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Pelvic Ring Injury ORIF 27217

sacral fracture xray

sacral fracture ct scan


ORIF Pelvic Ring CPT

ORIF Pelvic Ring Indications

  • Unstable pelvic ring injuries (SI joint dislocations, sacral fractures, etc)

ORIF Pelvic Ring Contraindications

  • Dysmorphism of the upper sacrum precludes iliosacral screws.
  • Obesity (iliosacral screw placement)
  • Soft tissue injury
  • Patients with abdominal / urologic contrast agents on board.

ORIF Pelvic Ring Alternatives

  • Nonoperative management, skeletal traction

ORIF Pelvic Ring Planning / Case Card

  • High-quality fluoro images of the entire pelvis must be varified before starting the surgery.
  • Distal femoral traction improves reduction.
  • At least 1cm must be available between the foramina on three sequential preop CT slices (cmm slices( for safe S2 sacral screw placement. (Moed BR, JOT 2006;20:378).

ORIF Pelvic Ring Technique

  • prone OSI table
  • vertical incision 1-2cm lateral to PSIS, from iliac crest to greater sciatic notch
  • reflect gluteus maximus to reveal greater sciatic notch, PIIS,inferior sacroiliac joint, piriformis(origin=lateral mass of sacrum)
  • sacrotuberous ligament, erector spinae, multifidus muscle,
  • allows visualization of ilium, sacroiliac joint, posterior sacrum
  • stronqest fixation seems to be iliosacral screws. 6.5-7mm cancellous screw into S1 body. Starting point on ilium is alonq a line running from iliac crest to greater sciatic notch @15mm anterior to and paralleling the crista glutea. 2 screws preferred. Optimal distance from crista glutea is 15-20mm. Risks=sacral nerve root, vessels, dura
  • sacroiliac joint dislocations must undergo reduction and fixation because they are a ligamentous injury and very unlikely to heal without fixation
  • Pelvic orthotic devices / binders can remain in place for up to 190 hours without causing soft tissue compromise (Krieg JC, J Trauma 2005;59(3):659-664).

ORIF Pelvic Ring Complications

  • Infection
  • Poor wound healing
  • Chronic Osteomyelitis
  • Pain
  • Painful hardware
  • Loss of reduction
  • Nonuion
  • Limb length discrepancy
  • Sitting imbalance
  • Gait disturbance
  • DVT / PE

ORIF Pelvic Ring Follow-up care

  • Post-op: 24hrs antibiotic, SCDs, Ted hose, Partial weight bearing. Review reduction on post op A/P pelvis, inlet and outletviews.
  • 7-10 Days: Wound check. Continue partial/non weight bearing
  • 6 Weeks: Advance weight bearing gradually. Review A/P pelvis, inlet and outletviews.
  • 3 Months: Review A/P pelvis, inlet and outletviews.
  • 6 Months: Return to labor. Review reduction on post op A/P pelvis, inlet and outletviews. Obtain follow-up CT scan.
  • 1Yr:Assess outcome. Review A/P pelvis, inlet and outlet views.

ORIF Pelvic Ring Outcomes

  • NO intraoperative nerve damage, 4% loss of reduction for S2 iliosacral screws(Moed BR, JOT 2006;20:378).
  • Good outcome studies are lacking. Outcomes are dependent on initial displacement, neurologic injury, urologic injury and adequacy of reduction.

ORIF Pelvic Ring Review References

  • Starr AJ, Chapter 41, Rockwood and Greens.
  • Olson SA, ICL 2005;54:383
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