of Interest Statement: Stryker – Consultant, Education OsteoConcentric - Consultant Acknowledgments No funding or assistance was utilized in writing of this manuscript. References: 1. Kregor PJ, Routt ML, Jr. Unstable pelvic ring disruptions in unstable patients. Injury 1999;30 Suppl 2:B19-28 2. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986;160(2):445-51 doi: 10.1148/radiology.160.2.3726125[published Online First: Epub Date]|. 3. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21(10 Suppl):S1133 doi: 10.1097/00005131-200711101-00001[published Online First: Epub Date]|. 4. Tile M. The management of unstable injuries of the pelvic ring. J Bone Joint Surg Br 1999;81(6):941-3
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5. Tile M, Pennal GF. Pelvic disruption: principles of management. Clin Orthop Relat Res 1980(151):56-64 6. Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma 1989;29(7):981-1000; discussion 00-2 7. Starks I, Frost A, Wall P, Lim J. Is a fracture of the transverse process of L5 a predictor of pelvic fracture instability? J Bone Joint Surg Br 2011;93(7):9679 doi: 10.1302/0301-620X.93B7.26772[published Online First: Epub Date]|. 8. Winkelmann M, Lopez Izquierdo M, Clausen JD, et al. Fractures of the transverse processes of the fourth and fifth lumbar vertebrae in patients with pelvic ring injuries: indicator of biomechanical instability but not shock. Bone Joint J 2018;100-B(9):1214-19 doi: 10.1302/0301-620X.100B9.BJJ-20180071.R1[published Online First: Epub Date]|. 9. Isler B. Lumbosacral lesions associated with pelvic ring injuries. J Orthop Trauma 1990;4(1):1-6 10. Isler B, Ganz R. Classification of pelvic ring injuries. Injury 1996;27 Suppl 1:SA3-12 11. Ben-Menachem Y, Coldwell DM, Young JW, Burgess AR. Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management. AJR Am J Roentgenol 1991;157(5):1005-14 doi: 10.2214/ajr.157.5.1927786[published Online First: Epub Date]|. 12. Blum L, Hake ME, Charles R, et al. Vertical shear pelvic injury: evaluation, management, and fixation strategies. Int Orthop 2018;42(11):2663-74 doi: 10.1007/s00264-018-3883-1[published Online First: Epub Date]|. 13. Routt ML, Jr., Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma 2002;16(1):45-8 doi: 10.1097/00005131-200201000-00010[published Online First: Epub Date]|. 14. Keating JF, Werier J, Blachut P, Broekhuyse H, Meek RN, O'Brien PJ. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma 1999;13(2):107-13 doi: 10.1097/00005131-199902000-00007[published Online First: Epub Date]|. 15. Bishop JA, Routt ML, Jr. Osseous fixation pathways in pelvic and acetabular fracture surgery: osteology, radiology, and clinical applications. J Trauma Acute Care Surg 2012;72(6):1502-9 doi: 10.1097/TA.0b013e318246efe5[published Online First: Epub Date]|. 16. Kaiser SP, Gardner MJ, Liu J, Routt ML, Jr., Morshed S. Anatomic Determinants of Sacral Dysmorphism and Implications for Safe Iliosacral Screw Placement. J Bone Joint Surg Am 2014;96(14):e120 doi: 10.2106/JBJS.M.00895[published Online First: Epub Date]|. 17. Lucas JF, Routt ML, Jr., Eastman JG. A Useful Preoperative Planning Technique for Transiliac-Transsacral Screws. J Orthop Trauma 2017;31(1):e25-e31 doi: 10.1097/BOT.0000000000000708[published Online First: Epub Date]|. 18. Reilly MC, Bono CM, Litkouhi B, Sirkin M, Behrens FF. The effect of sacral fracture malreduction on the safe placement of iliosacral screws. J Orthop
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Trauma 2003;17(2):88-94 doi: 10.1097/00005131-20030200000002[published Online First: Epub Date]|. 19. Tornetta P, 3rd, Matta JM. Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop Relat Res 1996(329):186-93 doi: 10.1097/00003086-199608000-00022[published Online First: Epub Date]|. 20. Hwang JS, Reilly MC, Shaath MK, et al. Safe Zone Quantification of the Third Sacral Segment in Normal and Dysmorphic Sacra. J Orthop Trauma 2018;32(4):178-82 doi: 10.1097/BOT.0000000000001100[published Online First: Epub Date]|. 21. Stover MD, Sims S, Matta J. What is the infection rate of the posterior approach to type C pelvic injuries? Clin Orthop Relat Res 2012;470(8):2142-7 doi: 10.1007/s11999-012-2438-9[published Online First: Epub Date]|. 22. Schildhauer TA, Bellabarba C, Nork SE, Barei DP, Routt ML, Jr., Chapman JR. Decompression and lumbopelvic fixation for sacral fracture-dislocations with spino-pelvic dissociation. J Orthop Trauma 2006;20(7):447-57 doi: 10.1097/00005131-200608000-00001[published Online First: Epub Date]|. 23. Schildhauer TA, Josten C, Muhr G. Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing. J Orthop Trauma 2006;20(1 Suppl):S44-51 24. Schildhauer TA, Ledoux WR, Chapman JR, Henley MB, Tencer AF, Routt ML, Jr. Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads. J Orthop Trauma 2003;17(1):22-31 doi: 10.1097/00005131-20030100000004[published Online First: Epub Date]|. 25. Schildhauer TA, Josten C, Muhr G. Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing. J Orthop Trauma 1998;12(5):307-14 doi: 10.1097/00005131-19980600000002[published Online First: Epub Date]|. 26. Williams SK, Quinnan SM. Percutaneous Lumbopelvic Fixation for Reduction and Stabilization of Sacral Fractures With Spinopelvic Dissociation Patterns. J Orthop Trauma 2016;30(9):e318-24 doi: 10.1097/BOT.0000000000000559[published Online First: Epub Date]|. 27. Hak DJ, Olson SA, Matta JM. Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the MorelLavallee lesion. J Trauma 1997;42(6):1046-51 doi: 10.1097/00005373199706000-00010[published Online First: Epub Date]|. 28. Tornetta P, 3rd, Dickson K, Matta JM. Outcome of rotationally unstable pelvic ring injuries treated operatively. Clin Orthop Relat Res 1996(329):147-51 doi: 10.1097/00003086-199608000-00018[published Online First: Epub Date]|. 29. Poole GV, Ward EF, Muakkassa FF, Hsu HS, Griswold JA, Rhodes RS. Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries. Ann Surg 1991;213(6):532-8; discussion 38-9 doi: 10.1097/00000658-199106000-00002[published Online First: Epub Date]|.
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30. Suzuki T, Shindo M, Soma K, et al. Long-term functional outcome after unstable pelvic ring fracture. J Trauma 2007;63(4):884-8 doi: 10.1097/01.ta.0000235888.90489.fc[published Online First: Epub Date]|. 31. Sharpe JP, Magnotti LJ, Gobbell WC, et al. Impact of early operative pelvic fixation on long-term self-reported outcome following severe pelvic fracture. J Trauma Acute Care Surg 2017;82(3):444-50 doi: 10.1097/TA.0000000000001346[published Online First: Epub Date]|. 32. Jones CB, Sietsema DL, Hoffmann MF. Can lumbopelvic fixation salvage unstable complex sacral fractures? Clin Orthop Relat Res 2012;470(8):2132-41 doi: 10.1007/s11999-012-2273-z[published Online First: Epub Date]|.
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Figure 1 A 24-year-old male jumped from a 30-foot structure resulting in polytrauma including injury AP Pelvis (A) and CT (B, C) demonstrating left Isler 2 L5/S1 injury with minimally comminuted zone 2 sacral fracture, right SI fracture dislocation, and
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left femoral fracture. He presented hypotensive, with bilateral lumbosacral plexus injury, traumatic brain injury, and severe posterior degloving. He required a percutaneous right iliac buttress Schantz pin insertion for reduction of the SI joint. He was placed in left skeletal traction. After 2 days of stabilization in the ICU, he had supine operative open fixation of the right SI joint with clamp fixation and closed reduction of the left sacral fracture. Percutaneous fixation with a combination of both partially and fully threaded screws allowed for adequate posterior fixation (D, E). Secondary to extra peritoneal bladder rupture with urethral injury, anterior fixation was performed with AIIS Schantz pin external fixation for 8 weeks. Final follow images demonstrate symmetrical reduction without loss of fixation (F, G).
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Figure 2 An 18-year-old female was involved in severe motor vehicle collision resulting in left Isler 3 L5/S1 injury with comminuted left zone 2 sacral fracture with intraforaminal debris and right SI joint subluxation (A, B). Prone, open debridement
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of the intraforaminal debris (C) allowed for save translation of sacral fracture with a freer elevator followed by compression of the fracture with a Weber clamp from the PSIS to the sacral spinous process (D). Lumbopelvic fixation was inserted with fusion of the L5/S1 secondary to the unstable injury pattern. The right SI joint was reduced with a partially threaded SI screw. At 2 year follow up, final symmetrical inlet and outlet images are noted (E, F).
Posterior Injury
Indirect Reduction Adequate
Safe Corridor/Osseous Fixation Pathway Adequate
Fixation Technique
Yes
Closed Pecutaneous Si Screws
No
Open Reduction 90/90 Plate Fixation
Yes
Open Reduction Plate or SI Screws
No
Open Reduction 90/90 Plate Fixation
Yes
SacroIliac Joint
No
Figure 3 Treatment algorithm for vertical shear SI joint injury.
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Posterior Injury
Indirect Reduction Adequate
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Safe Corridor/Osseous Fixation Pathway Adequate
Comminution Foraminal Debris SpinoPelvic Dissociation
Fixation Technique
No
Percutaneous SI with 1-2 TSTI Screw
Yes
Prone, Open Triangular Fixation
No
Prone, Open Lumbopelvic Fixation
Yes
Prone, Open 2 TSTI Screws
No
Prone, Open S TSTI Screws
Yes
Prone, Open Triangular Fixation
No
Prone, Open Lumbopelvic Fixation
Yes
Prone, Open Lumbopelvic Fixation
Yes
Yes
No
Sacral Fracture
Yes
No
No
Figure 4 Treatment algorithm for vertical shear Sacral Fracture.
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Figure 5 A 54-year-old male had PS ORIF and inadequate percutaneous fixation with a single TSTI screw without initial compression of the comminuted zone 2 sacral fracture resulting in early loss of fixation, screw migration, and typical cephalad-posterior migration of the vertical shear injury (A, B). Revision fixation required removal of anterior fixation, removal of the TSTI screw, prone open takedown of the nonunion followed by clamp compression and TRI fixation, and repeat anterior plate fixation (C).
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Figure 6 This CT image is from a 32-year-old female who had inadequate closed reduction with malreduction of a comminuted transforaminal sacral fracture and overcompression of the sacral one and two bodies with partially threaded screws (A). Postoperative exam resulted in left L5, S1 nerve root injuries resulting in emergent return to operative suite for revision surgery.
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Vertical Shear Pelvic Ring Injuries: Management Algorithm Clifford B. Jones MD, FAAOS, FAOA, FACS PII: DOI: Reference:
S0020-1383(20)30073-5 https://doi.org/10.1016/j.injury.2020.01.045 JINJ 8555
To appear in:
Injury
Received date: Revised date: Accepted date:
6 January 2020 26 January 2020 28 January 2020
Please cite this article as: Clifford B. Jones MD, FAAOS, FAOA, FACS , Vertical Shear Pelvic Ring Injuries: Management Algorithm, Injury (2020), doi: https://doi.org/10.1016/j.injury.2020.01.045
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
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Highlights The manuscript will describe the injury mechanism and pattern along with classifications and associated injuries. Initial treatment plan followed by stabilization of the polytrauma patient with a vertical shear injury will be described. The treatment algorithm will be discussed based upon location of posterior injury (SI joint vs Sacrum), ability to reduce via indirect methods, safe zone or osseous corridor for percutaneous screws, intraforaminal debris, spinopelvic dissociation, sacral comminution, patient comorbidities, and posterior skin quality will determine treatment options. Outcomes are based upon ability to obtain and maintain anatomic ring fixation, neural injury, associated injuries, and time to fixation.
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Vertical Shear Pelvic Ring Injuries: Management Algorithm
Clifford B. Jones, MD, FAAOS, FAOA, FACS Orthopaedic Surgery Division Chief, Dignity Health Medical Group, Phoenix AZ St Joseph’s Orthopaedic Surgery, McCauley Office Building, Suite 850, 500 West Thomas Road, Phoenix AZ 85013 Creighton Medical School – Phoenix C: 480-521-1614 [email protected]
Abstract Vertical shear pelvic ring injuries are multidirectionally unstable. Indirect pelvic reduction can be performed and can facilitate concurrent lifesaving interventions. Because of the inherent instability, fixation methods should be fortified with many methods to avoid loss of fixation and recurrence of deformity. Outcomes are related to final reduction quality, neural injury, and polytrauma. Key words: pelvic ring injury, treatment, vertical shear, lumbopelvic fixation, triangular fixation Introduction Pelvic ring injuries are common affecting all age groups. These injuries are the resultant of low energy falls in the elderly with osteoporotic bone or high energy forces in the younger population. Vertical shear pelvic ring injuries are by definition higher energy resulting in an unstable vertical displacement of the hemipelvis. Associated injuries locally and globally are common with increased morbidity and mortality [1 2]. The unstable nature of this injury necessitates surgical intervention to reduce and stabilize the pelvic ring. Imaging and Classification Initial imaging consists of the trauma scout anterior-posterior (AP) pelvis. Demonstrating injury and/or with the initial trauma evaluation, a CT will delineate the injury pattern, displacement, and associated injuries. Reformatted injury 3D CT is very helpful in evaluating the amount of displacement and type of deformity (rotational, vertical, posterior, cranial). Since X-rays are not averaged, true inlet and outlet images are better at defining injury but the quality can be variable. Without further movement or pain to the patient, reformatted 3D CT into inlet and outlet can provide better quality combined with Judet and views in between to further assess the injury and deformity. Injuries can be ligamentous (sacroiliac joint (SI), pubic symphysis (PS)), osseous (ramus, acetabulum, ilium, sacrum), and/or a combination of both. Classification can be descriptive (Judet) or based upon pattern. Vertical shear injuries are OTA/AO 61C with involvement of the ilium (61C1.1), SI joint (61C1.2) or sacrum (61C1.3) [3]. Tile also
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describes these injuries as a type C or vertically unstable [4 5]. Young and Burgess would classify as described vertical shear. Injuries can be subtle based upon initial presentation with minimal displacement [2 6].This can be especially true with patients intubated and paralyzed in the field before presentation or with associated spinal fractures and paralysis. Diagnosing a complete, non-impacted posterior ring injury and lumbar transverse process fractures can be pathognomonic for pelvic ring instability [7 8]. Further analysis of the lumbar-sacral articulation is also helpful in assessing the extent of posterior pelvic instability with injuries involving the L5S1 articulation such as Isler 2 (through the L5S1) and Isler 3 (medial to the L5S1 facet) [9 10]. Mechanism and Associated Injuries The mechanism is usually a vertically directed force to the hemi or complete pelvis such as a fall from height or sudden deceleration car accident or motorcycle accident [6 11 12]. A low energy fall onto a knee in an osteoporotic elderly patient can generate similar injury patterns. Secondary to these forces, associated injuries are common. Local injuries can consist of urological (urethral, bladder), pudendal nerve (erection, ejaculation), pelvic floor, vascular (pudendal, internal iliac, external iliac, common iliac, superior gluteal, venous plexus), and neurological (sciatic nerve, superior gluteal, lumbosacral plexus/nerve roots). Global injuries are bleeding (shock), visceral, spine, chest, and head. Expecting, preventing, and/or treating these other life threating injuries are paramount and performed in parallel with the trauma team. Initial Management Life saving measures for shock, chest, and head are initially based upon ATLS [6 11 12]. Orthopaedic intervention can proceed concurrently and support the life saving measures. Reducing a hip dislocation and pulling gentle traction to achieve length to the pelvis will assist reduction of pelvic volume. The pelvic volume can be reduced with application of a sheet, binder, or percutaneous clamp to the pelvis. I prefer a sheet or binder which can be can easily be adjusted and does not interfere with posterior fixation options [13].Reduce the widening manually before applying the device to avoid further shearing of the soft tissues. If sacral comminution and/or intraforaminal debris is present, be careful not to over compress and potentially create or worsening a nerve injury. Apply skeletal traction (20 lbs. or 12 kg, distal femur) to maintain length of the hemipelvis. Perform this as soon as possible in conjunction with the trauma team to facilitate resuscitation and pain control. If the surgeon is skilled and efficient and/or already in the operative suite for other procedures, a percutaneous “resuscitative” posterior sacro-iliac screw can be inserted for immediate pelvic volume reduction, improved stability, but with the potential for a non-anatomic reduction. Anatomic reduction is possible but is not the only goal at this stage of treatment. This temporary fixation lessens the need for binders but potentially may require staged additional anterior fixation and/or revision of posterior fixation if not anatomic [14]. Preoperative Planning Planning on operative intervention will be based upon patient stability, associated injuries, and pelvic treatment required to obtain and maintain pelvic ring stability. Secondary to patient instability and potentially extensive anterior and posterior surgery,
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patients need to be stabilized and monitored concerning hemoglobin, lactic acid, and ongoing resuscitation. Despite intervening with traction and binder, formal surgical intervention should be delayed until stable. Associated injuries such as bowel or bladder injury, may preclude open anterior fixation. Chest or spine injuries may preclude posterior, prone approaches. Timing, more than five days after injury, may preclude efficiency of percutaneous techniques. CT analysis will determine osseous corridors and sacral dysmorphism [15-17]. Multidirectional deformity may require open supine or prone approaches. Residual displacement should be assessed again intraoperatively to avoid displacement of greater than five millimeters to avoid inferior outcomes, increased fracture reduction stability, and smaller safe zone corridors to insert percutaneous screws. Perioperative Equipment Skilled and experienced trauma anesthesia is critical to safe and effective pelvic surgery. The anesthesiologist should be comfortable with polytrauma patients with chest and head trauma in both supine and prone positioning. Paralysis facilitates indirect and direct methods of deformity correction. A radiolucent table with the ability to apply traction improves fluoroscopy visualization. Traction weights up to 20 lbs (12 kg) should be available. A large fluoroscopy c-arm will improve visualization and lessen parallax. For supine cases, three folded radiolucent blankets placed under the patient from the pelvis proximally to the head allows for posterior percutaneous approaches in the supine position. To lessen brachial plexus injury, limit shoulder hyperextension shoulders during supine approaches. Fracture Reduction Fracture reduction can be accomplished with skeletal traction. Acceptable reduction should be scrutinized with imaging to assess symmetry. Intraoperative inlet assesses rotation and translation (anterior and posterior) reduction. Outlet assesses rotation and length (cranial and caudal) reduction. Lateral can determine the translation, rotation, and length with assessment of the iliac cortical density, sciatic notch, and acetabular overlay. Anterior reduction of PS and ramus injuries improves length, translation, and rotation of most hemipelvis injuries, therefore; anterior fixation will facilitate posterior pelvic reduction. Sacro-Iliac (SI) and Transsacral Transiliac (TSTI) Screws Sacro-Iliac (SI) and Transsacral Transiliac (TSTI) screws are best for reducible injuries, adequate safe zone size, sacroiliac joint dislocations, non-comminuted sacral injuries, hemipelvis injury without spinopelvic dissociation, transforaminal sacral fractures without compromising intraforaminal osseous debris or neural injury. Reduction quality is in the eye of the surgeon. Even though more percutaneous posterior fixation is being performed, posterior reduction quality should be within 5mm to improve screw fixation quality and safety and functional outcomes [18 19]. CT analysis will determine screw trajectory and safe zones of the osseous corridors. For SI injuries, a posterior to anterior, caudal to cranial screw will facilitate perpendicular screw insertion for symmetrical joint reduction and compression. For sacral injuries, a transiliac transsacral screw perpendicular to the fracture plane will facilitate reduction without translation. Comminuted sacral injuries can be compressed for osseous contact but should not be
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overcompressed and used judiciously with foraminal debris. Spinopelvic dissociation requires additional fixation. SI and TSTI screws can be inserted in the prone or supine position. I prefer the supine position because of familiarity with fluoroscopy, set up, traction, and polytrauma. Furthermore, anterior fixation can be performed with the same set up. Screws required are 6.5, 7.0, or 8.0 mm cannulated partial and fully threaded screws beginning at 75mm and ending at 180mm in length. If an adequate supine reduction is obtained, then I would compress the injury with a partially threaded screw until a symmetrical SI joint or sacral width is obtained at the sacral one level. I would then insert an additional fully threaded TSTI screw at the sacral two level. If possible, a sacral three fully threaded screw is inserted [20]. Depending on the comminution and safe zone geometry, the partially threaded zone one screw can be replaced with a fully threaded screw. If an adequate supine reduction cannot be obtained either with traction and/or percutaneous SI screw fixation, then I would abandon the supine percutaneous approach. For SI dislocations, I would reduce the SI joint via an open lateral window and perform an open reduction and compression of the SI joint with a clamp before SI screw insertion. For displaced sacral fractures, I would convert to an open prone parasacral approach [21]. Utilizing large point-to-point Weber clamps from the lateral posterior ilium to the midline sacral spine, the hemipelvis can be axially translated to obtain length and compressed. Like a “shoe horn”, a freer at the fracture site can facilitate anterior to posterior translation. Usually the caudal sacral fracture site will provide a good read for fracture reduction quality. With the clamp in position under compression, fully threaded sacral screws can then be inserted. If a good fracture site interdigitation can be achieved, then a minimum of two TSTI screws should be adequate (Figure 1). Lumbopelvic and Triangular Fixation Lumbopelvic (LP) fixation spans the fixation from the pelvis onto the lumbar spine unloading sacral fixation [22]. Triangular (TRI) fixation is lumbopelvic fixation with an additional transsacral transiliac screw which improves stability both axially and coronally [23 24]. With LP or TRI no anterior fixation is required and immediate weight bearing can begin [24 25]. Indications for LP or TRI are sacral dysmorphism precluding safe TSTI screw fixation, marked sacral comminution precluding stable sacral fixation, extension into the L5S1 facet (spinopelvic dissociation), sacral foraminal osseous intrusion with or without neural injury, and/or predicted patient noncompliance with weight bearing restrictions. Pelvic fixation is initiated with pedicle screw fixation into the sciatic buttress, which starts at the posterior inferior iliac spine, PIIS, and ends at the anterior inferior iliac spine (AIIS). TRI of the lumbar fixation is with pedicle screw fixation the lumbar 5 (L5) and possibly lumbar 4 (L4). Lumbopelvic fixation requires prone posterior approach. If an adequate indirect closed reduction is achieved, a percutaneous method of screw insertion can be performed. Severe degloving, skin friction burn, or posterior open wounds may be best treated with percutaneous methods. Inadequate reduction quality, neural injury with or without intraforaminal debris or osseous encroachment, or degloving requiring open debridement may benefit from a prone, open approach.
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The open approach is accomplished with a paramedian or a midline approach. If bilateral or requiring sacral neural decompression, the midline approach may be best [22]. If not requiring neural decompression, then the paramedian approach may be best. Upon the approach, avoid using Bovie electrocautery to avoid dural and/or neural injury. Dissect cranially to the L5 pedicle insertion site, laterally to the iliac crest, and caudally to the exit site of the sacral fracture site. Carefully remove and decompress intraforaminal debris. One adequate decompression is performed, translate, rotate, and compress the fracture with a spin down Weber clamp. Utilizing two clamps, one cranial and one caudal, will facilitate a symmetrical reduction. Insert the L5 pedicle screw. Create an inset area below the level of the posterior ilium to avoid screw head prominence. Insert the sciatic buttress pedicle screw (8.0mm, length 120-130 mm) utilizing iliac Judet (above the sciatic notch cranially and caudally) and role-over obturator Judet combine with outlet view (within the sciatic buttress medially and laterally). Flexion/extension and internal/external rotation can be corrected with the appropriate manual movement of the sciatic buttress insertion device. If rotational movement of the hemipelvis occurs with screw insertion, tap the screw before inserting to avoid loss of reduction. Insert the connecting rod and tighten the construct (Figure 2). Insert one or two TSTI screws above the sciatic buttress for sacral one and below the for sacral two screws. In patterns that reduce adequately with indirect traction methods and not requiring foraminal decompression, percutaneous LP and TRI fixation can be performed effectively [26]. This may be an effective method to reduce incisional complications in the setting of concomitant Morel-Lavalle’ degloving injuries. Treatment Algorithm Treatment should be based upon posterior injury (SI vs Sacral fracture), adequate posterior fixation with closed indirect method and/or anterior fixation, adequate safe zone and/or osseous fixation pathway, comminution, foraminal debris, and spinopelvic dissociation (Figure 3 and 4). Other variables are polytrauma, co-morbidities, degloving injury, surgeon skill, and time from injury. Postoperative Management Since these injuries are unstable, limited weight bearing and physical therapy directed range of motion or strengthening should be avoided for six to 12 weeks. Postoperative CT determination of injury reduction quality and minimal fracture site comminution may expedite weight bearing and therapy. Triangular fixation may allow for immediate weight bearing but should be individualized for each patient and injury pattern. Complications Complications include wound healing problems, inadequate fracture reduction, neural injury, and/or loss of fixation. With layered closure over a drain, modern posterior fixation constructs should be minimal [21]. In the setting of a large Morel-Lavalle’ degloving injury, percutaneous rather than open methods may optimize results [26 27]. Inadequate fixation should be determined based upon adequacy of reduction, amount of comminution, anticipated noncompliance, and/or amount of fixation. With unstable vertical shear with comminution, a minimum of two TSTI screws should be inserted
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(Figure 5). Neural injury can occur with inadequate reduction, intraforaminal debris, and/or over compression (Figure 6). Outcomes Quality of the posterior pelvic reduction within five millimeters is optimal and should not be more than one centimeter [19 28]. LP and TRI fixation may provide extra stability to avoid loss of fixation and recurrence of deformity. Vertical shear, pelvic ring injury, outcomes are related to associated injuries, especially neurological injuries [29 30]. Early operative fixation with open or percutaneous methods can improve outcomes [31]. Despite obtaining injury reduction and maintaining unstable injuries with rigid fixation, long term impairments can be expected [32]. Conclusion Vertical shear pelvic ring injuries are multidirectionally unstable injuries that are associated with a plethora of other injuries expected in polytrauma patients. Indirect pelvic reduction can be performed and can facilitate concurrent lifesaving interventions. Pelvic deformity can be reduced with indirect and direct methods. Because of the inherent instability, fixation methods should be fortified with many methods to avoid loss of fixation and recurrence of deformity. Outcomes are related to final reduction quality, neural injury, and polytrauma. CB Jones Conflict of Interest Statement: Stryker – Consultant, Education OsteoConcentric - Consultant Acknowledgments No funding or assistance was utilized in writing of this manuscript. References: 1. Kregor PJ, Routt ML, Jr. Unstable pelvic ring disruptions in unstable patients. Injury 1999;30 Suppl 2:B19-28 2. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986;160(2):445-51 doi: 10.1148/radiology.160.2.3726125[published Online First: Epub Date]|. 3. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21(10 Suppl):S1133 doi: 10.1097/00005131-200711101-00001[published Online First: Epub Date]|. 4. Tile M. The management of unstable injuries of the pelvic ring. J Bone Joint Surg Br 1999;81(6):941-3
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5. Tile M, Pennal GF. Pelvic disruption: principles of management. Clin Orthop Relat Res 1980(151):56-64 6. Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma 1989;29(7):981-1000; discussion 00-2 7. Starks I, Frost A, Wall P, Lim J. Is a fracture of the transverse process of L5 a predictor of pelvic fracture instability? J Bone Joint Surg Br 2011;93(7):9679 doi: 10.1302/0301-620X.93B7.26772[published Online First: Epub Date]|. 8. Winkelmann M, Lopez Izquierdo M, Clausen JD, et al. Fractures of the transverse processes of the fourth and fifth lumbar vertebrae in patients with pelvic ring injuries: indicator of biomechanical instability but not shock. Bone Joint J 2018;100-B(9):1214-19 doi: 10.1302/0301-620X.100B9.BJJ-20180071.R1[published Online First: Epub Date]|. 9. Isler B. Lumbosacral lesions associated with pelvic ring injuries. J Orthop Trauma 1990;4(1):1-6 10. Isler B, Ganz R. Classification of pelvic ring injuries. Injury 1996;27 Suppl 1:SA3-12 11. Ben-Menachem Y, Coldwell DM, Young JW, Burgess AR. Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management. AJR Am J Roentgenol 1991;157(5):1005-14 doi: 10.2214/ajr.157.5.1927786[published Online First: Epub Date]|. 12. Blum L, Hake ME, Charles R, et al. Vertical shear pelvic injury: evaluation, management, and fixation strategies. Int Orthop 2018;42(11):2663-74 doi: 10.1007/s00264-018-3883-1[published Online First: Epub Date]|. 13. Routt ML, Jr., Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma 2002;16(1):45-8 doi: 10.1097/00005131-200201000-00010[published Online First: Epub Date]|. 14. Keating JF, Werier J, Blachut P, Broekhuyse H, Meek RN, O'Brien PJ. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma 1999;13(2):107-13 doi: 10.1097/00005131-199902000-00007[published Online First: Epub Date]|. 15. Bishop JA, Routt ML, Jr. Osseous fixation pathways in pelvic and acetabular fracture surgery: osteology, radiology, and clinical applications. J Trauma Acute Care Surg 2012;72(6):1502-9 doi: 10.1097/TA.0b013e318246efe5[published Online First: Epub Date]|. 16. Kaiser SP, Gardner MJ, Liu J, Routt ML, Jr., Morshed S. Anatomic Determinants of Sacral Dysmorphism and Implications for Safe Iliosacral Screw Placement. J Bone Joint Surg Am 2014;96(14):e120 doi: 10.2106/JBJS.M.00895[published Online First: Epub Date]|. 17. Lucas JF, Routt ML, Jr., Eastman JG. A Useful Preoperative Planning Technique for Transiliac-Transsacral Screws. J Orthop Trauma 2017;31(1):e25-e31 doi: 10.1097/BOT.0000000000000708[published Online First: Epub Date]|. 18. Reilly MC, Bono CM, Litkouhi B, Sirkin M, Behrens FF. The effect of sacral fracture malreduction on the safe placement of iliosacral screws. J Orthop
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Trauma 2003;17(2):88-94 doi: 10.1097/00005131-20030200000002[published Online First: Epub Date]|. 19. Tornetta P, 3rd, Matta JM. Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop Relat Res 1996(329):186-93 doi: 10.1097/00003086-199608000-00022[published Online First: Epub Date]|. 20. Hwang JS, Reilly MC, Shaath MK, et al. Safe Zone Quantification of the Third Sacral Segment in Normal and Dysmorphic Sacra. J Orthop Trauma 2018;32(4):178-82 doi: 10.1097/BOT.0000000000001100[published Online First: Epub Date]|. 21. Stover MD, Sims S, Matta J. What is the infection rate of the posterior approach to type C pelvic injuries? Clin Orthop Relat Res 2012;470(8):2142-7 doi: 10.1007/s11999-012-2438-9[published Online First: Epub Date]|. 22. Schildhauer TA, Bellabarba C, Nork SE, Barei DP, Routt ML, Jr., Chapman JR. Decompression and lumbopelvic fixation for sacral fracture-dislocations with spino-pelvic dissociation. J Orthop Trauma 2006;20(7):447-57 doi: 10.1097/00005131-200608000-00001[published Online First: Epub Date]|. 23. Schildhauer TA, Josten C, Muhr G. Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing. J Orthop Trauma 2006;20(1 Suppl):S44-51 24. Schildhauer TA, Ledoux WR, Chapman JR, Henley MB, Tencer AF, Routt ML, Jr. Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads. J Orthop Trauma 2003;17(1):22-31 doi: 10.1097/00005131-20030100000004[published Online First: Epub Date]|. 25. Schildhauer TA, Josten C, Muhr G. Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing. J Orthop Trauma 1998;12(5):307-14 doi: 10.1097/00005131-19980600000002[published Online First: Epub Date]|. 26. Williams SK, Quinnan SM. Percutaneous Lumbopelvic Fixation for Reduction and Stabilization of Sacral Fractures With Spinopelvic Dissociation Patterns. J Orthop Trauma 2016;30(9):e318-24 doi: 10.1097/BOT.0000000000000559[published Online First: Epub Date]|. 27. Hak DJ, Olson SA, Matta JM. Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the MorelLavallee lesion. J Trauma 1997;42(6):1046-51 doi: 10.1097/00005373199706000-00010[published Online First: Epub Date]|. 28. Tornetta P, 3rd, Dickson K, Matta JM. Outcome of rotationally unstable pelvic ring injuries treated operatively. Clin Orthop Relat Res 1996(329):147-51 doi: 10.1097/00003086-199608000-00018[published Online First: Epub Date]|. 29. Poole GV, Ward EF, Muakkassa FF, Hsu HS, Griswold JA, Rhodes RS. Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries. Ann Surg 1991;213(6):532-8; discussion 38-9 doi: 10.1097/00000658-199106000-00002[published Online First: Epub Date]|.
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30. Suzuki T, Shindo M, Soma K, et al. Long-term functional outcome after unstable pelvic ring fracture. J Trauma 2007;63(4):884-8 doi: 10.1097/01.ta.0000235888.90489.fc[published Online First: Epub Date]|. 31. Sharpe JP, Magnotti LJ, Gobbell WC, et al. Impact of early operative pelvic fixation on long-term self-reported outcome following severe pelvic fracture. J Trauma Acute Care Surg 2017;82(3):444-50 doi: 10.1097/TA.0000000000001346[published Online First: Epub Date]|. 32. Jones CB, Sietsema DL, Hoffmann MF. Can lumbopelvic fixation salvage unstable complex sacral fractures? Clin Orthop Relat Res 2012;470(8):2132-41 doi: 10.1007/s11999-012-2273-z[published Online First: Epub Date]|.
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Figure 1 A 24-year-old male jumped from a 30-foot structure resulting in polytrauma including injury AP Pelvis (A) and CT (B, C) demonstrating left Isler 2 L5/S1 injury with minimally comminuted zone 2 sacral fracture, right SI fracture dislocation, and
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left femoral fracture. He presented hypotensive, with bilateral lumbosacral plexus injury, traumatic brain injury, and severe posterior degloving. He required a percutaneous right iliac buttress Schantz pin insertion for reduction of the SI joint. He was placed in left skeletal traction. After 2 days of stabilization in the ICU, he had supine operative open fixation of the right SI joint with clamp fixation and closed reduction of the left sacral fracture. Percutaneous fixation with a combination of both partially and fully threaded screws allowed for adequate posterior fixation (D, E). Secondary to extra peritoneal bladder rupture with urethral injury, anterior fixation was performed with AIIS Schantz pin external fixation for 8 weeks. Final follow images demonstrate symmetrical reduction without loss of fixation (F, G).
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Figure 2 An 18-year-old female was involved in severe motor vehicle collision resulting in left Isler 3 L5/S1 injury with comminuted left zone 2 sacral fracture with intraforaminal debris and right SI joint subluxation (A, B). Prone, open debridement
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of the intraforaminal debris (C) allowed for save translation of sacral fracture with a freer elevator followed by compression of the fracture with a Weber clamp from the PSIS to the sacral spinous process (D). Lumbopelvic fixation was inserted with fusion of the L5/S1 secondary to the unstable injury pattern. The right SI joint was reduced with a partially threaded SI screw. At 2 year follow up, final symmetrical inlet and outlet images are noted (E, F).
Posterior Injury
Indirect Reduction Adequate
Safe Corridor/Osseous Fixation Pathway Adequate
Fixation Technique
Yes
Closed Pecutaneous Si Screws
No
Open Reduction 90/90 Plate Fixation
Yes
Open Reduction Plate or SI Screws
No
Open Reduction 90/90 Plate Fixation
Yes
SacroIliac Joint
No
Figure 3 Treatment algorithm for vertical shear SI joint injury.
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Posterior Injury
Indirect Reduction Adequate
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Safe Corridor/Osseous Fixation Pathway Adequate
Comminution Foraminal Debris SpinoPelvic Dissociation
Fixation Technique
No
Percutaneous SI with 1-2 TSTI Screw
Yes
Prone, Open Triangular Fixation
No
Prone, Open Lumbopelvic Fixation
Yes
Prone, Open 2 TSTI Screws
No
Prone, Open S TSTI Screws
Yes
Prone, Open Triangular Fixation
No
Prone, Open Lumbopelvic Fixation
Yes
Prone, Open Lumbopelvic Fixation
Yes
Yes
No
Sacral Fracture
Yes
No
No
Figure 4 Treatment algorithm for vertical shear Sacral Fracture.
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Figure 5 A 54-year-old male had PS ORIF and inadequate percutaneous fixation with a single TSTI screw without initial compression of the comminuted zone 2 sacral fracture resulting in early loss of fixation, screw migration, and typical cephalad-posterior migration of the vertical shear injury (A, B). Revision fixation required removal of anterior fixation, removal of the TSTI screw, prone open takedown of the nonunion followed by clamp compression and TRI fixation, and repeat anterior plate fixation (C).
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Figure 6 This CT image is from a 32-year-old female who had inadequate closed reduction with malreduction of a comminuted transforaminal sacral fracture and overcompression of the sacral one and two bodies with partially threaded screws (A). Postoperative exam resulted in left L5, S1 nerve root injuries resulting in emergent return to operative suite for revision surgery.
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