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Pelvic Emergency Clamps : Anatomic Landmarks for a Safe Primary Application

The application of the pelvic clamp as a tool for emergency stabilization of unstable pelvic ring fractures has proved to be a life-saving procedure. Using correct technique, the pelvic clamp can be applied within a few minutes after the patients admission. To avoid severe complications (eg, pin perforation into the pelvis) during the application, anatomic landmarks for the correct pin placement have to be defined. The surface landmarks that are presently recommended for the correct pin placement are not always reliably found due to deformation of the body surface caused by swelling and hematoma. Our experience with 43 emergency applications of the pelvic C-clamp showed that reliable anatomic landmarks on the bony surface of the innominate bone could be identified to ensure correct pin placement. The ideal insertion point of the pins is an anatomic region on the lateral cortex of the ileum, where an easily palpable groove is formed by angulations of the lateral cortex of the iliac wing. Being increasingly used as an entry point for percutaneous transiliosacral screw fixations of sacroiliac joint injuries and sacral fractures, this region, which is close to the sacroiliac joint, represents an ideal point for maximum compression of the posterior pelvic ring. With the described technique, this groove can be identified easily even in emergency situations by blunt palpation with an instrument, avoiding the time-consuming use of a fluoroscope in most cases.

Supraacetabular External Fixation for Pelvic Ring Fractures

Objective:Closed reduction and maintenance of pelvic ring injuries by external stabilization.Indications:Emergency management of unstable type B and type C pelvic ring fractures.Definitive treatment of type B injuries.Definitive treatment of the anterior pelvic ring in type C injuries with transpubic instability after posterior internal stabilization.Adjunct stabilization of internal fixation.Stabilization of pelvic ring fractures in children.Contraindications:Poor general condition.Local soft-tissue damage.Local infection.Surgical Technique:Bilateral percutaneous insertion of Schanz screws into the supraacetabular area of iliac bone. Closed reduction and stabilization of the pelvic ring by compression and application of a connecting rod under image intensification.Postoperative Management:Depending on the patient’s condition and the degree of pelvic instability, a change to an open procedure may become necessary.Mobilization of the patient with partial weight bearing (one fifth of body weight) on the side of the injured posterior pelvic ring using forearm crutches, irrespective of the degree of stability of the pelvis.Results:Retrospective analysis of 64 supraacetabular external fixator applications to stabilize the anterior pelvic ring in 20 type B and 44 type C injuries.Iatrogenic lesions of the lateral femoral cutaneous nerve: 4.5%; all sensory disturbances completely reversed within 1 year. No pin site infection. In two patients (3%) primary perforation of the Schanz screw into the small pelvis not necessitating any treatment. No secondary displacements of the anterior or posterior pelvic ring in type B injuries nor for type C injuries, sacral fractures associated with fractures of the pubic ramus. One pseudarthrosis of the pubic and ischial rami requiring surgical treatment.

Bilateral iliac artery dissection following severe complex unstable pelvic fracture

The case of an 18-year-old polytrauma patient with a complete disruption of the right external iliac artery and a dissection of the left external iliac artery mainly caused by bilateral complex pelvic fractures type C, a subluxated horizontal fracture of the right acetabulum, and a transforaminal sacrum fracture is described.

[Osteotomy of the iliac fossa in the treatment of a hip dislocation associated with a two-column acetabular fracture. Modification of the ilioinguinal approach to avoid an extended surgical approach].

ZusammenfassungDie Zugangswahl zur operativen Versorgung von Acetabulumfrakturen ist von der Frakturmorphologie, den Begleitverletzungen sowie dem Allgemeinzustand des Patienten abhängig. Der ilioinguinale Zugang nach Letournel ist ein weitgehend atraumatischer Zugang, der eine gute Exposition der Acetabuluminnenseite ermöglicht. Die Verwendung dieses Zugangs ist jedoch bei begleitenden Frakturen der Hinterwand problematisch.Wir berichten über einen 39-jährigen polytraumatisierten Patienten, der u.xa0a. eine posteriore Hüftluxation mit einer 2-Pfeiler-Acetabulumfraktur erlitten hatte. Bei der operativen Versorgung wurde über einen ilioinguinalen Zugang eine Iliumosteotomie durchgeführt. Dadurch wurde die Reposition eines kraniolateral gelegenen Fragments möglich, sodass keine Erweiterung des Zugangs oder ein 2. Zugang benötigt wurde.AbstractOpen reduction and internal fixation is the treatment of choice for displaced acetabular fractures. The surgical approach depends on the fracture type, concomitant injuries, and general condition of the patient. The ilioinguinal approach provides a good exposure to the medial wall and is associated with an acceptable degree of surgical trauma. Exposure of the joint surface, however, is difficult when using the ilioinguinal approach.We report a case of a polytraumatized 39-year-old patient who sustained a posterior hip displacement and a two-column acetabular fracture. An osteotomy of the iliac ala was performed via an ilioinguinal approach to fragments of the acetabular surface that were displaced distally. Thereby, reposition of a craniolateral fragment was achieved without the need to extend the surgical approach or to perform a second incision.

Navigated reposition of transverse acetabulum fractures. A precision analysis

ZusammenfassungDie navigierte Repositionskontrolle auf der Basis von Computertomographiebilddaten konnte bisher kommerziell nicht eingesetzt werden. Mit einer neu entwickelten Software wurde in einem Laborversuch eine Acetabulumquerfraktur navigiert reponiert.Verglichen wurden die Ergebnisse mit visueller und taktiler Kontrolle an einem Kunststoff- und einem Kadaverbecken. Die Messung erfolgte mit einem magnetbasierten Navigationssystem. Gemessen wurde die residuale Dislokation als Translation und Rotation. Gegenüber der visuell kontrollierten Reposition ergab sich für die navigierte Reposition eine residuale Dislokation von 0,7xa0mm bzw. 0,9°. Die navigierte Reposition auf der Basis von CT-Bilddaten ist auch für die Reposition von Gelenkfrakturen unter Laborbedingungen präzise. Weitere Verbesserungen der Software sind geplant.AbstractUp to now navigated reduction control based on computed tomography (CT) image data could not be used commercially. With newly developed software, a transverse fracture of the acetabulum was reduced with navigation control in a laboratory test.The results were compared to visual and tactile control in a foam pelvis and specimen. Measurements were done with another magnet-based navigation system. The residual dislocation was measured with translation (mm) and rotation (degrees). Compared with visually controlled reduction, navigated reduction led to a residual dislocation of 0.7xa0mm and 0.9°. Navigated reduction based on CT image data is also accurate for reduction of joint fractures under laboratory conditions. Further improvements of the software are planned for later in vivo use.

Iliumosteotomie bei Hüftgelenkluxationsfraktur mit posterior-inferiorer gelenkfragmentdislokation: Modifikation des ilioinguinalen zugangs

ZusammenfassungDie Zugangswahl zur operativen Versorgung von Acetabulumfrakturen ist von der Frakturmorphologie, den Begleitverletzungen sowie dem Allgemeinzustand des Patienten abhängig. Der ilioinguinale Zugang nach Letournel ist ein weitgehend atraumatischer Zugang, der eine gute Exposition der Acetabuluminnenseite ermöglicht. Die Verwendung dieses Zugangs ist jedoch bei begleitenden Frakturen der Hinterwand problematisch.Wir berichten über einen 39-jährigen polytraumatisierten Patienten, der u.xa0a. eine posteriore Hüftluxation mit einer 2-Pfeiler-Acetabulumfraktur erlitten hatte. Bei der operativen Versorgung wurde über einen ilioinguinalen Zugang eine Iliumosteotomie durchgeführt. Dadurch wurde die Reposition eines kraniolateral gelegenen Fragments möglich, sodass keine Erweiterung des Zugangs oder ein 2. Zugang benötigt wurde.AbstractOpen reduction and internal fixation is the treatment of choice for displaced acetabular fractures. The surgical approach depends on the fracture type, concomitant injuries, and general condition of the patient. The ilioinguinal approach provides a good exposure to the medial wall and is associated with an acceptable degree of surgical trauma. Exposure of the joint surface, however, is difficult when using the ilioinguinal approach.We report a case of a polytraumatized 39-year-old patient who sustained a posterior hip displacement and a two-column acetabular fracture. An osteotomy of the iliac ala was performed via an ilioinguinal approach to fragments of the acetabular surface that were displaced distally. Thereby, reposition of a craniolateral fragment was achieved without the need to extend the surgical approach or to perform a second incision.