Stabilization of pelvic ring disruptions

A coordinated multispecialty effort is needed in the management of polytraumatized patients with unstable pelvic ring injuries. Early definitive pelvic internal fixation is difficult yet beneficial. The orthopedic surgeon should be involved in treatment at the time of patient presentation. Rapid pelvic ring stability should diminish pelvic hemorrhage. Early treatment decisions have a significant impact on subsequent options. A team approach to the management of these patients involving open communication among the various sub-specialties allows coordinated care and optimizes outcome. Simple two-pin 'resuscitation frames' may be used acutely to control bleeding and then converted to more stable forms of internal fixation. Simple anterior external fixation frames poorly control posterior pelvic ring instabilities. Pelvic antishock clamps are used when ongoing hemorrhage is secondary to posterior pelvic ring injuries. With an assistant performing a closed reduction, the clamp should be applied using fluoroscopic guidance, because bony landmarks may be difficult to identify secondary to obesity and deformity. Overcompression is avoided in patients with sacral foraminal fractures to prevent further nerve root damage. The pelvic antishock clamp is exchanged early for definitive internal fixation. Open wounds demand aggressive treatment in patients with associated pelvic ring injuries. The wounds should be debrided and thoroughly cleaned. Perineal open wounds usually require both fecal and urinary diversions. Closed degloving wounds also complicate pelvic fracture management. The treatment of pelvic ring fractures and dislocations is complicated by genitourinary disruptions. Early urethral realignment and bladder repair avoid suprapubic cystostomy and its potential complications. Low infection rates have been reported using this aggressive combination approach to genitourinary disruptions with pelvic internal fixation. The management strategy for the patient with intra- abdominal injuries in association with pelvic fractures should be thoroughly discussed by the orthopedist and general surgeon. Ideally, the pelvic ring should be stabilized, even if only temporarily, before the abdominal procedure. The midline wound should not extend below the umbilicus unless absolutely necessary. Supraumbilical wounds preserve the lower abdominal wall for orthopedic or urologic procedures. The location of a colostomy also should avoid anticipated orthopedic incisions. Early communication among the treatment team facilitates treatment methods. Coordinated procedures save valuable time and resources. Late reconstructions of pelvic ring deformities are difficult. Early accurate pelvic stabilization avoids these more complicated procedures. External fixation frames, except in certain cases of minimal displacements, do not provide stable pelvic fixation when used alone. Supplemental fixation of the posterior pelvic injuries with iliosacral screws is helpful.