What is the surgical treatment for pelvic fractures?

The pelvis refers to the connection between the waist and legs. Because there are two high protruding bones, it looks like a basin with the abdomen as a whole, so it is called the pelvis. In life, due to some unexpected situations, the pelvis may sometimes be fractured. In medicine, surgery is often used to treat pelvic fractures. How is surgical treatment of pelvic fracture performed?

Surgery

(1) The best time to perform surgery is within 7 days after injury, and no later than 14 days. Otherwise, the difficulty of reduction will be greatly increased, and the incidence of malunion and nonunion will also increase significantly.

(2) Select treatment methods based on fracture classification. Type A pelvic fractures in the AO classification are stable fractures and are generally treated conservatively, with bed rest for 4 to 6 weeks and early walking exercises. Type B fractures are anterior ring injuries and only require anterior fixation. Type C fractures are posterior ring or combined anterior-posterior injury and require combined anterior-posterior fixation of the pelvic ring.

(3) Indications for surgery: ① Failure of closed reduction; ② Residual displacement after external fixation; ③ Symphysis pubis separation greater than 2.5 cm or symphysis pubis locking; ④ Vertically unstable fracture; ⑤ Combined acetabular fracture; ⑥ Severe pelvic rotation deformity leading to lower limb rotation dysfunction; ⑦ Injury to the posterior pelvic ring structure with displacement >1 cm, or pubic displacement combined with posterior pelvic instability and shortening of the affected limb >1.5 cm; ⑧ Open posterior injury without perineal contamination. ⑨Pubic ramus fracture combined with femoral nerve and vascular injury, ⑩Open fracture.

(4) Surgical method

1) Anterior fixation is used to fix anterior ring instability, and is often used for symphysis pubis separation and pubic ramus fracture. The surgical indications are: a. symphysis pubis separation greater than 2.5 cm; b. symphysis pubis locking; c. pubic ramus fracture combined with femoral nerve and vascular injury; d. open pubic ramus fracture; e. combined with posterior pelvic instability.

The main fixation methods are external fixator, pubic reconstruction plate, and hollow lag screw.

2) Posterior fixation is used to fix posterior ring instability and is often used for sacroiliac joint separation, sacral fractures, etc. The surgical indications are: a. vertical unstable fracture; b. pelvic posterior ring structure injury displacement > 1 cm; c. open posterior injury without perineal contamination; d. combined acetabular fracture.

The main fixation methods are: C-clamp, presacral plate fixation; postsacral sacral bolt, sacral plate, sacral lag screw fixation

(5) Surgical approach and fixation method

1) External fixator front fixation. In most cases, external fixators are used for temporary fixation of unstable pelvic fractures, or in combination with other fixation methods to fix severely unstable pelvic fractures. They are not used as a routine final fixation option. The commonly used fixation method is the double nail method, that is, two threaded nails are driven into the iliac spines on both sides; when the condition is critical, one threaded nail can also be driven into each side. If long-term fixation is considered, a threaded nail can be driven above the anterior inferior iliac spine (upper edge of the acetabulum). Before placing the nails, you can use a bed sheet or something similar to hold the pelvis tightly.

Key points of the operation: ① Make a small incision 2 cm behind the anterior superior iliac spine; ② Drill from front to back along the direction of the iliac wing, drilling only through the outer cortex; ③ Insert the first 5mm threaded screw; ④ Insert the second threaded screw, 2 to 3 cm behind the first one; ⑤ Repeat steps 1 to 4 to insert the threaded screw in the opposite iliac spine; ⑥ Connect the threaded screws with short rods; ⑦ Connect the short rods with long rods; ⑧ Adjust the external fixator to reduce the fracture.

The nail placement on the upper edge of the acetabulum should be posterior and pointed toward the sacroiliac joint, and the operation should be performed under fluoroscopy to avoid entering the acetabulum.

2) C-clamp for posterior fixation. Direct compression of the sacroiliac joint is used for temporary fixation of posterior unstable fractures. It is easy to perform and can be performed in the emergency room. If the fracture is displaced, a fixator should be placed under traction and internal rotation of the lower limb.

Key points of surgery: a. The entry point is located at the intersection of the vertical line of the anterior superior iliac spine and the longitudinal axis of the femoral shaft; b. Hammer the fixation nail into the ilium; c. Tighten the fixation nail with a wrench and apply pressure.

3) Pubic reconstruction plate is used for pubic symphysis separation and pubic ramus fracture.