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A review of the definitive treatment of pelvic fractures.

One of the first systematic descriptions of pelvic fractures was that of French army surgeon Dr. Joseph-Francois Malgaigne. (1) In 1855, he published Traite des Fractures et des Luxations in which he described a "double-vertical" fracture of the pelvis with clinically apparent displacement of one hemipelvis involving disruption of both anterior and posterior aspects of the pelvic ring, which later came to be known as a "Malgaigne" fracture. It should be noted that this was described prior to the advent of x-ray technology in 1895, and therefore a precise correlation with current radiographic classification schemes cannot be made. However, the orthopaedic trauma literature through a majority of the 20th Century continued to reference the concept of "double-vertical" pelvic fractures, despite a lack of a strict definition of the "double-vertical" fracture subtype.

In a classic article published in the Journal of Bone and Joint Surgery in 1948, Holdsworth (2) assessed the outcomes of 50 cases of pelvic ring disruption with "displacement of one half of the pelvis outwards, or outwards and upwards," a description that would likely include Young and Burgess vertical shear (VS) type injuries and anterior posterior compression type 3 (APC-3) injuries, but it is less clear whether this would also overlap with other fracture types (LC-2, APC-2, APC-1, etc.). Holdsworth grouped the fractures based on the type of posterior ring injury, comparing pure sacroiliac (SI) joint dislocations to fracture dislocations involving the sacroiliac joint. The population was primarily involved in heavy labor, and treatment in all cases was non-operative, involving prolonged bedrest with a series of pulleys and a sling supporting the involved hemipelvis, using longitudinal traction as needed. Of 27 pure SI dislocations, 12 patients returned to "heavy work," while 15 were found it "too painful" to return to work. Of 15 fracture dislocations of the SI joint, 13 patients returned to "heavy work," while 2 found it to be "too painful" to return. The results suggested that pure SI dislocations led to worse outcomes with these described non-operative treatment techniques. While this evidence did not prove the superiority of operative to non-operative intervention, it at least supported the idea that certain pelvic ring injury patterns were more severe than others, and that for certain types of injuries the standard non-operative treatment led to relatively poor outcomes for a large majority of the patients.

Huittinen and Slatis (3) in 1972 reviewed over 103 "double-vertical" pelvic fractures with posterior lesions involving the sacrum (57), SI joint (18), and ilium (28). Treatment involved closed reduction under anesthesia if there was "significant" displacement and 6 to 10 weeks in a suspended pelvic sling with balanced or skeletal traction as needed. They showed a 98% return to work at 1 year, but this analysis excluded all patients with other biasing injuries, potentially skewing the group toward a less injured subset. Additionally, follow-up on 65 patients revealed 11 (16%) with persistent pain in the SI region, and high rates of nerve injury (46%), urinary, and sexual dysfunction. Raf (4) reviewed 65 "double-vertical" pelvic fractures treated non-operatively and also found significant rates of permanent disability, with 52% reporting chronic pain when fracturing through the sacrum or SI joint.

In the 1960s and 1970s, external fixation started to gain favor in the treatment of pelvic fractures despite the lack of any randomized trials comparing it to non-operative treatment. Early data from case series evaluating external fixation seemed to suggest some advantages when compared to the prior series treated non-operatively. Wild (5) reported on 45 "unstable" pelvic fractures treated with an anterior triangular Hoffman frame. The fractures included what would be Young and Burgess vertical shear, APC-2, APC-3, and "very displaced" lateral compression type injuries, with the largest number being lateral compression type. Results showed that in 28 of 32 patients with APC or LC type injuries, there was no pain at 3 months, but with vertical shear injuries, 6 of 11 were irreducible, and 3 of the 5 which were initially reducible subsequently lost reduction. Still, at 3 to 9 months, 7 out of 8 patients with vertical shear injuries had no pain, limp, or disability. Riska (6) reported on 56 "clinically unstable" pelvic fractures treated with external fixation using multiple iliac crest pins. Twenty-eight percent had residual displacement after surgery, three patients who were initially reduced following surgery subsequently lost reduction, and 16% had pain at final follow-up. Only 33 of 56 had mobilized on crutches by 7.5 weeks. Slatis and Karaharju (7) compared their results of external fixation to "conventional treatment" as reported in the literature. Their numbers were small (22 patients), and the study was retrospective, short-term, and with some imprecision in fracture classification, but they found that with ex-fix as compared to conventional treatment, the rate of gait impairment was 10% (versus 28% to 41%), and the rate of persistent pain was 5% (versus 17% to 52%).

Newer Classifications of Pelvic Fractures

The development of new classification systems for pelvic fractures provided an important framework with which to conceptualize this heterogeneous group of injuries and formed the basis for subsequent research. In 1980, George Pennal (8) described a classification based on the direction of the applied force (anteroposterior compression, lateral compression, and vertical shear), an idea that would later be co-opted by Young and Burgess. Letournel (9) described an anatomical classification essentially based on the location of fracture lines on the bony pelvis. Tile described a system of increasing instability, from type A (rotationally and vertically stable) to type B (rotationally unstable but vertically stable) to type C (rotationally and vertically unstable), later mirrored in large part by the AO/OTA classification. And in 1986, Young and Burgess (10) described their classification system, which is commonly used, reasonably reliable, and helpful in thinking about the forces involved in the injury. Koo (11) found the interobserver reliability to be "fail" for the Tile classification and "substantial" for Young and Burgess. Furey (12) found the interobserver reliability to be equivalent, but intraobserver reliability to be "moderate" for Tile and "substantial" for Young and Burgess. Nevertheless, each classification system has its merits and facilitates different insights into pelvic injuries in different ways. For the purposes of this review, we will focus on and utilize the Young and Burgess classification.

Definitive Management by Young and Burgess Fracture Type

With the caveat that certain fractures may become operative in the initial emergent phase of treatment, such as open pelvic fractures undergoing irrigation and debridement or widely displaced fractures in unstable patients undergoing external fixation, the first step in the definitive management of pelvic fractures most typically entails a decision between operative versus non-operative treatment. This multifactorial decision-making incorporates patient factors, concomitant injuries, and what is often described as the "stability" of a particular fracture pattern. But there is surprisingly little evidence as to which fracture patterns are truly "unstable." Even the concept of "instability" may be misleading, as it is not clear that fractures with a specific degree of mechanically reproducible motion or a specific amount of initial displacement would necessarily benefit from operative versus nonoperative treatment. The ideal metric would be a comparison of operative to non-operative treatment for each fracture type to determine which treatment method yields the best clinical outcomes. Just as humeral shaft fractures are initially mechanically unstable and may heal in non-anatomic positions with excellent clinical results, the pelvic fracture surgeon must remember that the ultimate goal is not rigid fixation for its own sake but rather excellent clinical outcomes by the safest and most effective means possible.

Lateral Compression Type 1 (LC-1)

LC-1 fractures occur from a medially directed force to the lateral aspect of the posterior pelvis, leading to internal rotation of the ipsilateral hemipelvis often with an impacted sacral fracture posteriorly and pubic rami fractures anteriorly. The anterior and posterior sacroiliac (SI) joint ligaments remain intact. The vast majority of LC-1 pelvic fractures are treated non-operatively with immediate weightbearing, with generally good results. Sembler Soles (13) followed the non-operative treatment of 118 minimally displaced (i.e., less than 10 mm) LC-1 fractures and found that all healed radiographically, with 8 fractures healing with greater than 1 cm of displacement, and only 1 of 118 failing non-operative treatment due to significant pain and early displacement. Bruce (14) showed that in the non-operative treatment of high energy LC-1 fractures with less than 5 mm initial sacral displacement, subsequent displacement to greater than 5 mm could be predicted by the fracture pattern. Dividing fractures into incomplete sacral fractures, complete sacral fractures with unilateral rami fracture, and complete sacral fractures with bilateral rami fractures, they found rates of displacement of 2.6%, 33%, and 68%, respectively. Gaski and coworkers (15) showed that non-operative treatment of 37 minimally displaced (i.e., less than 10 mm) LC-1 fractures with complete sacral fractures led to 35 out of 37 good or excellent functional outcomes.

While non-operative treatment has become the mainstay for these more minimally displaced fractures, there is no good data on whether and how to fix very displaced (i.e., greater than 1 cm) LC-1 fractures, particularly with significant comminution or distraction of the anterior sacral fracture component. Sagi (16) addressed the concept of "unrecognized instability" and suggested performing an exam under anesthesia and used an arbitrary cutoff of 2 cm of anterior overlap as an operative indication. Prior to fixation, it is important to understand that there is a paucity of data regarding the optimal operative indications and preferred fixation techniques for these more displaced and unstable types of LC-1 fractures. The surgical options generally include anterior fixation only with external fixator or plate and screws, posterior fixation only with SI screws or plates and screws, transsacral fixation, transiliac bars, spinopelvic fixation, or various combinations. Beckman (17) showed x-rays of more displaced LC-1 fractures to 111 OTA members and found only fair agreement on the operative versus non-operative decision. So while the vast majority of minimally displaced LC-1 fractures are likely best treated non-operatively, the most compelling indications for operative treatment may include significant comminution of the sacral fracture component without impaction and significant internal rotation of the hemipelvis such that externally rotating it to anatomic position will create pelvic instability posteriorly.

Lateral Compression Type 2 (LC-2)

LC-2 fractures include the iliac wing fractures and "crescent" fractures or SI joint fracture-dislocations. These injuries are rotationally unstable but vertically stable. While level 1 evidence is lacking, non-displaced or minimally displaced LC-2 fractures are often treated non-operatively. Displaced fractures are generally treated operatively, with techniques including closed reduction with percutaneous SI screws, open reduction with percutaneous SI screws, open reduction internal fixation (ORIF) with plating from an anterior or posterior approach, intramedullary screws from the PIIS to the AIIS along the sciatic buttress (the so-called "LC-2 type screw"), or various combinations. Fixation strategies are highly dependent on the precise locations of the fracture lines, making preoperative planning with a pelvic CT scan essential. Day (18) classified SI fracture dislocations into three types based on whether the fracture exits the SI joint laterally through the ilium in the anterior third (type 1), middle third (type 2), or posterior third (type 3) of the SI joint. Routt (19) found that the Day classification was somewhat associated with their treatment approach, with 75% of Day type 1 fractures being treated via an open anterior approach to the posterior pelvic ring followed by plating and with the majority of Day type 2 and 3 fractures treated with closed reduction and percutaneous SI screws. This is because Day type 1 fractures exit laterally through the ilium so far anteriorly that the displaced ilium does not contain sufficient bone in the path of a potential SI screw to be fixed in this way. Whatever fixation method is chosen, it is generally felt that if an adequate reduction cannot be obtained through closed means, a conversion to open reduction should be made. The data on what constitutes an "adequate" reduction is incomplete, but certainly the reduction is always off by at least as much as the greatest displacement visualized on any intraoperative fluoroscopic view.

Lateral Compression Type 3 (LC-3)

LC-3 fractures represent a combination of an LC-1 or LC-2 injury on one side, with a contralateral APC type pelvic ring injury. They are associated with higher energy and higher transfusion requirements. The generally accepted treatment of LC-3 fractures is to treat them as a combination of the way in which the individual LC and APC type injuries would be treated on their own for each hemipelvis. As an additional consideration, however, depending on intraoperative stability, it may be necessary to stabilize a very internally rotated LC injury first with a fully threaded SI screw in order to have a stable base on which to reduce and fix the contralateral APC injury. (20) Treatment decisions regarding LC-3 fractures suffer from the same lack of comparative outcomes data as the LC and APC type injuries that comprise them.

Anterior Posterior Compression Type 1 (APC-1)

APC-1 fractures are "open-book" type injuries in which there is disruption and widening of the pubic symphysis (but less than 2.5 cm) with the anterior SI ligaments still intact. These injuries are rotationally unstable but vertically stable. Traditional management of APC-1 fractures is summarized by Tile (21): "The open-book fracture with less than 2.5 cm of anterior symphyseal disruption can be managed non-operatively. The tendency is for the symphysis to heal in a slightly widened position with minimal long-term adverse effects." Sagi (16) again introduces the concept of "occult instability," and the possible need for a stress exam under anesthesia, finding that 50% of APC-1 fractures are actually occult APC-2 fractures. And the 2.5 cm cutoff has been brought into question by a cadaveric study by Doro (22) in which a progressively increasing external rotation force was applied, and it was found that while 2.5 cm of symphyseal diastasis is indeed the average distance at which the anterior SI ligaments tear, there was a large range, and 80% of cases fell outside the range of 2 cm to 3 cm. Their conclusion was that diastasis above 4.5 cm was highly suggestive of anterior SI ligament disruption (and therefore a diagnosis of APC-2 injury), and at 1.8 cm or less of diastasis the anterior SI ligaments were unlikely to be disrupted (thus supporting the diagnosis of an APC-1 injury), but in between this range there was significant variability regarding the state of the anterior SI ligaments.

Anterior Posterior Compression Type 2 (APC-2)

With a similar mechanism to APC-1 injuries, APC-2 injuries lie farther along the spectrum of soft tissue injury, with disruption of the anterior SI ligaments as well as the sacrotuberous and sacrospinous ligaments. The posterior SI ligaments remain intact. These injuries are rotationally unstable but vertically stable.

As noted by Langford, (23) "No study (prospective or retrospective) in the literature compares APC type II injuries managed surgically versus nonsurgically." Current practice, however, is to treat these injuries operatively and to do so using fixation of the anterior aspect of the pelvic ring only. Osterhoff (24) has suggested that posterior SI screws may also be sufficient fixation for most APC-2 fractures (only 8% of cases fixed with SI screws alone lost reduction and received additional anterior fixation). Conceptually, anterior fixation acts as a tension band with the intact posterior SI ligaments maintaining reduction of the posterior aspect of the pelvic ring. Anterior fixation options include symphyseal plating, anterior external fixation (with supra-acetabular or iliac crest pins), or superior pubic rami screws.

Typical current practice is treatment with anterior plating alone using a 4 to 6 hole plate. Tornetta (25) collected long-term (1 to 7 years) data on 29 patients with rotationally unstable (mostly APC-2) pelvic fractures treated with anterior plating alone. One third had concomitant acetabular fractures, but when groin pain due to acetabular fracture was excluded, 96% had no pain or pain only with strenuous activity, 96% were ambulating without support, and 83% had returned to work (75% to their original occupation). Sagi (26) retrospectively compared 2-hole plates to multi-hole (4 to 6 hole) plates and found rates of fixation failure and malunion to be decreased with multi-hole plates, although reoperation rate was similar. Studies have not shown an advantage to locking constructs or dual or multiplanar plating. (27, 28) In biomechanical studies, anterior external fixation was equivalent to anterior plating in resisting external rotation but less effective at resisting vertical displacement, and there may be more concern for loss of reduction when treating definitively with an external fixator. (29) In a simulated APC-2 fracture model, Simonian (30) found anterior fixation with a retrograde intramedullary ramus screw to be equivalent to anterior plating. Sagi (16) performed EUA on APC-2 injuries and found 39% showed greater than 1 cm of sagittal (rotational) displacement, perhaps suggesting a continuum of injury as the posterior SI ligaments become progressively stretched and attenuated.

Anterior Posterior Compression Type 3 (APC-3)

APC-3 injuries are open-book injuries that progress from front to back leading to complete disruption of the pubic symphysis, anterior SI ligaments, and posterior SI ligaments. Again, there is a lack of prospective outcomes-based data to guide treatment. But, these are clearly more unstable injuries with rotational and vertical instability, and current practice is typically to perform reduction and fixation of both the anterior and posterior aspects of the pelvis. Dujardin (31) showed that for APC and vertical shear type injuries anatomic reduction improves outcomes. However, there is still controversy over what amount of malreduction affects clinical outcomes. The selection bias of retrospective studies makes it difficult to determine, for instance, if greater malreduction increased the odds of a worse outcome or if a worse injury increased the odds of a malreduction. The order of fixation classically described by Letournel (9) is posterior to anterior, particularly in very widely displaced fractures; however, in some cases, anterior first fixation may be preferable as long as it allows sufficient freedom to subsequently reduce the posterior ring. Anterior fixation typically entails plating or external fixation. Posterior pelvic fixation is typically done with percutaneous SI screws or plating from an anterior or posterior approach, with other options, including transsacral fixation or transiliac bars.

Vertical Shear (VS)

Vertical shear pelvic injuries represent complete disruption of the pelvic ring both anteriorly and posteriorly, with vertical displacement of an entire hemipelvis. Historically, the conventional treatment with traction and slings resulted in generally poor results with 60% incidence of persistent pain, as well as problems with nonunion, leg length discrepancy, and permanent nerve and urethral damage. (32) Even treatment with external fixation alone has not proved to reliably obtain and maintain reduction in these injuries. (29) Dujardin (31) showed that reduction to within 5 mm was only achieved in 3 out of 16 vertical shear injuries using traction and anterior fixation, highlighting the highly unstable nature of these injuries. While Nepola (33) found that the amount of vertical displacement did not affect functional outcome, Mullis (34) found that for vertical shear pure SI joint dislocations, anatomic reduction was the only predictor of a more favorable functional outcome. Ultimately, it appears likely that better reduction improves outcomes, but the range of "acceptable" reductions is likely much greater than it is for acetabular fractures.

As treatment of highly unstable pelvic injuries (APC-3 and vertical shear) trended toward operative stabilization of both the anterior and posterior pelvic ring, results of treatment were still far from ideal. Pohlemann (35) reported outcomes of patients with over 2 years of follow-up after anterior and posterior fixation of Tile C injuries and found only 30% were pain-free, 70% had at least some neurologic deficit, and 20% were clinically doing poorly. Kabak (36) prospectively studied 40 Tile C injuries for 3.5 years. He found that anterior and posterior internal fixation yielded satisfactory radiographic outcomes. Clinical outcomes included a mortality rate of 5%, 3 deep infections that resolved with debridement, 7 nerve deficits (3 persistent), 14 "sexual problems" (6 persistent), and a 23% rate of persistent pelvic pain.

Biomechanical data for vertical shear injuries suggests that anterior plate fixation increases the stability of the construct, but that for the posterior fixation, there is no significant difference in stability between a single sacroiliac screw in S1, a single screw in S2, or a combination of a screw in S1 and a screw in S2. (37)

While Perreira (38) noted that outcomes correlated more with associated injuries than with fracture characteristics, Oransky (39) showed that the most frequent cause of malunion or nonunion is inadequate treatment. The current standard treatment for vertical shear pelvic injuries is still operative fixation of both the anterior and posterior pelvis.

Conclusion

In reviewing the current practices in the treatment of pelvic fractures based on fracture type, there are many unanswered questions. While there is a paucity of outcomes-based data supporting the treatment decisions for some types of pelvic fractures, it can be said that minimally displaced lateral compression injuries should continue to be managed nonoperatively, and that for highly unstable fractures, such as vertical shear type fractures, obtaining and maintaining reduction is difficult and likely benefits from operative stabilization of both the anterior and posterior aspects of the pelvic ring. Developing an evidence-based approach based on clinical outcomes will be critical in advancing the basis for the definitive treatment of pelvic fractures.

Daniel Bazylewicz, M.D., and Sanjit Konda, M.D.

Daniel Bazylewicz, M.D., Rothman Institute, Philadelphia, Pennsylvania. Sanjit Konda, M.D., NYU Hospital for Joint Diseases, New York, New York.

Correspondence: Daniel Bazylewicz, M.D., Rothman Institute, 2500 English Creek Avenue, Building 1300, Egg Harbor Township, New Jersey 08234; danbaz01@gmail.com.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

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Author:Bazylewicz, Daniel; Konda, Sanjit
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Date:Jan 1, 2016
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