|
Year |
2002 |
|---|---|
|
Question Number |
262(2) |
|
Category |
Musculoskeletal Trauma |
Question
What type of displaced unstable posterior pelvic ring injury will benefit most from open reduction and internal fixation?
1- Transforaminal sacral fracture
2- Sacral alar fracture
3- Iliac fracture
4- Sacroiliac fracture-dislocation
5- Sacroiliac dislocation
Figures
Answer (click for answer)
Preferred answer: 5
High-energy injuries of the pelvis produce several different types of posterior pelvic ring disruptions. It is these posterior lesions that have often been associated with poor functional results and persistent pain in past studies. Some authors have suggested that quality of posterior ring reduction was critical to restoring function and decreasing pain, and data from several studies support this. The cited paper, however, puts forth some new considerations. In their study, 88 patients with severe pelvic ring injuries (anteroposterior compression, lateral compression, and vertical shear) were treated by more conservative measures. These treatments consisted of bedrest, skeletal traction, external fixation, or a combination of these. In their series, these conservative methods generally gave satisfactory functional results. These results varied depending on the type of posterior pathology that was present. The patients who had posterior disruption from an iliac wing fracture or SI fracture-dislocation had the best prognosis. Interestingly, these satisfactory functional results were not dependent on the quality of reduction. Therefore, the authors suggested that ORIF of these fractures may not be necessary if anatomic reduction is not needed for good functional recovery (incorrect answers 3 and 4). The patients with sacral fractures have less benefit from a quality reduction for different reasons. In their series, the authors noted a high rate of fair and poor results with these fractures. Most of the dissatisfaction was secondary to pain which extended into the lower limb and was often associated with loss of reflexes. The authors postulated that this pain syndrome is likely do to radicular injury which occurs at the time of the trauma. The occurrence of this syndrome was not related to the quality of reduction of the sacral fracture. Thus, this set of patients may not require ORIF because it exposes them to increased surgical risk without improving their chances of a good functional result (incorrect answers 1 and 2). The patients with posterior disruption from a pure SI joint dislocation had the worst prognosis of all. These patients often demonstrated persistent pain and instability of the SI joint. It is this subset that benefited most from anatomic reduction and surgical stabilization (correct answer 5). The authors also noted that their conservative treatment measures were unable to gain a satisfactory reduction with most of these dislocations, again confirming the need for ORIF.
Reference: Dujardin FH, Hossenbaccus F, Duparc F, Biga N, Thomine JM: Long-term functional prognosis of posterior injuries in high-energy pelvic disruption. J Orthop Trauma 1998;12:145-151.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 395-403.