Executive Editor: Peter Trafton

Authors: Rahul Banerjee, Peter Brink, Matej Cimerman, Tim Pohlemann, Matevz Tomazevic

Pelvic ring - B2

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Glossary

General considerations

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

B2 (LC-I or LC-II) pelvic ring have varying degrees of internal rotation of the injured hemipelvis. Correction of excessive deformity may be necessary.

It is important to recognize that B2 injuries exhibit a spectrum of instability, and that some may displace without surgical repair while the majority can be treated nonoperatively.

Instability though unusual may be difficult to recognize without careful assessment.

Signs of instability:

  • Complete (anterior to posterior) sacral fracture
  • Comminuted sacral fracture
  • Multiple/bilateral ramus fractures
  • Comminuted ramus fractures

LC-II injuries, by definition, are unilateral, internally rotated, partially unstable, pelvic ring injuries with a crescent fracture-subluxation of the involved SI joint. However, these injuries do not all have the same level of instability. They may be undisplaced and stable, rotationally unstable, or even totally unstable (i.e. C1, rather than B2 injuries). Each must be assessed carefully to determine appropriate treatment.

Nonperative
Main indication Skill Equipment
Stable B2 injuries with acceptable deformity Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Stable B2 injuries, with acceptable deformity, and without radiographic or stress-exam signs of potential instability

Note: Early (2-3 weeks) follow-up, with x-rays, is advisable to exclude the possibility of progressive displacement, which is much harder to correct after a malunion has consolidated.

ExFix and traction in resource limited settings
Main indication Skill Equipment
Unstable pelvic injury without availability of posterior ring fixation Some specialized surgical experience Basic equipment only

Indications

  • Definitive correction of B2 deformity
  • Posteriorly unstable pelvic injury without availability of posterior ring fixation
  • Proximal displacement of the involved hemipelvis or risk thereof
  • Need to delay definitive surgery because of patient's condition

Contraindications

  • Availability of comprehensive pelvic ring fixation without excessive delay
External fixation
Main indication Skill Equipment
Significant internal rotation deformity or lower extremity shortening Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

  • For correction of significant internal rotation deformity and/or related lower extremity shortening
  • Insufficient lower extremity external rotation
  • Pubic ramus fractures which align satisfactorily with external fixator distraction
  • Progressive deformity or risk thereof

NOTE: An obliquely oriented anterior pelvic external fixator, with an ipsilateral supra-acetabular pin and a contralateral iliac crest pin, can be used to apply a distracting force that corrects internal rotation deformity. In other cases, the choice between crest pins or supra-acetabular pins is based on surgeon's preference. However, supraacetabular pins require image intensifier. These pins may be better tolerated than iliac crest pins, especially in obese patients.

Operative treatment
Main indication Skill Equipment
Significant internal rotation deformity; symphyseal disruption Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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

Indications

  • Significant internal rotation deformity, especially with pubic symphysis involvement
  • Locked pubic symphysis
  • Unstable crescent fracture
  • Tilt fracture
  • Insufficient lower extremity external rotation
  • Instability

Signs of instability:

  • Complete (anterior to posterior) sacral fracture
  • Comminuted sacral fracture
  • Multiple/bilateral ramus fractures
  • Comminuted ramus fractures

Note: Risk of instability is increased according to the number of signs present

*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2015-12-10