Pelvic Ring Fractures.

Treatment with Monolateral External Fixation

A.Pizzoli, L.Renzi Brivio
Orthopaedic and Traumatology Department, C. Poma Hospital Mantova (Italy)
Abstract
In the treatment of pelvic ring lesions is mandatory to identify the lesions which need surgical treatment.
Epidemiologic data demonstrated the association of these lesions with an high percentage of organ morbidity and
haemodinamic instability that is generally the primary cause of death.
The mortality rate is strictly correlated to the Type and degree of instability and the degree of open fracture.
For these reasons is important to perform a precise preoperative assessment using the most known classification:
Young-Burgess classification relative to the type and energy of the trauma (J.Trauma 83:848,1990) and
Tile classification related to the degree and plane of instability (JAAOS 4:143,1996).
According to Tile classification we can identify the lesions (partially or totally unstable) which need a surgical
treatment in emergency which is generally carried out using an external fixator or a pelvic clamp system.
In partially unstable lesions (horizontal instability) like “open or closed book” ex fix can be considered the treatment
of choice in emergency and also a possible alternative to ORIF as definitive treatment. The good tolerance of the
monolateral frame and its versatility allow a surgical approach to pelvic or abdominal organs when necessary and
permits an early rehabilitation program.
The possibility to manipulate the two-hemi pelvis with the fixator facilitates a proper recovery of pelvic morphology
reducing at the same time retroperitoneal bleeding.

In totally unstable lesions (horizontal and vertical instability) external fixation is extremely useful in emergency as
life-saving device but is not powerful enough to guarantee posterior stability. For this reason is possible, after acute
treatment, to associate external fixation to a minimal posterior stabilisation ( screws) as alternative to the standard
open surgical approach.
The authors will present their experience with this kind of treatment strategy using different monolateral frames in
relation to the type of injury and associated lesions.
 EXTERNAL FIXATION
IN PELVIC RING FRACTURES

Dott. A.L.Pizzoli
Orthopaedic and Traumatologic Department
C. Poma Hospital Mantova Italy
PELVIC RING ANATOMY

Bone Ligaments
POLITRAUMA + PELVIC RING
• Morbility (60-80%)
Head trauma 70%
Uro-genital lesions 63%
Neurological lesions 24%
Vascular lesions 23%
Abdominal lesions 20%

• Mortality
Unstable fractures (10-30%) Open (30-50%)
LIFE SAVING SURGERY
INSTRUMENTS
Link Orthofix External fixator
 PELVIC RING Instability

Type A

Type B

- STABLE

HORIZONTAL Instability. Type C

- UNSTABLE
VERTICAL /MIXED Instability

Tile 1990
Type 2: HORIZONTAL INSTABILITY

DEFINITIVE EXTERNAL FIXATION

 FIXATOR
APPLICATION
Open book (APC)
OPEN BOOK (APC)
Horizontally unstable –Vertically stable
Definitive treatment
ANTERIOR EX FIX
CLOSED BOOK (LC)
 Type 3: Vertical instability

Emergency Ex. Fix. + delayed posterior Int. Fix.

1.Anterior Standard Frame
2.Anterior triangular Frame
3.Anterior Frame + posterior fixation
 SACROILIAC JOINT STABILISATION
E. Letournel: Rev. Chir. Ortop 1981
Traitment chirurgical des trauamtismes du bassin en dehors du fractures du cotyle

1. OPEN (ant o post)

2. PERCUTANEOUS ( fluoroscopy)
3. PERCUTANEOUS (CT scan)
CT guided fixation of sacral fractures and SI joint disrutions
Nelson DW, DuweliusPJ: Radiology 180;527-532,1991
6 mesi
 Pelvic ring and External fixation

HORIZONTALLY UNSTABLE LESIONS

EMERGENCY and DEFINITIVE STABILIZATION

VERTICALLY UNSTABLE LESIONS

EMERGENCY STABILIZATION
ASSOCIATED TO INTERNAL FIXATION (5-7 DAYS LATER)
Mantova night view
SCREW PLACEMENT
Screws directions
Immagine HA
coated
Preferred approach
SCREW INSERTION
SCREW INSERTION
FIXATOR APPLICATION