Clinical Orthopaedics and Related Research®

, Volume 470, Issue 8, pp 2116–2123 | Cite as

Surgical Technique: A Percutaneous Method of Subcutaneous Fixation for the Anterior Pelvic Ring: The Pelvic Bridge

  • Timothy G. Hiesterman
  • Brian W. Hill
  • Peter A. Cole
Symposium: Disruptions of the Pelvic Ring: An Update



Management of pelvic ring injuries using minimally invasive techniques may be desirable if reduction and stability can be achieved. We present a new technique, the anterior pelvic bridge, which is a percutaneous method of fixing the anterior pelvis through limited incisions over the iliac crest(s) and pubic symphysis.

Description of Technique

An incision is made over each anterior iliac crest and a 6- to 8-cm incision is centered over the symphysis. Either a locking reconstruction plate or a spinal rod is placed through a subcutaneous tunnel overlying the external oblique fascia in the subcutaneous tissue, and fixation into the iliac crest and pubis is achieved to effect stability.


A randomized controlled trial comparing anterior pelvic external fixation (APEF) versus anterior pelvic internal fixation (APIF) for unstable pelvic ring injuries was begun in October 2010. Patients with unstable pelvic ring injuries were enrolled and followed with respect to fracture reduction, surgical pain, complications, and functional outcome scores.


As of January 2012, 23 patients met inclusion; however, 12 patients refused participation because of the possibility of external fixation, leaving 11 patients (four male, seven female) enrolled. At 6-month followup, there was a single pin tract infection in the APEF cohort and no complications or pain in the APIF cohort.


This clinical experience lends support to the use of a new minimally invasive technique to stabilize the anterior pelvis, particularly given the resistance on the part of patients to consider external fixation.

Level of Evidence

Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.



The authors thank Aaron R. Jacobson DC for help with preparation of the manuscript and useful comments


  1. 1.
    Barei DP, Shafer BL, Beingessner DM, Gardner MJ, Nork SE, Routt ML. The impact of open reduction internal fixation on acute pain management in unstable pelvic ring injuries. J Trauma. 2010;68:949–953.PubMedGoogle Scholar
  2. 2.
    Cole PA, Gauger EM, Anavian J, Ly TV, Morgan RA, Heddings AA. Anterior Pelvic External Fixator Versus Subcutaneous Internal Fixator in the Treatment of Anterior Ring Pelvic Fractures. J Orthop Trauma. 2012 February 21 [Epub ahead of print].Google Scholar
  3. 3.
    Dienstknecht T, Berner A, Lenich A, Nerlich M, Fuechtmeier B. A minimally invasive stabilizing system for dorsal pelvic ring injuries. Clin Orthop Relat Res. 2011;469:3209–3217.PubMedCrossRefGoogle Scholar
  4. 4.
    Doklamyai P, Agthong S, Chentanez V, Huanmanop T, Amarase C, Surunchupakorn P, Yotnuengnit P. Anatomy of the lateral femoral cutaneous nerve related to inguinal ligament, adjacent bony landmarks, and femoral artery. Clin Anat. 2008;21:769–774.PubMedCrossRefGoogle Scholar
  5. 5.
    Gansslen A, Pohlemann T, Paul C, Lobenhoffer P, Tscherne H. Epidemiology of pelvic ring injuries. Injury. 1996;27(suppl 1):SA13–SA20.Google Scholar
  6. 6.
    Gardner MJ, Mehta S, Mirza A, Ricci WM. Anterior Pelvic Reduction and Fixation Using a Subcutaneous Internal Fixator. J Orthop Trauma. 2011 October 28 [Epub ahead of print].Google Scholar
  7. 7.
    Goldstein A, Phillips T, Sclafani SJ, Scalea T, Duncan A, Goldstein J, Panetta T, Shaftan G. Early open reduction and internal fixation of the disrupted pelvic ring. J Trauma. 1986;26:325–333.PubMedCrossRefGoogle Scholar
  8. 8.
    Gylling SF, Ward RE, Holcroft JW, Bray TJ, Chapman MW. Immediate external fixation of unstable pelvic fractures. Am J Surg. 1985;150:721–724.PubMedCrossRefGoogle Scholar
  9. 9.
    Haidukewych GJ, Kumar S, Prpa B. Placement of half-pins for supra-acetabular external fixation: an anatomic study. Clin Orthop Relat Res. 2003;411:269–273.PubMedCrossRefGoogle Scholar
  10. 10.
    Kellam JF. The role of external fixation in pelvic disruptions. Clin Orthop Relat Res. 1989;241:66–82.PubMedGoogle Scholar
  11. 11.
    Kim WY, Hearn TC, Seleem O, Mahalingam E, Stephen D, Tile M. Effect of pin location on stability of pelvic external fixation. Clin Orthop Relat Res. 1999;361:237–244.PubMedCrossRefGoogle Scholar
  12. 12.
    Korovessis P, Stamatakis M, Baikousis A. Posterior stabilization of unstable sacroiliac injuries with the Texas Scottish Rite Hospital spinal instrumentation. Orthopedics. 2000;23:323–327.PubMedGoogle Scholar
  13. 13.
    Kuttner M, Klaiber A, Lorenz T, Fuchtmeier B, Neugebauer R. [The pelvic subcutaneous cross-over internal fixator] [in German]. Unfallchirurg. 2009;112:661–669.PubMedCrossRefGoogle Scholar
  14. 14.
    Lindahl J, Hirvensalo E, Bostman O, Santavirta S. Failure of reduction with an external fixator in the management of injuries of the pelvic ring: long-term evaluation of 110 patients. J Bone Joint Surg Br. 1999;81:955–962.PubMedCrossRefGoogle Scholar
  15. 15.
    Mason WT, Khan SN, James CL, Chesser TJ, Ward AJ. Complications of temporary and definitive external fixation of pelvic ring injuries. Injury. 2005;36:599–604.PubMedCrossRefGoogle Scholar
  16. 16.
    Moazzam C, Heddings A, Moodie P, Cole P. Anterior Pelvic Subcutaneous Internal Fixator Application: An Anatomic Study. J Orthop Trauma. 2012 February 14 [Epub ahead of print].Google Scholar
  17. 17.
    Palmer S, Fairbank AC, Bircher M. Surgical complications and implications of external fixation of pelvic fractures. Injury. 1997;28:649–653.PubMedCrossRefGoogle Scholar
  18. 18.
    Papakostidis C, Kanakaris NK, Kontakis G, Giannoudis PV. Pelvic ring disruptions: treatment modalities and analysis of outcomes. Int Orthop. 2009;33:329–338.PubMedCrossRefGoogle Scholar
  19. 19.
    Pohlemann T, Bosch U, Gansslen A, Tscherne H. The Hannover experience in management of pelvic fractures. Clin Orthop Relat Res. 1994;305:69–80.PubMedCrossRefGoogle Scholar
  20. 20.
    Ponsen KJ, Joosse P, Van Dijke GA, Snijders CJ. External fixation of the pelvic ring: an experimental study on the role of pin diameter, pin position, and parasymphyseal fixator pins. Acta Orthop. 2007;78:648–653.PubMedCrossRefGoogle Scholar
  21. 21.
    R Development Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2009.Google Scholar
  22. 22.
    Riemer BL, Butterfield SL, Diamond DL, Young JC, Raves JJ, Cottington E, Kislan K. Acute mortality associated with injuries to the pelvic ring: the role of early patient mobilization and external fixation. J Trauma. 1993;35:671–675; discussion 676–677.PubMedCrossRefGoogle Scholar
  23. 23.
    Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res. 2000;375:15–29.PubMedCrossRefGoogle Scholar
  24. 24.
    Routt ML Jr, Simonian PT. Internal fixation of pelvic ring disruptions. Injury. 1996;27(suppl 2):B20–B30.PubMedGoogle Scholar
  25. 25.
    Routt ML Jr, Simonian PT, Swiontkowski MF. Stabilization of pelvic ring disruptions. Orthop Clin North Am. 1997;28:369–388.PubMedCrossRefGoogle Scholar
  26. 26.
    Sagi HC, Coniglione FM, Stanford JH. Examination under anesthetic for occult pelvic ring instability. J Orthop Trauma. 2011;25:529–536.PubMedCrossRefGoogle Scholar
  27. 27.
    Simonian PT, Routt ML Jr. Biomechanics of pelvic fixation. Orthop Clin North Am. 1997;28:351–367.PubMedCrossRefGoogle Scholar
  28. 28.
    Starr AJ, Nakatani T, Reinert CM, Cederberg K. Superior pubic ramus fractures fixed with percutaneous screws: what predicts fixation failure? J Orthop Trauma. 2008;22:81–87.PubMedCrossRefGoogle Scholar
  29. 29.
    Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br. 1988;70:1–12.PubMedGoogle Scholar
  30. 30.
    Tucker MC, Nork SE, Simonian PT, Routt ML Jr. Simple anterior pelvic external fixation. J Trauma. 2000;49:989–994.PubMedCrossRefGoogle Scholar
  31. 31.
    Vaidya R, Colen R, Vigdorchik J, Tonnos F, Sethi A. Treatment of unstable pelvic ring injuries with an internal anterior fixator and posterior fixation: Initial clinical series. J Orthop Trauma. 2012;26:1–8.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Timothy G. Hiesterman
    • 1
  • Brian W. Hill
    • 1
  • Peter A. Cole
    • 1
  1. 1.Department of Orthopaedic SurgeryUniversity of MinnesotaSt PaulUSA

Personalised recommendations