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Re: Pelvic and acetabular fracture
послал Milton L. Routt 06 Июль 2009, 21:26
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This complex and displaced sacral injury is likely an H pattern...2 hemipelvic components, an upper sacral component which remains attached to the lumbar spine, and a caudal sacral component...there are typically anterior ring injuries as well...in this patient's example, the left sided acetabulum also has been exploded.
Most H pattern sacral fractures have the transverse fracture limb of the "H" at the upper-second sacral segment junction or disc region...some fracture thru the second segment, and some or at other sites...but most yield thru the upper-second sacral segments junction...with variable traumatic associated neurological findings.
Many also have a remote level identifiable spinal injury.
The hemipelvic components' displacements depend on their instability...this patient's left side seems to be the worst.
The transverse fracture limb liberates the upper sacral segment and its attached lumbar-thoracic-cervical spine to displace...usually anteriorly and in kyphosis.
The kyphosis and anterior translation of the upper sacral segment distorts the safe area for iliosacral screw usage...the imaging allows the surgeon to preoperatively plan if iliosacral screw fixation is a safe possibility.
Reduction accuracy improves overall stability for most such patterns...occasionally the alar zone comminution obviates this reality.
Fixation stability can be reliably achieved for simpler and less displaced or less comminuted fractures using transiliac-transsacral screws...for most adults, these are usually 170-190mm lengths through the upper sacral segment after reduction.
For those patterns with the transverse limb below the second sacral segment level, second sacral segment transiliac-transsacarl screws can also be used...these screws are usually 150-160 mm lengths.
Only recently have large screws of such length become available for these applications...and still for some patients, 180mm screws are too short.
Nevertheless, iliosacral screws can stabilize simpler patterns reliably...and some surgeons brace to supplement such fixation.
For this patient (according to the limited imaging available), it would seem that a combination of lumbo-pelvic fixation along with transiliac transsacral fixation is optimal...BUT the left sided pelvic implants must be applied in consideration of and in anticipation of the necessary acetabular fixation implants.
So you are correct, this pattern likely needs a great reduction and a powerful fixation construct to be durable...but the operative exposure and implants must be planned carefully if the acetabular fracture is to be accurately reduced and well stabilized.
I'd also seek and rule out remote level spine injury for this patient.
chip
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