Martin Bircher

Indications and techniques of external fixation of the injured pelvis

High energy pelvic ring disruption represents a serious clinical problem with an overall reported mortality rate of approximately 10% (1). However, the mortality for open pelvic fractures approaches 50% (2). This alarmingly high rate has two major components. The first is death due to uncontrollable haemorrhage, often associated with terminal diffuse intravascular coagulation. The second is linked with the serious associated injuries. Improved resuscitation techniques have a direct bearing on both these components and should reduce morbidity and mortality (3,4). The external fixator has a major role to play during resuscitation and, in particular, in the control of bleeding. However, this primary function must not be confused with the more limited secondary role for the external fixator as a definitive form of treatment for certain pelvic fractures. This paper gives clear guidelines on the indications for the use of the external skeletal fixator with pelvic fractures and goes on to discuss pin placement and frame configuration in relation to the biomechanics and biology of the injury.

Volume changes within the true pelvis during disruption of the pelvic ring - Where does the haemorrhage go?

Fractures of the pelvis are not only common but are very varied in their complexity. They represent 3% of all fractures (1), they account for 1 in every 1000 surgical admissions and are the third most commonly encountered injury in motor vehicle accident fatalities (2). However, only a small percentage of all pelvic fractures are associated with major disruption of the pelvic ring (3). Life threatening haemorrhage is a frequent complication of major pelvic fractures (1, 4) and haemorrhage is the leading cause of death in these patients (5, 6). It was believed that fracture and subsequent displacement of the ring greatly increased pelvic volume. However, clinical practice seemed to indicate that this might not be true. This study aimed to assess the change in pelvic volume which occurs in severely displaced pelvic fractures. A model of the bony pelvis was designed to permit extreme displacements of the symphyseal and sacroiliac joints. The volume of a polythene balloon placed within the true pelvis was measured as an indication of true pelvic volume. Our finding was that the increase in the volume of the true pelvis which occurs in a fracture with massive diastasis is much smaller than previously assumed.

Pelvic trauma management within the UK: a reflection of a failing trauma service

During the past 2-3 years it has become increasingly difficult for specialist pelvic centres to provide appropriate treatment for patients. Recent data from 3 such units has highlighted unacceptable delays from referral to operation. This article presents this data, analyses the reasons for the delays and the consequences. The focus on waiting list targets is deflecting resources away from specialist trauma services (including pelvic units) and has resulted in serious interruptions in treatment. Urgent action is required to prevent the management of these patients being compromised.

Surgical complications and implications of external fixation of pelvic fractures

The application of a pelvic external fixator can be a vital stage in the management of patients with severe pelvic fractures, either as part of the resuscitation phase or as definitive treatment. This paper shows the complication rate of pelvic external fixation to be 47 per cent. This high rate increases the morbidity associated with the fracture, and may also interfere with the definitive management. The majority of complications were associated with pin placement and the pin-bone interface. An understanding of the principles of external fixation and knowledge of the correct methods of application should reduce this complication rate.

The Reconstruction of Periprosthetic Pelvic Discontinuity

The surgical techniques and outcomes of acetabular reconstruction for periprosthetic pelvic discontinuity cases are reported. The mean time to surgery for 9 patients with acute pelvic discontinuity was 16.3 days, with 8 patients (88%) having posterior column plating and a porous metal acetabular cup. No cases required revision surgery, with a mean follow-up of 34 months (range, 24-67 months). Of the 62 chronic pelvic discontinuity cases, 20 had an ilioischial cage, with a revision rate of 29%. There were 42 cup-cage reconstructions with an 8-year survivorship of 86.3%, with a mean follow-up of 35 months (range, 24-93 months). Stable reconstruction of chronic pelvic discontinuity was achievable by distraction using a cup-cage acetabular reconstruction; however, satisfactory stability of acute pelvic discontinuity was achieved with compression of the posterior column using screw augmentation of the acetabular shell supplemented by posterior column plating.

Open reduction and internal fixation of a traumatic diastasis of the pubic symphysis: ONE-YEAR RADIOLOGICAL AND FUNCTIONAL OUTCOMES

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year. In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group. We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery.

Pelvic floor dysfunction in women after pelvic trauma

The aim was to assess symptoms of pelvic floor dysfunction in women following pelvic trauma. A retrospective questionnaire survey of 24 consecutive women was performed in a tertiary referral orthopaedic centre and urogynaecology unit. Sixteen women had a type B and eight a type C pelvic fracture (Association Osteosynthesis manual classification). The median age was 24 years (11–92). Twenty‐one women were nulliparous. Sixteen women reported de novo pelvic floor dysfunction. Bladder symptoms occurred in 12, bowel problems in 11 and sexual dysfunction in 7 of 17 sexually active women. Pelvic fracture seems to be a risk factor for pelvic floor dysfunction.

The early management of pelvic and acetabular fractures

One hundred consecutive referrals with pelvic and acetabular fractures treated over a three year period were reviewed with regard to their early management. Early management was subdivided into four areas: 1. initial assessment and treatment; 2. imaging; 3. referral; 4. management of associated injuries. The cases comprised 26 pelvic fractures (18 treated operatively), 69 acetabular fractures (50 treated operatively), and 5 combination fractures (3 treated operatively). Guidelines were laid down in each of the four areas of management and each patients management was compared with this ideal. 56% of cases had deficient management by our criteria. There were important failures in diagnosis and early treatment of these complex injuries. A set of simple guidelines is offered to help improve the situation.

Is it Possible to Classify Open Fractures of the Pelvis

AbstractOpen fractures of the pelvis are rare and potentially lethal injuries. This paper seeks to clarify the relationship between the complex bony and soft tissue injuries. It provides a new classification, which hopes to aid in these difficult management decisions in a group of seriously injured patients. Open pelvic injuries are classified into three groups, A, B, and C. Each of these groups is further subdivided into three subgroups. The importance of the soft tissue injury is emphasized, as it has a major influence mortality.

Pelvic and acetabular fractures in the United Kingdom: a continued public health emergency

In 1996 the quality of the early management of 100 consecutive patients referred to the SW Thames regional pelvic and acetabular unit between 1989 and 1992 was studied. The management of these patients was assessed in four specific areas, and guidelines were laid down. It was found that in 56% of patients the early management did not meet these suggested standards, with 34% having deficiencies in more than one area. These results were presented and published. Five years later, the early management of a further 100 consecutive referrals was assessed using these same guidelines, in order to close the audit loop. The treatment of 57% of patients still did not reach the guideline standards, but the number with problems in more than one area fell to 20%. There has been improvement in the early management of pelvic and acetabular injuries. The use of external fixation in cases of severe haemorrhage increased, but frames were often poorly applied. Early communication with the specialist centre was encouraged but unfortunately there was still an unacceptable delay in referral. The frequency of delayed referral actually increased during the 5 years between study groups.