Skip to main content

Advertisement

Log in

Vertical shear pelvic injury: evaluation, management, and fixation strategies

  • Review Article
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Vertical shear pelvic ring fractures are rare and account for less than 1% of all fractures. Unlike severely displaced antero-posterior compression and lateral compression pelvic fractures, patients’ mortality is lower. Nevertheless, patients must be managed acutely using well-defined ATLS protocols and institution-specific protocols for haemodynamically unstable pelvic ring fractures. The definitive treatment of vertical shear pelvic fractures is however more controversial with a paucity of literature to recommend the ideal reduction and fixation strategy. While the majority of injuries can be reduced and fixed in a closed manner, orthopaedic traumatologists should be familiar with the contraindications to those techniques as well as options such as tension band plating and lumbo pelvic fixation. Our paper reviews the acute management, associated injuries and definitive reduction and fixation strategies of vertical shear pelvic fractures. In addition, we propose a treatment algorithm for the selection of the most appropriate fixation technique.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Balogh Z, King KL, Mackay P et al (2007) The epidemiology of pelvic ring fractures: a population-based study. J Trauma 63(5):1066–1073

    Article  Google Scholar 

  2. Gänsslen A, Pohlemann T, Paul C et al (1996) Epidemiology of pelvic ring injuries. Injury 27(1):13–20

    Article  Google Scholar 

  3. Burgess AR, Eastridge BJ, Young JW et al (1990) Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 30(7):848–856

    Article  CAS  Google Scholar 

  4. Pennal GF, Tile M, Waddell JP et al (1980) Pelvic disruption: assessment and classification. Clin Orthop Relat Res 151:12–21

    Google Scholar 

  5. Bucholz RW (1981) The pathological anatomy of Malgaigne fracture-dislocations of the pelvis. J Bone Joint Surg Am 63(3):400–404

    Article  CAS  Google Scholar 

  6. Tile M (1988) Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br 70(1):1–12

    Article  CAS  Google Scholar 

  7. Manson T, O'toole RV, Whitney A et al (2010) Young-Burgess classification of pelvic ring fractures: does it predict mortality, transfusion requirements, and non-orthopaedic injuries? J Orthop Trauma 24(10):603–609

    Article  Google Scholar 

  8. Kellam JF, Meinberg EG, Agel J, Karam MD, Roberts CS (2018) Introduction: fracture and dislocation classification compendium-2018: international comprehensive classification of fractures and dislocations committee. J Orthop Trauma 32(1):S1–S10. https://doi.org/10.1097/BOT.0000000000001063

    Article  PubMed  Google Scholar 

  9. Guthrie HC, Owens RW, Bircher MD (2010) Fractures of the pelvis. J Bone Joint Surg Br 92(11):1481–1488

    Article  CAS  Google Scholar 

  10. Starks I, Frost A, Wall P et al (2011) Is a fracture of the transverse process of L5 a predictor of pelvic fracture instability? J Bone Joint Surg Br 93(7):967–969

    Article  CAS  Google Scholar 

  11. Edeiken-Monroe BS, Browner BD, Jackson H (1989) The role of standard roentgenograms in the evaluation of instability of pelvic ring disruption. Clin Orthop Relat Res (240): p. 63-76.

  12. Abdelfattah AA, Moed BR (2016) CT-generated radiographs in patients with pelvic ring injury: can they be used in lieu of plain radiographs? J Orthop Surg Res 11:26. https://doi.org/10.1186/s13018-016-0361-6

    Article  PubMed  PubMed Central  Google Scholar 

  13. Fang C, Alabdulrahman H, Pfeifer R, Tarkin IS, Pape HC (2017) Late reconstruction of severe open-book deformities of the pelvis—tips and tricks. Int Orthop 41(9):1777–1784. https://doi.org/10.1007/s00264-017-3549-4

    Article  PubMed  Google Scholar 

  14. Tornetta P III, Matta JM (1996) Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop Relat Res 329:186–193

    Article  Google Scholar 

  15. Kabak S, Halici M, Tuncel M et al (2003) Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): a report of 40 cases. J Orthop Trauma 17(8):555–562

    Article  Google Scholar 

  16. Elnady B, Shawky A, Abdelrahman H et al (2017) Posterior only approach for fifth lumbar corpectomy: indications and technical notes. Int Orthop 41(12):2535–2541. https://doi.org/10.1007/s00264-017-3570-7

    Article  PubMed  Google Scholar 

  17. Beckmann NM, Cai C (2016) CT incidence of Morel-Lavallee lesions in patients with pelvic fractures: a 4-year experience at a level 1 trauma center. Emerg Radiol 23(6):615–621

    Article  Google Scholar 

  18. Poenaru DV, Popescu M, Anglitoiu B et al (2015) Emergency pelvic stabilization in patients with pelvic posttraumatic instability. Int Orthop 39(5):961–965. https://doi.org/10.1007/s00264-015-2727-5

    Article  PubMed  Google Scholar 

  19. Dyer GS, Vrahas MS (2006) Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury 37(7):602–613

    Article  Google Scholar 

  20. Whitbeck MG Jr, Zwally HJ II, Burgess AR (2006) Innominosacral dissociation: mechanism of injury as a predictor of resuscitation requirements, morbidity, and mortality. J Orthop Trauma 20(1):S57–S63

    PubMed  Google Scholar 

  21. Giannoudis PV, Grotz MR, Tzioupis C et al (2007) Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma 63(4):875–883

    Article  Google Scholar 

  22. Holstein JH, Culemann U, Pohlemann T (2012) What are predictors of mortality in patients with pelvic fractures? Clin Orthop Relat Res 470(8):2090–2097

    Article  Google Scholar 

  23. Starr AJ, Griffin DR, Reinert CM et al (2002) Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma 16(8):553–561

    Article  Google Scholar 

  24. Karadimas EJ, Nicolson T, Kakagia DD, Matthews SJ, Richards PJ, Giannoudis PV (2011) Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature. Int Orthop 35(9):1381–1390

    Article  Google Scholar 

  25. Cothren CC, Osborn PM, Moore EE et al (2007) Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 62(4):834–839

    Article  Google Scholar 

  26. Fu CY, Wang YC, Wu SC, Chen RJ, Hsieh CH, Huang HC, Huang JC, Lu CW, Huang YC (2012) Angioembolization provides benefits in patients with concomitant unstable pelvic fracture and unstable hemodynamics. Am J Emerg Med 30(1):207–213

    Article  Google Scholar 

  27. Tosounidis TH, Mauffrey C, Giannoudis PV (2017) Optimization of technique for insertion of implants at the supra-acetabular corridor in pelvis and acetabular surgery. Eur J Orthop Surg Traumatol 28(1):29–35

    Article  Google Scholar 

  28. Jang JY, Shim H, Jung PY, Kim S, Bae KS (2016) Preperitoneal pelvic packing in patients with hemodynamic instability due to severe pelvic fracture: early experience in a Korean trauma center. Scand J Trauma Resusc Emerg Med 24:3. https://doi.org/10.1186/s13049-016-0196-5

    Article  PubMed  PubMed Central  Google Scholar 

  29. Tai DK, Li WH, Lee KY, Cheng M, Lee KB, Tang LF, Lai AK, Ho HF, Cheung MT (2011) Retroperitoneal pelvic packing in the management of hemodynamically unstable pelvic fractures: a level I trauma center experience. J Trauma 71(4):E79–E86

    Article  Google Scholar 

  30. Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE, Stahel PF (2009) Direct retroperitoneal pelvic packing versus pelvic angiography: a comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury 40(1):54–60

    Article  Google Scholar 

  31. Schwartz DA, Medina M, Cotton BA, Rahbar E, Wade CE, Cohen AM, Beeler AM, Burgess AR, Holcomb JB (2014) Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention. J Trauma Acute Care Surg 76(1):134–139

    Article  Google Scholar 

  32. Chiara O, di Fratta E, Mariani A, Michaela B, Prestini L, Sammartano F, Cimbanassi S (2016) Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a propensity score analysis. World J Emerg Surg 11:22–29

    Article  Google Scholar 

  33. Brenner ML, Moore LJ, DuBose JJ, Tyson GH, McNutt MK, Albarado RP, Holcomb JB, Scalea TM, Rasmussen TE (2013) A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg 75(3):506–511

    Article  Google Scholar 

  34. Costantini TW, Coimbra R, Holcomb JB et al (2016) AAST pelvic fracture study group. Current management of hemorrhage from severe pelvic fractures: results of an American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg 80(5):717–723

    Article  CAS  Google Scholar 

  35. Jain S, Bleibleh S, Marciniak J et al (2013) A national survey of United Kingdom trauma units on the use of pelvic binders. Int Orthop 37(7):1335–1339. https://doi.org/10.1007/s00264-013-1828-2

    Article  PubMed  PubMed Central  Google Scholar 

  36. Langford JR, Burgess AR, Liporace FA et al (2013) Pelvic fractures: part 1. Evaluation, classification, and resuscitation. J Am Acad Orthop Surg 21(8):448–457

    Article  Google Scholar 

  37. Pizanis A, Pohlemann T, Burkhardt M et al (2013) Emergency stabilization of the pelvic ring: clinical comparison between three different techniques. Injury 44(12):1760–1764

    Article  CAS  Google Scholar 

  38. Papathanasopoulos A, Tzioupis C, Giannoudis VP et al (2010) Biomechanical aspects of pelvic ring reconstruction techniques: evidence today. Injury 41(12):1220–1227

    Article  CAS  Google Scholar 

  39. Berber O, Amis AA, Day AC (2011) Biomechanical testing of a concept of posterior pelvic reconstruction in rotationally and vertically unstable fractures. J Bone Joint Surg Br 93(2):237–244

    Article  CAS  Google Scholar 

  40. Langford JR, Burgess AR, Liporace FA et al (2013) Pelvic fractures: part 2. Contemporary indications and techniques for definitive surgical management. J Am Acad Orthop Surg 21(8):458–468

    Article  Google Scholar 

  41. Sagi HC, Ordway NR, DiPasquale T (2004) Biomechanical analysis of fixation for vertically unstable sacroiliac dislocations with iliosacral screws and symphyseal plating. J Orthop Trauma 18(3):138–143

    Article  CAS  Google Scholar 

  42. Gardner MJ, Routt ML Jr (2011) Transiliac-transsacral screws for posterior pelvic stabilization. J Orthop Trauma 25(6):378–384

    Article  Google Scholar 

  43. Keating JF, Werier J, Blachut P et al (1999) Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma 13(2):107–113

    Article  CAS  Google Scholar 

  44. Stover MD, Sims S, Matta J (2012) What is the infection rate of the posterior approach to type C pelvic injuries? Clin Orthop Relat Res 470(8):2142–2147

    Article  Google Scholar 

  45. Martin MP 3rd, Rojas D, Mauffrey C (2017). Reduction and temporary stabilization of Tile C pelvic ring injuries using a posteriorly based external fixation system. Eur J Orthop Surg Traumatol. Dec 5. https://doi.org/10.1007/s00590-017-2104-8

    Article  Google Scholar 

  46. Suzuki T, Hak DJ, Ziran BH et al (2009) Outcome and complications of posterior transiliac plating for vertically unstable sacral fractures. Injury 40(4):405–409

    Article  Google Scholar 

  47. Reilly MC, Bono CM, Litkouhi B et al (2006) The effect of sacral fracture malreduction on the safe placement of iliosacral screws. J Orthop Trauma 20(1):S37–S43

    PubMed  Google Scholar 

  48. Camino WG, Zderic I, Gras F et al (2016) Analysis of sacro-iliac joint screw fixation: does quality of reduction and screw orientation influence joint stability? A biomechanical study. Int Orthop 40(7):1537–1543. https://doi.org/10.1007/s00264-015-3007-0

    Article  Google Scholar 

  49. Lindahl J, Hirvensalo E (2005) Outcome of operatively treated type-C injuries of the pelvic ring. Acta Orthop 76(5):667–678

    Article  Google Scholar 

  50. Moed BR, O'Boynick CP, Bledsoe JG (2014) Locked versus standard unlocked plating of the symphysis pubis in a type-C pelvic injury: a cadaver biomechanical study. Injury 45(4):748–751

    Article  Google Scholar 

  51. Harvey-Kelly KF, Kanakaris NK, Obakponovwe O, West RM, Giannoudis PV (2014) Quality of life and sexual function after traumatic pelvic fracture. J Orthop Trauma 28(1):28–35

    Article  Google Scholar 

  52. Van Zwienen CM, van den Bosch EW, Snijders CJ et al (2004) Biomechanical comparison of sacroiliac screw techniques for unstable pelvic ring fractures. J Orthop Trauma 18(9):589–595

    Article  Google Scholar 

  53. Albert MJ, Miller ME, MacNaughton M et al (1993) Posterior pelvic fixation using a transiliac 4.5-mm reconstruction plate: a clinical and biomechanical study. J Orthop Trauma 7(3):226–232

    Article  CAS  Google Scholar 

  54. Giannoudis PV, Tzioupis CC, Pape HC et al (2007) Percutaneous fixation of the pelvic ring: an update. J Bone Joint Surg Br 89(2:145–154

    Article  Google Scholar 

  55. Hao T, Changwei Y, Qiulin Z (2009) Treatment of posterior pelvic ring injuries with minimally invasive percutaneous plate osteosynthesis. Int Orthop 33(5):1435–1439

    Article  Google Scholar 

  56. Schildhauer TA, Ledoux WR, Chapman JR et al (2003) Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads. J Orthop Trauma 17(1):22–31

    Article  Google Scholar 

  57. Sagi HC, Militano U, Caron T et al (2009) A comprehensive analysis with minimum 1-year follow-up of vertically unstable transforaminal sacral fractures treated with triangular osteosynthesis. J Orthop Trauma 23(5):313–319

    Article  Google Scholar 

  58. Papakostidis C, Kanakaris NK, Kontakis G et al (2009) Pelvic ring disruptions: treatment modalities and analysis of outcomes. Int Orthop 33(2):329–338

    Article  CAS  Google Scholar 

  59. Burlew CC, Moore EE, Mauffrey C, Stahel PF et al (2017) Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg 82(2):233–242

    Article  Google Scholar 

  60. Poelstra KA, Kahler DM (2005) Supra-acetabular placement of external fixator pins: a safe and expedient method of providing the injured pelvis with stability. Am J Orthop (Belle Mead NJ) 34(3):148–151

    Google Scholar 

  61. Ponsen KJ, Joosse P, Van Dijke GA et al (2007) External fixation of the pelvic ring: an experimental study on the role of pin diameter, pin position, and parasymphyseal fixator pins. Acta Orthop 78(5):648–653

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Cyril Mauffrey.

Ethics declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest to report in relation to the preparation of this work.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Blum, L., Hake, M.E., Charles, R. et al. Vertical shear pelvic injury: evaluation, management, and fixation strategies. International Orthopaedics (SICOT) 42, 2663–2674 (2018). https://doi.org/10.1007/s00264-018-3883-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-018-3883-1

Keywords

Navigation