External fixation for pelvic injuries

Patient with unstable pelvic injury in ED

Type C1

Pelvic injuries form about 3-4 % of all skeletal

injuries but it is likely to rise as more vehicles are put on our roads ( 200%+ increase in last 5 years!)

Low energy trauma in osteoporotic person High energy RTA Fall from height Earthquake/ war

Emergent application in the E.D for unstable

patient with pelvic injury As adjunct to control bleeding in pelvic injury

(?) As a definitive fixation in certain open injuries In combination with limited Internal fixation Children with pelvic injuries Pregnant women

indications

Morel-Lavelle lesion

Retroperitoneal bleed ? Urethral injury

Pelvic C- clamp

Contraindications:

Poor general condition. Local soft-tissue damage. Local infection.

The external fixator is the most commonly

used treatment for surgical stabilization of the pelvic ring in emergency situations.

Its advantages are ease of handling and its availability in most hospitals

The inadequate biomechanical stability of some configurations of external fixation is a concern. Although adequate holding power was measuredfor open-book type B injuries unstable in rotation,the load limits for vertically unstable type C injuries is poor

On account of the superior holding power of theSchanz screws in the supraacetabular region comparedwith their placement in the iliac crest and on accountof the superior soft-tissue coverage, the technicallymore demanding placement of Schanz screwsin the supraacetabular area is preferred to their placement in the iliac crest.

The good and excellent results of all treatments ofpelvic injuries are 79.8%, and of these 83.2% are with internal fixation solely, while 78.5% are with external fixation solely and hybrid fixation. The difference is less than 5%, and having in

mind that in many cases the external fixation was irreplaceable, we would like to emphasize again that this method still has its importance and certain place today.

Pavlin Apostolov, Martin Burnev, Petar MilkovClinic of Orthopaedics and Traumatology

MBAL “Saint Anna” Hospital - Varna, Bulgaria

Advantages

• Percutaneous screw insertion. • Minimal soft-tissue damage. • Reduced bleeding from pelvic bones and venous plexuses thanks to the reduction. • Direct mechanical compression effect on the posterior pelvic ring. • Immediate application in the emergency ward or the intensive care unit. • Early mobilization with partial weight bearing for type B injuries thanks to pain reduction

Axel Gänsslen, Tim Pohlemann, Christian KrettekOperat Orthop Traumatol 2005;17:296–312

Disadvantages

• If misdirected can penetrate into hip. • May be awkward for very obese patients,

particularly when sitting. • Has to be combined with internal fixation in

type C injuries.

Preoperative Work Up

• Pelvic radiographs, if necessary oblique views or

computed tomography. • Identify type of injury & direction of

instability • Antibiotics generally not necessary.

Anesthesia and Positioning

• General anesthesia. • Standard supine position. • Free draping of the lower limb on the side of the injured pelvis. • Positioning of the patient in such away that the following views are possible: – view of entire pelvis; – oblique views allowing a 40° rotation in the transverse plane: inlet and outlet views; – oblique views allowing a 30° rotation in the sagittal plane: ala and obturator views.

Know where thicker bone is available for pins to hold well

To obtain the maximal screw length, and therefore an optimal screw purchase, a drilling angle of approximately 20° must be selected for the Schanz screw

In the frontal plane there is a triangular area of cancellous bone along iliopectineal line.

With the patient supine, the direction of drilling is inclined approximately 10–20° caudally

The capsule of the hip originates on average 16 mm (11–20 mm) above the anterior rim of the acetabulumTo avoid the screw being placed intraarticular, a distance of approximately 1.5–2 cm cranial to the anterior rim of the acetabulum should therefore be selected. This roughly corresponds to a position just cranial to the anterior inferior iliac spine.

Surface marking

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The orientation of the ala of the iliac bone is determined by palpation withan instrument [30], a Kirschner wire [28] or the finger. Only the cortical boneis perforated by the drill bit, and the Schanz screw is then introduced intothe drill hole and further advanced between the two laminae of the iliacbone without predrilling.

Hybrid fixation

Patient comfortably mobilized with ExFix

Tamponade effect is doubtful

Everyone treating pelvic injuries should know

how to do a good external fixation. Temporary emergent Tx in ED May be used as part of hybrid stabilization May be definitive in open injuries –

(colostomy) Supra-pubic fixation preferable to iliac crest

(superior) fixation

summary

Thank you