Comminuted fractures of the Iliac Wing

Purpose: Comminuted iliac fractures are uncommon and difficult to treat. The purpose of this study is to further delineate the fractures, to present a management protocol, and to evaluate the results of treatment. Design: Retrospective clinical study. Setting: Level one trauma center at Harborview Medical Center. Patients: During a sixty-eight-month period, 695 patients with pelvic ring disruptions were treated at a level one trauma center. Thirteen (1.9%) of these patients had a severely comminuted iliac fracture. All patients were men, ranging in age from twenty to eighty years (mean, 38 years). These patients were polytraumatized and had a mean Injury Severity Score of 23. Eleven of the thirteen patients had severe iliac and flank degloving injuries. Five patients had open fractures, one with fecal contamination requiring diverting colostomy. Six patients with clinical signs of hemodynamic instability had local arterial injuries associated with their fractures. All five patients with extension of the fracture into the greater sciatic notch were found to have a local arterial injury on angiography. One patient had a lumbosacral plexopathy on the fractured side. Four patients had traumatic brain injuries. Intervention: All thirteen patients were treated operatively. Routine pelvic external fixation was not possible because of the iliac comminution. Stable internal fixation was accomplished by an anterior iliac surgical exposure using lag screw and plate combinations. The open wounds and degloving injuries were treated with irrigation, debridement, and closed suction drainage. Main Outcome Measurements: Healing and stability of fixation were assessed clinically and on pelvic radiographs. Results: Comminuted iliac fractures were divided into two patient groups, according to associated pelvic ring disruption. Follow-up evaluations were available for all patients at a mean of eighteen months after injury. There were no deaths. All of the fractures healed clinically and radiographically. In one patient, fecal contamination caused a polymicrobial wound infection, and this patient had an associated delay in union of the fracture. Another patient with an open fracture developed a deep wound infection. Both infections responded to local management and antibiotics. There were no complications associated with the degloving injuries. Conclusions: Comminuted iliac fractures occur in two distinct patterns and are associated with numerous local injuries that complicate management. Management protocols should include early open reduction and stable internal fixation. Traumatic open wounds should not be closed primarily. Primary closure with closed suction drainage is effective in the management of associated degloving injuries. Extension of the fracture into the greater sciatic notch warrants further evaluation with pelvic angiography.