Fractures of the Pelvis and Acetabulum E-Book

Marvin Tile

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 2489

Veröffentlichungsjahr: 2015

Beschreibung

The fourth edition of this well-known and highly regarded book by Marvin Tile et al. is now a two-volume set of books based on the AO principles of operative management of fractures, as applied to the pelvis and acetabulum. With the collaboration of over 80 international expert surgeons and through hundreds of images and illustrations, each volume emphasizes decision making based on the assessment of the personality of the injury through the patient's history, physical examination, and interpretation of radiographic investigations. Access to video presentations demonstrating surgical approaches and reduction techniques performed by world-renowned experts is included.

Hear the authors discuss Fractures of the Pelvis and Acetabulum.

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Marvin Tile | David L Helfet | James F Kellam | Mark Vrahas

Fractures of the Pelvis and Acetabulum

Principles and Methods of Management—Fourth Edition

Volume 1

Pelvis

857 illustrations/images

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Copyright © 2015 by AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, SwitzerlandDistribution by Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany, and Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA

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ISBN: 978-3-13-200631-7e-ISBN: 978-3-13-200671-3

Preface

I began writing the first edition of this book, Fractures of the Pelvis and Acetabulum in 1982 and it was published in 1984, 30 short years ago. That first edition was a labor of love; an attempt to summarize the pioneering work of my mentor, Dr George Pennal on pelvic ring disruption and the work of Robert Judet and Emile Letournel on acetabular trauma. Along with the summary of the pioneering work in this field, new thoughts on classification, biomechanics, and treatment of these injuries was formulated. This was the adolescent phase of knowledge in this important and growing field of pelvic trauma.

By the time of the second edition in 1995, this field had come of age, and by the third edition in 2003, it had become a mature subspecialty of orthopaedic traumatology. This new fourth edition was deemed necessary because of significant advances in diagnosis and treatment, primarily using new technology.

This new fourth edition is published by AOTrauma. Almost all the chapters have been extensively rewritten. All the chapter authors, including the new ones, are internationally renowned and all have made substantial contributions to our pelvic knowledge base. The section on minimally invasive techniques using image guidance has also been expanded.

The drawings have been skillfully redone, and many new cases added. Also included are new in-depth videos of surgical approaches and reduction and fixation techniques by world renowned experts.

The chapters on outcomes of care have been rewritten and include an extensive bibliography.

The editors believed that with all the updated materials, the expanded edition should be divided into two volumes. Dr Mark Vrahas has joined with Dr James Kellam as coeditors of volume 1, Pelvis, and Dr David Helfet has remained as editor of volume 2, Acetabulum.

The first edition published 30 years ago was a small, single volume, largely single author, deeply personal book. Although the book has evolved in this fourth edition to a two-volume multiauthored text, with new videos, new illustrations, and extensive rewriting of the text, I am proud, along with my coeditors, that the basic philosophy of care of the severely injured patient has remained; care based on a careful assessment of the personality of the injury including both patient and fracture factors. Although our technology is rapidly changing, this philosophy will remain as the hallmark of exemplary patient care.

Marvin Tile, CM, MD, BSc (Med), FRCS (C)

Acknowledgments

Marvin Tile, MD

To my wife and companion, Esther, for her continuing love and support during our 60 years of marriage together.

To my growing family, Gary, Rosemary, Katy and her partner David Albert; Sari and her partner, Jacob Diskin, and Noah Tile; Stephen and his partner Helene, David, Rachel, and Abby Tile; Steve, Deborah, Ian and his wife Samantha, and Annie Cass; Andrew Tile and his partner, Candy Ramberansingh; Caya and Keeley Tile for their love and devotion and for bringing balance and joy to my life.

To my associate, Shirley Fitzgerald, whom I have known and worked with for 50 years, for her loyalty and friendship, and for helping so much with the first three editions of this book.

In addition to those acknowledged in the first and previous editions of this book, I am indebted to the following individuals for their support, dedication and hard work in bringing this fourth edition to completion:

I welcome Mark Vrahas as my coeditor along with David Helfet and Jim Kellam, and thank them for their role as section editors and in the reorganization of this edition into two volumes:Volume 1Pelvis—James Kellam and Mark VrahasVolume 2Acetabulum—David Helfet

To Jim Kellam for leading the production of the excellent videos which are an essential part of this publication.

To all the authors who contributed to previous editions as well as this one, and all the new authors for their contributions to this fourth edition, which required much work in rewriting the chapters.

To the staff of the AO Education Institute, led by Urs Ruetschi for taking on the task of publishing the fourth edition of this book.

To Vidula H Bhoyroo, who took over as managing editor of this project, and with her very hard work, personality and intellect, and with the dedicated help of Jessada Mahatthananchai, Amber Parkinson, Jecca Reichmuth, and Roger Kistler brought this new edition to fruition. I and my coeditors are eternally grateful.

James F Kellam, MD

To my family, Lynda, Lindsay, Patrick as well as Stephanie and her husband Chris and our grandson Hudson for their support and understanding and adding enjoyment to my life.

To my patients who without their trust would never have allowed me to achieve the expertise and skill to be a compassionate and knowledgeable physician and surgeon.

We are grateful to Drs Michael D Stover, Keith Mayo, David Stephens, Stephen Sims, and Mark Reilly for producing the material for the surgical approach videos. Robin Green and Sergei Nikokoshev have done an excellent job in producing and editing the surgical approach videotapes. Our thanks to Urs Rüetschi and Kathrin Lüssi who had the vision and courage to start this project as well as Cristina Lusti. Our appreciation goes to Vidula H Bhoyroo, Jessada Mahatthananchai, Amber Parkinson, Roger Kistler, and Jecca Reichmuth for their support, never-ending patience, and most important their willingness to collaborate with the editors and authors to produce this book. Finally, we thank all the authors who did a tremendous job in producing up-to-date informative and well-documented chapters. Their support will make this book a true classic in the field of pelvic and acetabular fracture management.

David L Helfet, MD

To my wife, Molly, and children, Kelly and Arthur John (A.J.), for their continued love, support, and understanding.

Also to all those colleagues, fellows, and residents who have contributed to my learning and maturation as a pelvic and acetabular fracture surgeon.

Mark Vrahas, MD

For my parents, Mark and Ruthann, who nurtured my dreams; my wife Cynthia who inspires me; and my sons Mark, Alexander, and Remy who fill my life with pride and joy.

Contributors

Editors

Marvin Tile, CM, MD, BSc (Med), FRCS (C)Professor Emeritus, Surgery University of TorontoOrthopaedic SurgeonSunnybrook Health Sciences CentreRoom MG3012075 Bayview AvenueToronto, ON M4N 3M5Canada

James F Kellam, MD, FRCS (C), FACS, FRCS (I)ProfessorDepartment of Orthopaedic SurgeryUniversity of Texas Health Science Center at Houston6431 Fannin StreetHouston, TX 77030USA

David L Helfet, MDProfessor of Orthopaedic SurgeryWeill Medical College of Cornell UniversityDirector, Orthopaedic Trauma ServiceHospital for Special Surgery/New York PresbyterianHospital535 East 70th StreetNew York, NY 10021USA

Mark Vrahas, MDAssociate Professor Harvard Medical SchoolVice Chairman, Department of OrthopaedicsMassachusetts General HospitalPartners Chief of Orthopaedic TraumaMassachusetts General HospitalBrigham and Women's HospitalHarvard University55 Fruit Street, YAW 3CBoston, MA 02114USA

Authors

Timothy S Achor, MDDepartment of Orthopaedic SurgeryFellowship Director, Orthopaedic Trauma FellowshipUniversity of Texas Health Science Center at HoustonMemorial Hermann—Texas Medical Center6400 Fannin StreetSuite 1700Houston, TX 77030USA

Jorge E Alonso, MDProfessor, Department of Orthopaedic SurgeryDirector of Orthopaedic TraumaUniversity of South Alabama3421 Medical Park DriveMobile, AL 36693-3330USA

Mario Arduini, MDUniversity of Rome, “Tor Vergata”Viale Oxford, 81Rome 00133Italy

David E Asprinio, MDProfessor and ChairmanDepartment of Orthopaedic SurgeryNew York Medical CollegeDirector of Orthopaedic SurgeryWestchester Medical CenterMacy Pavillion S10695 Grassland RoadValhalla, NY 10595USA

Craig S Bartlett III, MDAssociate Professor of OrthopaedicsMedical Director of Orthopaedic TraumaThe University of VermontOrthopaedic Specialty Center192 Tilley DriveSouth Burlington, VT 05403USA

Peter Bates, FRCS (Trauma and Orth)Barts Health at Royal London HospitalOrthopaedic DepartmentSecond FloorJohn Harrison HousePhilpot StreetLondon E1 1BBUnited Kingdom

Martin Beck, MDHead, Clinic for Orthopaedic SurgeryLuzerner Kantonsspital6004 LuzernSwitzerland

Martin D Bircher, FRCSPelvic Unit St George's Hospital and Medical SchoolBlackshaw RoadTootingLondon SW178OTUnited Kingdom

Philip A Brady, MB, BCh, BAO, BMedSci, FRCS(Tr & Orth)Consultant Orthopaedic SurgeonBlackrock ClinicRock Road, BlackrockCounty DublinIreland

Holly Brown Lenard, MD, PLLCOrthopaedic Surgeon11211 Prosperity Farms RoadSuite C-114Palm Beach Gardens, FL 33410USA

Eben A Carroll, MDAssistant ProfessorDepartment of Orthopaedic SurgeryDirector of Orthopaedic TraumaWake Forest University School of MedicineMedical Center BlvdWinston-Salem, NC 27157-1070USA

Musa Citak, Prof, Dr medEndoklinik HamburgHolstenstraße 222767 HamburgGermany

Carol E Copeland, MDAssociate ProfessorDepartment of Orthopaedics and RehabilitationDivision of Orthopaedic TraumaPenn State Hershey Medical Center500 University Drive, H089Hershey, PA 17033USA

Colin V Crickard, MDDepartment of Orthopaedic SurgeryCarolinas Medical Center1025 Morehead Medical DriveSuite 300Charlotte, NC 28204USA

Ulf Culemann, Prof, Dr medChefarzt der Klinik für UnfallchirurgieAKH-GruppeAllgemeines Krankenhaus CelleSiemensplatz 4S 29223 CelleGermany

David C Dewar, MBBS, B (Med) Sc, FRACSOrthopaedic SurgeonDepartment of OrthopaedicsJohn Hunter HospitalUniversity of NewcastleLocked Bag 1Hunter Region Mail CentreNewcastle, 2310Australia

Claudio Dora, Prof Dr medDepartment of OrthopedicsUniversity of ZurichBalgrist HospitalForchstrasse 3408008 ZürichSwitzerland

Thomas A Einhorn, MDProfessor and ChairmanDepartment of Orthopaedic SurgeryBoston University Medical Center720 Harrison AvenueSuite 808Boston, MA 02118USA

Wolfgang K Ertel, MD, FACSSurgeon in ChiefDepartment of Special Orthopaedic and TraumaSurgeryCharitéCampus Benjamin FranklinHindenburgdamm 3012203 BerlinGermany

Emily L Exten, MDDepartment of Orthopaedic SurgeryMeriter Hospitals & Clinics202 S Park StreetMadison, WI 53715USA

Carl R Freeman, MDLieutenant Commander, USNAssistant Professor of SurgeryF. Edward Herbert School of MedicineUniformed Services University of the Health SciencesDepartment of Orthopaedic SurgeryNaval Hospital Jacksonville2080 Child StreetJacksonville, FL 32214USA

Axel Gänsslen, Dr medConsultantKlinik für Unfallchirurgie, Orthopädie undHandchirurgieKlinikum der Stadt WolfsburgSauerbruchstraße 738440 WolfsburgGermany

Reinhold Ganz, MDEmeritusUniversity of BernWalchstrasse 103073 GümligenSwitzerland

Sean E Garvin, MDAssistant Attending AnesthesiologistHospital for Special SurgeryClinical Assistant Professor, AnesthesiologyWeill Medical College of Cornell University535 East 70th StreetNew York, NY 10021USA

Joshua L Gary, MDAssistant Professor of Orthopaedic SurgeryUniversity of Texas Health Science Center at HoustonDepartment of Orthopaedic Surgery6400 Fannin StreetSuite 1700Houston, TX 77030USA

William H Geerts, MDThromboembolism ProgramRoom D674Sunnybrook Health Sciences Centre2075 Bayview AveToronto, ON M4N 3M5Canada

John T Gorczyca, MDProfessor of OrthopaedicsChief, Division of Orthopaedic TraumaUniversity of Rochester Medical Center601 Elmwood AvenueBox 665Rochester, NY 14642USA

Douglas ST Green, MDHospital for Special Surgery535 East 70th StreetNew York, NY 10021USA

Andrew Grose, MDDepartment of Orthopedic SurgeryNew York Medical CollegeWestchester Medical Center19 Bradhurst AvenueHawthorne, NY 10532USA

Karen Hand, MDMemorial Hospital at Gulfport1340 Broad AvenueSuite 450Gulfport, MS 39501USA

John H Healey, MD, FACSProfessor of Orthopaedic SurgeryWeill Medical CollegeCornell UniversityMemorial Sloan-Kettering Cancer Center1275 York AvenueNew York, NY 10065USA

Patrick DG Henry, MD, FRCSCAssistant ProfessorUniversity of TorontoDepartment of Surgery, Division of OrthopaedicSurgerySunnybrook Health Sciences Centre2075 Bayview AvenueToronto, ON M4N 3M5Canada

Eero Hirvensalo, MD, PhDAssociate ProfessorHelsinki UniversityChairman, Musculoskeletal Division of SurgeryHelsinki University HospitalTöölö HospitalTopeliuksenkatu 500029 HUS, HelsinkiFinland

Alexander Hofmann, PD Dr medDepartment of Orthopaedics and Trauma SurgeryUniversity Medical CenterJohannes Gutenberg UniversityLangenbeckstr. 155131 MainzGermany

Jörg H Holstein, Priv-Doz, Dr medKlinik für Unfall-, Hand- undWiederherstellungschirurgieUniversitätsklinikum des Saarlandes66421 Homburg/SaarGermany

Devon M Jeffcoat, MDDavid Geffen School of Medicine at UCLA10833 Le Conte Avenue76-143 CHSLos Angeles, CA 90095USA

Richard J Jenkinson, MD, MSc, FRCS (C)Assistant Professor, University of TorontoSunnybrook Health Sciences CentreRoom MG 3212075 Bayview AvenueToronto, ON M4N 3M5Canada

Matthew L Jimenez, MDClinical Professor of Orthopaedic SurgeryIllinois Bone and Joint InstituteDepartment of Orthopaedic SurgeryUniversity of Illinois8930 Waukegan RoadMorton Grove, IL 60053USA

Eric E Johnson, MDMullikin Professor of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA10833 Le Conte AvenueRoom 76-138Los Angeles, CA 90095USA

David M Kahler, MDProfessor, Department of Orthopaedic SurgeryUniversity of Virginia Health SystemBox 800159Charlottesville, VA 22908-0159USA

Ron Kodama, MD, FRCSCProfessor of Surgery, Division of UrologyUniversity of TorontoSunnybrook Health Sciences CentreRoom MG 4062075 Bayview AvenueToronto, ON M4N 3M5Canada

Hans J Kreder, MD, MPH, FRCS (C)Professor, University of TorontoOrthopaedic Surgery and HPMEChief, Holland Musculoskeletal ProgramMarvin Tile Chair and Chief, Orthopaedic SurgerySunnybrook Health Sciences Centre2075 Bayview AvenueToronto, ON M4N 3M5Canada

Christian Krettek, Prof, Dr medMedizinische Hochschule HannoverCarl Neubergstrasse 130625 HannoverGermany

William D Lack, MDDepartment of Orthopaedic Surgery andRehabilitationLoyola University Medical Center2160 S First AveMaywood, IL 60153USA

Joseph M Lane, MDChief of Metabolic Bone Diseases ServiceDepartment of Orthopaedic SurgeryHospital for Special Surgery523 East 72nd StreetNew York, NY 10021USA

Kelly Lefaivre, BScH, MD, MSc (Epid), FRCSCAssociate Professor, Department of OrthopaedicsDivision of Orthopaedic TraumaUniversity of British ColumbiaVancouver General Hospital3rd Floor Ortho Trauma2775 Laurel StreetVancouver, BC V5Z 1M9Canada

Michael Leunig, PD, Dr medHead of OrthopaedicsSchulthess ClinicLengghalde 28008 ZürichSwitzerland

Meir (Iri) Liebergall, MDProfessorChairman, Orthopedic Surgery ComplexThe Hadassah-Hebrew University Medical CenterPO Box 12000Jerusalem, il-91120Israel

Jan Lindahl, MDHead of Pelvis and Lower ExtremityTrauma UnitHelsinki University HospitalTöölö HospitalTopeliuksenkatu 500029 HUS, HelsinkiFinland

Ted Manson, MDAssociate ProfessorR Adams Cowley Shock Trauma CenterDivision of Orthopaedic Trauma22 South Greene StreetRoom T3R59Baltimore, MD 21201-1544USA

Jeffrey W Mast, MD4790 Caughlin Parkway #140Reno, NV 89519USA

Keith A Mayo, MDProfessor of Orthopaedic SurgeryDirector, Hansjörg Wyss Hip and Pelvis CenterUniversity of Washington School of Medicine1959 Northeast Pacific Street B307Seattle, WA 98195USA

Dana C Mears, MD, PhDClinical Professor of Orthopaedic SurgeryUniversity of Pittsburgh Medical CenterGreater Pittsburgh Orthopaedic Associates5820 Centre AvenuePittsburgh, PA 15206USA

Berton R Moed, MDThe Hansjörg Wyss Endowed Chair in OrthopaedicSurgeryProfessor and ChairmanDepartment of Orthopaedic SurgerySaint Louis University School of Medicine3635 Vista Avenue7th Floor Desloge TowersSt Louis, MO 63110USA

Rami Mosheiff, Prof, Dr medHead of Orthopedic Trauma UnitDepartment of Orthopedic SurgeryHadassah University HospitalEin KeremPO Box 12000Jerusalum, il-91120Israel

Sean E Nork, MDProfessorHarborview Medical CenterDepartment of Orthopaedic SurgeryUniversity of Washington325 Ninth AvenueBox 359798Seattle, WA 98104USA

Markku T Nousiainen, BA (Hons), MS, MEd, MD,FRCS (C)Assistant Professor, Department of SurgeryUniversity of TorontoSunnybrook Health Sciences CentreSuite 62143 Wellesley Street EastToronto, Ontario M4Y 1H1Canada

Peter J O'Brien, MD, FRCSCAssociate ProfessorHead, Division of Orthopaedic TraumaDepartment of OrthopaedicsUniversity of British Columbia2775 Laurel St3rd FloorVancouver, BC V5Z 1M9Canada

Steven A Olson, MD, FACSProfessor, Department of Orthopaedic SurgeryVice Chair and Chief, Division of OrthopaedicTraumaChairman, Perioperative Executive CommitteeDuke University HospitalDUMC 3389Durham, NC 27710USA

Michel Oransky, MDAurelia HospitalVia Aurelia 860Rome 00165Italy

Robert V O'Toole, MDAssociate ProfessorR. Adams Cowley Shock Trauma CenterDepartment of OrthopaedicsUniversity of Maryland School of MedicineT3R6222 South Greene StreetBaltimore, MD 21201-1544USA

Joshua C Patt, MD, MPHCarolinas Medical CenterDepartment of Orthopaedic SurgeryResidency Program DirectorMusculoskeletal Oncology andSpine Surgery1025 Morehead Medical DriveSuite 300Charlotte, NC 28204USA

Jason L Pittman, MDDepartment of Orthopaedic SurgeryBoston University Medical Center720 Harrison AvenueSuite 808Boston, MA 02118USA

Tim Pohlemann, MDUniversitätsklinikum SaarlandDirektor Klinik für Unfall-, Hand- und WiederherstellungschirurgieGebäude 57Kirrberger Straße 166421 Homburg/SaarGermany

Jason W Roberts, MDOrthopaedic Trauma SurgeryBronson Healthcare MidwestClinical Assistant ProfessorWestern Michigan University School of MedicineKalamazoo, MI 49007USA

Pol M Rommens, Prof Dr med, Dr.h.cDirector, Department of Orthopaedics andTraumatologyUniversity Medical CenterJohannes Gutenberg UniversityLangenbeckstrasse 155131 MainzGermany

Milton Lee (Chip) Routt Jr, MDProfessorAndrew R. Burgess Endowed ChairDepartment of Orthopedic SurgeryUniversity of TexasMemorial Hermann Medical Center6400 Fannin StreetSuite 1700Houston, TX 77030USA

Joel Rubenstein, MD, FRCP (C)Associate ProfessorDepartment of Medical ImagingSunnybrook Health Sciences Centre2075 Bayview AvenueToronto, ON M4N 3M5Canada

Anas Saleh, MDDepartment of Orthopedic SurgeryCleveland Clinic Foundation9500 Euclid AvenueCleveland, OH 44195USA

Carlos Sancineto, MDHospital Italiano de Buenos AiresChief, Orthopaedic Trauma SectionPotosi 4247 Buenos Aires, 1181 Argentina

Raj Satkunasivam, MDSunnybrook Health Sciences Centre2075 Bayview AvenueRoom MG406North York, ON M4N 3M5Canada

Gregory J Schmeling, MDMedical College of WisconsinMilwaukee Medical ComplexBox 1498700 W Wisconsin AvenueMilwaukee, WI 53226USA

Stephen H Sims, MDDepartment of OrthopaedicsCarolinas Medical Center1025 Morehead Medical DriveSuite 300Charlotte, NC 28204USA

Theddy Slongo, MDSenior Consultant, Paediatric Trauma andOrthopaedicsUniversity Children's HospitalDepartment of Paediatric Surgery3010 BernSwitzerland

Adam J Starr, MDDepartment of Orthopaedic SurgeryUT Southwestern Medical Center5323 Harry Hines BlvdDallas, TX 75390-8883USA

David JG Stephen, MD, FRCS (C)Associate ProfessorUniversity of TorontoOrthopedic SurgerySunnybrook Health Sciences CentreRoom MG3652075 Bayview AvenueNorth York, ON M4N 3M5Canada

Michael D Stover, MDProfessor, Feinberg School of MedicineNorthwestern University676 N St ClairSuite 1350Chicago, IL 60611USA

Volker StüberMedizinische Hochschule HannoverKlinik für UnfallchirurgieCarl-Neuberg-Straße 130625 HannoverGermany

Timo Stübig, Dr medMedizinische Hochschule HannoverKlinik für UnfallchirurgieCarl-Neuberg-Straße 130625 HannoverGermany

Lisa M Tibor, MDDepartment of OrthopaedicsKaiser Permanente Medical Center1200 El Camino RealSouth San Francisco, CA 94030USA

Aasis Unnanuntana, MDAssociate ProfessorDepartment of Orthopaedic SurgerySiriraj HospitalMahidol University2 Wang Lang Road, SirirajBangkoknoi district, BangkokThailand

Manyi Wang, MDProfessor and ChiefDepartment of Orthopedic TraumaBeijing Jishuitan HospitalBeijing Xin Jie Kou Dong Jie No. 31100035 BeijingChina

Michael J Weaver, MDClinical Instructor, Harvard Medical SchoolDepartment of Orthopaedic SurgeryBrigham and Women's Hospital75 Francis StreetBoston, MA 02115USA

David S Wellman, MDAssistant Attending Orthopaedic SurgeonHospital for Special SurgeryInstructor in Orthopaedic SurgeryWeil Cornell Medical College535 E 70th StreetNew York, NY 10021USA

Xinbao Wu, MDAssociate ProfessorDepartment of Orthopedic TraumaBeijing Jishuitan HospitalBeijing Xin Jie Kou Dong Jie No. 31100035 BeijingChina

Shiwen Zhu, MDAssociate ProfessorDepartment of Orthopedic TraumaBeijing Jishuitan HospitalBeijing Xin Jie Kou Dong Jie No.31100035 BeijingChina

Michael Zlowodzki, MDIndiana UniversityIU Health Methodist Hospital1801 N Senate BlvdSuite 535Indianapolis, IN 46202USA

Volume 1

Section 1Principles of the treatment of pelvic ring injuries

1.1      Anatomy of the pelvic ring

Marvin Tile, James F Kellam

1   Introduction

2   Structural stability

3   Interior of pelvis

4   References

1.2      Biomechanics and methods of internal fixation

John T Gorczyca

1   Introduction

2   Anatomical structures

3   Concept of pelvic stability

4   Injury force patterns

5   Biomechanics of pelvic fixation

6   Conclusion

7   References

1.3      Pathoanatomy, mechanisms of injury, and classification

Kelly Lefaivre, Peter J O'Brien, Marvin Tile

1   Introduction

2   Pathoanatomy

3   Mechanisms of injury

4   Classification

5   Comprehensive classification

6   Type 61-A: stable

7   Type 61-B: partially stable

8   Type 61-C: completely unstable (Young-Burgess APC III, VS)

9   Pelvic ring disruption associated with acetabular fracture

10 Conclusion

11 References

1.4      General assessment and management of the polytrauma patient

Wolfgang K Ertel, James F Kellam

1   Introduction

2   General principles

3   Principles of damage control

4   Relationship of pelvic fractures to injuries in other systems

5   Specific treatment of pelvic disruption in a multiply injured patient

6   Control of pelvic hemorrhage

7   Definite fracture care in the multiply injured patient

8   Conclusion

9   References

1.5      Defining the injury: assessment and principles of management of pelvic ring fractures

Richard J Jenkinson, Marvin Tile, Joel Rubenstein

1   Introduction

2   Clinical assessment

3   Radiographic assessment

4   Principles of management of pelvic ring fractures

5   References

Section 2Techniques

1.6      Surgical approaches to the pelvis

Michael J Weaver, James F Kellam

1   General considerations

2   Approaches to the anterior ring

3   Approaches to the posterior ring

4   Anterior (intrapelvic) approach to the sacroiliac joint

5   Posterior (extrapelvic) approach to the sacroiliac joint and lateral sacrum

6   Sacral approach

7   References

1.7      External fixation of the pelvic ring

Pol M Rommens, Alexander Hofmann

1   Introduction

2   Biomechanical aspects

3   Indications

4   Application methods

5   Pin placement in the iliac crest

6   Pin placement in the anterior inferior iliac spine

7   Frame design

8   Aftercare

9   Conclusion

10 References

1.8.1   Internal fixation of the injured pelvic ring: rationale

Marvin Tile

1   Introduction

2   Benefits of internal fixation

3   Risks

4   Individual types: rationale

5   Conclusion

6   References

1.8.2   Internal fixation of the injured pelvic ring: navigation

Rami Mosheiff, Meir (Iri) Liebergall

1   Patient selection and indications

2   Preoperative assessment

3   Surgical technique

4   Principles of navigation and guidance

5   Conclusion

6   References

1.8.3   The management of the injured pelvic ring: internal fixation of stable pelvic ring fractures (type A)

Markku T Nousiainen, Philip A Brady

1   Patient selection/indications

2   Nonoperative management

3   Preoperative planning

4   Surgical techniques

5   Postoperative care

6   Results

7   Complications

8   Conclusion

9   References

1.8.4   The management of the injured pelvic ring: internal fixation of the anterior pelvic injuries—open book type (B1)

Sean E Nork

1   Introduction

2   Nonoperative management

3   Preoperative planning

4   Surgical techniques

5   Postoperative care

6   Results

7   Complications

8   Conclusion

9   References

1.8.5   Internal fixation of lateral compression fractures (type B2)

Stephen H Sims

1   Patient selection and indications

2   Nonoperative treatment

3   Preoperative planning

4   Surgical technique

5   Special fracture considerations

6   Postoperative care

7   Results

8   Conclusion

9   References

1.8.6   Internal fixation of unstable fractures (types B3 and C)

Milton Lee (Chip) Routt Jr, Timothy S Achor

1   Patient selection/indications

2   Nonoperative management

3   Preoperative planning

4   Surgical techniques

5   Postoperative care

6   Results

7   Complications

8   Conclusion

9   References

1.9      Sacral fractures

Tim Pohlemann, Jörg H Holstein, Ulf Culemann

1   Introduction

2   Anatomy

3   Neurovascular anatomy

4   Clinical importance of the sacral anatomy

5   Classification

6   Incidence and injury mechanism

7   Patient selection and indications

8   Preoperative planning

9   Surgical techniques

10 Surgical approaches

11 Fracture stabilization and choice of implants

12 Completely unstable pelvic ring injury (type C) with major displacement and without neurological deficit

13 Postoperative care

14 Complications

15 Conclusion

16 References

Section 3Special indications

1.10    Lumbosacral instability and stabilization

Colin V Crickard, Joshua C Patt

1   Introduction

2   Preoperative planning

3   Surgical technique

4   Decompression technique

5   Closure technique

6   Postoperative care

7   Outcomes

8   Conclusion

9   References

1.11    Open pelvic fracture

Robert V O'Toole, Ted Manson

1   Introduction

2   Classification

3   Initial management

4   Preoperative planning

5   Surgical techniques

6   Tips and tricks

7   Postoperative care

8   Results

9   Complications

10 Conclusion

11 References

1.12    Pelvic ring disruption in women: genitourinary and obstetrical implications

Carol E Copeland

1   Introduction

2   The nonpregnant female patient

3   The pregnant trauma patient

4   Pelvic trauma as a consequence of pregnancy

5   Conclusion

6   References

1.13    Urological injuries in pelvic ring trauma: assessment and management in male patients

Ron Kodama, Raj Satkunasivam

1   Anatomy and classification

2   Bladder injuries

3   Pelvic fracture urethral injuries

4   Conclusion

5   References

1.14    Injury to the pelvis in pediatric patients: the immature skeleton

Theddy Slongo

1   Anatomy and classification

2   Patient selection and indications

3   Preoperative planning

4   Surgical techniques

5   Postoperative care

6   Results and outcomes

7   Complications

8   Conclusion

9   References

1.15.1 Insufficiency fractures of the pelvis: metabolic and nonoperative workup

Aasis Unnanuntana, Anas Saleh, Joseph M Lane

1   Introduction

2   Etiology and pathogenesis

3   Assessment and medical evaluation

4   Nonoperative management

5   Conclusion

6   References

1.15.2 Insufficiency fractures of the pelvis: operative management

Karen Hand, James F Kellam

1   Patient selection and indications

2   Preoperative planning

3   Surgical techniques

4   Postoperative care

5   Conclusion

6   References

Section 4Results and complications

1.16.1 Outcomes after pelvic ring injuries: general concept and conclusion

Patrick DG Henry, Richard J Jenkinson, Hans J Kreder

1   Introduction

2   Outcomes and complications following pelvic ring injuries

3   Injury and treatment factors related to outcome

4   Conclusion

5   References

1.16.2 Outcomes after pelvic ring injuries: critical review of the world experience

Axel Gänsslen

1   Introduction

2   Health outcomes and management

3   Level of evidence and evidence-based practice

4   Basis of outcomes evaluation of pelvic ring injuries

5   Outcomes after type A injuries

6   Outcomes after type B injuries

7   Outcomes after type C injuries

8   Conclusion

9   References

1.17    Venous thromboembolism in pelvic trauma

William H Geerts

1   Introduction

2   Epidemiology of venous thromboembolism in pelvic trauma

3   Diagnosis of clinically suspected venous thromboembolism

4   Treatment of venous thromboembolism in patients with pelvic trauma

5   Prevention of venous thromboembolism in pelvic trauma

6   Screening for asymptomatic deep vein thrombosis

7   Practical aspects of thrombosis prevention in patients with pelvic fracture

8   Conclusion

9   References

1.18    Complications of pelvic trauma

Andrew Grose, David E Asprinio, Marvin Tile

1   Introduction

2   Early complications

3   Late complications

4   Conclusion

5   References

1.19    Malunion and nonunion of the pelvis: posttraumatic deformity

Michael D Stover, William D Lack

1   Incidence

2   Etiology

3   Deformity

4   Definition

5   Symptomatology

6   Patient evaluation

7   Treatment

8   References

Volume 2

Section 5Principles of the treatment of acetabular fractures

2.1      Anatomy of the acetabulum

Carl R Freeman, Michael Leunig, Martin Beck, Reinhold Ganz

1   Introduction

2   Hip development

3   Acetabular landmarks

4   Acetabular structure

5   Radiographic anatomy

6   Hip stability

7   Acetabular orientation

8   Acetabular cartilage

9   Acetabular biomechanics

10 Hip circulation

11 Summary

12 References

2.2      Biomechanics of acetabular fractures

Steven A Olson

1   Normal hip mechanics

2   Acetabular fractures

3   Mechanics of acetabular fixation

4   Conclusion

5   References

2.3      Pathoanatomy and classification of acetabular fractures

Jorge E Alonso, James F Kellam, Marvin Tile

1   Introduction

2   Mechanism of injury

3   Diagnosing the fracture

4   Letournel-Judet classification (AO/OTA Fracture and Dislocation Classification)

5   Conclusion

6   References

2.4      Defining the injury: assessment and principles of management of acetabular fractures

Markku T Nousiainen, Philip A Brady, Marvin Tile

1   Introduction

2   Clinical assessment

3   Radiographic assessment

4   Postoperative assessment

5   Imaging of complications and associated injuries

6   Conclusion

7   References

2.5      Decision making: nonoperative and operative indications for treatment of acetabular fractures

Steven A Olson, Michael Zlowodzki

1   Introduction

2   Pelvic anatomy

3   Fracture classifications

4   Nonoperative treatment of acetabular fractures

5   Operative treatment of acetabular fractures

6   Choice of operative approach

7   Special circumstances

8   Delayed fracture indications

9   Acute total hip arthroplasty

10 Conclusion

11 References

2.6      General assessment and perioperative management of acetabular fractures

Andrew Grose, Douglas ST Green, Sean E Garvin

1   Introduction

2   Evaluation of the patient as a whole

3   Evaluation of the patient as a surgical candidate

4   Medical optimization and anesthetic management

5   General guidelines for anesthesia for pelvic fractures

6   Anesthetic plan: nuances for associated injuries

7   Blood/fluid resuscitation

8   Conclusion

9   References

Section 6Techniques

2.7      Specific surgical approaches and technique

Craig S Bartlett III, David L Helfet

1   Introduction

2   Indications for surgery and perioperative considerations

3   The geriatric patient

4   Timing of surgery

5   Preoperative planning

6   Selection of the optimal surgical approach

7   Specific approaches

8   Surgical technique

9   Alternative to Kocher-Langenbeck: the modified Gibson approach

10 Other special technical factors: trochanteric flip osteotomy with surgical dislocation of the femoral head for treatment of fractures of the acetabulum

11 Extension of the ilioinguinal approach

12 Postoperative management

13 Conclusion

14 References

2.8      Planning and decision making: surgical approaches

David C Dewar, David L Helfet

1   Why should we plan?

2   Timing

3   Imaging

4   Planning/templating

5   Operating room preparation

6   Specific challenges to reducing individual fracture patterns

7   Approach planning

8   Anterior approaches

9   Posterior approaches

10 Transtrochanteric approach

11 Extensile approaches

12 Conclusion

13 References

2.9.1   Computer-assisted closed techniques of reduction and fixation

David M Kahler

1   Introduction

2   Early experience

3   Computer-assisted orthopedic surgery (image-guided surgery)

4   3-D (CT-based) versus 2-D (image intensification-based) surgical navigation for pelvic and acetabular fractures

5   Screw trajectories for specific acetabular fracture patterns

6   Reduction of radiation exposure to patient and surgeon

7   Conclusion

8   References

2.9.2   Image intensifier−assisted closed techniques of reduction and fixation

Joshua L Gary, Peter Bates, Adam J Starr

1   Introduction

2   Screw pathways and image intensifier visualization

3   Surgical indications

4   Operative techniques

5   Specific fracture configurations

6   Hardware options

7   Complications

8   References

2.10.1 Techniques of reduction and fixation for acetabular fractures: open methods

Jeffrey W Mast

1   Introduction

2   Posterior wall fractures

3   Reduction techniques

4   Associated fractures

5   Conclusion

6   References

2.10.2 Surgical management of wall and column fractures (type A)

Berton R Moed, David JG Stephen

1   Type A fractures: posterior wall (A1), posterior column (A2), and anterior column or anterior wall (A3)

2   Type A1: posterior wall fractures

3   Type A2: posterior column fractures

4   Type A3: anterior column or anterior wall

5   Conclusion

6   References

2.10.3 Surgical management of B types: B1, B2, B3

David S Wellman, David L Helfet

1   Introduction

2   Patient selection/indications

3   B1: transverse fractures (including transverse with an associated posterior wall fragment)

4   Transverse with posterior wall

5   B2: partial articular fractures (T-type)

6   B3: anterior column with posterior hemitransverse fractures

7   References

2.10.4 Surgical management of associated both-columnfractures (type C)

Ketih A Mayo

1   Introduction

2   Patient selection/indications

3   Preoperative planning

4   Surgical techniques

5   Operating room logistics/patient positioning

6   Reduction and fixation

7   Postoperative care

8   Results

9   Complications

10 Conclusion

11 References

2.11.1 Cerclage wires and cable fixation for an acetabular fracture

Marvin Tile, Dana C Mears

1   Introduction

2   Instrumentation for cable fixation of the acetabulum

3   Preferred fractures for the use of cable fixation

4   Other applications of cables inserted through the ilioinguinal approach

5   Cable fixation for an acetabular fracture managed with an acute total hip replacement

6   Conclusion

7   References

2.11.2 Intrapelvic approach in acetabular fractures

Eero Hirvensalo, Jan Lindahl

1   Introduction

2   Indications

3   Technique for the intrapelvic approach

4   Reduction and fixation techniques

5   Complications

6   Conclusion

7   References

2.11.3 Use of bone substitutes

Jason L Pittman, Thomas A Einhorn

1   Introduction

2   Bone cements

3   Biological agents used to augment fracture healing

4   Conclusion

5   References

2.11.4 Intraoperative assessment of acetabular fractures

Christian Krettek, Volker Stüber, Timo Stübig, Musa Citak

1   Introduction

2   Intraoperative assessment

3   Postoperative imaging

4   References

Section 7Special situations

2.12    The elderly patient with an acetabular fracture

Eben A Carroll, David L Helfet

1   Introduction

2   Acute total hip arthroplasty

3   Minimally invasive techniques

4   Open reduction and internal fixation

5   Technical tricks

6   Treatment failure and delayed total hip arthroplasty

7   Conclusion

8   References

2.13    Primary total hip arthroplasty for acetabular fracture

Dana C Mears

1   Introduction

2   Indications for an acute total THA

3   Contraindications to acute THA

4   Preoperative assessment

5   Surgical strategies for acute THA with stabilization of the acetabulum

6   Standard surgical technique

7   Techniques for specific fracture patterns

8   Small incision techniques for THA and their use for acute acetabular fractures

9   Alternative strategies for fracture fixation and buttressing of bone graft

10 Results

11 Complications

12 Conclusion

13 References

2.14    Total hip arthroplasty after acetabular fracture

Matthew L Jimenez

1   Introduction

2   Total hip arthroplasty for failed treatment of acetabular fractures

3   Early THA for acute treatment of acetabular fractures

4   Late hip arthroplasty

5   Technical considerations

6   Postoperative management

7   Conclusion

8   References

2.15    Pathological pelvic fractures and acetabular reconstruction in metastatic disease

John H Healey, Holly Brown Lenard

1   Introduction

2   Metastatic disease of the acetabulum

3   Classification

4   Basic principles

5   Technique

6   Tumor-related conditions affecting the pelvis

7   Conclusion

8   References

2.16    Acetabular fracture in the pediatric patient: the immature skeleton

Theddy Slongo

1   Anatomy and classification

2   Diagnostics

3   Decision for nonoperative or operative therapy

4   Surgical techniques

5   Postoperative care

6   Results

7   Complications

8   Conclusion

9   References

2.17    Posttraumatic acetabular dysplasia

Reinhold Ganz, Lisa M Tibor, Claudio Dora

1   Introduction

2   Pathophysiology

3   Pathomorphology

4   Symptoms

5   Surgical correction

6   References

Section 8Results and complications

2.18    Early complications

Gregory J Schmeling, Jason W Roberts, Emily L Exten

1   Introduction

2   Mortality

3   Thromboembolism

4   Infection

5   Nerve injury

6   Malreduction

7   Failure of fixation

8   Vascular injury

9   Intraarticular hardware

10 Trochanteric osteotomy

11 References

2.19    Late complications

Gregory J Schmeling, Jason W Roberts, Emily L Exten

1   Avascular necrosis

2   Late infection

3   Nonunion

4   Heterotopic ossification

5   Posttraumatic osteoarthrosis

6   Conclusion

7   References

2.20    Surgical management of delayed acetabular fractures

Eric E Johnson, Devon M Jeffcoat

1   Anatomy

2   Patient selection and indications

3   Preoperative planning

4   Surgical techniques

5   Postoperative care

6   Results

7   Complications

8   Conclusion

9   References

2.21    Late acetabular reconstruction

Manyi Wang, Xinbao Wu, Shiwen Zhu

1   Introduction

2   Indications

3   Surgical treatment: potential problems

4   Surgical algorithm

5   Complications

6   Results

7   Conclusion

8   References

2.22    Malunion and nonunion

Michel Oransky, Carlos Sancineto, Mario Arduini

1   Anatomy and classification

2   Patient selection/indication

3   Preoperative planning

4   Operative technique

5   Results

6   Complications

7   Conclusion

8   References

2.23    Results of treatment for fractures of the acetabulum

Martin D Bircher

1   Introduction

2   Natural history: why operate?

3   Historical results: methods of assessment and outcomes

4   Letournel's results: the gold standard

5   Summary of Letournel's results

6   How do we improve outcomes in the 21st century?

7   Conclusion

8   References

Principles of the treatment of pelvic ring injuries

Section 1

1.1      Anatomy of the pelvic ring

Marvin Tile, James F Kellam

1   Introduction

2   Structural stability

3   Interior of pelvis

4   References

1.2      Biomechanics and methods of internal fixation

John T Gorczyca

1   Introduction

2   Anatomical structures

3   Concept of pelvic stability

4   Injury force patterns

5   Biomechanics of pelvic fixation

6   Conclusion

7   References

1.3      Pathoanatomy, mechanisms of injury, and classification

Kelly Lefaivre, Peter J O'Brien, Marvin Tile

1   Introduction

2   Pathoanatomy

3   Mechanisms of injury

4   Classification

5   Comprehensive classification

6   Type 61-A: stable

7   Type 61-B: partially stable

8   Type 61-C: completely unstable (Young-Burgess APC III, VS)

9   Pelvic ring disruption associated with acetabular fracture

10 Conclusion

11 References

1.4      General assessment and management of the polytrauma patient

Wolfgang K Ertel, James F Kellam

1   Introduction

2   General principles

3   Principles of damage control

4   Relationship of pelvic fractures to injuries in other systems

5   Specific treatment of pelvic disruption in a multiply injured patient

6   Control of pelvic hemorrhage

7   Definite fracture care in the multiply injured patient

8   Conclusion

9   References

1.5      Defining the injury: assessment and principles of management of pelvic ring fractures

Richard J Jenkinson, Marvin Tile, Joel Rubenstein

1   Introduction

2   Clinical assessment

3   Radiographic assessment

4   Principles of management of pelvic ring fractures

5   References

1.1      Anatomy of the pelvic ring

  Marvin Tile, James F Kellam

1 Introduction

This chapter describes the important surgical anatomy necessary to understand injuries to the pelvic ring and their treatment, especially operative treatment. A more detailed account of pelvic anatomy is best found in anatomy texts [1].

The pelvis is a ring structure made up of three bones: the sacrum and the two innominate bones. In turn, the innominate bones are formed by the fusion of the three separate ossification centers from the ilium, the ischium, and the pubis. They meet at the triradiate cartilage, which fuses by the age of 16 years. The three bone components of the pelvis have no inherent stability; if all soft tissues were removed from the pelvis, then it would fall apart (Fig 1.1-1). Yet, in vivo it is able to withstand major forces; therefore, the soft tissues must confer stability to the pelvic girdle while the bone provides structure. Stability and structure to allow weight transference are the essential anatomical features of the pelvis.

Fig 1.1-1 Anatomy of the pelvis.

2 Structural stability

The pelvic ring is formed by the connection of the sacrum to the innominate bones at the sacroiliac joints and the symphysis pubis. Because the major weight-bearing forces are transmitted from the hip joint through the iliac bone, across the sacroiliac joint into the sacrum and up the spine, it must be assumed that the major stabilizing structures are posterior (Fig 1.1-2). The anterior joint (the symphysis pubis) acts like a strut, preventing collapse of the pelvis, rather than a major weight-bearing, stabilizing structure. Absence of this anterior strut, as in patients with congenital bladder exstrophy (Fig 1.1-3) or trauma victims (Fig 1.1-4), only minimally affects this weight-bearing function. Many mammals possess a posterior bone strut to provide posterior stability (Fig 1.1-5). In humans this function is accomplished by the strong posterior sacroiliac, sacrospinous, and sacrotuberous ligaments.

2.1 Posterior pelvic stability

2.1.1 Sacroiliac joints

The adjacent iliac and sacral surfaces of the sacroiliac joint are divided into two parts: a lower one, the articular surfaces, and an upper one, the tuberosities (Fig 1.1-6). The articular surface of the sacrum is covered with hyaline cartilage, and the adjacent surface of the ilium is covered with fibrocartilage; however, the articulation is not truly a synovial joint. Embryonically, the sacroiliac joints develop not as other synovial joints do, as clefts in a continuous rod of condensed mesenchyme, but by the direct contact of the ilium and sacrum posteriorly. In the upright position the body weight pushes the sacrum down between the wings of the ilium causing approximately 5° of dorsoventral rotation as the innominate bones move backward and the anterior pubic rami swing upward [2]. This motion is markedly restricted by the posterior ligamentous complex, the strongest being the interosseous ligaments [3].

Fig 1.1-2a–b The major posterior stabilizing structures are ligaments.

a Ligaments from anterior aspect of pelvis.

b Ligaments from posterior aspect of pelvis.

Fig 1.1-3 X-ray of a 39-year-old woman with congenital bladder exstrophy. Note the total lack of anterior stability because of excessive widening of the symphysis pubis. Despite this, the sacroiliac joints have remained intact and show no evidence of instability.

Fig 1.1-4 AP x-ray of the pelvis of a 21-year-old woman who had previously lost a portion of the superoinferior pubic rami in an open fracture of the pelvic ring at 12 years old. The superior ramus fracture entered the right acetabulum. No posterior instability is noted despite the pelvic ring gap. The patient has no symptoms referable to the sacroiliac joints or the gap anteriorly. She was seen for an unrelated medical condition.

Fig 1.1-5 The skeleton of an elephant shows the symphysis ischium, a solid bone strut posteriorly.

Fig 1.1-6a–b The important landmarks of the pelvis are shown including the adjacent articular surfaces of the sacroiliac joint and symphysis (light blue areas).

2.1.2 Interosseous sacroiliac ligaments

The interosseous sacroiliac ligaments, the strongest in the body, unite the tuberosities of the ilium and sacrum, and confer stability on the posterior sacroiliac complex (Fig 1.1-7).

2.1.3 Posterior sacroiliac ligaments

Two distinct bands are described:

• The short posterior sacroiliac ligament consists of a number of fibers that pass obliquely from the tubercle or ridge of the sacrum to the posterior superior and posteroinferior spine of the ilium.

• The long posterior sacroiliac ligament comprises longitudinal fibers that run from the posterior superior iliac spine to the lateral portion of the sacrum, intermingling with the origin of the sacrotuberous ligament, and covering the short ligament (Fig 1.1-8).

2.1.4 Anterior sacroiliac ligaments

Anterior sacroiliac ligaments are strong, flat bands, comprising transverse and oblique fibers that pass from the anterior surface of the sacrum to the adjacent anterior surface of the ilium (Fig 1.1-9).

2.1.5 Sacrotuberous ligament

The sacrotuberous ligament is an extremely strong, broad band extending from the lateral portion of the entire dorsum of the sacrum and the posterior surfaces of the posterior superior and inferior iliac spines to the ischial tuberosity. In some areas it covers, and in others it is contiguous with, the sacrospinous ligaments. The medial border extends as a falciform border to the ischial tuberosity, where it is continuous with the obturator fascia. Laterally, at its superior origin, it gives attachment to the gluteus maximus. The sacrotuberous ligament forms a portion of the pelvic outlet (Fig 1.1-10, Fig 1.1-11).

Fig 1.1-7 Cross-section through the sacroiliac joints shows the direction of the interosseous sacroiliac ligaments.

Fig 1.1-8 The posterior sacroiliac ligaments are much stronger and hold the posterior ilium and sacrum together.

Fig 1.1-9 The anterior sacroiliac ligament is a broad, thin structure crossing the anterior aspect of the joint.

Fig 1.1-10a–b

a Sacrospinous/sacrotuberous exterior ligaments.

b Sacrospinous/sacrotuberous intrapelvic ligaments.

Fig 1.1-11 Symphysis.

2.1.6 Sacrospinous ligament

The sacrospinous ligament is a strong triangular sheet arising from the lateral margin of the sacrum and the coccyx, deep to the sacrotuberous ligament, and passing to the ischial spine. It divides the ischial area into the greater sciatic notch and the lesser sciatic foramen. Its pelvic surface covers and is adherent to the coccygeus muscle (Fig 1.1-10).

2.1.7 Iliolumbar ligaments

The pelvis is secured to the axial skeleton at the lumbosacral articulation by the strong L5/S1 intervertebral disc and two ligaments. The iliolumbar ligament is the markedly thickened portion of the fascia covering the quadratus lumborum. Bilaterally, this strong ligament attaches the tip of the fifth lumbar transverse process to the iliac crest. Lying just below the level of the apex of the iliac crest, these transverse processes are usually large, somewhat conical, and tilt upward.

2.1.8 Lateral lumbosacral ligament

The lateral lumbosacral ligament spreads downward from the L5 transverse process to the ala of the sacrum. Its sharp medial edge may abut the anterior ramus of the fifth lumbar root.

2.1.9 Posterior tension band

All the posterior ligaments collectively form the posterior tension band of the pelvis, binding together the skeletal elements to resist deforming forces. The transversely placed ligaments, short posterior sacroiliac, anterior sacroiliac, iliolumbar, and sacrospinous resist transverse rotational forces, whereas those that are vertically placed resist longitudinal shearing forces. These ligaments must act together to assure a stable posterior pelvis [3].

2.2 Anterior pelvic stability

2.2.1 Symphysis pubis

The opposed bone surfaces of the symphysis pubis are covered by hyaline cartilage and are united by layers of fibrocartilage and fibrous tissue. In the fibrocartilage, a cleft frequently appears, often as part of the aging process. Superiorly and anteriorly, dense ligamentous fibers blend with the fibrocartilage; inferiorly, the symphysis is reinforced by a more independent structure, the inferior pubic or arcuate ligament (Fig 1.1-11).

3 Interior of pelvis

Because visceral injury is so commonly associated with disruption of the pelvic girdle, a description of the proximity of these structures to the skeleton is in order. Pelvis is Latin for basin. The basin is divided into two sections by the pelvic brim: the true pelvis (below) and the false (above). The pelvic brim consists of the promontory of the sacrum, iliopectineal line, pubic crest, and upper portion of the symphysis pubis. The posterior portion of the pelvic brim is extremely thick in keeping with its weight-bearing function. No muscle crosses the pelvic brim.

3.1 False pelvis

The false pelvis is formed by the ala of the sacrum and the iliac fossa—the fan-shaped inner surface of the ilium covered entirely by the iliacus muscle (Fig 1.1-12).

3.2 True pelvis

The true pelvis is the deep basin below the pelvic brim (Fig 1.1-12). The lateral wall comprises the pubis and ischium, with a small triangular portion of the ilium—the weight-bearing portion. The obturator foramen separating the pubis from the ischium is covered by a membrane, deficient only on top to allow the obturator vessels and nerve to escape from the pelvis. At this point they are vulnerable and may be torn in pelvic trauma or surgical approach (Fig 1.1-13). The obturator internus muscle and fascia, which leave the pelvis through the lesser sciatic foramen, originate from the obturator membrane and cover the lateral wall of the true pelvis (Fig 1.1-14).

The piriformis arises from the lateral mass and anterior portion of the sacrum, leaving the pelvis through the greater sciatic notch. It is the key to the position of the sciatic nerve. In most people, the entire nerve leaves the pelvis below this muscle; although in some the peroneal division either pierces it or, rarely, escapes above it (Fig 1.1-14).

3.2.1 Pelvic diaphragm

The levator ani and the coccygeus form the floor or diaphragm of the true pelvis supporting the pelvic organs and separating them from the perineum. This diaphragm comprises voluntary muscle and is perforated by the urethra, rectum, and vagina (Fig 1.1-15).

Fig 1.1-12a–b

a The false pelvis (above the pelvic brim) and the pelvic brim and true pelvis below in orange.

b The true pelvis (orange shading) below the pelvic brim.

Fig 1.1-13a–b

a This view shows the true pelvis and the relationship of the lumbosacral plexus and obturator nerve. The pudendal nerve can be seen superior to the ischial spine.

b The obturator fascia covers the obturator internus and has a small aperture in its superior corner where the obturator nerve exits the pelvis. The pudendal nerve can be seen traversing posterior to the coccygeus and sacrospinous ligament and entering the true pelvis through the lesser sciatic notch.

Fig 1.1-14 This posterior view of the pelvis demonstrating the relationship of the sciatic nerve to the piriformis muscle and external hip rotators (the gemelli and internal obturator muscle). Also, the course of the internal obturator from its origin inside the true pelvis to the insertion on the greater trochanter is seen.

Fig 1.1-15a−b

a The pelvic floor from the true pelvis.

b Views of the pelvic floor from below.

3.3 Structures at risk

3.3.1 Lumbosacral and coccygeal nerve plexus

The lumbosacral and coccygeal nerve plexuses are derived from the anterior rami of the T12–S4 spinal nerves. The L4–S1 segments are of surgical significance. Injury to all these segments has been reported, including occasional injury to the femoral nerve. The pelvic splanchnic nerves—the nervi erigentes—arise from the anterior rami of S2, S3, and S4. These nerves are responsible for bladder and sexual function, particularly in men (see also Fig 1.1-16).

3.3.2 Lumbosacral plexus

The lumbosacral plexus is formed by a branch of the L4 root crossing the L5 transverse process and the L5 root which crosses and grooves the ala of the sacrum where it joins with L4 to form the lumbosacral trunk. The upper four anterior sacral rami leave the sacral foramina, grooving the lateral mass of the sacrum. The lumbosacral trunk and the first sacral root unite anterior to the sacroiliac joint, and they in turn unite with S2, S3, and S4 anterior to the piriformis, ending in two terminal branches, the sciatic and pudendal nerves, and many collateral branches, including the superior and inferior gluteal nerves. The branches of the sacral plexus may be grouped as follows:

• Branches from the roots of the plexus: rami from the roots of the plexus include muscular branches to the piriformis, levator ani, and coccygeus and the pelvic splanchnic nerve.

• Branches that pass through the greater sciatic notch: the sciatic nerve forms the largest branch of the sacral plexus. It leaves the pelvis between the lower border of the piriformis and the ischial border of the greater sciatic notch. Its two divisions, the tibial and perineal, are loosely held together. This nerve is commonly injured in pelvic trauma, especially in posterior dislocation of the hip with or without an acetabular fracture. The perineal division is most prone to injury in this location, and the least likely to recover.

Fig 1.1-16 The formation of the lumbosacral plexus occurs as the L4 and L5 roots merge with the S1 root at the sacral ala and then join the S2 and S3 roots anterior to the sacroiliac joint.

Because the major supply of the peroneal division of the sciatic nerve is the L5 root, it may be difficult to determine clinically whether the injury is to the nerve as it passes through the greater sciatic notch behind the hip joint or to the root.

The pudendal nerve (S2−4) escapes between the piriformis and coccygeus just medial to the sciatic nerve. The collateral nerves arising from the plexus include the superior gluteal, inferior gluteal, the nerve to the obturator internus (L5, S1, S2), the nerve to the quadratus femoris (L4, L5), and the posterior cutaneous nerve of the thigh (S1, S2, S3). The superior gluteal nerve (L4, L5, S1) and its artery and vein escape from the pelvis by winding around the greater sciatic notch. Injury to the nerve is uncommon, although the artery may be injured by trauma. This nerve is in jeopardy in posterior approaches to the hip joint for acetabular fractures because application along the posterior plate may require excessive retraction, and resultant stretching of the nerve. The inferior gluteal nerve (L5, S1, S2) escapes from the pelvis beneath the piriformis and behind the sciatic nerve to supply the gluteus maximus.

Three branches that emulate the coccygeal plexus terminal branches are the perforating cutaneous branch of S2 and S3, and the perineal branch of S4. These descend anterior to the coccygeus, where they become cutaneous and supply the skin of the buttock and perineum.

3.3.3 Anterior coccygeal plexus

The anterior coccygeal plexus is formed by the anterior rami of S5 and C1, ending in the anterior caudal nerve, a sensory nerve supplying the coccygeal area.

3.3.4 Blood vessels

Massive hemorrhage is the major complication of a pelvic disruption. Precise knowledge of the anatomy of the pelvic vasculature is essential because embolization of the bleeding vessel has emerged as one of the treatment options. The arteries of the pelvis are the median sacral, superior rectal, and internal iliac—the last being the most surgically significant (Fig 1.1-17).

3.3.5 Median sacral artery

The median sacral artery is the continuation of the aorta; therefore, it hugs the vertebral column and may be injured in a sacral disruption. However, it is a small vessel and therefore not of major surgical significance.

3.3.6 Superior rectal (hemorrhoidal) artery

The superior rectal artery—the continuation of the superior mesenteric—is rarely involved in pelvic trauma.

3.3.7 Internal iliac artery

The internal iliac is the vessel of major importance in pelvic trauma. It arises from the common iliac artery in the false pelvis and extends to the pelvic brim, where it splits into anterior and posterior divisions (see Fig 1.1-17a). It crosses medial to the external iliac vein, the psoas muscle, and the obturator nerve during its course. The ureter lies anteriorly, and its vein posteriorly. Severe trauma to the pelvis may disrupt the internal iliac artery or even the common iliac artery; survival is unlikely in those cases. Usually, the superior gluteal, iliolumbar, and lateral sacral arteries arise from the posterior division; all others, including the obturator artery, arise from the anterior division.

Posterior division: Because of their location on the skeletal plane and because severe trauma to the pelvic ring usually causes posterior displacement, vessels in the posterior division are most prone to damage. The superior gluteal artery is the largest branch of the internal iliac artery. It courses across the sacroiliac joint to the greater sciatic notch, where it lies against the ilium, making a U-turn around the notch into the gluteal region, accompanied by its nerve and vein (Fig 1.1-16, Fig 1.1-17). Damage to this large artery is a common cause of massive hemorrhage in pelvic disruption because its course on the ilium crosses the common area of pelvic trauma. Also, traumatic aneurysm of the artery has been reported. The illiolumbar artery is the somatic artery of the fifth lumbar segment; therefore, it must ascend to that level. As it crosses the ala of the sacrum, it too is commonly injured. The lateral sacral artery descends lateral to the anterior sacral foramina and in front of the sacral plexus.

Fig 1.1-17a−b

a Arteries of the pelvis.

b Veins of the pelvis.

Anterior division: The visceral branches supply the bladder, genitalia, and a portion of the rectum. They are: (1) the obliterated obturator artery, which clings to the peritoneum on the side wall of the pelvis above the level of the bladder and ends in the superior vesical arteries that supply the upper surface of the bladder; and (2) the inferior vesical and middle rectal arteries, which run in the retropubic leash of veins and supply the bladder and genitalia.

The limb and perineal branches include the internal pudendal artery and inferior gluteal artery, which descend anterior to the sacral plexus and pass between the borders of the piriformis and coccygeus into the gluteal region. The inferior gluteal artery passes between the first, second, or third sacral nerves and leaves the pelvis inferior to the piriformis to supply the gluteus maximus. The internal pudendal artery crosses the ischial spine and returns to the pelvis through the lesser sciatic foramen in the company of its own nerve. Both may be torn by trauma to this area. The obturator artery runs along the side wall of the pelvis to the obturator foramen, lying between its nerve and vein. As it leaves the pelvis through the superior defect in the obturator membrane, it may be disrupted in common injuries to the pubic rami.

3.3.8 Pelvic veins

The pelvic viscera lie upon a massive thin-walled venous plexus through which the arteries thread their way. Most drain into the internal iliac vein but some drain into the superior rectal, then into the inferior mesenteric, and on to the portal vein (Fig 1.1-17b). Massive bleeding may occur from this venous plexus following pelvic trauma.

3.3.9 Perineum and genitourinary anatomy

Because this chapter deals mainly with skeletal injury, a detailed description of the gastrointestinal and genitourinary systems is not in order; however, genitourinary injuries are so common and so potentially devastating that some description is needed. The female perineum (Fig 1.1-18) consists of the pelvic diaphragm with the urethra (Fig 1.1-18b), vagina, and rectum. These structures are relatively pliable and are not commonly injured. However, the vagina may be perforated by bone spicules from pubic rami fractures in particular when the injury is due to a lateral compression force.

Controversy has arisen over the conventional anatomical description of the male urethra and newer anatomical and urological information. The urogenital diaphragm is depicted in most texts as in Fig 1.1-19, as two separate fascial layers spanning the pubic arch with skeletal muscle between. Normally, the prostate is believed to sit on the superior layer of fascia but separate from the urogenital diaphragm, the only connection being the membranous urethra that perforates the diaphragm at its midpoint. Obviously, if the prostate is displaced or the urogenital diaphragm suddenly shifts, the membranous urethra ruptures at this natural plane between the apex of the prostate and the superior layer of the diaphragmatic fascia. Colapinto [4] offered a different explanation from clinical studies and found that most urethral ruptures were not of this “classic” variety but occurred below the urogenital diaphragm. These anatomical studies show that the junction between the prostate and urogenital diaphragm is not a natural weak spot but the prostate and urogenital diaphragm tend to be a single unit. The membranous urethra is strong in this region, surrounded by smooth muscle that extends into the prostatic urethra. The muscle ends abruptly at the inferior surface of the diaphragm where the bulbous urethra begins; thus, this is the truly weak area of the urethra, and the location of the rupture of the bulbous urethra confirms a clinical finding. Based on these studies, Colapinto [4] has classified urethral tears as described in Fig 1.1-20.

Fig 1.1-18a−b

a Female perineum.

b Female urogenital diaphragm.

Fig 1.1-19 The male perineum.

Fig 1.1-20a−d Colapinto [4] classification of urethral tears.

a Normal: prostate and urogenital diaphragm blend together as one unit.

b Type I: clinical findings may suggest a complete rupture but in fact the urethra is intact although attenuated.

c Type II: classic supradiaphragmatic injury.

d Type III: supradiaphragmatic rupture. A complete rupture is shown but partial type III rupture also occurs. Type III injuries are common. A retrograde urethrogram in these patients shows perineal extravasation.

4 References

1. Grant JCB.An Atlas of Anatomy. 6th ed. Baltimore, MD: Williams & Wilkins. 1972.

2. Oonishi, H, Isha, H Hasegawa T. Mechanical analysis of the human pelvis and its application to the artificial hip joint by means of the three dimensional finite element method. J Biomech. 1983;16(6):427–444.

3. Vukicevic´ S, Marusic´ A, Stavljenic´ A, et al. Holographic analysis of the human pelvis. Spine. 1991 Feb;16(2):209–214.

4. Colapinto V. Trauma to the pelvis: urethral injury. Clin Orthop Relat Res. 1980;Sep; (151):46–55.

1.2      Biomechanics and methods of internal fixation

  John T Gorczyca

1 Introduction

Proper treatment of pelvic injuries requires an understanding of pelvic stability. This chapter reviews the anatomical and physiological concepts of pelvic stability and summarizes the biomechanical literature regarding stabilization of the unstable pelvic injury.

2 Anatomical structures

For anatomical structures, see Chapter 1.1.

2.1 Anterior

The superior and inferior pubic rami act as an anterior strut to maintain the shape and stability of the pelvic ring against physiological and applied forces. Although congenital or traumatic absence of the anterior structures has little effect on pelvic stability in some people, these cases are exceptions. In the acutely injured pelvis, anterior fractures significantly affect pelvic stability. Likewise, injuries to the pubic symphysis, a strong ligamentous and cartilaginous structure that withstands tension (external rotation) and shear forces at the anterior pelvis, contribute to significant instability in some acute injuries. But when injured in isolation, the disrupted pubic symphysis has little effect on pelvic ring stability.

2.2 Posterior

Pelvic stability depends on an intact posterior sacroiliac osseoligamentous complex. This complex is a well-designed biomechanical structure in that it can resist prolonged, powerful forces and can support weight-bearing forces from the spine to the lower extremities during most activities. Most normal forces applied to the pelvis tend to push the sacrum anteriorly and the innominate bones posteriorly. The shapes of the pelvic bones affect the way that they interact. On the inlet view, the sacrum appears wider anteriorly and is held in position by tension in the ligaments, with the strongest ligaments located posteriorly. On the outlet view, the sacrum appears as a classic “keystone” in which applied forces create compression between the bones, contributing to stability of the ring (Fig 1.2-1). This complex interaction between the bones at the sacroiliac joint may have evolved to allow a small amount of motion (shock absorption) but not excessive motion.

The anterior sacroiliac ligaments are flat and strong, allowing them to resist external rotation and shearing forces at the sacroiliac joint. However, with weight bearing, the powerful posterior sacroiliac ligaments resist the majority of the load. The posterior sacroiliac ligamentous structure is similar to a suspension bridge, with the posterior sacroiliac spines acting as the towers, the sacrum as the bridge deck, and the posterior sacroiliac ligaments as the suspending cable (