1 Introduction topenlarge
In extensive vertical displacement, longitudinal traction is advisable as initial treatment. If a definite treatment is not available, it may also be used as a definite treatment.
In this case appropriate nursing is essential to prevent pressure wounds and good respiratory and musculo-skeletal physiotherapy to avoid pulmonary complications.
It is clear that immediate pelvic splinting is beneficial, by its ability to reduce bleeding from the unstable pelvis. But, a pelvic binder cannot maintain pelvic alignment until healing is advanced. Until bony stability is obtained with external fixation, a pelvic binder or wrap is advisable to minimize ongoing bleeding.
The long term outcome of significant pelvic ring injuries is often poor. Deformity, failure to heal satisfactorily and related disability are best avoided by anatomic reduction and stable fixation. Additional advantages of stable fixation are relief of pain and early mobilization. When the necessary resources are available, this is achievable for most pelvic ring injuries.
Optimal treatment requires detailed diagnostic imaging, an advanced surgical suite and specialized instruments and implants. When these are not available, the surgeon is still faced with the challenge of obtaining and maintaining the best reduction possible. Instead of accepting deformity, pelvic external fixation with traction is suggested as the most appropriate alternative.
In most resource limited settings, the possibility of placing a pelvic external fixator is, or can be made, available. This may provide adequate control of pelvic alignment during bed rest.
Unfortunately, an external fixator, applied anteriorly, does not control posterior instability in C-type pelvic ring injuries, with complete posterior arch disruption. However, additional skeletal traction can supplement an anterior fixator and improve maintenance of overall pelvic alignment. This is why external fixation should be supplemented for treating unstable pelvic ring injuries.
Choice of external fixation
We recommend the use of an iliac crest based external fixator for this technique.
External fixator pins can be placed securely in the iliac crest with limited open exposure, but supra acetabular pins require C-arm fluoroscopy satisfactory pin placement.
Choice of traction
Counteract the deforming forces produced by even limited activities of a bed-bound patient, requires weights of 7 – 12 kg, depending of patient size and pelvic deformity. This above the tolerable limit for skin traction. Skeletal traction can be applied to the lower extremities through a pin in the distal femur, or tibial tubercle (as illustrated), as long there is no significant knee joint injury.
Distal displacement of an unstable hemipelvis is unusual, but if it is present, skeletal traction should not be applied as this will increase the deformity.