Aims. Paediatric pelvic ring fractures are rare but severe injuries, presenting significant treatment challenges. This study aimed to analyze patient characteristics and explore trends in incidence, treatment methods, and mortality associated with these injuries. Methods. This multicentre, retrospective cohort study analyzed paediatric patients (aged ≤ 18 years) with pelvic ring fractures treated between 2001 and 2021 at two level 1 trauma centres. Data on patient demographics, injury characteristics, treatment approaches, and outcomes were collected, and visual trend analysis was conducted to identify patterns. Results. A total of 157 patients with pelvic ring fractures were included. The median age was 15 years (IQR 12 to 17), with 52% (n = 81) being female. Traffic accidents were the leading cause of injury, accounting for 68% of cases (n = 106). Concomitant injuries were observed in 83% of patients (n = 131). The one-year mortality rate was 11.5%, with 76% of deaths occurring within 48 hours of admission, primarily due to traumatic brain injury (53%). Most patients (60%) were treated nonoperatively, while 48% of surgically treated patients underwent internal fixation without prior external fixation. Visual trend analysis revealed an increase in the absolute number of paediatric pelvic ring fractures over time, though no significant shift towards surgical treatment was observed. Among surgically treated patients, there was a trend towards open reduction and internal fixation rather than external fixation as definitive treatment. Nonoperative treatment was more common in children (69%) than in adolescents (55%). For surgical cases, external fixation was preferred in children (44%), while ORIF was more common in adolescents (53%). Conclusion. The incidence of paediatric pelvic ring fractures has increased over time, with a high mortality rate largely attributable to severe neurotrauma. There has been a shift towards surgical treatment without prior external fixation, with differences noted in the treatment approaches between children and adolescents, particularly in surgical fixation methods. Cite this article: Bone Jt Open 2025;6(3):254–263

Pelvic ring fractures usually result from significant trauma, frequently requiring operative stabilisation. The use of an anterior internal fixator (INFIX) is a new technique. This temporary construct is quick and easy to apply using pre-existing spinal implants. No reports of functional outcomes or compartive studies with existing surgical techniques exist in indexed literature. We present a prospective comparative case matched series of 21 patients treated with pelvic INFIX. 1:1 matching was achieved to a cohort of patients treated with open reduction and internal fixation (ORIF) based on fracture pattern. All patients with rotationally and/or vertically unstable pelvic ring fractures treated within our level 1 trauma centre were considered for inclusion. Patients were prospectively followed up with health outcome measures (SF-36, EQ-5D) and joint specific outcome scores (Oxford and Harris hip scores). Results. No statistically significant differences in age (mean 42v38 p=0.3143), length of stay, or operative time were seen. The ISS was significantly higher in the INFIX group (32v22 p=0.0019). Mean INFIX removal was at 14 weeks. Baseline responses were obtained on admission where feasible. Although there was no significant difference between the treatment groups, the ORIF group showed a significantly greater deterioration from the baseline than the INFIX group, suggesting INFIX better maintains pre-injury function. 29% of patients experienced LCNT palsy whilst the INFIX was in situ. 6 patients in the INFIX group experienced some form of metal work failure (3 required surgical removal), compared with 7 ORIF patients (4 required removal). Conclusions. Pelvic INFIX achieves bony stabilisation of unstable pelvic fractures, and should be considered for rotational or vertically unstable fractures requiring operative intervention. Despite higher ISS scores, INFIX patients performance in joint specific and global health functioning scores was not significantly different from ORIF patients. We do not use INFIX for pelvic fractures with symphyseal disruption

Traumatic disruption of the pelvic ring has a high risk of mortality. These injuries are predominantly due to high-energy, blunt trauma and severe associated injuries are prevalent, increasing management complexity. This population-based study investigated predictors of mortality following severe pelvic ring fractures managed in an organised trauma system. Cases aged greater than 15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based state-wide Victorian State Trauma Registry for analysis. Patient demographic, pre-hospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated. There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged greater than 65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15–34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), while patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres). The findings highlight the importance of the need for effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches

Introduction

Sacral fractures were previously treated with transiliac bars, sacroiliac screws or posterior plates. Sacroiliac screws are not as invasive, but the risk of intra-operative neurovascular damage must be considered. Posterior plate fixation is slightly invasive. In 2006, we conceived a new fixation method with spinal instrumentation system, and I will introduce it.

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection

Introduction. Pelvic and acetabular injuries are relatively rare and surgical reconstruction usually occurs only in specialist centres. As part of their work up there is a local protocol for radiological investigations including Judet oblique views for acetabular fractures, pelvic inlet and outlet for pelvic ring fractures and urethrograms for sustaining anterior pelvic injury. The aim of this service evaluation was to assess whether patients had these radiological investigations prior to transfer. Methods. The last 50 patients transferred for surgery were evaluated (41 male, 9 female), average age 48 (range 17–86). Four were excluded as original radiology not available and one due to non-acute presentation. Regional PACS systems were accessed and radiological investigations recorded. Results. Transfers were from 17 different hospitals including 27 acetabular fractures, 17 pelvic ring fractures and one patient with both. 22 patients sustained isolated injuries. 16 patients were investigated radiologically asstipulated in the protocol. No inlet/outlet views were performed for 10 of the ring fractures, and no Judet views for eight of the acetabular fractures. An antero-posterior pelvic radiograph was not performed on one patient. No urethro/cystogram was performed for 10 pelvic ring fractures. Average time to transfer 5.4 days (range 0–22). Discussion. A significant proportion of patients are not assessed as per protocol prior to transfer. This can lead to undetected injuries, delays to diagnosis or definitive management and increased morbidity/mortality. The reasons for not being able to perform these investigations need to be understood

High energy pelvic injury poses a challenging setting for the treating surgeon. Often multiple injuries are associated, which makes the measurement of short- and long-term functional outcomes a difficult task. The purpose of this study was to determine the incidence of pelvic dysfunction and late impacts of high energy pelvic ring fractures on pelvic floor function in women, with respect to urinary, sexual and musculoskeletal function. This was compared to a similar cohort of women with lower limb fractures without pelvis involvement. The data in our study was prospectively gathered between 2010 and 2013 on 229 adult females who sustained injury between 1998 and 2012. Besides demographic and operative variables, the scores of three validated health assessment tools were tabulated: King's Health Questionnaire (KHQ), Female Sexual Function Index (FSFI) and the Short Musculoskeletal Functional Assessment (SMFA). A multivariate regression analysis was done to compare groups. The incidence of sexual dysfunction was 80.8% in the pelvis and 59.4% in the lower extremity group. A Wilcoxon rank sum test showed a significant difference in KHQ-score (p<0.01) with the pelvis group being worse. When adjusting for age, follow-up and Injury Severity Score this difference was not significant (p=0.28), as was for FSFI and SMFA score. The mean FSFI scores of both groups met the criteria for female sexual dysfunction (<26). Patients with a Tile C fracture have better FSFI scores (16.98) compared to Tile B fractures (10.12; p=0.02). Logistic regression predicting FSFI larger than 26.5 showed that older age and pelvic fractures have a higher likelihood having a form of sexual dysfunction. Sexual dysfunction after lower extremity trauma is found in patients regardless of pelvic ring involvement. Urinary function is more impaired after pelvic injuries, but more data is needed to confirm this. Older age and pelvic fracture are predictors for sexual dysfunction in women. This study is important as it could help counsel patients on the likelihood of sexual dysfunction, something that is probably under-reported and recognized during our patient follow up

The October 2012 Trauma Roundup. 360. looks at: which patients die from pelvic ring fractures; monolateral distraction osteogenesis; surgical management of pelvic and peroneal blast injuries; weekend warriors at risk of going AWOL; early experience with the locking attachment plate; and fibula nailing - an alternate, and viable technique

Aims: To determine the incidence and pattern of pain in patients with displaced pelvic ring injuries treated surgically. To investigate the link between pain and neurological injury. Methods: All patients with pelvic ring fractures treated surgically were contacted by a postal questionnaire. Assessment was made from validated pain scores, pain maps, a Visual Analog Scale (VAS) and correlated with outcome scores including SF36 and Euroqol. Injuries were classified using the Young and Burgess (YB) classification. Results: There was a response rate of 85% (151 of 178 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs). 72% were male. There were 31% Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries. 76% of all patients reported activity related pain; 70% of APC, 73% of LC and 86% of VS injuries (p=0.05, Chi-squared test). These results correlated directly with the pain domain of the Euroqol tool. There were however no statistically significant differences in the interference of pain with work (SF36) or the VAS between injury classes. There was a 15% prevalence of neurological injury in the cohort (9% of APC, 11% of LC and 27% of VS injuries; p=0.03 Chi-squared test). There were no statistically significant differences in the prevalence of moderate to severe pain (Euroqol) or the VAS between those with and without significant neurological injury. The presence of neurological injury significantly affected return to employment but not return to sports or social activities. Conclusions: These results illustrate the prevalence of significant morbidity in patients with surgically treated pelvic ring fractures. Presence of pain could be linked to injury category but a link with neurological injury was not obvious. This can help give prognostic information to patients suffering displaced pelvic ring injuries requiring surgical reconstruction

Introduction: Open reduction and internal fixation (ORIF) is considered the treatment of choice in dislocated unstable pelvic fractures. However ORIF has several drawbacks, such as considerable soft tissue trauma, a substantial intraoperative blood loss and up to 25% infectious complications. To overcome these problems mini-invasive osteosynthesis techniques have been developed. Methods: Analysis of the problem revealed necessary changes on the level of intraoperative imaging, surgical approach, reduction devices and technology integration. Intraoperative imaging with computertomography gives all the time an appropriate representation of the real position of bony fragments of the pelvis. A new type of axial reduction clamps allows fracture reduction through small incisions. Preshaped plates can be pushed underneath the soft tissue. Computer navigation helps to place screws in a save manner percutaneously. Results: We present the setting of a new multifunctional image guided therapy suite, which is an optimal platform for mini-invasive treatment of fresh dislocated anterior and posterior pelvic ring fractures, as well as for percutaneous treatment of pelvic non unions. The technique of reduction and fixation of an anterior pelvic ring fracture through two small incisions instead of a full ilio-inguinal approach is shown. A case of percutaneous bone grafting of a delayed union of the sacrum is presented. Conclusions: Mini-invasive osteosynthesis techniques require appropriate imaging tools, new reduction devices and most notably special skills. However all together may reduce severe side effects of conventional pelvic surgery

Aims: To determine the incidence and pattern of sexual dysfunction in patients with displaced pelvic ring injuries treated surgically. To investigate a link between sexual and urological dysfunction. Methods: All patients with pelvic ring fractures treated surgically were contacted by a postal questionnaire. Sexual function was assessed using elements of the validated Sexual Function Questionnaire. Patients were also asked specifically about new-onset sexual and urological dysfunction. Injuries were classified using the Young and Burgess (YB) classification. Results: There was a response rate of 85% (151 of 178 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs). 72% were male. 31% were Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries. 32% of all patients reported significant new sexual problems (36% of males and 24% of females). Of the males, 31% reported erectile dysfunction (12% absolute impotence), 32% reported decreased arousal and 21% reported ejaculatory problems. Of the females, 16% reported decreased arousal, 5% reported anorgasmia and 3% reported painful orgasms. There were no reported cases of dyspareunia in the female patients. 41% of APC, 15% of LC and 39% of VS injuries reported significant new sexual problems (p=0.02, Chi-squared test). There was a 12% prevalence of significant new urological dysfunction in the entire cohort, with 27% of those with sexual dysfunction also reporting urological dysfunction. This compares with a 5% prevalence of urological dysfunction in patients without sexual dysfunction (p< 0.0001, Chi-squared test). Conclusions: This large outcome study of UK patients illustrates the significant prevalence of new onset sexual dysfunction in patients with surgically treated pelvic ring fractures. The results also suggest an association between sexual and urological dysfunction. This can help give prognostic information to patients and plan service provision

Introduction: Displaced fractures of the pelvic ring represents challenge for the trauma surgeon. Patients: From January 1999 to December 2006, the treatment was given to 134 patients (81 males, 53 females, aged 18–73 years) with pelvic ring fracture and dislocation. According to the AO (1988) classification, B type were 95, C type were 39 in cases. Surgical technique: Closed reduction and retention of unstable pelvic injuries (type B and C injuries), in order to restore the form and function of the posterior pelvis by percutaneous iliosacral screw and when is necessary antegrad screw fixation of the anterior pelvic ring osteosynthesis, using conventional fluoroscopy. 134 patients with a posterior pelvic fracture or fracture dislocation underwent screw fixation with fluoroscopy with 8.0-mm, or 9.0 mm cannulated screws, placed in a transiliosacral position in the vertebral body of SI, and S II. Among these patient, 71 fixed with percutaneuos screw in the anterior pelvic ring fracture too. Results: The average operating time was 23 min, the average screening time 2,11 min. Iatrogenic nerve damage was not found. All fractures healed within 3 months. 17% of the patients had residual pain, which were permanent or intermittent. Partly the reason could be the SI arthrosis, as we can see in 13% of the patients, or the fracture healing caused foramen stricture. Unfortunately we have lost 11 patients. The Majeed functional scoring was applied. In conclusion we could say that 81% of our patients were in the excellent and good category. Conclusions: The technique of percutaneous cannulated screws internal fixtion for treating the posterior and anterior portion of the pelvis has the advantages of small trauma, less bleeding stiff fixtion, which is an ideal and minimally invasive technique

Background: Unstable pelvic ring fractures are frequently associated with severe hemodynamic instability and mortality. Hemorrhage control of these disrupted pelvic fractures requires an urgent reduction of the intrapelvic volume and immediate mechanical stabilization. The aim of this study was to investigate the control of the intrapelvic volume and pelvic stability by different modes of external stabilization in a cadaver model. Methods: Various degrees of pelvic ring instability were induced in unembalmed human torsos. Haemorrhage induced volume displacement into the presacral and retroperitoneal space (RPP) was assessed by positioning two infusion lines right in front of the sacroiliac joint. The abdominal pressure measurement (IAP) was obtained by a percutaneous catheter in the abdominal cavity. Baseline pressure measurements of the intra pelvic volume were documented before and after dissection for uni-as bilateral instability. Reduction of pelvic instability was performed by non invasive T-POD. ®. Pelvic Stabilizer, a supraacetabular, iliac crest fixator, application of the pelvic C-Clamp without and with pelvic packing. Results: Baseline measurements (RPP) of the intact pelvis showed an average increase of 8,03 cmH2O per 1000 cc of infused fluid. In case of uni- and bilateral instability the pressure decreased to a rate of 2,88 and 1,48 cmH2O per 1000 cc. Following the application of each device an increase of RPP of 3,5 cmH2O (pelvic binder), 3,2 cmH2O (anterior frames), 5,4 cmH2O (C-Clamp) and 8,4 cmH2O (C-Clamp + packing) per 1000 cc was obtained in case of unilateral instability. In bilateral disruptions a significantly lower increase of pressure up to 4,0 cmH2O was seen. Conclusions: We investigated the efficacy of various external stabilization Methods: on potential hemorrhage on experimentally induced uni- and bilateral pelvic ring fractures. In case of intact pelvis the retroperitoneal space responds to fluid application with rapidly rising pressures. The application of external devices enable the reduction of the pelvic volume and thereby the retroper-itoneal pressure increase. The C-clamp combined with pelvic packing resulted to be superior

Introduction: Pelvic ring injuries represent a complex injury pattern and sometimes have significant consequences. The aim of this retrospective study is to delineate the indications of surgical treatment with emphasis in the anatomic reconstruction. Materials and Methods: 85 patients with pelvic ring fracture with or without acetabular fracture reviewed retrospectively. The average patient age was 34 years. Operative treatment was provided to 26 patients. Six isolated acetabular fractures were treated by ORIF. Twenty pelvic ring fractures were treated, by anterior Ex-Fix in five cases, Ex-Fix plus sacroiliac screws in three, anterior reconstruction plate plus sacroiliac screws in two, anterior plate plus sacral bars in three. The remaining seven patients with an additional acetabular fracture treated with anterior plate for the pelvis and plates for the acetabulum. Results: All the acetabular fractures were anatomically reduced. All fractures consolidated and no patient has developed hip AVN or post-traumatic arthritis. Brooker’s grade III ossifications complicated two patients. Partial neurological deficit of sciatic nerve was seen in three cases of acetabular fractures that improved spontaneously. A case of vertical shearing sacral fracture through the foramina presented with lumbosacral plexus paresis that recovered near normal function in 6 months. Deep infection complicated a case that subsided at 2 weeks on antibiotics and serial surgical debridement. Conclusions: The strict application on rational criteria and an exquisite surgical technique caring of the soft tissues produce satisfactory outcome of these injuries. The above-described surgical treatment shortens the hospital stay and allows early physiotherapy to restore function

Introduction: Percutaneous cannulated screw placement (PCSP) is a safe method of internal fixation, indicated for pelvic ring fractures. Due to the close proximity of neurovascular structures to the path of the screw placed in either the Posterior elements (PE) or Anterior column (AC), pre-operative planning is needed to prevent injury. This study aims to develop a pre-operative protocol for the Australian population, regarding the safe number of screws and size of screw that may be placed. Additionally, results from the study may help identify patients at increased risk of injury during PCSP. Methods: All patients were from the Australian population and had been admitted into the emergency department at The Royal Melbourne Hospital. Control patients had no pathology in the pelvis, while treated group patients had pelvic ring fractures and were treated with PCSP. Safe corridor measurements of the PE and AC were taken in the control patients. Pelvic CT scans, taken as part of trauma protocol, were reconstructed using 3D modelling and the dimensions of the whole (3 dimensional) safe corridor measured. The accuracy of screw placement was determined in each treated patient. Accuracy was assessed by the screenshot method, the post-operative CT method or by both methods. In both methods, accuracy was taken as the deviation between the positions of the actual screw and planned screw. Results: There were 22 control patients and 12 treated patients. The mean ± (standard deviation, SD) minimum measurement of the safe corridor at the PE was 15.6 ± 2.3 mm (range 11.6 mm to 20.2 mm) and at the AC was 5.9 ±1.6 mm (range 3.0 mm to 10.0 mm). The mean ± (SD) accuracy of screw placement was 6.1 ± 5.3 mm and ranged from a displacement of 1.3 mm to 16.1 mm. Conclusion: The minimum dimensions of the safe corridor and the accuracy of screw placement occurred over a wide range. We recommend that dimensions of the safe corridor be assessed pre-operatively in every patient using 3D modelling to determine the safe number and size of screw that can be placed

Background Non-weight bearing hip is a common problem in the elderly population after a minor fall. Magnetic reasonance imaging (MRI) is used to diagnose occult fractures in the hip and the pelvic ring in these individuals. The aim of this study is to find the relationship between the incidence of occult fractures in the hip and that in the pelvic ring following low velocity trauma in the elderly. Material and Methods Between January 2000 and February 2004, 106 elderly patients (mean age = 81.4 years; range = 67–101 years), underwent an MRI scan of the pelvis and hip to rule out fracture neck of femur. All of them presented with a non-weight bearing hip after a history of low velocity injury. All had standard radiographs of the pelvis and the hip which did not reveal a fracture of the femoral neck. However, eight patients had fracture of the pubic rami visible on plain radiographs. MRI scans were subsequently performed in all of them to rule out an occult fracture of the femoral neck. Results Out of the 106 patients, 17 (16%) had intracapsular neck of femur fracture, 26 (24.5%) had extracapsular neck of femur fracture, 26 (24.5%) had pubic rami fracture, 17 (16%) had sacral fractures, and 37 (34.9%) had no fractures. All the sacral fractures occurred in patients with pubic rami fractures. Further except in one patient where the pubic rami fracture and the sacral fracture were contralateral, the remaining 16 patients had ipsilateral pubic rami and sacral fractures. None of the patients with pelvic ring fracture had associated femoral neck fracture. Conclusion Inability to weight bear after a fall is a common presentation in the elderly population. Falls can lead to fracture neck of femur or a fracture of the pelvic ring but seldom both. We can also conclude that in an elderly patient with low velocity injury, if a pelvic ring fracture is detected in the plain radiograph there is no indication for further MRI to rule out femoral neck fracture. Further, the fracture in the anterior and posterior pelvic ring commonly involves the same side than the contralateral side, in the elderly after trivial trauma

High-energy pelvic ring fractures are associated with polytrauma where staged surgery is recommended. While temporary skeletal stabilisation is part of the acute management, definitive care is done in a later phase. The purpose of this study was to evaluate the safety and efficacy of acute pelvic ORIF by comparing its short term outcome with those who were stabilised late. A 45-month retrospective review of the prospective pelvic fracture database of a level one trauma centre was performed. All high-energy trauma patients who were potential candidates for minimally invasive internal fixation of the pelvic ring were included. Patients were categorised as acute ORIF (<24 hrs) or late ORIF (>24 hrs). Demographics, ISS, pelvic AIS, 24 hour pack cell transfusions, physiological parameters, time to operating theatre, angiography requirement, LOS and mortality were recorded. Data was presented as mean+/−SD or percentages. Statistical significance was determined at ∗p<0.05 based on univariate analysis. Forty-three patients met inclusion criteria, seventeen patients had acute definitive ORIF (5.5 hrs to OT) and twenty-six late definitive ORIF (5 days to OT). Acute and late ORIF patients had statistically not different demographics (age: 48+/−22 years vs 40+/− 14, gender: 82% vs 79% males), injury severity (ISS: 30+/−18 vs 24.5+/−13, pelvic AIS: 3.7+/− 1 vs 3.4+/− 1.1) and 24 hour transfusion (4.7+/−5 U vs 6.6+/−4 U). Initial shock parameters were significantly worse in the acute ORIF group (∗SBP 69.7+/−17 vs 108+/−21 mmHg, ∗BD -7.35+/−4 vs -4.9+/−1.5 mEq/L, ∗Lactate 6.67+/−7 vs 2.51+/−1.3 mmol/L). Angiography was used 18% (3/17) vs 21% (6/29) of the cases. All early ORIF patients survived and one (3%) of the late ORIF patients died. The trend in shorter hospital LOS was not significant in the early ORIF group (25+/− 24 vs 37+/− 32 days) while the ICU LOS was comparable (12/17 patients with 2.9+/−2.5 days vs 15/26 patients with 3.7+/−3.6 days). Minimally invasive acute ORIF of unstable pelvic ring fractures could be performed even in severely shocked polytrauma patients. The procedure did not lead to increased rates of transfusion, mortality, ICU LOS or overall LOS. Furthermore, all these parameters showed a trend towards benefit compared to a staged approach

Aim: To study the postoperative results of an alternative method of pin placement for acute pelvic ring stabilization with an external fixation. Introduction: External fixation for stabilization of pelvic ring fractures is the only and a safe method for emergency treatment. According to literature pins of the fixator should be placed urgently on the superior iliac rim and as soon as general condition of the patient permits, revision is required in order to manage in a finitive way the injury. Material-Method: Inclusion criteria were high energy trauma, severe pelvic instability, heamodynamic instability, acute management of a pelvic fracture and minimum follow up of 2 years. Patients with a simultaneus major head, chest or abdominal injury were excluded from the study. Between 2000–01, 19 patients (15 male and 4 female with a mean age of 28 years old) underwent acute pelvic stabilization with an external fixation. In 12 patients, mechanism of injury was road accident and in 7 patients a fall from a height. Fracture type according to Tyle classification was 2 type A, 12 type B and 5 type C. In 6 patients the pins were placed in an oblique plane to the superior iliac rim (Group I) and in 13 patients there were placed in the sagital plane, just below the superior anterior iliac spine (Group II). The mean time for external fixation application was 15 min for group I and 22 min for group II. Results: 14 patients were heamodynamically stabilized in the early postoperative period and 5 patients were transmitted to Intensive Care Unit. In 17 patients a rigid fixation of the pelvis was achieved and remained as a definite method of treatment and in 2 patients of Group I, replacement of the external fixator and an adjacent stabilization of posterior elements was required. No patient required adjacent posterior element stabilization as the primary reduction and stabilization was satisfactory. Mean time of stabilization was 7 weeks for type A, 10 weeks for type B and 11 weeks for type C fractures. 13 patients were totally recovered and returned to their previous occupation and 6 patients have minor problems that are attributed to the pelvic ring fracture. Conclusions: External fixator’s placement for pelvic ring stabilization should be performed in a way that it will be a finitive method for osteosynthesis of the pelvis. We suggest pin placement in the sagital plane, below the superior anterior iliac spine instead of placement at the superior iliac rim

Objectives. Osteosynthesis of anterior pubic ramus fractures using one large-diameter screw can be challenging in terms of both surgical procedure and fixation stability. Small-fragment screws have the advantage of following the pelvic cortex and being more flexible. The aim of the present study was to biomechanically compare retrograde intramedullary fixation of the superior pubic ramus using either one large- or two small-diameter screws. Materials and Methods. A total of 12 human cadaveric hemipelvises were analysed in a matched pair study design. Bone mineral density of the specimens was 68 mgHA/cm. 3. (standard deviation (. sd). 52). The anterior pelvic ring fracture was fixed with either one 7.3 mm cannulated screw (Group 1) or two 3.5 mm pelvic cortex screws (Group 2). Progressively increasing cyclic axial loading was applied through the acetabulum. Relative movements in terms of interfragmentary displacement and gap angle at the fracture site were evaluated by means of optical movement tracking. The Wilcoxon signed-rank test was applied to identify significant differences between the groups. Results. Initial axial construct stiffness was not significantly different between the groups (p = 0.463). Interfragmentary displacement and gap angle at the fracture site were also not statistically significantly different between the groups throughout the evaluated cycles (p ⩾ 0.249). Similarly, cycles to failure were not statistically different between Group 1 (8438, . sd. 6968) and Group 2 (10 213, . sd. 10 334), p = 0.379. Failure mode in both groups was characterised by screw cutting through the cancellous bone. Conclusion. From a biomechanical point of view, pubic ramus stabilisation with either one large or two small fragment screw osteosynthesis is comparable in osteoporotic bone. However, the two-screw fixation technique is less demanding as the smaller screws deflect at the cortical margins. Cite this article: Y. P. Acklin, I. Zderic, S. Grechenig, R. G. Richards, P. Schmitz, B. Gueorguiev. Are two retrograde 3.5 mm screws superior to one 7.3 mm screw for anterior pelvic ring fixation in bones with low bone mineral density? Bone Joint Res 2017;6:8–13. DOI: 10.1302/2046-3758.61.BJR-2016-0261

Objective. We reviewed clinical results with minimally invasive method and using a new developed plate for unstable pelvic ring fractures, especially vertically unstable sacral fractures. Materials & Methods. Between 2002 and 2010, 35 patients with vertically unstable sacral fractures were treated with minimally invasive method and using an M-Shaped transiliac plate which was developed by the author. This plate is anatomically designed for posterior pelvic ring, and achieved rigid fixation. Patients included 19 male and 16 female, with the mean age of 46.2 (range, 17∼79) years old. According to the AO classification, 23 patients had a C1 injury, 9 had a C2 fracture, and 3 patients sustained a C3 injury of the pelvic ring. Functional outcome was assessed using the Majeed's functional evaluation and radiography. Minimum follow-up was one year. Results. All patients were not fixed anterior of pelvic ring. The average of surgical time was 85 minutes (range: 45∼150), and intraoperative blood loss was 332.8 ml (range: 35∼1055). Postoperative functional results were excellent and good in 30 patients (85.7 %), and fair in four cases due to infection or sciatic nerve paralysis, and one case of poor was nonunion. Three patients complicated wound healing delayed, but there were no residual pain and re-displacement. Conclusion. Using an M-Shaped transiliac plate can be achieved significant outcome and rigid fixation with minimal invasion for vertically unstable sacral fractures