37 Pelvic Fractures: External Fixation and C-Clamp

37.Pelvic Fractures: External Fixation and C-Clamp

Enes M. Kanlic

Hector O. Pacheco

Indications/Contraindications

Injuries to the pelvic ring range from simple stable fractures as the result of low-energy forces to life-threatening injuries with hemodynamic instability. The incidence of pelvic fractures in Sweden is approximately 37 per 100,000 patients per year (1). Pelvic fractures account for 3% to 8% of all fractures seen in the emergency room but are present in up to 25% of multiply injured patients. Mortality rates in patients with complex pelvic fractures and associated visceral injuries can be as high as 20% to 25%, and for patients with open pelvic fractures, the mortality rate ranges from 15% to 50% (1,2,3,4,5,6).

Of the several classification schemes for pelvic fractures, we favor the Tile classification, which is used to predict instability in the injured pelvic ring. Tile A injuries are stable fractures that can be managed nonoperatively. Tile B injuries are rotationally unstable but vertically stable. Tile C injuries are both rotationally and vertically unstable.

External fixation is utilized primarily in the management of patients with hemodynamic instability following pelvic fractures. Specific indications for anterior external fixation include selected, rotationally unstable, Tile B1 and B2 pelvic fractures. We strongly favor external fixation following fracture when the local conditions in and around the pelvis or abdomen are contaminated, such as with open fractures, diverting colostemies or a suprapubic urinary catheter must be placed. In addition, patients with concomitant visceral injuries, especially those whose injuries would be exacerbated when the abdomen is open, are often treated with pelvic external fixation. Occasionally, anterior-ring external fixation is used to augment posterior ring fixation.

The most common indication for anterior-ring external fixation is in a critically ill, unstable patient with a translationally unstable pelvic injury (Tile C). A resuscitative frame with ipsilateral supracondylar traction is used when a C-clamp is unavailable or not applicable.

Contraindications to external fixation are stable pelvic-ring injuries (Tile A) and patients with associated fractures of the iliac wing in which stable pin placement would be difficult or impossible. External fixation should be avoided when internal fixation can be performed on a stable patient in a timely fashion.

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Preoperative Planning

Patient Stabilization

In the field or emergency room setting, emergency care workers and paramedics trained in advanced trauma life support (ATLS) often play a critical role. In patients with hemodynamic instability and a potentially unstable pelvic-ring injury, a single attempt at reduction should be considered. The responder applies traction to the unbroken lower extremity on the shortened or deformed side of the pelvis with manual lateral compression on the iliac wings or greater trochanters. The knees and ankles should be slightly flexed and internally rotated and taped together before a noninvasive external fixation device (wrapped sheet or pelvic binder) is applied (Fig. 37.1). When done at the scene of an accident, emergent transfer to an institution capable of treating pelvic trauma may be life saving (7,8).

Hemodynamically unstable patients with pelvic ring injuries require prompt evaluation and simultaneous aggressive resuscitation. Initial measures include airway control and aggressive fluid resuscitation through two 14- to 16-gauge intravenous catheters in the upper extremities. Physical examination should be directed for signs of possible mechanical instability of the pelvis. Tell-tale signs include a history of high-energy trauma from motor vehicle or motorcycle collisions, falls from a height, or rollover motor-vehicle collisions. On clinical examination, a shortened and malrotated extremity, asymmetric iliac spines, swelling or blood on genitals and perineum, contusion or ecchymosis in the lower abdomen or pelvis suggest pelvic instability. Gentle, manual, iliac-wing compression from lateral toward the midline may reveal a mobile hemipelvis and mechanical instability. A careful neurological examination to assess for leg sensation and motor function is critical. Vaginal and rectal digital exams with guaiac test for occult blood and with speculums (time permitting) help rule out an occult open fracture. If overlooked and not treated, a fracture hematoma that comes in contact with a contaminated environment may cause a life-threatening pelvic infection.

The care of a hemodynamically unstable patient with a displaced pelvic fracture is the responsibility of a multidisciplinary trauma team that includes a general surgeon, anesthesiologist, orthopedic surgeon, and invasive radiologist. Trauma protocols are helpful in evaluating and treating critically ill patients, establishing priorities, and guiding treatment. Using the algorithm (Fig. 37.2), Ertel et al (9) were able to save 15 of 20 patients (75%) who presented with multiple injuries that included unstable pelvic injuries with an average Injury Severity Score (ISS) of 41.2 卤 15.3. Fifteen patients had massive hemorrhage (14 were in extremis), and five were in hemorrhagic shock. Two of them required subdiaphragmatic clamping of the aorta to stabilize a disastrous hemodynamic situation.

As part of the primary survey, a focused abdominal sonogram for trauma (FAST) or computed tomography (CT) scan can be used to determine the presence of free fluid in intraperitoneal,

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retroperitoneal, or pericardial cavities. Arterial blood gas with blood lactate levels and/or base deficit analyses are good indicators of the hemorrhagic state and tissue oxygenation (9,10,11).

 Methods of pelvic fracture stabilization.

Figure 37.1. Methods of pelvic fracture stabilization.

An orthopedic damage-control algorithm for patients with pelvic fracture. (From Ertel W. General assessment and management of the polytrauma patient. In: Tile M, Helfet D, Kellam J, eds. Fractures of the pelvis and acetabulum. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003:71 with permission.)

Figure 37.2. An orthopedic damage-control algorithm for patients with pelvic fracture. (From 

Ertel W. General assessment and management of the polytrauma patient. In: Tile M, Helfet D, Kellam J, eds. Fractures of the pelvis and acetabulum. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003:71

 with permission.)

A chest x-ray is an important part of the trauma work-up because it can be used to rule out a pneumothorax, hemopneumothorax, tension pneumothorax, or flail chest. A single

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anteroposterior (AP) radiograph of the pelvis can be used to diagnose a pelvic fracture correctly in approximately 90% of cases. X-ray signs of instability are (a) >5-mm displacement of the sacroiliac (SI) joint in any plane (inlet and outlet views will improve accuracy if circumstances allow), (b) posterior fracture gap, and (c) avulsions of the transverse process of fifth lumbar vertebra or avulsion fractures of the sacrospinous ligament. By definition, a stable pelvic injury can withstand normal physiologic forces without abnormal deformation. The surgeon should not routinely manual test for pelvic ring stability because he/she could dislodge blood clots in a hemodynamically unstable patient. One-time manual testing, to exclude a situation in which the pelvis had been unstable but has since been reduced, may be permissible by an experienced surgeon in cases where the x-rays do not clearly demonstrate an unstable injury (12,13).

Numerous studies have shown that in patients with multiple injuries, exsanguination and closed head injury are the main causes of mortality within the first 24 hours after injury. Damage control surgeries, for hemorrhage control, decompression of body cavities such as in the chest and head, and contamination control of abdominal perforations, as well as devitalized tissue debridement in the extremities, improve survival. Determination of the patient's hemodynamic status and initial response to resuscitation measures allow placement of the patient in one of three protocol categories that dictate treatment (see Fig. 37.2).

A subset of multiply injured patients presents in extremis (i.e., without measurable vital signs). Most of these patients need a crash laparotomy, thoracotomy, and/or pelvic/abdominal packing (with or without temporary aortic cross-clamping) to survive (Fig. 37.3). While awaiting the response of the patient to aggressive resuscitation therapy, a C-clamp or an anterior, pelvic, external fixator should be applied. Subsequent, repeated, pelvic/abdominal packing against a firm stabilized pelvis will be much more effective in tamponading the bleeding.

If the patient is in a persistent shock category despite adequate fluid replacement, blood transfusions, and medications over 2 hours, an external fixator or C-clamp should replace a pelvic sheet or binder. Numerous studies have shown that in patients with unstable pelvic injuries in which ligaments and fascial planes that support the pelvic floor have been disrupted, self-tamponade rarely occurs (14). Huittinen and Sl盲tis (15) have estimated that 80% to 90 % of bleeding following fracture and/or dislocation comes from disruption of the lumbosacral venous plexus and fracture bone surfaces and that only 10% have an arterial origin. The most common technique for stopping the diffuse bleeding (venous or arterial small vessels) is by tamponade. In patients who require abdominal exploration, laparotomy

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will make the pelvis more unstable because the muscle forces pulling on the iliac wings are diminished (16). A correctly applied pelvic frame will improve pelvic stability yet not impede the surgeon's ability to perform either a supraumbilical laparotomy (from xiphoid process to symphysis for positive intra-abdominal fluid) (Fig. 37.4) or infraumbilical (absent intraperitoneal injury). If a patient with an unstable pelvic fracture requires a laparotomy for intraperitoneal injuries, exploration and packing to control retroperitoneal bleeding may be accomplished as well. Disruption of the soft tissues in the pelvic floor allows easy, direct access to both sides of sacrum and bladder for packing (17). Major arteries and veins (external iliac and femoral) that are damaged also require direct access and surgical hemostasis. In massive retroperitoneal bleeding caused by blunt trauma, Ertel et al (9) recommended that the hematoma in the central zone be explored. This method also allows assessment of the posterior reduction by direct manual palpation from inside the pelvis. Bleeding is better controlled when the bone surfaces or joint are directly opposed (interdigitating) and compressed. If significant displacement exists, loosening and adjusting the external fixator, previously applied to improve the fracture reduction, can be performed. To achieve firm local compression against the reduced posterior pelvis, the surgeon may need to repeat the tamponade and look quickly again for any major bleeding sources. If hemodynamic instability persists despite all measures (including partially closed distal-abdominal fascia for better support of packing), then the patient should be transferred for a contrast-enhanced CT of the abdomen. The study is fast and highly accurate in determining the presence or absence of ongoing pelvic hemorrhage (18). Patients with visualized contrast extravasation, as shown on CT scans, are candidates for angiography and embolization. Following a similar protocol, the Hannover Trauma Center was able to reduce mortality rate from 46% to 25% (8,10,15,17,19).

Aortic cross-clamping and C-clamp placement in a policeman, who was struck by an automobile while standing alongside a highway.

Figure 37.3. Aortic cross-clamping and C-clamp placement in a policeman, who was struck by an automobile while standing alongside a highway. On admission, he was in extremis, and crash laparotomy was conducted, and a C-clamp and pelvic packing were applied. Bleeding was controlled by temporary cross-clamping of the aorta. The patient survived the night but expired the following morning secondary to a severe closed-head injury.

In most North American trauma centers, if evidence of intra-abdominal free fluid is not found on ultrasound exam or diagnostic peritoneal lavage (DPL) after noninvasive pelvis stabilization, angiography and embolization of identifiable bleeding arteries is usually the next step. Angiography does not address venous bleeding, is time consuming (which is particularly problematic for a patient in hemorrhagic shock), and may cause gluteal muscle necrosis. In addition, only 3% to 5% of patients with unstable pelvis receive major benefit from the procedure, which requires specialized personnel and equipment (13,20,21,22).

In a very small subgroup of patients, hemipelvectomy may be life saving (20,23). High-energy pelvic injuries that are concomitant with a major vessel injury (e.g., to the common external iliac or femoral artery), which are characterized by lack of blood flow to the extremity, and a profound neurologic deficit (and/or intraoperative finding of stretched and ruptured nerves) cause such persistent hemodynamic instability that reconstruction attempts are futile.

Open fractures with wounds in the rectal or vaginal vicinity require irrigation and debridement,

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a diverting colostomy placed as far as possible from subsequent surgical approaches to the pelvis, and immediate distal-colon washout. In addition, a broad spectrum of prophylactic antibiotics should be given (2,3,4,5,6).

 Laparotomy following application of an anterior external-fixation device.

Figure 37.4. Laparotomy following application of an anterior external-fixation device. A C-clamp is covered by sheets.

Every male patient with an unstable pelvic injury (with or without blood on ureteral meatus) requires a retrograde urethrogram before bladder catheterization. In our experience, a rectal exam cannot reliably predict the position of the prostate and possible urethral injury. A urethral injury in this setting is usually treated with a suprapubic catheter inserted percutaneously or openly during laparotomy. Patients with hematuria and intact urethra must undergo a contrast study to rule out a bladder rupture. If no explanation for hematuria is identified, an abdominal CT and intravenous pyeolography is used to investigate the upper urogenital tract. In a polytrauma patient, routine CT scans without contrast will show a ruptured kidney perirenal hematoma; contrast may be contraindicated with kidney damage or poor function. If an emergent invasive radiology procedure is contemplated, contrast studies (urological and gastrointestinal) should be done after angiography (13,20).

Pelvic Stabilization

Critically ill patients with unstable pelvic injuries require early pelvic stabilization to improve fracture stability, provide a tamponade effect, improve clotting, and reduce pain. In patients with multiple injuries, including life-threatening conditions, the speed and safety of pelvic stabilization is more important than the initial accuracy of reduction or sophistication of frame constructs.

Noninvasive Methods

A bed sheet wrapped and secured with towel clamps or a hand-tied knot placed around the pelvis and greater trochanter, with the hips slightly flexed and internally rotated, can often provide short-term tamponade and stabilization (2 to 3 hours) (Fig. 37.5). This stabilization method is most effective when applied after a simple reduction maneuver using traction and pressure over the iliac wings. Unnecessary transfers should be avoided, and the patient should only be turned once for a spinal exam.

Commercially available pelvic binders are easy to apply and readjust as needed (Fig. 37.6). However, these devices limit access to the abdomen and groin. Vacuum splints and beanbag positioners, while bulky, can be helpful and allow better abdominal and inguinal access while providing pelvic immobilization (Fig. 37.7). It is unfortunate that they are not always available and do not work well in large patients.

External immobilization with a sheet as a pelvic binder in a patient with an unstable pelvic injury. Sheet wrapped around the iliac-crests, ankles and lower extremities fixed in internal rotation with a gauze-roll provide rapid temporary immobilization with ongoing fluid resuscitation.

Figure 37.5. External immobilization with a sheet as a pelvic binder in a patient with an unstable pelvic injury. Sheet wrapped around the iliac-crests, ankles and lower extremities fixed in internal rotation with a gauze-roll provide rapid temporary immobilization with ongoing fluid resuscitation.

The use of a pelvic binder in a mechanically unstable, open, pelvic fracture. It is easy to apply and adjust as needed. Access to the abdomen and inguinal regions may be limited, and binder repositioning to the trochanteric regions may be necessary.

Figure 37.6. The use of a pelvic binder in a mechanically unstable, open, pelvic fracture. It is easy to apply and adjust as needed. Access to the abdomen and inguinal regions may be limited, and binder repositioning to the trochanteric regions may be necessary.

 Vacuum splints apply pressure over a large area and provide good temporary fixation. They are radiolucent and allow full access to the abdomen and inguinal areas

Figure 37.7. Vacuum splints apply pressure over a large area and provide good temporary fixation. They are radiolucent and allow full access to the abdomen and inguinal areas.

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External Fixation

Riemer at al (24) reported a decrease in the mortality rate from 26% to 6% when external fixation was introduced as a part of resuscitation protocol at their institution. External fixation provides better bony stabilization than noninvasive methods, and the technique is minimally invasive and relatively easy and safe to apply. External fixation also helps control pain and patient mobilization. However, an anterior frame does not adequately stabilize translational, Tile C fracture patterns. Unlike the posterior C-clamp, the frame may limit access to the abdomen. With attempts to compress and immobilize the anterior pelvic ring, the fracture gap posteriorly may be increased, which may lead to greater instability and bleeding. Transfemoral skeletal traction of 25 to 30 lb, with the hip flexed, can improve the posterior fracture reduction.

In most trauma centers, external fixation is used primarily as a temporary resuscitation frame until the patient's general condition has improved and elective internal fixation can be employed. When anterior frames were used as a definitive fixation method for Tile C fractures, failure rates as high as 70% were reported. While the optimal time to convert from external to internal fixation is unknown, we prefer to wait at least 7 days to avoid 鈥渢he second hit鈥� phenomena. Earlier fixation may be feasible in patients in which percutaneously placed ilio-sacral screws can produce adequate reductions in the supine position (see Fig. 37.33). Combined posterior鈥搃nternal fixation and anterior鈥揺xternal fixation (when anterior internal fixation is not applicable) can provide adequate stability for patient mobilization. However, discomfort, pin tract problems, and loosening limit long-term application (13,25,26,27,28,29,30). The stability of external fixation is determined by the (a) host (type of pelvis mechanical instability, patient size, and quality of bone); (b) frame characteristics (design and location, number and size of pins), and (c) application (quality of reduction and pin placement).

Anterior External Fixation

Iliac-Crest External Fixation

Procedure

The frame is applied with the patient in the supine position on a flat top radiolucent operating fracture table with traction attachments available, and if time allows, c-arm control (Fig. 37.8). Except in dire circumstances, a full prep and sterile technique is used for pin placement in either an open or percutaneous approach. With the open technique,

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an 8-cm incision in the anterior third of the iliac crest is started 2- to 3-cm posterior to the anterior鈥搒uperior iliac spine (ASIS) (Figs. 37.9 and 37.10) to avoid damage to the lateral femoral cutaneous nerve. To decrease the chance of skin stretching by the fixator pins, the incision should be made after manual reduction and compression of iliac wings. This incision provides appropriate orientation for the insertion point of the pins, and it could be incorporated into an internal fixation approach as part of a staged reconstruction. Stab incisions have also been advocated if later surgical approaches might be necessary. In cases where lasting external fixation is planned, 2-cm incisions directed toward the umbilicus are less likely to cause soft-tissue necrosis and are used for a percutaneous approach after iliac wing reduction.

A patient with a Tile C, unstable, open, pelvis fracture as well as an avulsed rectum, liver injuries, and a right leg amputation

Figure 37.8. A patient with a Tile C, unstable, open, pelvis fracture as well as an avulsed rectum, liver injuries, and a right leg amputation. The previously applied C-clamp has been removed. Staged reconstruction with percutaneous IS screws on the left side and an anterior external-fixator frame is planned. Both lower extremities are secured to the traction attachments to facilitate fracture reduction.

 An open approach to the right iliac crest. It is started 2 to 3 cm proximal to the ASIS (surgeon's right index finger is on ASIS)

Figure 37.9. An open approach to the right iliac crest. It is started 2 to 3 cm proximal to the ASIS (surgeon's right index finger is on ASIS).

The incision is deepened. Separating the insertions of abdominal and gluteal muscles and incising the periosteum allow for good orientation of the width of the iliac crest. If the iliacus muscle is not elevated from the inner table of iliac crest, the danger of entering the retroperitoneal hematoma can be minimized.

Figure 37.10. The incision is deepened. Separating the insertions of abdominal and gluteal muscles and incising the periosteum allow for good orientation of the width of the iliac crest. If the iliacus muscle is not elevated from the inner table of iliac crest, the danger of entering the retroperitoneal hematoma can be minimized.

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Pin Placement

The iliac crests normally overhang the iliac wings, and to place the pins between the external and internal iliac-cortical table, the insertion of pins should be initiated between the medial third and half of iliac crest. Two pins should be placed in each ilium for a emergently used (before laparotomy) resuscitation frame, or three pins should be placed when adequate time is available. The iliac wings have a slight curvature, and the pins may not align in a straight line. The pins should be at least 1 cm apart. In the supine position, the iliac crest angles approximately 45 degrees toward the operating table, but the angle varies from patient to patient (Fig. 37.11). The outer cortex is opened with an appropriate drill bit inclined from cranial toward the greater trochanter; it is aimed for the bone stock of anterior pillar above the acetabulum. The surgeon manually advances 5-mm-diameter pins through the opening hole while trying to feel and not penetrate the internal or external tables. This procedure is not always easy, especially in obese patients.

Several techniques can be used to improve the accuracy of pin placement. The surgeon can insert Kirschner (K) wires on both sides of the iliac wing to serve as a guide. Some external fixation sets come with a special guide where a long arm is rested on the inner table. In another technique, the c-arm is used. Obturator oblique views show the iliac wing profile and pin position (Fig. 37.12). Of course, elevation of the gluteal and iliac muscles from both sides of the pelvis allows direct visual control of the iliac wing for pin placement. However, extensive soft-tissue dissection on the inside of the iliac wings can enter the retroperitoneal hematoma and should be avoided. The stability of the pins is assessed by a gentle trial of in-line traction. When secure, the pins are captured by pin-to-bar clamps and attached to a connecting bar. The same is done on the opposite side, and both independent bars can be manipulated to improve the fracture reduction.

For open book injuries (Tile B1), anterior compression alone will suffice. For bucket handle, lateral-compression injuries (Tile B2), opening and external rotation of the compressed iliac wing is required. Completely unstable, translational injuries (Tile C) require anterior pins and some type of posterior fixation. The bars are connected anteriorly with one or two transverse bars by bar-to-bar connectors that form a trapezoidal frame (Sl盲tis type) (Fig. 37.13). The frame should be positioned to allow for laparotomy, additional soft-tissue swelling, and the patient to maintain an upright position in bed (Fig. 37.14). If any soft-tissue tension is caused by the pins (Fig. 37.15), they should be released by small relaxing incisions and sutured without tension to avoid pin-tract discomfort, necrosis, and infection (Fig. 37.16). The fracture reduction and pin placement are checked with the c-arm, and final permanent radiographs are obtained as condition permits (10,13,25).

 A CT scan showing the orientation of the pelvis in the supine position. The ilium lies at an angle of approximately 45 degrees. The surgeon must consider this orientation when placing the iliac crest pins. (From Rommens PM, Hesmann MH. External fixation for the injured pelvic ring. In: Tile M, Helfet DL, Kellam JF, eds. Fractures of the pelvis and acetabulum. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003:208 with permission).

Figure 37.11. A CT scan showing the orientation of the pelvis in the supine position. The ilium lies at an angle of approximately 45 degrees. The surgeon must consider this orientation when placing the iliac crest pins. (From 

Rommens PM, Hesmann MH. External fixation for the injured pelvic ring. In: Tile M, Helfet DL, Kellam JF, eds. Fractures of the pelvis and acetabulum. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003:208

 with permission).

 C-arm view following pin placement

Figure 37.12. C-arm view following pin placement.

An anterior鈥搒uperior iliac crest, trapezoidal frame. This patient has a diverting colostomy, suprapubic catheter, and significant soft-tissue defect on right upper thigh.

Figure 37.13. An anterior鈥搒uperior iliac crest, trapezoidal frame. This patient has a diverting colostomy, suprapubic catheter, and significant soft-tissue defect on right upper thigh.

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Supra-acetabular External Fixation

The bone above the acetabulum is thick and strong and holds pins well. Biomechanical studies have been shown that pins and frames in this 鈥渓ow route鈥� provide better SI joint stability than 鈥渦pper route鈥� (iliac crest) frames (31,32). Some authors (20) feel that this route is ideal for emergent anterior-pelvic fixation because of the ease of palpating this thick bone, quickly putting one pin at each side, reducing the pelvis, and connecting the frame with a single anterior-transverse bar. We and others (10,33) feel that for those with limited experience with this technique, the risk of penetrating the hip joint or damaging the neurovascular structures in the greater sciatic notch, especially in the absence of the c-arm, is high.

The set-up for the low route is the same as for the iliac crest procedure. We recommend c-arm control of the surgical steps.

Procedure

A K wire is used under c-arm visualization to localize the anterior鈥搃nferior iliac spine (AIIS). Just lateral to the AIIS projection, a 2-cm, transverse, skin incision is made. This will allow less skin-pin interference when the patient is mobilized.

The soft tissues are bluntly separated down to bone in longitudinal fashion to avoid potential damage to the lateral, femoral, cutaneous nerve. A protection sleeve with an inner trocar is advanced with an oscillating motion. Through the trocar, the outer cortex is opened with a drill. A 5- or 6-mm diameter pin with threads of 50 to 70 mm and length of at least 180 mm is advanced through the trocar (Fig. 37.17). The entry point should be at the level of the AIIS, advanced toward the acetabular roof, and checked on an iliac, oblique, c-arm view (Fig. 37.18). To avoid the sciatic notch, the pin is directed toward the SI joint: 30 degrees

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medial in the sagittal direction (Fig. 37.19) and 20 degrees less than perpendicular (about 70 degrees) to the caudo-cranial axis (Fig. 37.20). Another pin is placed in the opposite side, and after additional reduction maneuvers, both pins are connected by a single bar (Figures 37.21 and 37.22). The bar should be far enough from the skin to allow for additional swelling. Correctly done, this low route will not obstruct a laparotomy approach, and patients are usually able to sit without difficulties with a frame in place (34).

 External fixation frames should be placed to allow eventual mobilization and an upright position

Figure 37.14. External fixation frames should be placed to allow eventual mobilization and an upright position.

 An example of soft tissues under tension around the pins. If the incision is not made in reduced iliac-wing position and it is not perfectly above the medial half of the iliac crest, the soft tissue may be compromised after pin placement. Such an outcome may cause significant discomfort, tissue necrosis, and possible infection.

Figure 37.15. An example of soft tissues under tension around the pins. If the incision is not made in reduced iliac-wing position and it is not perfectly above the medial half of the iliac crest, the soft tissue may be compromised after pin placement. Such an outcome may cause significant discomfort, tissue necrosis, and possible infection.

 A soft-tissue release by an incision perpendicular toward the direction of tension. The incision can be closed without any undue tissue stretching.

Figure 37.16. A soft-tissue release by an incision perpendicular toward the direction of tension. The incision can be closed without any undue tissue stretching.

 Supra-acetabular external-fixation pin placement under c-arm control. A 2-cm incision is made, and the soft tissues are spread down to the bone. The external fixation pin with soft-tissue-protecting sleeve should be utilized.

Figure 37.17. Supra-acetabular external-fixation pin placement under c-arm control. A 2-cm incision is made, and the soft tissues are spread down to the bone. The external fixation pin with soft-tissue-protecting sleeve should be utilized.

Supra-acetabular pin placement. The iliac oblique view helps the surgeon ensure that the pin does not penetrate the hip joint nor pass through the greater sciatic notch.

Figure 37.18. Supra-acetabular pin placement. The iliac oblique view helps the surgeon ensure that the pin does not penetrate the hip joint nor pass through the greater sciatic notch.

Supra-acetabular pin placement. The obturator oblique view helps the surgeon guide the drill and pin toward the SI joint.

Figure 37.19. Supra-acetabular pin placement. The obturator oblique view helps the surgeon guide the drill and pin toward the SI joint.

Anterior Frames Postoperative Management

The soft tissues around the pins are stabilized by split gauze sponges for light compression for a day or two, and they are cleaned regularly to avoid crusting, fluid retention, and infection. Skin tension around the pins should be identified and released under local anesthesia. The frame construct should allow the patient to maintain an upright position such that pulmonary function is facilitated.

Rotationally unstable injuries with two pins in a high-frame configuration or one pin in a low-frame configuration provide enough stability for patients to bear weight. Selected, oblique, unilateral, posterior, ilium or sacral fractures with an anterior injury, if reduced well, are stabilized sufficiently with an anterior fixator to permit weight bearing. After mobilization, pelvic x-rays should be used to verify stability and assure that no reduction has been lost. An anterior frame does not provide enough stability for weight bearing on bilateral posterior injuries.

Stability may be improved with good reduction, posterior compression, several large diameter pins, a curved bars鈥揵ow fixator, a combination of iliac crest and supra-acetabular frames, and application of multiple techniques. Lateral compression injuries heal in 6 to 8 weeks; symphyseal diastasis heals in 6 to 10 weeks.

Tile C translational injuries with complete instability cannot be sufficiently controlled with an anterior frame alone. If a C-clamp is unavailable or not applicable (posterior iliac fracture), then in addition to an anterior frame, supracondylar femoral traction with 25 lb can be used with the hip slightly flexed to improve posterior and superior displacement (13,25,26).

Posterior Fixation, C-Clamp

The use of devices similar to the C-clamp were published in the German literature in 1964 and 1972, but the modern era reemerged with the reports of Ganz et al in 1991 and

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Buckle et al in 1995 (20,35,36). Biomechanical testing has shown that the C-clamp provides better fixation than any other type of pelvic external fixation in posterior, unstable, pelvic injuries (26). It improves the conditions for effective hemostasis by compressing fracture surfaces, eliminating motion and dislodgement of formed clots, decreasing pelvic volume. It also may enhance self-tamponade and provides firm support for pelvic packing when needed. Many patients show an immediate improvement of vital signs after frame application.

. Supra-acetabular pin placement angles.

Figure 37.20. Supra-acetabular pin placement angles. (Modified from 

Pohlemann T, Lobenhoffer PH, Tscherne H. Therapie. In: Tscherne H, Pohleman T, eds. Becken and acetabulum. Berlin: Springer; 1998:143

 with permission.)

Supra-acetabular frame from the front.

Figure 37.21. Supra-acetabular frame from the front. One pin on each side is enough for resuscitation purposes, and if longer use is planned or a higher degree of instability is present, then two pins and two connected bars will provide better stability.

AP radiograph with right SI screws and a supra-acetabular frame. This minimally invasive combination of fixation was chosen to treat a patient with multiple injuries that include a Tile C pelvic fracture.

Figure 37.22. AP radiograph with right SI screws and a supra-acetabular frame. This minimally invasive combination of fixation was chosen to treat a patient with multiple injuries that include a Tile C pelvic fracture.

The landmarks for placement of a pelvic C-clamp. In the reduced position, the intersection of a line in the femur longitudinal axis and one that is vertical from the ASIS is the correct entry point. Palpation to effect transition of the oblique portion of iliac wing from an anterior into more vertical posterior position is helpful.

Figure 37.23. The landmarks for placement of a pelvic C-clamp. In the reduced position, the intersection of a line in the femur longitudinal axis and one that is vertical from the ASIS is the correct entry point. Palpation to effect transition of the oblique portion of iliac wing from an anterior into more vertical posterior position is helpful. (Modified from 

Pohlemann T, Regel G, Bosch U, et al. Notfallbehandlung und komplextrauma. In: Tscherne H, Pohleman T, eds. Becken and acetabulum. Berlin: Springer; 1998: 98

 with permission.)

The C-clamp produces direct posterior compression and stabilization, yet leaves unobstructed access to the abdomen (see Fig. 37.29) and perineum (see Fig. 37.31). It is indicated only for a posteriorly unstable pelvic injury in a hemodynamically unstable patient. Contraindications are hemodynamically stable patients and those with posterior iliac-wing fractures.

The C-clamp set has a rectangular frame (Ganz) or two semicircular tubes connected by a central ratcheting gear (Browner's pelvic stabilizer). Both have large pins with sharp tips, and outside threads allow for connection with the frame and for additional dialed compression. Sets should be sterilely packed and available in emergency and operating rooms.

Figure 37.23 illustrates the position of the pin insertion at the intersection of a line along the long axis of the femur and with a vertical line angled down from the ASIS. If landmarks are missing because of deformity and swelling, the C-arm makes for a much safer procedure. The pin tip should be placed on the outside surface of the ilium at the level of the reduced, posterior, SI joint, where the bone is the thickest. The transition of the oblique and vertical portion of the iliac wings' lateral surfaces is presented in Figure 37.23. With the patient supine, the surgeon can palpate the bony landmark with a hemostat through a 2- to 3-cm longitudinal incision on the side of injury (Figs. 37.24 and 37.25). Compression pins are screwed into the threaded compression bolts and attached to the arms connected with the central ratcheted gear. The central gear is then released so the arms can be spread to accommodate patient size, and the compression pin attached to the fixator arm is 鈥渨alked鈥� on the lateral iliac wing until the vertical portion is felt (Fig. 37.26). The sharp tip is pushed into the bone and held there until the same procedure is done with other pin on opposite side.

When both pins are firmly anchored into the bone, the fracture is reduced, the arms are compressed, and central gear is tightened. Additional incremental compression is possible by screwing the pins centrally through the compression bolts (Figs. 37.27, 37.28, 37.29, 37.30, 37.31, 37.32 and37.33). Overtightening should be avoided if in cases of transforaminal sacral fracture, which can cause additional sacral-nerve damage. If the patient's condition does not improve despite aggressive resuscitation efforts and pelvic stabilization, then the patient should be taken to the operating room for laparotomy and pelvic packing (see Fig. 37.2). Otherwise, the pins are sterilely covered, the frame supported by towels, and pin care is assumed in day or two. Pelvic x-rays are obtained when possible.

AP pelvic x-ray shows a translationally unstable, open (ruptured rectum and perirectal tissue), left-sided pelvic-ring injury with extravasation of contrast after urethrogram and right T-type acetabular fracture

Figure 37.24. AP pelvic x-ray shows a translationally unstable, open (ruptured rectum and perirectal tissue), left-sided pelvic-ring injury with extravasation of contrast after urethrogram and right T-type acetabular fracture. The patient also had a closed head injury, chest injury, right-open-forearm fracture, and left-proximal-humerus fracture.

 The incision location for C-clamp pin placement. If the patient's hemodynamic status allows and an operating room is available, c-arm control should be used because it will improve pin placement and the accuracy of reduction.

Figure 37.25. The incision location for C-clamp pin placement. If the patient's hemodynamic status allows and an operating room is available, c-arm control should be used because it will improve pin placement and the accuracy of reduction.

 C-clamp application. Compression pins are inside of the frame

Figure 37.26. C-clamp application. Compression pins are inside of the frame, and the first pin is 鈥渨alked鈥� on the lateral wall of iliac wing on the stable side. The pin is pushed hard into the bone and held in place until reduction and the opposite pin is placed. The clamp may be applied in the emergency room, intensive care unit (ICU), or operating room.

 The c-arm view shows the first pin anchored on the intact side.

Figure 37.27. The c-arm view shows the first pin anchored on the intact side.

A clinical picture of the C-clamp in place. Posterior stabilization is achieved, and the frame can be rotated up or down to make space for additional procedures.

Figure 37.28. A clinical picture of the C-clamp in place. Posterior stabilization is achieved, and the frame can be rotated up or down to make space for additional procedures.

Posterior C-clamp and anterior iliac-crest frame in place. The patient's condition was stable, and enough time was available to apply an anterior frame before a laparotomy was conducted.

Figure 37.29. Posterior C-clamp and anterior iliac-crest frame in place. The patient's condition was stable, and enough time was available to apply an anterior frame before a laparotomy was conducted.

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Complications

Complications include the following conditions:

vascular or nerve damage if pins slip into greater sciatic notch,

intrapelvic pin penetration and intestinal perforation,

loss of reduction,

pin loosening, and/or

displacement of unstable hemiplevis into true pelvis.

The C-clamp is converted to the internal fixation as soon as patient condition allows, usually in 2 to 5 days. If internal fixation is impossible, then the clamp should be removed, and anterior fixation with supracondylar traction applied (9,35,36).

AP pelvis x-ray shows the pelvic ring temporarily reduced and fixed with the posterior C-clamp and iliac-crest anterior fixator

Figure 37.30. AP pelvis x-ray shows the pelvic ring temporarily reduced and fixed with the posterior C-clamp and iliac-crest anterior fixator.

Pelvic fixation allows lithotomy position for surgery on the rectal injury.

Figure 37.31. Pelvic fixation allows lithotomy position for surgery on the rectal injury.

Clinical picture after primary surgeries with stable, external, posterior and anterior fixation. Rectal injury was debrided and irrigated, and a suprapubic cystotomy and diverting left-sided colostomy with distal colon irrigation were performed as well.

Figure 37.32. Clinical picture after primary surgeries with stable, external, posterior and anterior fixation. Rectal injury was debrided and irrigated, and a suprapubic cystotomy and diverting left-sided colostomy with distal colon irrigation were performed as well.

AP pelvic x-ray with anatomically reduced, left, SI joint and SI screws that were used to replace the C-clamp 2 days after it was employed.

Figure 37.33. AP pelvic x-ray with anatomically reduced, left, SI joint and SI screws that were used to replace the C-clamp 2 days after it was employed.

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Recommended Readings

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3. Davidson B, Simmons G, Williamson P, et al. Pelvic fractures associated with open perineal wounds: a survivable injury. J Trauma 1993;35(1):36鈥�39.

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20. Pohlemann T, Regel G, Bosch U, et al. Notfallbehandlung und komplextrauma. In: Tscherne H, Pohleman T, eds. Becken and acetabulum. Berlin: Springer; 1998:89鈥�116.

21. Agolini SF, Shah K, Jaffe J, et al. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma1997;43(3):395鈥�399.

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27. Kellam JF. The role of external fixation in pelvic disruptions. Clin Orthop 1989;241:66鈥�82.

28. Matta JM, Saucedo T. Internal fixation of pelvic ring fractures. Clin Otrhop 1989;242:83鈥�97.

29. Burgess A, Eastridge B, Young, et al. Pelvic ring disruption: effective classification systems and treatment protocols. J Trauma 1990;30(7): 848鈥�856.

30. Mears DC, Fu FH. Modern concepts of external skeletal fixation of the pelvis. Clin Orthop 1980;151:65鈥�72.

31. Kim WY, Hearn TC, Seleem O, et al. Effect of pin location on stability of pelvic external fixation. Clin Orthop 1999;361:237鈥�244.

32. Egbers HJ, Draijer F, Haveman D, et al. Stabilisierung des beckenrings mit fixateur externe鈥揵iomehanische untersuchungen und klinische erfahrungen. Orthop盲de 1992;21:363鈥�372.

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35. Ganz R, Krushell R, Jakob R, et al. The antishock pelvic clamp. Clin Orthop 1991;267:71鈥�78.

36. Buckle R, Browner B, Morandi M. Emergency reduction for pelvic ring disruptions and control of associated hemorrhage using pelvic stabilizer.Tech Ortho 1994;4(9):258鈥�266.