Minimally Invasive Manipulative Reduction and Fixation of Pelvic (Pubic & Sacral) Fractures

This month's case features a 19 years old male who was injured in a high-speed automobile accident. He was the driver of the vehicle and medics at the scene noted significant intrusion of the driver’s side of the car. He was extracted from the vehicle, complained of pelvic and back pain. On presentation to the emergency department, he was awake and alert, and continued to complain of severe left sided low back and hip area pain. He was initially hemodynamically unstable but responded to routine volume resuscitation. His physical examination revealed left pelvic and back pain with any attempted passive movement. Compressive pelvic exam identified pelvic mechanical instability and related exacerbation of his complaints. There was no pelvic deformity or abnormal other findings. The lower extremity neurological and vascular examinations were within normal limits, excepting muscle power limitations due to pain.

Plain pelvic radiographs and a computed tomography scan demonstrated displaced left sided pubic ramus and sacral fractures. The axial CT images demonstrated the fracture and deformity details. The left hemipelvis was flexed and internally rotated relative to the uninjured right side.  The patient was fully resuscitated and evaluated. He and his parents were counseled regarding the various non-operative and operative treatment options, as well as the risks and benefits of each. They opted for attempted manipulative reduction and percutaneous fixation if possible, and agreed to open reduction and internal fixation if needed.

On the day after injury, the patient was medically stable and cleared for surgery. He was anesthetized, positioned supine on the radiolucent operating table, elevated on a soft lumbo-sacral support, and the entire abdomen and bilateral flanks were included in the sterile operating field. After the preoperative patient/procedure verification was completed and antibiotic prophylaxis administered, a simple 2 pin anterior oblique pelvic external fixation device was applied using bilateral 5mm pins inserted into the right iliac crest and left supra-acetabular areas. The single bar oblique frame was oriented to correct the left hemipelvic flexion and internal rotation deformities. The compression-distraction device was applied to the bar remote from the injured areas so to not obstruct pelvic fluoroscopic imaging.  The manipulative reduction was assessed using fluoroscopy until satisfactory ramus and sacral re-alignment reductions were achieved.  Then antegrade superior pubic ramus medullary screw and iliosacral screw fixations were placed percutaneously through small stab wounds under multiplanar fluoroscopic guidance. The postoperative imaging confirmed the reduction accuracy, deformity correction, and screw safety. On the day after surgery, he was comfortable and began his rehabilitation including weight of limb protected weight bearing using crutches, and isometric exercises for the subsequent 6 weeks. He returned for follow up evaluation with no complaints, radiographic union of his fractures, and was released to his normal activities 3 months after injury.

Authored By: M.L. Chip Routt, Jr.,M.D