Session I - Pelvic Trauma

Early Results of ORIF of Unstable Sacral Fractures

Axel Gänsslen, MD; Timothy Pohlemann; Tobias Hüfner; H.C. Pape; Harald Tscherne, Hannover Medical School, Hannover, Germany

Introduction/Purpose: Most fractures of the sacrum are part of a stable pelvic ring injury. Thus, conservative treatment is the treatment of choice in this specific fracture group. Since the early 90's closed reduction techniques (percutaneous transiliosacral screw fixation) and internal fixation of sacral fractures became popular. The purpose of the present study was the evaluation of the early results after open reduction and internal fixation of unstable sacral fractures.

Material and Methods: Between 1989 and 1996 a series of 40 patients with sacral fractures as part of their translational pelvic ring injury (C-type) were treated at the author's institution. Specific data were collected with respect to patient demographics, mechanism of injury, concomitant injuries, Injury Severity Score (ISS), sacral-related neurologic deficits, mortality, fracture treatment and complications.

Results: There were 22 males and 18 females. The mean age for the group was 35.3 years (range 16-64). Beside motor vehicle accidents (50%), 47.5% had a fall from a height (60% of these as suicidal jumpers). The mean ISS was 17.9 (range 9-48). The most common associated injuries were head injuries, chest injuries and lower extremity injuries in nearly 50%. The pelvic injury was most commonly a C-1.3 type (77.5%), followed by a C-2.3 type (17.5%) and a C-3.2 type in 5% (OTA classification). The mean primary sacral displacement was 14.5mm. One patient died due to severe chest trauma after a polytrauma situation, representing a mortality rate of 2.5%. Primary neurologic deficits were present in 30%, most involving the L5 and S1 nerve roots. There was no correlation between primary displacement and primary neurology. Cases were operated on average 8 days after injury (range 0-21). In 70% a longitudinal incision was used. Overall, the mean operation time was 150 minutes, the mean blood loss was 800 ml. Intraoperatively in 23 cases (57.5%) a nerve root decompression was performed. Type of osteosynthesis were local sacral plating in 24, sacral bars in 5, iliosacral plating in 6, transiliosacral screws in 3, ilioiliacal plating in one, and a combination of sacral bars and iliosacral plating in one case. The anterior pelvic ring was fixed in 90% of the cases. In 87.5% the posterior pelvic ring was fixed anatomically; four patients had residual displacement 5mm; one pregnant woman was fixed in 26mm displacement. Postoperatively, neurologic deficits were unchanged in 10 cases; one had partial recovery and one had complete recovery. Complications occured in 20% (two deep infections, one superficial infection, three secondary displacements, one implant breakage, one hematoma, one iatrogenic nerve injury with complete recovery, one DVT), only in one case after local sacral plate fixation.

Discussion/Conclusions: Open reduction and internal fixation is a safe procedure in stabilizing unstable sacral fractures. The rate of complications and the postoperative result was best for localized sacral osteosynthesis.