Operative treatment

Before proceeding with definitive repairs, the patient must be fully resuscitated, fully evaluated, and fit for anesthesia and surgery by a prepared team.

These are complex and unusual injuries. Anterior pelvic arch injuries are typically present in at least one location. Anatomic reduction and stable fixation of all disruptions is the appropriate definitive treatment.

Emergency care for pelvic ring injuries should be available and preplanned at every trauma hospital. Patients with complex pelvic ring injuries may need to be referred to a specialized center. Definitive care of complex pelvic ring injuries may be centralized so that patient referral may need to be considered.

Before undertaking definitive treatment of pelvic ring injuries, It is essential to know the functional status of the patient's lumbosacral nerve roots. A careful and detailed examination is necessary, to assess perineal sensation, voluntary anal sphincter contraction, and bulbo-cavernosus reflex. Cystometrography may be helpful to assess bladder neuromotor function.

Neurologic abnormalities should be correlated with anatomic site of injury:

• If a lumbo-sacral nerve deficit is present in extra sacral injuries, further investigation and possible treatment must be considered.
• If a sacral nerve deficit is present with a sacral fracture, the nerves should be decompressed with fracture reduction and/or sacral laminectomy.

It is important to recognize that bilateral sacral alar fractures may represent lumbo-sacral dissociation, as described by Roy-Camille and others. These may have “U”, “H”, or “λ” patterns, including a transverse component through the central sacrum, which may be displaced and flexed. This compromises the sacral canal and is often associated with nerve root injury. Decompression of the injured nerve roots, with posterior spino-pelvic fixation is advised for these unusual and complex injuries. The prognosis for neurologic recovery is guarded.

An explicit, written pre-operative plan is strongly encouraged. The following provides an outline of recommended steps.

Assess and consider:

• Whole patient (physiologic status and other injuries)
• Pelvic region & organ systems (local details of pelvic region including soft tissues and related organ system injuries)
• X-rays and CT scans (reviewed in detail for patients individual anatomy, each injury, and overall pelvic configuration)

For each injury, determine displacement, stability, and a strategy for reduction and fixation (relevant techniques are outlined and discussed below)

The relevant reduction and fixation procedures are organized according to anatomical structures in the lower part of the diagnosis page. Consider this as a "menu" for selecting your procedures and approaches.

Finally review the step-by-step list to:

• Confirm plan
• List equipment and implants
• Consider potential problems and solutions
• Share the plan with other members of the operative team – including nursing staff, radiographic technician, and anesthesia staff.

Note:

• Minimizing the amount of additional soft tissue damage and operative blood loss is important. Efficient use of surgical time is required to avoid excessively long procedures.
• Sufficient blood replacement must be available. Intraoperative blood salvage should be considered.

Each injury will have its own particular features that must be considered in planning and carrying out definitive treatment.

It is impossible to describe all possibilities here. However, the following general guidelines offer some suggestions:

• Usually, the most displaced fracture or dislocation is addressed first.
• Reduction of a widely displaced anterior arch disruption may aid indirect reduction of posterior injuries.
• Monitor the overall pelvic shape, as well as the way individual injuries appear to fit together. Full size inlet and outlet x-rays of the whole pelvis may be necessary. It is important to restore the overall symmetry and configuration of the pelvis.
• Be sure to identify and correct posterior and proximal displacement of both hemipelves.
• Consider provisional internal or external fixation to progressively stabilize the pelvis during reconstruction. This should allow for adjustments as necessary to reduce additional sites of displacement.
• It may be helpful to identify a posterior key fragment (large fragment which can be reduced to the axial skeleton). Addressing this first may restore one stable hemipelvis to provide a basis for reconstructing the pelvic ring.
• Both posterior arch disruptions should be fixed directly to ensure adequate stability for load-bearing from spine to either lower extremity.
• In U- or H-shaped sacral fractures the upper central sacral segment is the base of the spine. Ilio sacral screws may be successful for stabilizing U- or H-shaped fractures if they are undisplaced. However, optimal stability is obtained with lumb pelvic fixation, connecting lower lumbar pedicle screws to iliac screws.

If both anterior and posterior approaches will be required, the surgeon must choose the best order for the procedures (with change of patient positioning from prone to supine or vice versa). This information must be communicated to the other members of the surgical and anesthesia teams to ensure appropriate planning and preparations.

Typically, the posterior approach (prone position) is performed first.

At the completion of the posterior procedure, a postoperative dressing is applied.

The patient is turned supine (“log-rolled”) onto an adjacent stretcher.

The patient is transferred back onto the operating table.

The anterior operative area is prepared and draped as necessary.

If an anterior procedure to be performed first, followed by a posterior approach, the sequence is reversed and the patient turned in a similar fashion.

After pelvic surgery, routine hemoglobin and electrolyte check out should be performed the first day after surgery and corrected if necessary.

After extensile approaches in the anterior pelvis, the bowel function may be temporarily compromised. This temporary paralytic ileus generally does not need specific treatment beyond withholding food and drink until bowel function recovers.

Adequate analgesia is important. Non pharmacologic pain management should be considered as well (eg. local cooling and psychological support).

Prophylaxis for deep vein thrombosis (DVT) and pulmonary embolus is routine unless contraindicated. The optimal duration of DVT prophylaxis in this setting remains unproven, but in general it should be continued until the patient can actively walk (typically 4-6 weeks).

Dressings should be removed and wounds checked after 48h, with wound care according to surgeon's preference.

Dressings should be removed and wounds checked after 48h, with wound care according to surgeon's preference.

The following guidelines regarding physiotherapy must be adapted to the individual patient and injury.

It is important that the surgeon decide how much mechanical loading is appropriate for each patient's pelvic ring fixation. This must be communicated to physical therapy and nursing staff.

For all patients, proper respiratory physiotherapy can help to prevent pulmonary complications and is highly recommended.
Upper extremity and bed mobility exercises should begin as soon as possible, with protection against pelvic loading as necessary.

Mobilization can usually begin the day after surgery unless significant instability is present.
Generally, the patient can start to sit the first day after surgery and begin passive and active assisted exercises.

For unilateral injuries, gait training with a walking frame or crutches can begin as soon as the patient is able to stand with limited weight bearing on the unstable side.

In unstable unilateral pelvic injuries, weight bearing on the injured side should be limited to "touch down" (weight of leg). Assistance with leg lifting in transfers may be necessary.

Progressive weight bearing can begin according to anticipated healing. Significant weight bearing is usually possible by 6 week but use of crutches may need to be continued for three months. It should remembered that pelvic fractures usually heal within 6-8 weeks, but that primarily ligamentous injuries may need longer protection (3-4 months).

Fracture healing and pelvic alignment are monitored by regular X-rays every 4-6 weeks until healing is complete.

Extra precautions are necessary for patients with bilaterally unstable pelvic fractures. Physiotherapy of the torso and upper extremity should begin as soon as possible. This enables these patients to become independent in transfer from bed to chair. For the first few weeks, wheelchair ambulation may be necessary. After 3-4 weeks walking exercises in a swimming pool are started.

After 6 weeks, if pain allows, the patient can start walking with a three point gait, with less weight bearing on the more unstable side.

Full weight bearing is possible after complete healing of the bony or ligamentous legions, typically not before 12 weeks.