Chapter 53 - Fractures of Acetabulum and Pelvis

James L. Guyton
John R. Crockarell
Acetabular Fractures
The treatment of acetabular fractures is a complex area of orthopaedics that is being continually refined. It
involves a definite learning curve, probably best documented in a report by Matta and Merritt of the first
100 acetabular fractures treated operatively by Matta. Grouping the surgical reductions chronologically in
groups of 20 clearly demonstrated that experience improved the ability to avoid unsatisfactory reductions
and to perform anatomical reductions ( Fig. 53-1 ). Kebaish, Roy, and Rennie demonstrated this same
concept by comparing the reductions obtained by experienced pelvic trauma surgeons to those obtained
by less experienced surgeons, who had a much lower rate of anatomical reduction ( Fig. 53-2 ). The
quality of acetabular fracture reduction is the single most important factor in the long-term outcome of
these patients, and such surgery should be undertaken only by surgeons with sufficient experience.
Because of the complex nature of this subject, the surgeon who wishes to perform acetabular fracture
surgery also is referred to the standard texts by Letournel and Judet, Tile, and Mears and Rubash, as well
as to the contributions of authors such as Matta, Mast, Kellam, Helfet, and others.

INITIAL TREATMENT
Acetabular fractures generally are caused by high-energy trauma, and associated injuries are frequent.
Treatment of the entire patient should follow accepted Advanced Trauma Life Support (ATLS) protocol,
with orthopaedic management of the acetabular fracture appropriately integrated into the treatment plan.
In general, operative treatment of an acetabular fracture should not be performed as an emergency except
when it is part of open fracture management or is performed for a fracture associated with an irreducible
dislocation of the hip. In the latter case, urgent open reduction of the hip dislocation and treatment of the
associated fracture are required to prevent the complications of avascular necrosis and ongoing
cartilaginous damage to the femoral head.
Closed reduction of hip dislocations should be performed with sedation in the emergency room or with
general anesthesia and fluoroscopy. The patient then can be placed in skeletal traction sufficient to
maintain reduction and possibly slight distraction of the hip while the other acute injuries are treated and
roentgenographic studies of the pelvis are obtained.

Figure 53-1 A, Percentage of anatomical reductions per group of 20 for first 100 cases. B, Number of unsatisfactory
reductions of displaced acetabular fractures per group of 20 for Matta's first 100 surgical cases. (From Matta JM, Merritt PO:
Clin Orthop 230:83, 1988.)

Figure 53-2 Quality of reduction of acetabular fractures obtained by experienced pelvic trauma surgeons compared with
surgeons with less experience. Mild incongruency is defined as up to 4 mm of fracture displacement, moderate incongruency
as 4 to 10 mm, and severe incongruency as more than 10 mm. (From Kebaish AS, Roy A, Rennie W: J Trauma 31:1539, 1991.)

The older term central fracture-dislocation of the hip was previously used to describe any acetabular
fracture with medial subluxation of the femoral head. Although this terminology has been replaced with
more descriptive fracture classification systems, a true central fracture-dislocation, with the femoral head
completely dislocated medially into the pelvis, is an unusual injury that requires urgent treatment ( Fig.
53-3 ). The femoral head can be locked between the fracture fragments, making reduction extremely
difficult. Closed reduction with general anesthesia and fluoroscopic assistance should be attempted. After
reduction, the femoral head is extremely unstable and will easily redisplace into the pelvis if skeletal
traction is not maintained.
If closed reduction of a hip dislocation associated with an acetabular fracture is unsuccessful, the
immediate treatment of the hip depends on the experience of the surgeon. To a surgeon with ample
experience in treating acetabular fractures, a rapid CT scan of the pelvis with 3-mm cuts can demonstrate
the obstruction to reduction of the hip dislocation and the acetabular fracture pattern, which will allow
formulation of an operative plan for reduction and internal fixation ( Fig. 53-4 ). If the surgeon lacks the
experience to perform the needed surgery, transfer to a facility capable of managing such injuries should
be immediate.
In our trauma center, patients with significantly displaced acetabular fractures are placed in skeletal
traction of 20 to 35 pounds while in the resuscitation area to minimize further injury to the femoral head
by the sharp fracture surfaces. After the patient has been stabilized and roentgenographic studies have
been completed, an appropriate treatment plan is formulated.

Figure 53-3 Central fracture-dislocation. In true central fracture-dislocation, intrapelvic femoral head can become locked
between superior and inferior fracture fragments.

Figure 53-4 Anteroposterior pelvic roentgenogram (A) and CT scan (B) of irreducible hip dislocation with posterior wall
acetabular fracture. The posterior wall fragment is incarcerated, blocking reduction.

ANATOMY
The acetabulum can be described as an incomplete hemispherical socket with an inverted horseshoeshaped articular surface surrounding the nonarticular cotyloid fossa. This articular socket is composed of
and supported by two columns of bone, described by Letournel and Judet as an inverted Y ( Fig. 53-5 ).
The anterior column is composed of the bone of the iliac crest, the iliac spines, the anterior half of the
acetabulum, and the pubis. The posterior column is the ischium, the ischial spine, the posterior half of the
acetabulum, and the dense bone forming the sciatic notch. The shorter posterior column ends at its
intersection with the anterior column at the top of the sciatic notch. The column concept is used in
classification of these fractures and is central to the discussion of fracture patterns, operative approaches,
and internal fixation.
The dome, or roof, of the acetabulum is the weight-bearing portion of the articular surface that supports
the femoral head ( Fig. 53-6 ). Anatomical restoration of the dome with concentric reduction of the
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femoral head beneath this dome is the goal of both operative and nonoperative treatment. The
quadrilateral surface is the flat plate of bone forming the lateral border of the true pelvic cavity and thus
lying adjacent to the medial wall of the acetabulum ( Fig. 53-7 ). The iliopectineal eminence is the
prominence in the anterior column that lies directly over the femoral head. Both the quadrilateral surface
and the iliopectineal eminence are thin and adjacent to the femoral head, limiting the types of fixation that
can be used in these regions.

Figure 53-5 The two column concept of Letournel used in classification of acetabular fractures (see text). (From Mayo KA:
Orthop Clin North Am 18:43, 1987.)

The neurovascular structures passing through the pelvis are at risk during the original injury and
subsequent treatment, and the various surgical approaches are designed around these structures. The
sciatic nerve exiting the greater sciatic notch inferior to the piriformis muscle frequently is injured with
posterior fracture-dislocations of the hip and fractures with posterior displacement ( Fig. 53-8 ). The
functioning of both the tibial and common peroneal components of the sciatic nerve must be carefully
documented in the emergency room and after subsequent interventions (including reduction of a hip
dislocation and changes in traction). The superior gluteal artery and nerve exit the greater sciatic notch at
its most superior aspect and can be tethered to the bone at this level by variable fascial attachments.
Fractures that enter the superior portion of the greater sciatic notch can be associated with significant
hemorrhage, possibly requiring angiography with embolization of the superior gluteal artery. Before
performing the extensile approaches that rely on a superior gluteal artery-based vascular pedicle, Bosse et
al. recommended preoperative angiographic confirmation of its patency. Knowledge of the intrapelvic
relationships of the lumbosacral trunk, common and external iliac vessels, and inferior epigastric vessels,
as well as the obturator artery and nerve, becomes crucial as retractors, reduction forceps, drills, and
screws are used. One particularly noteworthy anatomical relationship is the occasional large anastomosis
between the external iliac artery or inferior epigastric artery and the obturator artery known as the corona

Figure 53-6 Superior dome of acetabulum.

Figure 53-7 A, Iliopectineal eminence overlies dome of acetabulum. B, Quadrilateral surface lies adjacent to medial wall of
acetabulum. (Redrawn from Reckling FW, Reckling JB, Mohn MP, eds: Orthopaedic anatomy and surgical approaches, St
Louis, 1990, Mosby.)

Figure 53-8 Piriformis divides greater sciatic notch and is key to this region. Sciatic nerve is shown leaving pelvis below this
muscle; superior gluteal artery, vein, and nerve are above it. (From Tile M: Anatomy. In Tile M: Fractures of the pelvis and
acetabulum, Baltimore, 1995, Williams & Wilkins.).

mortis ( Fig. 53-9 ). Failure to ligate this vascular connection during the ilioinguinal approach can lead to
significant hemorrhage that is difficult to control as the external iliac vessels are mobilized. Letournel
described this anomaly as being present only rarely, but cadaveric dissections by Tornetta, Hochwald, and
Levine found that an arterial or venous anastomosis of variable caliber was present in 84% of specimens.

ROENTGENOGRAPHIC EVALUATION
The acetabulum is evaluated roentgenographically with an anteroposterior pelvic view, as well as with the
45-degree oblique views of the pelvis described by Judet and Letournel, commonly called Judet views.
Inclusion of the opposite hip in the roentgenographic field on the anteroposterior and Judet views is
essential for evaluation of symmetrical contours that may have slight individual variations and to
determine the width of the normal articular cartilage in each view. The medial clear space between the
femoral head and the roentgenographic teardrop in the injured and uninjured hips should be compared on
the anteroposterior view as an indication of femoral head subluxation.
The roentgenographic landmarks seen on each view are demonstrated in Figs. 53-10 and 53-11 . Fractures
that traverse the anterior column disrupt the iliopectineal line, whereas fractures that traverse the posterior
column disrupt the ilioischial line. Each fracture pattern in the classification of Letournel and Judet has
typical roentgenographic characteristics with respect to the disruption or intactness of the
roentgenographic landmarks, as demonstrated for a posterior column fracture in Fig. 53-12 . Evaluation of
the various fracture patterns from the standard roentgenograms requires an understanding of the three5

dimensional implications of the status of each of the roentgenographic landmarks, as well as a threedimensional grasp of pelvic bony anatomy and the possible variations of fracture lines within a given
fracture pattern. In the operating room, the three standard views can be obtained with fluoroscopy. The
restoration of the roentgenographic landmarks is a guide to the adequacy of fracture reduction.

Figure 53-9 Arterial and venous anastomosis between external iliac and obturator systems. In this example, connection
originates from inferior epigastric vessels and passes over superior ramus. (From Tornetta P III, Hochwald N, Levine R: Clin
Orthop 329:97, 1996.)

The anatomical dome is a three-dimensional structure composed of subchondral bone and its overlying
cartilage that articulates with the weight-bearing portion of the femoral head. Multiple studies have
concluded that the single most important factor affecting long-term outcome in both operatively and
nonoperatively treated acetabular fractures is maintenance of a concentric reduction of the femoral head
beneath an intact or anatomically reconstructed dome. The dome, or roof, can be seen on the
anteroposterior and Judet views of the pelvis, but the subchondral bone demonstrated on each of these
views is only 2 to 3 mm wide and represents only that small portion of the actual articular weight-bearing
surface that is tangential to the roentgen beam. Matta et al. developed a system for roughly quantifying
the acetabular dome after fracture, which they called the roof arc measurements. These measurements
involve determining how much of the roof remains intact on each of the three standard roentgenographic
views: anteroposterior, obturator oblique, and iliac oblique. The medial roof arc is measured on the
anteroposterior view by drawing a vertical line through the roof of the acetabulum to its geometric center.
A second line is then drawn through the point where the fracture line intersects the roof of the acetabulum
and again to the geometric center of the acetabulum. The angle thus formed represents the medial roof arc
( Fig. 53-13, A ). The anterior and posterior roof arcs are similarly determined on the obturator oblique
and iliac oblique views, respectively ( Fig. 53-13, B and C ). Although these are rough quantitations, they
are useful in the assessment of fractures of the posterior or anterior column, transverse fractures, T-type
fractures, and associated anterior column and posterior hemitransverse fractures; they have limited
usefulness for evaluating both-column fractures and fractures involving the posterior wall. According to
Matta et al, if any of the roof arc measurements in a displaced fracture are less than 45 degrees, operative
treatment should be considered.

Figure 53-10 Landmarks of standard anteroposterior roentgenogram of hip. 1, Iliopectineal line beginning at greater sciatic
notch of ilium and extending down to pubic tubercle. 2, Ilioischial line formed by posterior four fifths of quadrilateral surface
of ilium. 3, The roentgenographic teardrop composed laterally of most inferior and anterior portion of acetabulum and medially
of anterior flat part of quadrilateral surface of iliac bone. 4, Roof of acetabulum. 5, Edge of anterior lip of acetabulum. 6, Edge
of posterior lip of acetabulum. (From Judet R, Judet J, Letournel E: J Bone Joint Surg 46A:1615, 1964.)

Figure 53-11 A, Obturator oblique view of hip. B, Iliac oblique view of hip. (From Judet R, Judet J, Letournel E: J Bone Joint
Surg 46A:1615, 1964.)
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CT has proved invaluable in the treatment of acetabular fractures. Axial cuts must be taken with thin (3
mm) intervals and corresponding slice thicknesses. The entire pelvis generally is included to avoid
missing a portion of the fracture, and comparison to the opposite hip is performed routinely. The surgeon
must learn to move from image to image, following the fracture lines and envisioning the obliquities and
displacements of the fracture lines demonstrated. A plastic pelvic model is helpful when learning this
technique and later for drawing more complex fractures directly on the model. In general, the transverse
fracture lines and fractures of the anterior and posterior walls are in the sagittal plane, paralleling the
quadrilateral surface when viewed on axial CT images ( Figs. 53-14 and 53-15 ). Anterior and posterior
column fractures usually extend through the quadrilateral surface and into the obturator foramen with a
more coronal orientation; variant fracture types, however, may not follow these patterns.
Some authors have suggested that axial CT images overestimate the extent of comminution of acetabular
fractures; however, in reality, only existing fracture lines are demonstrated on the images. In transverse
fractures, moving proximally on successive cuts, small fragments of the anterior and posterior walls
enlarge to coalesce medially, becoming the axial cross section of the ilium. What appears to be separate
anterior and posterior wall fracture fragments on more inferior cuts is in reality the distal extent of a
single proximal fragment. An oblique fracture line divides the acetabulum, so the more inferior CT cuts
appear to have three fragments when in reality there are only two. By studying the individual fragments
on multiple successive cuts, the entire fracture can be appreciated, giving a true mental three-dimensional
picture. High-resolution coronal and sagittal reconstructions of the fracture are helpful in the preoperative
evaluation of complex fractures by delineating fractures that lie directly in the plane of a given axial CT
image.
Olson and Matta demonstrated that CT scanning can give the same information about the acetabular dome
as the roof arc measurements on the anteroposterior and oblique roentgenographs. Axial CT scanning
showing the superior 10 mm of the acetabular roof to be intact corresponded to roentgenographic roof arc
measurements of 45 degrees. They also found that fracture of the cotyloid fossa did not jeopardize
stability of the femoral head under the dome if the fossa extended to within 10 mm of the apex of the roof
and the articular surface was intact.

Figure 53-12 Fracture of posterior column of acetabulum. A, Anteroposterior view shows intact iliopectineal line, with
disrupted ilioischial line. B, Iliac oblique (Judet) view shows disrupted posterior column and intact anterior wall. C, Obturator
oblique (Judet) view shows intact anterior column in profile.
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Three-dimensional CT reconstructions ( Fig. 53-16 ) of a fracture have become very sophisticated and can
be projected in many different views with subtraction of the femoral head that demonstrate unique
features of the various fracture patterns. Some surgeons who treat acetabular fractures find routine use of
these reconstructions invaluable. However, we have found that these images rarely change our evaluation
of the fracture or operative plan. Thus, while we occasionally obtain three-dimensional reconstructions in
complicated fractures, we generally rely on axial CT images with coronal and sagittal reconstructions
correlated with the standard three plain roentgenographic views.

CLASSIFICATION
The classification of acetabular fractures described by Letournel and Judet ( Fig. 53-17 ) is the most
widely used classification system. They divided acetabular fractures into two basic groups: simple
fracture types and the more complex associated fracture types. Simple fracture types are isolated fractures
of one wall or column along with transverse fractures; this type includes fractures of the posterior wall,
posterior column, anterior wall, or anterior column, and transverse fractures. The associated fracture types
have more complex fracture geometries and include T-type fractures, combined fractures of the posterior
column and wall, combined transverse and posterior wall fractures, anterior column fractures with a
hemitransverse posterior fracture, and both-column fractures.
Although several of the associated fracture types involve both columns of the acetabulum, the designation
both-column fracture in this classification denotes that none of the articular fracture fragments of the
acetabulum maintain bony continuity with the axial skeleton: a fracture line divides the ilium, so the
sacroiliac joint is not connected to any articular segment. The spur sign, demonstrated on the obturator
oblique view, is pathognomonic of a both-column fracture. It represents the remaining portion of the ilium
still attached to the sacrum and is seen projected lateral to the medially displaced acetabulum ( Fig. 5318 ).
The AO group has developed an alphanumeric classification system for acetabular fractures based on the
severity of the fracture: type A fractures include fractures of a single wall or column, type B fractures
involve both anterior and posterior columns (transverse, or T-type, fractures), and type C fractures involve
both anterior and posterior columns, but all articular segments, including the roof, are detached from the
remaining segment of intact ilium ( Fig. 53-19 ). Type C fractures are those designated both-column
fractures in the Letournel and Judet classification. Each type has subtypes 1, 2, and 3 (e.g., A1, A2, or
A3), depending on the characteristics of the fracture.

Figure 53-13 Roof arc measurement, as described by Matta et al. A, Medial roof arc is measured on anteroposterior view. B,
Anterior roof arc is measured on 45-degree angle obturator oblique view. C, Posterior roof arc is measured on 45-degree angle
iliac oblique view. (From Matta JM et al: Clin Orthop 205:230, 1986.).

Figure 53-14 Orientation of fracture lines through acetabulum as seen on CT scan.

Figure 53-15 A, Anterior column fracture with typical fracture orientation. B, Posterior wall fracture.

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Figure 53-16 Three-dimensional CT reconstruction of both-column fracture.

Figure 53-17 Letournel and Judet classification of acetabular fractures. A, Posterior wall fracture. B, Posterior column
fracture. C, Anterior wall fracture. D, Anterior column fracture. E, Transverse fracture. F, Posterior column and posterior wall
fracture. G, Transverse and posterior wall fracture. H, T-shaped fracture. I, Anterior column and posterior hemitransverse
fracture. J, Complete both-column fracture. (Redrawn from Letournel E, Judet R: Fractures of the acetabulum, New York,
1981, Springer-Verlag.)

One of the disconcerting facts in long-term follow-up of acetabular fractures has been the very different
outcomes that occur after anatomic reduction of fractures of the same type in the current classification
schemes. Some characteristics of acetabular fractures that have a significant effect on the outcome of
treatment are not included in either the Letournel and Judet or the AO classification. Tile proposed adding
qualifiers (factors that affect the prognosis of the injury) to the AO classification scheme including:
femoral head subluxation or dislocation, acetabular or femoral articular surface damage, intraarticular
fragments, and nondisplaced fractures. The Letournel and Judet classification is the most widely accepted
and is used throughout the remainder of this section.
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Figure 53-18 Spur sign in both-column fracture of acetabulum.

TREATMENT
With longer follow-up of operatively treated acetabular fractures as has been reported by Matta and
others, it has become clear that fractures with even small residual incongruencies of the critical portion of
the acetabulum lead to long-term arthritis more often than similar fractures with perfect reductions. Based
on this information, the indications for open reduction and internal fixation (ORIF) of acetabular fractures
have become more inclusive.
Indications for Nonoperative Treatment
Nondisplaced and Minimally Displaced Fractures.

Fractures that traverse the weight-bearing dome but are displaced less than 2 mm can be treated with
nonweightbearing or skeletal traction for 4 to 8 weeks depending on the fracture characteristics.
Roentgenograms should be obtained immediately after the patient is first mobilized and periodically
thereafter to ensure that no displacement has occurred.
Fractures with Significant Displacement but in Which the Region of the Joint Involved Is Judged To Be Unimportant Prognostically.

This determination is made with the roof arc measurements described by Matta and Olson as 45 degrees
for each roof arc: medial, anterior and posterior. Vrahas, Widding, and Thomas have questioned whether
the 45-degree value is the most appropriate for each roof arc. In a study of cadaver hips they proposed
acceptable roof arc measurements as 25 degrees for the anterior roof arc, 45 degrees for the medial roof
arc, and 70 degrees for the posterior roof arc. As a rough guide, they recommended ORIF of displaced
fractures exiting the posterior column above the upper border of the ischial spine as well as fractures
exiting the anterior column through the iliac wing.
Most authors agree that displaced fractures through the weight-bearing dome should be treated with
operative reduction and internal fixation, regardless of how they may line up in traction. These fractures
have a tendency to displace, leading to inferior results. The only exception to this rule is a comminuted
both-column fracture that attains secondary congruence (see below).
Posterior wall fractures associated with posterior fracture-dislocations of the hip require separate
consideration and are evaluated after closed reduction. Larger posterior wall fragments lead to posterior
hip instability and require fixation. A cadaver study by Vailas, Hurwitz, and Wiesel demonstrated that
posterior wall fractures involving more than 50% of the posterior wall consistently led to posterior hip
instability. A similar study by Keith, Brashear, and Guilford demonstrated posterior hip instability with all
fractures involving 40% or more of the acetabular wall. In a group of patients examined with CT scanning
after closed reduction of posterior hip fracture-dislocations, Calkins et al. reported that instability of the
hip occurred when less than 34% of the articular surface of the posterior wall remained; if more than 55%
of the posterior wall remained, stability was maintained. Most authors advocate that any patient for whom
nonoperative treatment of a small posterior wall fracture is being considered should have a clinical
evaluation of hip stability with flexion to 90 degrees.
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Tornetta performed fluoroscopic stress views on 41 hips with acetabular fractures for which ORIF was
not indicated by roof arc measurements or by posterior wall size on CT scan images. He found that 3 of
these hips subluxated on stress views without frank instability noted clinically and required ORIF. These
hips would have passed the traditional clinical test of testing stability by flexing the hip to 90 degrees.
Secondary Congruence in Displaced Both-Column Fractures.

A both-column fracture, by definition, has all its fragments free to move independent of the remaining
ilium. Frequently, comminuted both-column fracture fragments assume a position of articular secondary
congruency around the femoral head, even though the femoral head is displaced medially and there may
be gaps between the fracture fragments ( Fig. 53-20 ). The concept of secondary congruence was
described by Letournel, and closed treatment of these fractures has yielded reasonable and occasionally
exceptional results.

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Figure 53-19 AO classification of acetabular fractures. Type A: fracture involves only one of two columns of acetabulum; type
A1: posterior wall fracture and variations; type A2: posterior column fracture and variations; type A3: anterior wall and
anterior column fracture. Type B: transverse fractures, portion of roof remains attached to intact ilium; type B1: transverse
fracture and transverse plus posterior wall fracture; type B2: T-shaped fracture and variations; type B3: anterior wall or column
plus posterior hemitransverse fracture. Type C: fractures of anterior and posterior columns, no portion of roof remains attached
to intact ilium; type C1: anterior column fracture extending to iliac crest; type C2: anterior column fracture extending to
anterior border of ilium; type C3: fractures enter sacroiliac joint. (From Mller ME, Allgwer M, Schneider R, Willenegger H:
Manual of internal fixation: techniques recommended by the AO-ASIF group, ed 3, Berlin, 1991, Springer-Verlag.).

Figure 53-20 A and B, Left hip displays comminuted both-column acetabular fracture with secondary congruence. Right hip
has T-shaped fracture with medial dome impaction. C, Three years after closed treatment in skeletal traction. Left hip has
minimal cartilage space loss. Right hip developed posttraumatic arthritis requiring total hip replacement.

The concept applies only to this specific subset of fractures and cannot be applied to other fracture types.
Medical Contraindications to Surgery.

In patients with multiple trauma, medical contraindications from multisystem injury are common, even in
previously healthy patients. Although early fracture fixation and mobilization are basic tenets of
multitrauma treatment protocols, complex fractures may require long operative procedures with
significant blood loss. Occasionally, the severity of the medical condition mandates that operative
intervention be delayed. If possible, the articular cartilage of the hip should be protected during these
delays with the patient in skeletal traction. Occasionally, severe head trauma with a tenuous, evolving
spectrum of injury may preclude a surgical procedure. However, a head injury is not necessarily a
contraindication to surgery. Frequently, the eventual neurological outcome cannot be reliably assessed in
the immediate postinjury period, when acetabular ORIF can most reliably be performed.
Parker and Copeland have reported the use of percutaneous fluoroscopic screw fixation in suitable
fractures in severely injured patients and in patients with severe medical comorbidities. They stated that
this form of treatment is not a substitute for formal ORIF, although it could be considered in these patients
to allow mobilization.
Local Soft Tissue Problems, Such as Infection, Wounds, and Soft Tissue Lesions from Blunt Trauma.

An open wound in the anticipated surgical field is a contraindication, as is systemic infection. The MorelLavalle lesion is a localized area of subcutaneous fat necrosis over the lateral aspect of the hip caused by
the same trauma that causes the acetabular fracture. The size and extent of this lesion are variable, and
14

operating through it has been associated with a higher rate of postoperative infection. Hak, Olson, and
Matta found the infection rate to be 12% with repeated postoperative wound debridement, packing, and
healing by secondary intention. Alternatively, some fractures can be treated through the ilioinguinal
approach, thus avoiding the affected area.
The presence of a suprapubic catheter generally is considered a contraindication to acetabular ORIF by
the ilioinguinal approach. Bacterial colonization of the catheter has been anecdotally reported to increase
the rate of infection. The best method of avoiding this situation is to discuss with the urologist the
possibility of avoiding suprapubic drainage of the bladder. We have occasionally delayed surgery to allow
a previous suprapubic catheter tract to seal before proceeding with the ilioinguinal approach.
Elderly Patients with Osteoporotic Bone in Whom Open Reduction May Not Be Feasible.

Helfet et al., in a report of open reduction and internal fixation in a series of patients over 60 years of age,
questioned this indication for nonoperative treatment. In their study only one fracture lost its reduction
because of fixation failure, and complications were similar to those in younger patients. Matta reported
that patients over the age of 40 had slightly worse clinical outcomes than younger patients. He correlated
this with greater difficulty in attaining perfect reductions in this age group rather than age itself. In our
experience, rare comminuted fractures in elderly, osteopenic patients cannot be treated by standard ORIF.
The options for these patients include traction, immediate mobilization, and rarely primary total hip
arthroplasty.
Indications for Operative Treatment

An acetabular fracture with 2 mm or more displacement in the dome of the acetabulum as defined by any
roof arc measurements less than 45 degrees is an indication for operative intervention as is any
subluxation of the femoral head from a displaced acetabular fracture noted on any of the three standard
roentgenographic views. Also, more than 50% involvement of the articular surface of the posterior wall or
clinical instability with hip flexion to 90 degrees in posterior wall fractures should also be considered a
candidate for operative treatment. As stated above, posterior wall fractures with more than 50% of the
wall involved are generally considered unstable and do not require any test of stability. However,
posterior wall fractures involving less than 50% of the wall may be unstable, and are clinically tested by
flexing the hip to 90 degrees with the patient sedated or anesthetized.
Incarcerated Fragments in the Acetabulum after Closed Reduction of a Hip Dislocation.

Small avulsed fragments of the ligamentum teres that stay sequestered in the cotyloid fossa and do not
affect the congruency of the hip probably do not require excision. Fragments noted on CT scan to be
lodged between the articular surfaces of the femoral head and the acetabulum warrant excision.
Prevention of Nonunion and Retention of Sufficient Bone Stock for Later Reconstructive Surgery.

The last indication is debatable and should be applied only in cases of extreme deformity, because total
hip arthroplasty after failed ORIF of an acetabular fracture may be more difficult than hip arthroplasty
after nonoperative management. The presence of scarring from previous surgeries, hardware, and
heterotopic bone can complicate such secondary reconstruction.
Most authors advocate waiting 2 to 3 days after injury before performing acetabular surgery to allow the
patient to be adequately stabilized and to allow pelvic bleeding to subside. Ideally, operative reduction
and internal fixation of acetabular fractures should be performed within 5 to 7 days of injury. Anatomical
reduction becomes more difficult after that time because hematoma organization, soft tissue contracture,
and subsequent early callus formation all hinder the process of fracture reduction, especially if the more
limited Kocher-Langenbeck or ilioinguinal exposure is used. After a delay of more than 15 days, a more
extensile exposure may be necessary to obtain adequate reduction.
If surgical stabilization is indicated, detailed evaluation of the fracture configuration and classification is
necessary to plan the operative approach. Some fracture patterns are routinely reduced through an anterior
ilioinguinal approach, whereas others are more appropriate for the posterior Kocher-Langenbeck
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approach. Prone positioning of the patient may aid the reduction of some acetabular fractures treated
through the Kocher-Langenbeck approach by not allowing the weight of the leg to displace the fracture.
With transverse and some T-type fractures, the choice of an anterior or posterior approach is determined
by which exposure allows access to the side of the fracture with the maximal displacement. Osteotomy of
the trochanter can also aid exposure of transverse fractures or extensive fractures of the posterior column.
This osteotomy does not seem to affect the vascularity of the femoral head and has a high rate of union, as
shown by Bray, Esser, and Fulkerson. However, Heck, Ebraheim, and Foetisch found that trochanteric
osteotomy was associated with a 44% rate of heterotopic ossification, which was Brooker grade IV in 9%
(bony ankylosis).
More complicated fractures may require one of the extensile approaches, such as the extended iliofemoral
approach described by Letournel and Judet, the triradiate approach of Mears and Rubash, or the Tapproach described by Reinert et al. If an extensile exposure is used, Bosse et al. recommended
confirmation of the patency of the superior gluteal artery with angiography because this may be the only
vascular pedicle supplying the abductor muscles. This recommendation was based primarily on clinical
observation of patients with extensile exposures as well as concerns about the collateral circulation of the
abductor muscle mass and was further supported by cadaveric studies by Juliano, Bosse, and Edwards.
This recommendation has not been universally accepted and was not supported by a canine study by
Tabor et al., with ligation of the superior gluteal artery followed by various surgical approaches showing
ischemia yet no frank necrosis with extensile approaches. They still recommended caution when
considering the use of an extensile approach with a suspected superior gluteal artery injury.
To prevent complications of extensile exposures, Helfet and Schmeling advocated the use of limited
exposures and indirect reduction techniques. Using only the Kocher-Langenbeck and the ilioinguinal
approaches, they were able to obtain satisfactory reductions in 91% of 84 complex fractures. Routt and
Swiontkowski, Schmidt and Gruen, and Winquist have advocated using both anterior and posterior
approaches for some fractures. These approaches can be made either sequentially or simultaneously, with
the patient in a floppy lateral position. Modifications of the ilioinguinal approach to allow access to the
lateral aspect of the iliac wing have been described by Gorczyca, Powell, and Tile and by Weber and
Mast. The modified Stoppa approach, described by Cole and Bolhofner, uses a midline incision to expose
the internal surface of the pelvis and the quadrilateral surface.

16

Figure 53-21 Specialized instruments and implants for treatment of acetabular fractures.

We prefer to use skeletal traction on a radiolucent fracture table on which the perineal post can be raised
or lowered when the patient is in the lateral position. Others have stated that they prefer to drape the limb
free to allow positioning of the limb to facilitate exposure. The standard operative approaches are
described in Chapter 1 .

TREATMENT OF SPECIFIC FRACTURE PATTERNS

Detailed surgical recommendations and techniques for acetabular fracture stabilization are too numerous
to be included here, and the reader is referred to the standard texts of Letournel and Judet as well as Tile.
Before embarking into this field, we strongly recommend one of the available comprehensive
instructional courses including cadaver dissection and ORIF workshops. Specialized pelvic equipment,
implants, and facilities are required for optimal treatment of these fractures, including a radiolucent
fracture table, a full array of screw sizes and lengths (up to 110 mm), and reconstruction plates that can be
contoured in three dimensions, as required by the convoluted configuration of the acetabulum ( Fig. 53-21
). Pelvic clamps developed by the AO/ASIF group for reduction of fracture fragments are especially
helpful. Treatment strategies for specific fractures are shown in Fig. 53-22 .
Posterior Wall Fractures

The most common fracture treated by the average orthopaedist is the posterior wall fracture. These
fractures are treated through a Kocher-Langenbeck approach (Technique 1-62 (Box Not Available) ) with
the patient positioned either prone or lateral using lag screws and a reconstruction plate placed from the
ischium, over the retroacetabular surface onto the lateral ilium ( Fig. 53-23 ). If the fracture extends
superiorly into the dome, a trochanteric osteotomy may be performed to allow additional exposure. To
avoid avascular necrosis of the posterior wall, the posterior wall fragments must not be detached from the
posterior capsule. The use of spring plates has been advocated by Goulet et al. to improve stability in
comminuted fractures. These are made out of one third tubular plates by cutting or breaking the plate
through the last screw hole and bending down the remaining end as tines that are used to capture bone
fragments that cannot be easily fixed with screws. The spring plate is slightly overcontoured so that when
the reconstruction plate is applied over the spring plate, the captured fragments are held firmly in
position. We have found this technique very useful in fractures with multiple fragments and fractures that
extend very close to the acetabular rim ( Fig. 53-24 ).
Although a posterior wall fracture is the easiest fracture pattern to reduce, the reported long-term results
after this fracture have been variable. Avascular necrosis of the femoral head as a result of associated hip
dislocation, marginal impaction, multiple fracture fragments, and osteochondral injuries of the femoral
head all adversely affect the outcome of these fractures. Intraarticular screw placement must be avoided,
even if it requires leaving some of the screws out of the buttress plate. Intraoperative fluoroscopy in
multiple views should be used to ensure that all screws are extraarticular.
Posterior Column Fractures

Posterior column fractures are relatively uncommon and, if significantly displaced, require operative
reduction and internal fixation ( Fig. 53-25 ). The Kocher-Langenbeck approach is used routinely.
Rotational deformity must be corrected in addition to displacement by placing a Shanz screw in the
ischium to control rotation while the fracture is reduced with a reduction clamp. Typical fixation is with a
lag screw combined with a contoured reconstruction plate along the posterior column.

17

18

Figure 53-22 A, Multifragmented posterior wall fracture with intraarticular comminution. B, Posterior column fracture with a
lag screw reaching the anterior column. C, Transverse fracture with a lag screw reaching the anterior column. D, Associated
transverse and posterior wall fracture. E, Associated T-type acetabular fracture. Lag screws inserted into both anterior and
posterior columns. F, Anterior column fracture. Several lag screws are placed between inner and outer tables of innominate
bone. G, Associated anterior column and posterior hemitransverse fracture. Screws inserted from pelvic brim must reach distal
to fracture line and engage in posterior column. H, Both-column fracture operated on through ilioinguinal approach. Screws
inserted from pelvic brim reach posterior column. I, Both-column fracture. Internal fixation performed through extended
iliofemoral approach. Two very long screws are inserted into anterior column and reach superior pubic ramus. (From
Templeman DC et al: Instr Course Lect 48:481, 1999.)

Anterior Wall and Anterior Column Fractures

Isolated anterior wall fractures are uncommon and sometimes associated with anterior hip dislocation.
Fractures requiring surgery are fixed with a buttress plate applied through an ilioinguinal or iliofemoral
approach. Anterior column fractures are approached similarly, with fixation by a contoured plate along
the pelvic brim ( Fig. 53-26 ). At the level of the iliopectineal eminence, the medial wall of the
acetabulum is thin, and generally screws should not be placed in this region. Anterior column fractures
that exit higher through the iliac wing also require fixation along the iliac crest as well.

Figure 53-23 Posterior wall fracture fixed with contoured 3.5-mm pelvic reconstruction plate.

19

Figure 53-24 Posterior wall acetabular fracture treated with spring plate and associated contoured pelvic reconstruction plate.

Figure 53-25 A, Posterior column fracture of acetabulum. B, Postoperative roentgenograph showing definitive fixation and
also demonstrating Brooker grade III heterotopic ossification.

20

Figure 53-26 Fixation of low anterior column fracture with contoured plate along pelvic brim.
Transverse Fractures

These fractures, although apparently simple, present a spectrum of difficulty. Selection of the appropriate
approach is crucial because fractures with primarily anterior displacement can be very difficult to reduce
through a posterior approach. Transtectal fractures, or fractures that occur above the cotyloid fossa, have
the worst prognosis, and accurate reduction is essential. Juxtatectal fractures, those that occur at the
junction of the cotyloid fossa with the articular surface, also usually require reduction, whereas infratectal
fractures frequently can be treated nonoperatively.
Typical reduction is through a posterior approach, using a Farabeuf clamp to reduce the fracture while
rotation is controlled by a Schanz screw in the ischium. The intraarticular reduction can be assessed
directly by distracting the limb in traction and palpating the reduction of the quadrilateral surface through
the greater sciatic notch. Posterior fixation typically is with a buttress plate along the posterior column
with anterior fixation, using a 3.5-mm lag screw placed into the anterior column from a position above the
acetabulum. Care must be taken with placement of the anterior lag screw because of the proximity of the
iliac vessels.
From the ilioinguinal approach, reduction can be performed by a variety of methods, including plate
reductions as well as using a large spiked reduction clamp placed on the quadrilateral surface and the
lateral surface of the region of the anterior inferior spine. Typical fixation is a contoured plate along the
pelvic brim with at least one lag screw directed down the posterior column ( Fig. 53-27 ). Occasionally,
extensile or combined approaches are necessary for more complex transverse fractures.
Posterior Column Fracture with Associated Posterior Wall Fracture

A Kocher-Langenbeck approach is used, with or without a trochanteric osteotomy. The column fracture is
reduced first, and a short reconstruction plate is placed posteriorly along the posterior edge of the column.
A separate plate is used for the wall fragment; the screws through this plate secure rotational reduction of
21

the posterior column fragment. When the wall fragment is small, spring plates can be used instead of a
separate wall plate ( Fig. 53-28 ).

Figure 53-27 Transverse acetabular fracture with primarily anterior displacement fixed from anterior ilioinguinal approach.
Transverse Fracture with Associated Posterior Wall Fracture

This common fracture can be difficult to reduce. The posterior wall component requires a posterior
exposure, but reduction of the anterior part of the transverse fracture can be difficult through a KocherLangenbeck approach, particularly when the wall fragment is large with minimal or no intact posterior
column cortical surface with which to judge the reduction. An extensile or combined approach frequently
is necessary for this injury. Fixation is variable depending on the fracture specifics and the approach used
( Fig. 53-29 ).
T-Type and Anterior ColumnPosterior Hemitransverse Fractures

A T-type fracture with minimal posterior displacement is similar to an anterior column-posterior

hemitransverse fracture, which typically has only minimal posterior displacement. These two patterns can
be treated through an ilioinguinal approach with a contoured plate placed along the pelvic brim and lag
screws extending into the posterior column. When a T-type fracture has severe posterior displacement but
minimal anterior displacement, a posterior approach alone may be sufficient, usually with placement of an
anterior column lag screw. If both the anterior and posterior components of the fracture are significantly
displaced, extensile or combined approaches usually are required. Occasionally, with these fractures and
other associated fracture types, a separate, displaced and comminuted medial wall fragment is present.

22

Figure 53-28 Posterior column and posterior wall acetabular fracture fixed with two plates. The first reconstructs posterior
column, then second reconstruction plate (supplemental spring plate) fixes posterior wall fragments.

If it is proximal enough to affect stability, a spring plate bent at a 100- to 110-degree angle can be placed
under an anterior column plate to maintain reduction of this fragment ( Fig. 53-30 ).
Both-Column Fractures

These fractures are sometimes described as T-type fractures that have their transverse component above
the dome of the acetabulum. They have varying degrees of comminution and can be extremely complex
and difficult to treat. Many both-column fractures can be treated through an anterior ilioinguinal approach
( 53-31 ), but a posterior or extensile exposure is required for involvement of the sacroiliac joint, a
significant posterior wall fracture, or intraarticular comminution that requires reduction under direct
vision. In general, reduction is begun from the most proximal portion of the fracture and proceeds toward
the joint. Each small fragment must be anatomically reduced because small malreductions in the ilium
above the fracture become magnified at the level of the joint. Combined anterior and posterior approaches
are advocated by some to limit the morbidity associated with extensile approaches. Fixation is as varied
as the fracture patterns and the approaches used.

POSTOPERATIVE CARE
Postoperatively, closed-suction drainage is used, antibiotic therapy is continued for 48 to 72 hours, and
passive motion of the hip is begun on the second or third day. Touch-down ambulation with crutches
usually is allowed by the second to fourth day and progresses gradually depending on other injuries. This
minimal weight-bearing status is continued for approximately 8 weeks in patients with simple fractures
and 12 weeks in most others. Rehabilitation of the abductor muscle group is essential after the KocherLangenbeck and extensile exposures. Prophylaxis for deep venous thrombosis and heterotopic
ossification is performed as discussed under complications.

23

OUTCOME AND COMPLICATIONS

Reported overall mortality rates after acetabular fractures range from 0% to 2.5%. In Letournel's series,
the mortality in patients over 60 years of age was 5.7%. Helfet, Borrelli, and DiPasquale reported no
deaths in 18 patients over age 60 who were treated with operative reduction and internal fixation.
Letournel's series of 940 patients with acetabular fractures is the largest in the literature. Of 569 patients
who underwent operative reduction and internal fixation within 21 days of injury, 17% of those followed
for at least 1 year had posttraumatic arthritis. After perfect reduction of 418 fractures, the rate of
posttraumatic arthritis was 10.2%, and after imperfect reduction of 151 fractures it was 35.7%. Bothcolumn and transverse-posterior wall fractures had worse results than other associated fracture types,
primarily because of imperfect reduction. Posterior wall fractures, although reduced nearly perfectly in
98%, resulted in posttraumatic arthritis in 17%. Matta, Helfet, Mayo, and others have reported smaller
series with similar results.
Avascular necrosis occurs more frequently after fractures associated with posterior dislocation.
Letournel's reported rate of avascular necrosis after posterior dislocation was 7.5%. For other fractures in
his series, avascular necrosis occurred in 1.6%. Avascular necrosis is roentgenographically apparent
within 2 years of injury in most patients. Avascular necrosis of the posterior wall can be caused by the
injury or by excessive fracture site exposure because the only vascular supply of these fragments is the
injured posterior capsule of the hip.
Infections are reported to occur in 1% to 5% of patients and may destroy the hip joint. Certain factors are
thought to increase the risk of infection, including the presence of a suprapubic catheter in ilioinguinal
approaches and the Morel-Lavalle lesion in Kocher-Langenbeck and extensile approaches.
Sciatic nerve palsies as a result of the initial injury occur in approximately 10% to 15% of patients with
acetabular fractures. Sciatic nerve injury as a result of surgery occurs in 2% to 6% of patients and is more
often associated with posterior fracture patterns treated through the Kocher-Langenbeck and extensile
exposures. Many authors, including Helfet et al., Moed, Maxey, and Minster, and Calder, Mast, and
Johnstone, have advocated intraoperative monitoring of somatosensory evoked potentials (SSEP) as a
means of decreasing the incidence of intraoperative sciatic nerve injury, especially with posterior
approaches. Helfet et al. have reported the use of spontaneous electromyography (EMG) monitoring in
addition to SSEP monitoring. They noted that changes in the spontaneous EMG signal allowed earlier
detection and removal of noxious sciatic nerve stimuli with significantly less SSEP changes as compared
to a group monitored by SSEP alone. However, Matta, as well as Stannard, and Alonzo have found that
with experience their rate of iatrogenic nerve injury without monitoring is similar to the levels quoted in
studies recommending routine monitoring. They do not routinely perform intraoperative nerve monitoring
and question the usefulness of routine monitoring when the operating surgeon is sufficiently experienced.
Fassler et al., in a report of 14 patients with sciatic nerve injuries, found that the peroneal component of
the sciatic nerve was more often involved than the tibial component and that the tibial component had a
greater chance of recovery; complete peroneal palsies had the worst prognosis. Functional recovery has
been shown in approximately 65% of patients, and function may improve up to 3 years after injury.
Heterotopic ossification (HO) occurs after most extensile approaches, with moderate to severe heterotopic
ossification occurring in 14% to 50% of patients when no prophylaxis is used; it occurs after the KocherLangenbeck approach in approximately 25% of patients in whom no prophylaxis is used ( Fig. 53-32 ).
Heterotopic ossification is rare after the ilioinguinal approach unless the external surface of the ilium is
stripped. McLaren, as well as Johnson, Kay, and Dorey, and Moed and Maxey demonstrated the
effectiveness of indomethacin in decreasing significant heterotopic ossification after acetabular fracture
surgery. This has been called into question by Matta and Siebenrock who found indomethacin to be
ineffective in their prospective series. Letournel, Slawson et al., and Bosse et al. demonstrated the
effectiveness of low-dose radiation in decreasing the incidence of significant heterotopic ossification;
Moed and Letournel noted an additive effect when the two regimens were combined.
24

Figure 53-29 Transverse posterior wall acetabular fracture fixed through Kocher-Langenbeck approach with additional
trochanteric osteotomy.

Currently, for patients treated with the Kocher-Langenbeck or extensile approaches, we use indomethacin,
25 mg three times a day for 4 to 6 weeks, or radiation with a one-time dose of 700 cGy in patients in
whom indomethacin is contraindicated. We do not use routine low-dose radiation in young patients
because the long-term effects of this dose of radiation are not yet known.
Thromboembolic complications can be the most devastating, and the management of these problems is
controversial. Deep venous thrombosis has been reported to occur in 8% to 61% of patients with
acetabular fractures; however, this is very dependent on the method used to detect the thrombosis.

25

Figure 53-30 T-type acetabular fracture with significant anterior and posterior displacement as well as separate medial wall
fragment that affected stability. Sequential anterior and posterior approaches were used, and medial wall spring plate was
added for fixation of medial wall fragment.

26

Figure 53-31 Both-column acetabular fracture treated through ilioinguinal approach with indirect reduction of acetabulum and
fixation placed on internal surfaces of pelvis.

Montgomery, Potter, and Helfet found that magnetic resonance venography (MRV) was more sensitive
than a venogram in detecting clots within the intrapelvic veins and contralateral extremity. In a
subsequent study, they reported that MRV detected asymptomatic DVTs in 34% of their patients; 49%
were above the level of the inguinal ligament. They recommended inferior vena cava filter placement in
most patients with proximal DVTs and had only a 1% incidence of nonfatal pulmonary embolism. The
reported risks of pulmonary embolism range from 2% to 6%.
Our current protocol involves the use of subcutaneous enoxaparin and intermittent compression boots
while patients are awaiting surgery. We obtain a preoperative screening duplex Doppler scan in any
patient in whom the injury is more than 2 to 4 days old. As suggested by Collins et al., we use Greenfield
vena cava filters in patients with positive duplex scans and also frequently use them in high-risk groups,
as recommended by Webb et al., including patients over 60 years of age, patients with contraindications
to anticoagulation, and patients in whom obesity, malignancy, or a history of prior deep venous
thrombosis is a factor. Postoperatively, anticoagulation with enoxaparin followed by warfarin is continued
for 6 weeks unless medically contraindicated.

27

Figure 53-32 Brooker grade IV heterotopic ossification occurred in spite of postoperative radiation.

TOTAL HIP ARTHROPLASTY AS TREATMENT FOR ACETABULAR FRACTURE

Joly and Mears and Jimenez et al. reported treating some acetabular fractures with extremely poor
prognoses with primary total hip arthroplasty, using adjunctive fixation of the acetabular fracture with
plates or cables and multiple screw fixation of the cup. We have used this technique for salvage of hip
function in a few older individuals (approximately 1% to 2% of our cases) with similar indications.
Examples include a comminuted, incongruous, both-column fracture referred to us 3 weeks after injury
( Fig. 53-33 ) and an unreduced posterior fracture-dislocation of the hip with severe marginal impaction
and femoral head erosion referred to our institution 4 weeks after injury. One concern with this technique
is that the cementless acetabular component could fail to incorporate adequately in the healing acetabular
bed. In their series of 57 patients, Joly and Mears found that routinely the acetabular shells would subside
1 to 3 mm during fracture healing, then typically stabilize. They emphasized the avoidance of extensile
approaches to minimize the risk of infection.

Figure 53-33 A, Both-column acetabular fracture 3 weeks after injury. B, Two years after primary total hip replacement.

Total hip arthroplasty performed for posttraumatic arthritis after acetabular fracture has been found not to
reproduce the same results as total hip arthroplasty performed for degenerative arthritis. Romness and
Lewallen noted a fourfold to fivefold increase in the loosening and revision rates for cemented acetabular
sockets used in total hip arthroplasties for posttraumatic arthritis after acetabular fractures compared with
arthroplasties for degenerative arthritis in a similar group of patients. The results of cementless sockets
28

may be better. Weber, Berry, and Harmsen reported no loosening of 22 uncemented acetabular
components placed after previous ORIF of an acetabular fracture at 3.9 years follow-up. In general, prior
attempts at operative fixation of acetabular fractures make subsequent total hip replacement more difficult
with scarring, retained hardware, and heterotopic ossification.
Pelvic Fractures
Fractures of the adult pelvis, exclusive of the acetabulum, generally are either (1) stable fractures
resulting from low-energy trauma, such as falls in elderly patients or (2) fractures caused by high-energy
trauma that result in significant morbidity and mortality. As is true of fractures of other bones, low-energy
trauma to the pelvis generally produces stable fractures that can be treated symptomatically with crutchor walker-assisted ambulation and that can be expected to heal uneventfully in most patients. High-energy
pelvic fractures often are managed operatively, with the treatment method determined by the degree of
pelvic stability remaining after the injury. This section focuses on these high-energy injuries, their
management both in the resuscitative and reconstructive phases, and their potential complications.
High-energy pelvic fractures result most commonly from motor vehicle accidents, falls, motorcycle
accidents, automobile-pedestrian encounters, and industrial crush injuries. The potential complications of
high-energy pelvic fractures include injuries to the major vessels and nerves of the pelvis and the major
viscera, such as the intestines, the bladder, and the urethra. Degloving injuries to the surrounding soft
tissues, both open and closed, also may accompany these fractures and complicate their treatment.
Reported mortality from severe pelvic fracture ranges from 10% to as high as 50% in some earlier series
of open pelvic fractures. Gilliland et al. and others demonstrated that risk factors for increased mortality
include the patient's age and injury severity score, associated head or visceral injury, blood loss,
hypotension, coagulopathy, and unstable or open pelvic fractures. Early mortality most commonly results
from hemorrhage or closed head injury, while late mortality occurs from sepsis or multiple system organ
failure.
Immediately after injury, mortality can result from severe intrapelvic hemorrhage. Tile and others have
developed treatment algorithms for the management of polytraumatized patients with pelvic fractures and
hemodynamic instability ( Fig. 53-34 ). Hemorrhage frequently results from fracture surfaces and small
vessels in the retroperitoneum. Only 5% to 10% of patients with pelvic fractures bleed from arterial
sources identified by angiography and treated with embolization. Patients with hemodynamic instability
and unstable pelvic fractures should be evaluated for other sources of hemorrhage. CT scan of the chest
and abdomen, supraumbilical peritoneal lavage, or abdominal ultrasound can be used for this assessment.
If this evaluation is negative and hemodynamic instability persists, an external fixator should be applied
immediately to decrease motion at the fracture sites as well as to decrease pelvic volume and generate
tamponade of the pelvic venous plexus. Riemer et al. reported a decreased mortality rate, from 26% to
6%, after adopting an external fixation and early mobilization protocol for patients with pelvic fractures.
Their mortality rate for hypotensive patients fell from 41% to 21%.
Open pelvic fractures are extremely difficult injuries to manage, with reported mortality rates of up to
50%. If the retroperitoneal space is open, no tamponade effect occurs to prevent excessive bleeding.
Sepsis caused by fecal contamination is a major cause of mortality with this injury, and immediate
diverting colostomy is indicated in patients with perineal wounds. Faringer et al. anatomically classified
open pelvic wounds into zones, and recommended selective fecal diversion for patients with open wounds
involving the rectum or anus, soft tissue wounds in close proximity to the anus, or large avulsion flaps
with associated ischemic pelvic tissue ( Fig. 53-35 ).
Routine vaginal and rectal examinations should be performed in patients with open pelvic fractures
because fracture fragments can penetrate these structures, with devastating consequences if timely and
appropriate debridement is not performed. External fixation can minimize fracture motion and further soft
tissue injury.

29

ANATOMY
Bucholz, Pennal et al., Young and Burgess, and others have extensively evaluated the anatomy and
pathomechanics of pelvic ring disruptions, and their work has added greatly to our understanding of these
injuries. The pelvis is composed anteriorly of the ring of the pubic and ischial rami connected with the
symphysis pubis. A fibrocartilaginous disc separates the two pubic bodies. Posteriorly, the sacrum and the
two innominate bones are joined at the sacroiliac joint by the interosseous sacroiliac ligaments, the
anterior and posterior sacroiliac ligaments, the sacrotuberous ligaments, the sacrospinous ligaments, and
the associated iliolumbar ligaments ( Fig. 53-36, A ). This ligamentous complex provides stability to the
posterior sacroiliac complex because the sacroiliac joint itself has no inherent bony stability. Tile has
compared this relationship of the posterior pelvic ligamentous and bony structures to a suspension bridge
with the sacrum suspended between the two posterior superior iliac spines ( Fig. 53-36, B ).

30

Figure 53-34 Treatment algorithm for patients with pelvic fractures, multiple trauma, and hemodynamic instability. (From Tile
M: Fractures of the pelvis and acetabulum, Baltimore, 1984, Williams & Wilkins.)

31

Figure 53-35 Three zones of injury that guide decisions regarding need for colostomy in open pelvic fractures. According to
Faringer et al. Zone I injuries often require colostomy, while diversion is rarely required for zone III wounds. Zone II injuries
are diverted selectively with wounds into subcutaneous fat of anterior groin or medial thigh possibly requiring colostomy.
(From Faringer et al: Arch Surg 129:960, 1994.)

Pelvic stability is determined by ligamentous structures in various planes. The primary restraints to
external rotation of the hemipelvis are the ligaments of the symphysis, the sacrospinous ligament, and the
anterior sacroiliac ligament. Rotation in the sagittal plane is resisted by the sacrotuberous ligament.
Vertical displacement of the hemipelvis is controlled by all the mentioned ligamentous structures, but if
other ligaments are absent, it may be controlled by intact interosseous sacroiliac and posterior sacroiliac
ligaments, along with the iliolumbar ligament. Frequently, a rotationally unstable hemipelvis may remain
vertically stable because of these intact ligamentous structures. This has significant implications in
classification, prognosis, and treatment.

CLASSIFICATION
Bucholz, in a classic study of 150 consecutive victims of fatal motor vehicle accidents, found pelvic
fractures in 31%. He separated them into three groups: group I had displaced anterior ring injuries with
minimally displaced, stable sacral fractures or incomplete tearing of the anterior sacroiliac ligament;
group II had anterior injuries associated with a rotational opening of the sacroiliac joint with disruption of
only the anterior sacroiliac ligaments, sparing the posterosuperior sacroiliac ligament complex; and group
III had complete disruption of the anterior and posterior hemipelvis.
Pennal et al. developed a mechanistic classification in which pelvic fractures are described as
anteroposterior compression injuries, lateral compression injuries, or vertical shear injuries. Tile modified
the Pennal system to make it an alphanumeric system involving three groups based on the concept of
pelvic stability ( Box 53-1 ): A (stable), B (rotationally unstable but vertically stable), and C (rotationally
and vertically unstable). This classification is widely used in the current literature.
Type A (stable) fractures are further divided into two groups. Type A1 fractures do not involve the pelvic
ring, such as avulsion fractures of the iliac spines or the ischial tuberosity and isolated fractures of the
iliac wing. Type A2 fractures are stable fractures of the pelvic ring with minimal displacement, such as
commonly result from low-energy falls in elderly patients.
Type B fractures are rotationally unstable. Type B1 fractures include open book fractures or anterior
compression injuries in which the anterior pelvis opens through a diastasis of the symphysis or through a
fracture of the anterior pelvic ring ( Fig. 53-37, A ). The posterior sacroiliac and interosseous ligaments
remain intact. Tile described stages of this injury. In the first stage, the symphysis separation is less than
2.5 cm, and the sacrospinous ligament remains intact. In the second stage, the diastasis is more than 2.5
cm with rupture of the sacrospinous ligament and the anterior sacroiliac ligament. In the third stage, the
lesions are bilateral, creating a B3 injury. Type B2-1 fractures are lateral compression injuries with
32

ipsilateral fractures ( Fig. 53-37, B ) and type B2-2 fractures have a lateral compression component but
the fractures are contralateral, a bucket handle injury. The ligamentous structures generally are not
disrupted by the internal rotation of the hemipelvis.
Box 53-1. Classification of Pelvic Ring Lesions

TYPE A: STABLE (POSTERIOR ARCH

INTACT)
A1: Avulsion injury
A2: Iliac wing or anterior arch fracture
caused by a direct blow
A3: Transverse sacrococcygeal fracture
TYPE B: PARTIALLY STABLE
(INCOMPLETE DISRUPTION OF
POSTERIOR ARCH)
B1: Open book injury (external rotation)
B2: Lateral compression injury (internal
rotation)
B2-1: Ipsilateral anterior and posterior
injuries
B2-2: Contralateral (bucket handle) injuries
B3: Bilateral
TYPE C: UNSTABLE (COMPLETE
DISRUPTION OF POSTERIOR ARCH)
C1: Unilateral
C1-1: Iliac fracture
C1-2: Sacroiliac fracture-dislocation
C1-3: Sacral fracture
C2: Bilateral, with one side type B, one side
type C
C3: Bilateral
From Tile M: J Am Assoc Orthop Surg 4:143, 1996.

Type C fractures ( Fig. 53-37, C ) are unstable both rotationally and vertically. These include vertical
shear injuries and anterior compression injuries with disruption of the posterior ligamentous complex.
Type C1 fractures include unilateral fractures of the anterior and posterior complex, subdivided by the
location of the posterior fracture. Type C2 fractures include bilateral injuries with one hemipelvis
vertically stable and the other unstable. Type C3 fractures are bilateral fractures that are both vertically
33

and rotationally unstable. Tile's classification of pelvic ring fractures relates directly to the type of
treatment indicated and the prognosis of the injury.

Figure 53-36 A, Major posterior stabilizing structures of pelvic ring (posterior view). B, Tile compares relationship of
posterior pelvic ligamentous and bony structures to suspension bridge, with sacrum suspended between two posterosuperior
iliac spines. (From Tile M: J Am Assoc Orthop Surg 4:143, 1996.)

Young and Burgess proposed a different modification of the original Pennal classification, adding a new
category for combined mechanical injuries ( Table 53-1 ). In a subsequent series, lateral compression
(LC) injuries were the most common injury pattern, accounting for 41% of the patients, followed by
anteroposterior compression (APC) injuries (26%), acetabular fractures (18%), combined mechanical
(CM) injuries (10%), and vertical shear (VS) injuries (5%). Hypovolemic shock and large blood
requirements were more common in patients with vertically unstable APC type 3 injuries than in those
with vertically stable APC or LC injuries. In Young and Burgess' series, patients with the most severe LC
injuries (type 3) had no associated head injuries, whereas those with less severe LC injuries had head
injury rates similar to those for patients with other pelvic injury patterns.
Sacral fractures have been classified separately by several authors. Currently, the classification used most
often is that proposed by Denis, Davis, and Comfort ( Fig. 53-38 ): type 1 fractures occur lateral to the
neural foramina through the sacral ala; type 2 fractures are transforaminal; type 3 fractures occur medial
or central to the neural foramina. Transverse fractures of the sacrum are classified as type 3 injuries
because they involve the spinal canal.

ROENTGENOGRAPHIC EVALUATION
34

The standard roentgenographic projections required for evaluation of pelvic fractures are an
anteroposterior view of the pelvis and 40-degree caudad inlet and 40-degree cephalad outlet views
described by Pennal et al. ( Fig. 53-39 ). The inlet view demonstrates rotational deformity or
anteroposterior displacement of the hemipelvis. The outlet view demonstrates vertical displacement of the
hemipelvis, sacral fractures, and widening or fracture of the anterior pelvis.

Figure 53-37 Tile classification of pelvic fractures based on forces acting on pelvis. A, Type B1: External rotation or anteroposterior compression through
left femur (arrows) disrupts symphysis, pelvis, and anterior sacroiliac ligament until ilium impinges against posterior aspect of sacrum. If force stops at this
level, partial stability of pelvis is maintained by interosseous sacroiliac ligaments. B, Type B2-1: Lateral compression (internal rotation) force implodes
hemipelvis. Rami may fracture anteriorly, and posterior impaction of sacrum may occur, with some disruption of posterior structures, but partial stability is
maintained by intact pelvic floor and compression of sacrum. C, Type C: Shearing (translational) force disrupts symphysis, pelvic floor, and posterior
structures, rendering hemipelvis completely unstable. (From Tile M: J Am Assoc Orthop Surg 4:143, 1996.)
TABLE 53-1 -- Injury Classification Keys
Category

Common Characteristics

Differentiating Characteristics

LC1

Anterior transverse fracture (pubic rami)

Sacral compression on side of impact

LC2

Anterior transverse fracture (pubic rami)

Crescent (iliac wing) fracture

LC3

Anterior transverse fracture (pubic rami)

Contralateral open book (APC) injury

APC 1

Symphyseal diastasis

Slight widening of pubic symphysis and/or SI joint; stretched but

intact anterior and posterior ligaments

APC 2

Symphyseal diastasis or anterior vertical fracture

Widened S1 joint, disrupted anterior ligaments; intact posterior

ligaments

APC 3

Symphyseal diastasis or anterior vertical fracture

Complete hemipelvis separation but no vertical displacement;

complete sacroiliac joint disruption; complete anterior and posterior
ligament disruption

VS

Symphyseal diastasis or anterior vertical fracture

Vertical displacement anteriorly and posteriorly, usually through SI

joint, occasionally through iliac wing and/or sacrum

CM

Anterior and/or posterior, vertical and/or transverse components

Combination of other injury patterns; LC/VS or LC/APC

35

TABLE 53-1 -- Injury Classification Keys

Category

Common Characteristics

Differentiating Characteristics

From Brugess AR et al: J Trauma 83:848, 1990.

LC, Lateral compression, APC, anteroposterior compression; VS, vertical shear; CM, combined mechanism.

Figure 53-38 Denis classification of sacral fractures, in which three zones of injury are differentiated: zone I, sacral ala; zone
II, foraminal region; and zone III, spinal canal. Most medial fracture extension is used to classify injury. (From Denis F, Davis
S, Comfort T: Clin Orthop 227:67, 1988.)

Computed tomography is an essential part of the evaluation of any significant pelvic injury, allowing
evaluation of the posterior portion of the pelvic ring that may be poorly seen on standard
roentgenographs. Before the widespread use of CT scanning, many pelvic fractures were assumed to be
purely anterior injuries, although isolated anterior lesions actually are rare. CT also can disclose
minimally displaced fracture lines that enter the acetabulum and possibly affect the treatment plan.
Different roentgenographic signs should be sought as indications of fracture stability. Widening of the
symphysis of more than 2.5 cm has been correlated with rupture of the sacrospinous ligament and a
rotationally unstable pelvis. Avulsion fractures of the lateral sacrum and ischial spine also are signs of
rotational instability. Widening of the anterior pelvis causes rupture of the anterior sacroiliac ligament,
making the sacroiliac joint appear widened on the anteroposterior view. However, as demonstrated by
axial CT images, the posterior ligaments of the sacroiliac joint may remain intact, maintaining the vertical
stability of the pelvis ( Fig. 53-40 ). Impacted fractures of the anterior cortex of the sacrum are common
with lateral compression injuries and generally are stable, but a sacral fracture with a gap usually
indicates vertical instability. An avulsion fracture of the tip of the L5 transverse process at the attachment
of the iliolumbar ligament is another indication of vertical instability.
Vertical instability usually is defined as 1 cm or more of cephalad migration of one hemipelvis. In some
pelvic injuries vertical instability is apparent, but if vertical stability is questionable, stress testing can be
beneficial. Bucholz recommended a push-pull test in which, under roentgenographic control, the
examiner pushes up on one extremity while pulling down on the other. This maneuver is then reversed,
again under roentgenographic control, and the maximal displacement between the two films is
determined. If more than 1 cm of cephalad displacement is possible with this test, the fracture is vertically
unstable. This test should be performed one time only, with permanent films obtained for accurate
measuring of cephalad migration. Push-pull testing should not be performed in acutely injured patients
with ongoing hemodynamic instability nor in zone II or III sacral fractures in which potential neurological
injury could occur.

36

Figure 53-39 A, Forty-degree caudad inlet view of pelvis. B, Forty-degree cephalad outlet view of pelvis.

TREATMENT: RESUSCITATION PHASE

During acute resuscitation, management of patients with pelvic fractures should follow one of the existing
trauma protocols ( see Fig. 55-34 ). The MAST suit (military antishock trousers) has proved beneficial
during patient transport but is not used routinely in the evaluation/resuscitation phase. The MAST suit has
been associated with compartment syndromes of the lower extremities when left inflated for long periods
and can lead to severe hypotension when deflated. It also encumbers abdominal and lower extremity
evaluation and vascular access. A deflatable bean bag has been suggested to stabilize the pelvis
temporarily in the initial resuscitation phase.

37

Figure 53-40 A, Tile type B1 pelvic injury with diastasis of symphysis and anterior widening of sacroiliac joint. B, CT scan
shows that posterior sacroiliac joint ligaments are intact.
External Fixation

In patients with an unstable pelvic fracture who demonstrate hemodynamic instability after an initial fluid
bolus, emergency external fixation should be performed early in the resuscitation effort. Some authors
advocate the placement of such fixators in the emergency room. Reported benefits are (1) a tamponade
effect on the retroperitoneal hematoma, effected by reducing the retroperitoneal volume; (2) less motion
of the fracture surfaces, which allows more effective clot formation; and (3) greater patient mobility
during transport and for CT scanning and other evaluations. Moreno et al., Burgess et al., and others noted
a reduction in the transfusion requirements of patients with unstable pelvic fractures who were treated
with immediate external fixation compared with those who did not undergo immediate fixation.
Many variations of pelvic external fixators are available. We generally use a simple anterior frame with
two 5-mm pins in each iliac wing. Vertically unstable fractures usually also are treated with ipsilateral
distal femoral skeletal traction until definitive internal fixation can be done.
TECHNIQUE 53-1 (Poka and Libby)
Anterior pelvic frame fixation can be applied in the trauma bay, intensive care unit, or operating room in
approximately 20 to 30 minutes. If early frame application, as advocated by Poka and Libby, is to be used
the frame construct must provide easy access to the abdomen and allow for subsequent abdominal
distention. In the emergent application of a pelvic external fixator, the following basic technical principles
must be observed: adequate soft tissue protection via guide sleeves for drilling and pin insertion; skin
incisions at 90 degrees to the iliac crest and large enough to accommodate guide sleeves; 5 mm or larger
blunt half-pins, 180 mm in length or longer; 2 or 3 pin clusters per hemipelvis; converging pin placement
into the anterior third of the iliac wing; a frame construct that provides clearance from and access to the
abdomen; and dual frame construct to allow independent free manipulation without loss of pelvic
reduction.

Figure 53-41 Pin placement in hemipelvis in relation to body. (From Poka A, Libby EP: Clin Orthop 329:54, 1996.)

Pin Placement. Pins can be placed percutaneously or via an open technique. If the pins are placed
percutaneously, palpate the anterosuperior iliac spines along with the greater trochanters. Make transverse
stab incisions in the skin approximately 2 cm posterior to the anterosuperior iliac spine. Place the trochar
tip drill guides in the stab wounds and seat on the iliac crest. Move the drill guide medially and laterally to
obtain a feel for the center of the iliac crest. Remembering that there is an overhang to the outer table of
the hemipelvis, place the drill guide along the inner two thirds of the crest. While aiming the drill guide
toward the greater trochanter, use the drill bit to open the cortex of the iliac crest. Next, tighten a blunttipped half-pin into position with a drill brace, aiming the pin toward the greater trochanter and allowing it
to find its way between the tables of the hemipelvis.
With an open technique, make a longer transverse skin incision. This will allow placing a finger or
Kirschner wire along the inner table to aid pin direction parallel to the inner table and still aiming toward
38

the greater trochanter. These techniques diminish the chances of cortical penetration. Place one or two
additional half-pins with similar technique along the iliac crest. Again, the pins should be placed in a
converging configuration ( Fig. 53-41 ). Attention to detail and careful half-pin placement are of
paramount importance.
Well-placed pins ensure maximal bone to pin interface, which provides the stable foundation on which an
anterior frame can be constructed.
Frame Construction and Fracture Reduction/Stabilization. Apply two upright bars to each pin cluster
and connect them to cross bars, thereby creating a dual Slatis-type rectangular frame construct. Each
independent frame can be loosened subsequently and manipulated, thereby allowing access to the
abdomen. Polk and Libby recommend modular type fixators that allow individual, independent frame
construction.
Once the pins are in position and the frame is constructed, before tightening, reduce the displaced pelvic
ring injury. It is important that the injury type is recognized so that appropriate reduction maneuvers can
be performed. Tile B injuries require relatively simple maneuvers. Open book types require closure of
the book; lateral compression injuries require opening the book. Remember that Tile C injuries are
unstable posteriorly, and simple book-closing maneuvers can further displace the disrupted posterior
pelvic anatomy. Therefore, apply bilateral compressive forces to the pelvic ring posteriorly. If both hips
are intact (not fractured), apply compressive forces at the greater trochanters before frame tightening. If
associated with vertical displacement, apply longitudinal traction simultaneously. Anterior external
fixation is not stable enough to neutralize hemipelvic migration. Therefore, apply longitudinal traction by
proximal tibial or distal femoral skeletal traction until definitive internal fixation can be carried out. This
traction helps neutralize the displacing forces on the unstable pelvis. Monitor the adequacy of reduction
by fluoroscopy or plain film roentgenography.
Complete the open reduction, tighten the frame, and examine the pin sites. If the skin is under tension,
then adequate skin and soft tissue release is required.
AFTERTREATMENT.

If used for the definitive treatment of the pelvic fracture, the frame is left in place for 8 to 12 weeks,
depending on the fracture type and reduction. Pin site care must be meticulous, with peroxide swabs used
twice daily to clean away the crusted transudate that often forms. The dressing about the pin site should
apply some compression to the skin to minimize motion about the pins. If a pin becomes infected and
loose, it should be replaced and the original pin site should be curetted.
Pelvic Clamps

Because in vertically unstable fractures an anteriorly applied external fixator does not control motion in
the posterior sacroiliac complex, two pelvic clamps have been developed to help control the posterior
pelvis in the resuscitation phase: the Ganz C-clamp ( Fig. 53-42 ) and the pelvic stabilizer developed by
Browner and associates. These devices use large, percutaneously placed pins over the region of the
sacroiliac joint

39

Figure 53-42 Ganz antishock pelvic fixator for immediate, provisional stabilization of pelvic fractures.

posteriorly. We believe that an iliac wing fracture close to the sacroiliac joint is a contraindication to the
use of this device, and we use it only as a temporary stabilizing device that should be removed within 5
days if possible.
TECHNIQUE 53-2 (Ganz et al.)
With the patient supine, palpate the posterosuperior iliac spine and draw an imaginary line between it and
the anterosuperior iliac spine. Insert the nail on this line, approximately 3 to 4 fingerbreadths anterolateral
to the posterosuperior iliac spine ( Fig. 53-43, A ). Do not make the entry point too distal, to avoid
endangering the gluteal vessels or the sciatic nerve. Make a generous stab wound over each entry point,
insert the Steinmann pins, and make sure the side arm can slide freely ( Fig. 53-43, B ). Advance the pins
until bone is contacted and then use a hammer to drive the pins approximately 1 cm into the bone ( Fig.
53-43, C ). Slide the two side arms medially toward one another until the ends of the threaded bolts,
sliding over the pins, come into contact with the bone. Drive the threaded bolts inward with a wrench to
apply compression to the unstable hemipelvis. This closes the diastasis and stabilizes the posterior pelvic
ring ( Fig. 53-43, D ).
Correct cranial displacement of the hemipelvis by placing traction on the ipsilateral leg before applying
compression. Correct dorsal displacement by manual traction using the T-handle applied to a Schanz pin
placed in the anterosuperior iliac spine. Carry out other necessary manipulations in a similar manner.
Check the reduction maneuvers roentgenographically, or if other procedures are necessary immediately,
obtain a roentgenogram as soon as possible.
The device can be applied in an oblique configuration by placing the Steinmann pin on the side of the
stable hemipelvis in the anterosuperior iliac spine. When the bolt is tightened, one component of the force
vector on the unstable side is directed anteriorly, which helps reduce a posteriorly displaced hemipelvis.
Once the clamp is in place, additional diagnostic or therapeutic procedures can be performed. If a
laparotomy is required, rotate the crossbar around the fixed axis of the Steinmann pins away from the
abdomen so that it lies distally on the thighs. If a procedure on the proximal femur is required, rotate the
crossbar cephalad so that it rests on the abdomen ( Fig. 53-43, E ). Leave the clamp in place until
definitive internal fixation can be performed. Once the posterior fracture has been exposed and reduction
clamps or pins are in place, remove the C-clamp.

40

Figure 53-43 Application of Ganz fixator (see text). A, Nail insertion site. B, Steinmann pins are inserted, and free sliding of
side arm is ensured. C, Pins are driven approximately 1 cm into bone. D, Driving threaded bolts inward applies compression to
close diastasis and stabilize posterior pelvic ring. E, Crossbar can be rotated to allow laparotomy or access to proximal femur.
(Courtesy R. Ganz, MD.)

If hemorrhage is not controlled after application of the anterior external fixator or pelvic clamp,
angiographic evaluation is indicated. In approximately 10% of patients, a major arterial injury can be
identified and treated by embolization. Although not generally advocated in this country, Pohlemann et al.
recommend retroperitoneal exploration and packing to control bleeding in these patients.

TREATMENT: RECONSTRUCTIVE PHASE

Stable, nondisplaced pelvic fractures (Tile type A) do not require operative stabilization and can be
adequately managed with early mobilization and analgesics. Historical studies describing the
nonoperative treatment of displaced pelvic fractures (Tile types B and C) with traction or a pelvic sling
have shown disappointing results, especially in patients with displaced sacral fractures and sacroiliac
dislocations. In a 1948 review of pelvic fractures treated nonoperatively, Holdsworth found that of 27
patients with sacroiliac joint dislocations, only 12 were able to do heavy manual labor and 15 had
significant pain in the sacroiliac region. Patients with sacral and posterior iliac fractures had better results.
41

In a series of 101 unstable pelvic fractures treated nonoperatively, Raf also noted that fractures involving
the sacroiliac joint or the sacrum resulted in moderate to severe pain in 42% compared with 12% of
patients with iliac wing fractures.
The significant morbidity associated with nonoperative treatment of displaced, unstable pelvic fractures
has led to a more aggressive operative approach. Operative reduction and stabilization have been
advocated for rotationally unstable but vertically stable (Tile type B) fractures with a pubic symphysis
diastasis of more than 2.5 cm, pubic rami fractures with more than 2 cm displacement, or other
rotationally unstable pelvic injuries with significant limb-length discrepancy of more than 1.5 cm or
unacceptable pelvic rotational deformity. Operative treatment of rotationally unstable pelvic fractures can
be accomplished by an anterior external fixator used for definitive treatment or open reduction and
internal fixation with anterior plating. Retrograde pubic ramus screws placed percutaneously or with an
open technique also have been described by Routt, Simonian, and Grujic for anterior fixation.
External fixation has been widely described for the definitive treatment of Tile type B injuries. Kellam
obtained and maintained reduction in 83% of type B1 injuries and 66% of type B2 injuries. In the type B
injuries, if an adequate reduction (<1 cm displacement) was maintained, 100% of patients were
functionally normal, but if the reduction was not maintained, 80% required analgesics for posterior pain.
This method may be especially useful in patients with associated genitourinary or gastrointestinal injuries
with significant contamination or other soft tissue problems that might preclude anterior open reduction
and internal fixation.
Some authors advocate anterior pelvic internal fixation of Tile type B injuries. Tornetta, Dickson, and
Matta reported no pain or pain only with strenuous activity in 96% of their patients after anterior internal
fixation of rotationally unstable but vertically stable fractures. They advocate the use of a single four- or
six-hole 3.5-mm reconstruction plate. In contrast to many other authors, Matta does not consider a
suprapubic catheter a contraindication to anterior internal fixation of pelvic fractures and advocates early
primary repair of bladder injuries to prevent contamination of the pelvic fracture hematoma. He reported
no infections in 7 patients with suprapubic catheters and anterior pelvic internal fixation. Tile has
advocated double plating of the symphysis in type C injuries when posterior fixation is contraindicated by
soft tissue problems.
Anterior Internal Fixation of Tile Types B and C Pelvic Fractures

TECHNIQUE 53-3 (Matta and Tornetta)

Approach the symphysis through a Pfannenstiel incision (Technique 1-69 (Box Not Available) ). With
older fractures, remove early callus and scar to make fracture mobilization easier.
For reduction of the symphysis, place a Weber clamp anterior to the rectus muscles onto the body of the
pubis bilaterally. If there is any anterior displacement, place the point of the forceps more anterior on
that side to effect a reduction force. Thus the forceps are placed such that once the reduction has been
obtained, the points are on the same level ( Fig. 53-44, A ). Fractures with cephalad displacement of the
hemipelvis are more difficult to reduce. Use pelvic reduction forceps to aid in this reduction ( Fig. 5344, B and C ). Place one 4.5-mm screw anteriorly on each side of the symphysis. On the side with the
posterior displacement, place the screw through a 4.5-mm gliding hole and anchor it to the bone with a
small plate and nut from within the pelvis. This allows the use of the pelvic reduction forceps to full
mechanical advantage without the risk of screw pullout. Once the reduction has been obtained, place a
six-hole, curved, 3.5-mm reconstruction plate on the superior surface of the symphysis for fixation. A
small amount of compression can be obtained by eccentrically drilling the medial holes. Double plating
is used only in type C injuries when it is not certain that posterior fixation is possible during the initial
procedure, as in a patient undergoing emergency laparotomy.
Place a malleable retractor in the space of Retzius during reduction and fixation to prevent injury to the
bladder. Drain this space with closed-suction drainage postoperatively during routine wound closure. We
42

typically give antibiotics prophylactically for 48 hours.

If internal fixation of a pubic ramus fracture is indicated in a type B or C pelvic fracture, it is performed
through an ilioinguinal incision similar to that used for fixation of anterior column acetabular fractures
(Technique 1-60 (Box Not Available) ).
Tile type C pelvic injuries require posterior fixation to regain vertical stability. External fixation alone is
not recommended as definitive treatment for vertically unstable pelvic fractures, because the posterior
instability cannot be controlled by this treatment method. In Kellam's series, after adequate reduction of
type C fractures, only 50% of patients were pain free with no job or lifestyle changes. After inadequate
reduction of type C injuries, only 33% returned to their previous occupations. For type C fractures that
involve the sacroiliac joint, Kellam recommends anatomical reduction of the posterior injury and internal
fixation with fusion of the sacroiliac joint.
Some authors, however, are skeptical that anatomical reduction of type C injuries has a considerable
effect on patient outcome. Miranda et al. compared results in 80 patients with pelvic fractures, of which
61% were treated with external fixation and 39% were treated nonoperatively. They reported similar rates
of return to previous occupation for Tile types A, B, and C injuries (75% to 81%). The average residual
vertical hemipelvis displacement in type C injuries was 21 mm. The number of patients who perceived
pain as the worst sequela of their injury was similar among the three groups, regardless of treatment.
For Tile type C fractures (rotationally and vertically unstable) the anterior ring can be fixed with either an
external fixator or an anterior plate as described above. Posterior treatment generally is determined by the
portion of the posterior ring disrupted. For sacral fractures and sacroiliac joint disruptions, Matta and
Saucedo, Routt, Meier, and Kregor, and others have described image intensifier-directed screw fixation
from the ilium posteriorly into the sacral body ( Fig. 53-45 ). This technique risks damage to the L5 nerve
root and iliac vessels anterior to the body of the sacrum and to the sacral nerve roots within its bony
confines, and it requires excellent roentgenographic technique and a thorough understanding of the threedimensional anatomy of the pelvis. Because neurological injury occurs with 30% of transforaminal sacral
fractures (Denis zone II fractures), some authors advocate open reduction and internal fixation of such
fractures with decompression of the involved neural foramina. Transiliac rod fixation has been reported
by several authors for sacral disruptions, although there is a risk of neurological injury with compression
of the sacrum ( Fig. 53-46 ). Tension band plating also can be used between the two posterior iliac crests (
Fig. 53-47 ). Simpson et al. reported excellent results with the use of the anterior retroperitoneal approach
for anterior plating of the sacroiliac joint because it allowed direct observation of the joint ( Fig. 53-48 ).
If this approach to the sacroiliac joint is used, the superior gluteal artery, L4 nerve root, and lumbosacral
trunk must be carefully protected, especially in the inferior third of the joint. For iliac wing fractures,
open reduction and pelvic reconstruction plate fixation techniques are used. For fracture-dislocations of
the sacroiliac joint (the so-called crescent fracture), the fracture can be reduced and fixed anteriorly or
posteriorly, with or without hardware transfixing the sacroiliac joint.

43

Figure 53-44 Anterior internal fixation of pelvic fracture (see text). A, Type II symphysis diastasis is reduced with Weber
clamp placed anterior to rectus muscle. B, Points of clamp are placed at same level on pubic body so that with closure any
sagittal plane rotation of symphysis is reduced. C, Views from inside and outside pelvis demonstrate positioning of Jungbluth
clamp with gliding hole and anchoring plate. (Redrawn from Matta JM, Tornetta P III: Clin Orthop 329:129, 1996.)

44

Figure 53-45 Iliosacral screw fixation for sacroiliac or sacral fracture.

Tornetta and Matta used iliosacral screws for posterior fixation in most of 48 Tile type C fractures after
open posterior reduction of sacral fractures, fracture-dislocations of the sacroiliac joint, and most pure
sacroiliac joint dislocations. They reported that two thirds of patients returned to their preinjury
occupations, and 16% changed occupations because of an associated injury. Associated neurological
injuries compromised the final result in 35% of patients. The authors concluded that reduction of the
posterior injury to within 10 mm was adequate for functional results. They also cautioned that residual
displacement could lead to arthritic changes at longer follow-up, and stressed the importance of obtaining
an anatomic reduction, if possible.
Cole, Blum, and Ansel reported good results in 64 consecutive patients with type C fractures. The
majority of posterior injuries were treated with percutaneous iliosacral screws. Crescent fractures were
treated with anterior or posterior plating in addition to the iliosacral screws. For comminuted sacral
fractures with significant rotational deformity, transiliac bars supplemented the iliosacral screws. During
the period of study, the authors abandoned the use of external fixation as definitive treatment of the
anterior pelvis to improve the stability and accuracy of the anterior reduction and to avoid the pubic
tenderness that is seen in patients treated with external fixation.
In a series of 68 consecutive fractures (43 of them Tile type C fractures) that were treated with
percutaneous iliosacral screw fixation, Routt et al. described difficulty in obtaining closed reduction of
pure sacroiliac joint dislocations; open reduction of the sacroiliac joint often was necessary before
percutaneous screw placement. They emphasized that the surgeon must be familiar with the variations of
upper sacral anatomy and that fluoroscopic imaging, including the lateral sacral view, must be excellent.

45

Figure 53-46 Transiliac rod fixation of sacral fractures. A, Large Steinmann pin (8 to 10 mm) is drilled from outer aspect of
one ilium through opposite ilium. B, Second rod is inserted approximately 1.5 cm distal and parallel to first.
Internal Fixation: Posterior Screw Fixation of Sacral Fractures and Sacroiliac Dislocations (Prone)

TECHNIQUE 53-4 (Matta and Saucedo)

Position the patient prone on a long radiolucent board to allow anteroposterior, caudad, and cephalad
projections with an image intensifier ( Fig. 53-49 ). Use a standard posterior vertical incision, 2 cm lateral
to the posterior superior spine, for sacroiliac dislocations, fracture-dislocations, or sacral fractures. Reflect
the posterior portion of the gluteal muscles from the posterior iliac wing and the gluteus maximus origin
from the sacrum. Expose the greater sciatic notch to evaluate reduction. For sacral fractures, elevate the
multifidus muscles to expose the fracture of the posterior sacral lamina.
For sacroiliac dislocations, place pointed reduction forceps from the sacrum to the iliac wing for
reduction. Use palpation through the greater sciatic notch, as well as direct observation, to evaluate the
reduction. Under image intensifier control, insert screws perpendicular to the iliac wing across the
sacroiliac joint into the sacral ala, directing the screws toward the S1 vertebral body. Carefully target the
drill bit and screws by multiple anteroposterior, caudad, and cephalad image intensifier projections.
For sacral fractures, perform reduction in the same manner, checking the reduction with palpation through
the greater sciatic notch and observation of the posterior sacral lamina. Insert one or two screws into the
S1 vertebral body placed from the lateral surface of the iliac wing. If necessary, apply a thin, malleable
plate across the posterior sacrum from ilium to ilium as a tension band just above the greater sciatic notch.
Close the wounds in the standard manner over suction drains.
46

Figure 53-47 Tension band plating.

AFTERTREATMENT.

Prophylactic antibiotic therapy is begun at the time of surgery and is continued for 48 to 72 hours. The
suction drains are removed at 48 hours. If the posterior injury is unilateral, gait training is begun when the
patient is comfortable, allowing 15 kg of weight-bearing on the affected extremity. Weight-bearing is
progressed to weight-bearing as tolerated at 6 to 8 weeks. Patients with unstable bilateral posterior
fractures are allowed standing pivot transfers in and out of a wheelchair, but weight-bearing is not
allowed for 6 to 8 weeks.
Percutaneous Iliosacral Screw Fixation of Sacroiliac Disruptions and Sacral Fractures (Supine)

Routt et al. described this technique, reported its outcome and complications, and studied the anatomical
and roentgenographic variations of upper sacral morphology that affect surgical technique. Their series of
articles is essential reading for the trauma surgeon endeavoring to perform this technique. They
emphasize the fact that the normal sacral ala has an inclined anterosuperior surface, the sacral alar slope,
that extends from proximal-posterior to distal-anterior ( Fig. 53-50 ). Anterior to the sacral ala in this
region run the L5 nerve route and the iliac vessels. The cortex of the alar slope forms the anterior
boundary of the safe zone for passage of iliosacral screws into the body of S1. The posterior boundary
of the safe zone is formed by the foramen of the S1 nerve root.
The sacral alar slope can be estimated on a true lateral fluoroscopic view of the sacrum by identifying the
iliac cortical density (ICD), which demarcates the anterior cortical thickening of the iliac portion of the SI
joint ( Fig. 53-51 ). The inclination of the alar slope can be more acute in patients with sacral dysplasia,
narrowing the safe zone for screw passage. Routt et al. detected sacral dysplasia in 28 of 80 patients with
pelvic fractures evaluated by inlet/outlet and true lateral images. In 94% of nondysplastic upper sacral
segments the ICD coincided with the alar slope as seen on the preoperative CT scan. This makes it a
useful roentgenographic landmark for determining the anterior border of the safe zone ( Fig. 53-52 ).
However, 6% of nondysplastic sacral alae displayed an anterior concavity or recession when viewed in
the axial plane, projecting the ICD anterior to the alar slope on the true lateral view. Preoperative CT
scanning was useful to determine the dimensions of the safe zone and to identify recessed sacral alae
( Fig. 53-53 ). A recessed sacral ala allows for in-out-in screws that can injure the L5 nerve root ( Fig.
53-54 ). Routt et al. emphasized that the posterior pelvis must be accurately reduced to allow
47

superimposition of the greater sciatic notches and both ICDs on the true lateral image. With this as a
necessary criterion for screw passage, using the ICD as the anterior marker for the safe zone and being
aware of anterior sacral recession, no screw placement errors were noted in 51 consecutive patients.
Screws used to fix sacroiliac joint disruptions are placed perpendicular to the joint, whereas screws used
to fix sacral fractures are placed more transversely to allow passage of the screw into the contralateral ala.

Figure 53-48 Anterior plating of sacroiliac joint.

TECHNIQUE 53-5 (Modified from Routt et al.)

Position the patient supine on a radiolucent table, with the feet at the end of the table to allow imaging of
the entirety of both extremities if needed. Place a soft support beneath the lumbosacral spine to slightly
elevate the patient from the table ( Fig. 53-55, A ). Position the C-arm fluoroscopy unit opposite the
injured hemipelvis so that the screen is easily visible to the operating team. Use biplanar fluoroscopy to
simulate pelvic inlet and outlet roentgenographic views. Because the amount of individual lumbar lordosis
varies, the amount of tilt will be slightly different for each patient.

48

Figure 53-49 Posterior screw fixation of sacral fractures and sacroiliac dislocations. Patient positioning. Anteroposterior,
caudad, and cephalad image intensifier projections show drill bit and screw position. (Redrawn from Matta JM, Saucedo T:
Clin Orthop 242:83, 1989; original by Zilbert.)

Rapid imaging can be accomplished by marking the position of the C-arm tilt needed to reproduce these
views. Obtain a lateral sacral view to confirm lumbosacral osteophytes or other deformity.

Figure 53-50 Alar slope and locations of fifth lumbar and intraosseous first sacral nerve roots and their relationships with ala.
(Redrawn from Routt MLC Jr, Simonian PT, Agnew SG, Mann FA: J Orthop Trauma 10:171, 1996.)

Administer intravenous cephalosporin antibiotic prophylaxis. Isolate the perineum, unless urethral access
is needed by the urologist for a combined procedure. Prepare and drape the chest, abdomen, and lower
extremities as necessary. If access to the entire extremity is needed, place femoral traction pins either
preoperatively or intraoperatively and connect them with sterile rope. The fracture pattern and
49

displacement determine how much weight is necessary. Manually protect any lower extremity fractures
during preparation and draping.
Various techniques can be used to manipulate the injured hemipelvis: percutaneous Schanz screws placed
in the gluteus medius tubercle, anteroinferior iliac spine, and trochanteric line of the femur; distal femoral
traction pin and anterior external fixation frame (or femoral distractor), alone or in combination; and
simple manipulation of the hip. Use C-arm fluoroscopy to guide reduction. Anatomical reduction and
fixation of the anterior ring fracture or dislocation usually improves posterior dislocations. If closed
reduction of the posterior ring is unsuccessful, consider reducing the disrupted sacroiliac joint through an
anterior approach. Open reduction of a sacral fracture is performed through a posterior approach.
The number and location of screws to be placed are determined preoperatively. After reduction, identify
the insertion site on the lateral ilium by placing a 0.45-mm Kirschner wire percutaneously through the
abductor muscle mass, using biplanar inlet and outlet imaging for wire guidance. The insertion site and
direction should place the wire from the ilium, perpendicular to and across the sacroiliac joint (or sacral
fracture), through the sacral ala, cephalad to the S1 neural foramina, and caudad to the L5-S1 disc space,
terminating within the body of the S1 or contralateral sacral ala. Because of the anterior sacral slope, the
planned screw location should avoid the anterior portion of the ala. With the 0.45-mm wire aimed in the
correct direction, make a 1-cm stab wound centered over the wire. Pass a blunt, 2-mm, cannulated drill
sleeve over the wire to the lateral ilium. Remove the Kirschner wire and replace it with a terminally
threaded 2-mm pin. Drill this pin to just engage the dense cortical bone of the lateral ilium. Using the drill
sleeve as a directional aid and using intermittent biplanar imaging to confirm correct insertion, advance
the guide pin just to the level of the lateral aspect of the ipsilateral first sacral neural foramen. Obtain a
lateral sacral image to determine the relationship of the pin tip to the sacral alar slope and its
anteroposterior position relative to the first sacral vertebral body; the pin tip should be located beneath the
sacral alar slope and centered within the vertebral body. For sacroiliac joint disruptions, advance the pin
just to the midline of the first sacral vertebral body ( Fig. 53-55, B ). For sacral fractures, advance the pin
beyond the midline to improve fixation ( Fig. 53-55, C ). As the pin is advanced within the contralateral
ala, use a lateral image to ensure that the pin tip is beneath the contralateral alar slope ( Fig. 53-55, D ).

Figure 53-51 Iliac cortical density (ICD) can be identified on lateral roentgenogram (A) and CT scan (B) for estimation of
sacral alar slope.

50

Figure 53-52 CT scan confirms narrow safe zone (solid arrows) resulting from dysplastic upper sacral segment. Anterior
articular surfaces of SI articulations are noted to be planar bilaterally. Undulating tongue-in-groove portions are situated
posteriorly. ICD is noted bilaterally (open arrows). (From: Routt MLC et al: J Orthop Trauma 10:171, 1996.)

Figure 53-53 Recessed sacral ala (solid arrows) relative to dense iliac bone adjacent to SI joint, the ICD (open arrow). CT scan
best demonstrates these uncommon situations. Nerve roots can be seen surrounded by fat within these recessed alae, especially
on uninjured right side of patient. (From Routt MLC et al: J Orthop Trauma 10:171, 1996.)

Figure 53-54 Screws inserted without using lateral sacral image and ICD. Screws appear to be intraosseous on inlet (A) and
outlet (B) pelvic roentgenograms, yet postoperative CT scan (C) shows that cephalad/anterior no. 2 iliosacral screw on patient's
left side is extraosseous. Left L5 nerve root was injured. (From Routt MLC et al: J Orthop Trauma 10:171, 1996.)

Determine the appropriate pin depth with a reverse ruler ( Fig. 53-55, E ) or another pin of equal length.
Use the cannulated drill and tap to prepare the screw pathway. Place the cannulated screw over the pin,
51

using a washer, and tighten it. Remember that the washer alters the appropriate screw length slightly ( Fig.
53-55, F ). Partially threaded screws should be used to provide compression at the fracture/dislocation
site. Overcompression must be avoided in transforaminal sacral fractures, as neurological injury could
result. Use biplanar imaging during drilling, tapping, and screw insertion to ensure that the pin has not
been inadvertently advanced as a result of binding. Remove the pin manually to prevent breakage as the
tip contacts the end of the cannulated screw. Tighten the screw and evaluate the reduction
fluoroscopically. Loosen the traction and manipulation devices and recheck the pelvic images to ensure
stability. Then, using the manipulation pins in the ilium, stress the ring fixation under fluoroscopy. Insert
additional fixation if necessary. Irrigate the wound, remove the percutaneous manipulation pins, and close
the skin edges. Note and record the total fluoroscopy time. Obtain permanent roentgenographic pelvic
inlet and outlet views and a lateral sacral view.

Figure 53-55 Percutaneous screw fixation of sacroiliac joint disruption. (From Routt MLC et al: Tech Orthop 3:35, 1993.)

52

Figure 53-56 Anterior approach and stabilization of sacroiliac joint. A, Incision for anterior approach. B, After reduction,
sacral ala is fixed to ilium with two two-hole dynamic compression plates.
Anterior Approach and Stabilization of Sacroiliac Joint

Simpson et al. described an anterior fixation technique that initially used staples but now uses dynamic
compression plates, reconstruction plates, or four-hole plates. They emphasize the proximity of the L5
nerve root to the sacroiliac joint during the exposure. Subsequent cadaver studies by Atlihan et al. have
shown that the L4 nerve root and lumbosacral trunk are actually in closer proximity to the sacroiliac joint,
particularly in its inferior third, and must be carefully protected.
TECHNIQUE 53-6 (Simpson et al.)
Place the patient supine and make the upper half of a Smith-Petersen incision along the anterior iliac crest
( Fig. 53-56, A ). Extend the incision to the most superior portion of the crest anteriorly and to the
anteroinferior iliac spine inferiorly. Subperiosteally, dissect the iliacus muscle and medially retract it and
the abdominal contents to expose the sacroiliac joint. Take care not to injure the L5 nerve root lying
approximately 2 to 3 cm medial to the joint. Anchor two sharp-tipped Hohmann retractors into the sacral
ala to retract the abdominal contents medially. Use careful, intermittent retraction to avoid ilioinguinal or
lumbosacral nerve root neuralgias. Once the sacroiliac joint has been exposed through retrofascial
dissection, manipulate the hemipelvis with a heavy bone clamp applied to the iliac crest while an assistant
manipulates the leg. Distal traction on the leg and internal rotation of the hemipelvis usually are required
for reduction. Do not debride the cartilaginous surfaces of the joint. After reduction, fix the sacral ala to
the ilium with two, two-hole dynamic compression plates and 4.5-mm screws ( Fig. 53-56, B ). Close the
soft tissues over drains.
AFTERTREATMENT.

When patient comfort allows, ambulation is begun with crutches or a walker with touch-down weightbearing on the affected side.
Iliac wing fractures can be approached through a similar retroperitoneal approach. Reduction is
performed with pointed reduction forceps and fixation is obtained by a 3.5-mm reconstruction plate and
standard lag screw technique.

53

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