Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures.

BACKGROUND: There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment. MATERIALS AND METHODS: The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment. RESULTS: Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated. CONCLUSIONS: This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients. LEVEL OF EVIDENCE: IV. TRIAL REGISTRATION: not applicable (consensus paper).

Endosteal plating for the treatment of malunions and nonunions of distal femur fractures.

PURPOSE: To describe the surgical technique and the outcome of a case series of nonunion and malunion of distal femur fractures treated with an endosteal medial plate combined with a lateral locking plate and with autogenous bone grafting. METHODS: We retrospectively analyzed a series of patients with malunion or nonunion of the distal femur treated with a medial endosteal plate in combination with a lateral locking plate, in a period between January 2011 and December 2019, Database from chart review was obtained including all the clinical relevant available baseline data (demographics, type of fracture, mechanism of injury, time from injury to surgery, number of previous surgical procedures, type of bone graft, and type of lateral plate). Time to bone healing, limb alignment at follow-up and complications were documented. RESULTS: Ten patients were included into the study: 7 male and 3 female with mean age of 48.3 years (range 21-67). The mechanism of trauma was in 8 cases a road traffic accident and in 2 cases a fall from height. According to AO/OTA classification 5 fractures were 33 A3, 3 were 33 C1, 1 was 33 C2 and 1 was 33 C3. The average follow up was 13.5 months. In all cases but one bony union was achieved. Bone healing was observed in average 3.3 months after surgery. No intraoperative or postoperative complications were reported. CONCLUSION: A medial endosteal plate is a useful augmentation for lateral plate fixation in nonunion or malunion following distal femur fractures, particularly in cases of medial bone loss, severe comminution, or poor bone quality. LEVEL OF EVIDENCE: Level IV (retrospective case series).

FRAGILITY FRACTURES OF THE SACRUM: A SILENT EPIDEMIC.

Fragility fractures of the sacrum (FFS) are caused by low-energy trauma in the elderly population. Due to the nuanced symptomatology, many FFS remains unrecognized and the prevalence is underestimated. The clinical presentation varies, typically presenting with weightbearing low back pain without even remembering of a previous trauma. Radiographs are usually insufficient for the diagnosis and second level imaging modalities are required. In particular, magnetic resonance demonstrated the highest diagnostic accuracy. Treatment should aim to guarantee early mobilization and weightbearing, efficient pain relief and early discharge from the hospital to a proper facility for rehabilitation. Conservative treatment is reserved to non-displaced fractures with an adequate pain relief within one week allowing early mobilization. Otherwise, surgical treatment must be preferred. Nowadays, minimally invasive techniques, such as ileo-sacral screws or trans-sacral bar osteosynthesis, are safe and effective procedures and have overcome open procedures. In more complex patterns, with complete dissociation between the pelvic ring and the ilio-lumbar spine, spino-pelvic fixation is the procedure of choice.

An international survey of pelvic trauma surgeons on the management of pelvic ring injuries.

INTRODUCTION: There exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement. METHODS: A 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question. RESULTS: Nineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement. DISCUSSION: This study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.

Nonunions and malunions after pelvic fractures: why they occur and what can be done?

MATERIALS AND METHODS: Between 1987 and 2005, 55 patients were treated operatively to correct 44 malunions and 11 nonunion of the pelvic ring. These pathologies were the consequence of a nonoperative initial treatment for 38 cases, or of an inappropriate indication, such as the use of an external fixator as the definitive treatment of an unstable pelvic fracture in 15 and symphysis cerclage wiring in 2. Three patients had undergone ORIF of the lumbar spine performed by neurosurgeons, but the pelvic fractures below were ignored. On the basis of damaging mechanisms and of the main instability plane, initial lesions were classified as follows: 32 shearing lesions, 11 rotatory by antero-posterior compression, 7 by lateral compression, 5 mixed. In 23 cases the site of the posterior lesion was the sacrum, 4 of which were H fractures type; 13 were sacroiliac joint dislocations, or rotatory instability of the joint (in 2 cases the lesion was bilateral), 8 were sacroiliac dislocation fractures (crescent fractures); 7 were fractures of the iliac wing. Four patients only had pubic symphysis diastasis. Indications for surgery were pain associated with deformity or instability. Surgery was performed through a multistage procedure. Mean surgery time was 6h (range: 2-10h), with a mean blood loss of 700ml (range: 200-5000ml). Follow-up ranged from a minimum of 16 months to a maximum of 14 years (mean: 5.85 years). RESULTS: At the last follow-up, all patients but one had consolidated and were considered stable. All patients had improved walking ability. Six patients still report pain. Even if most of the deformity were corrected with a significant decrease of pre-operative symptoms achieved, deformity correction was considered satisfactory but not anatomic, in 12 patients (21%). Complications occurred in 24% of patients but most were temporary. CONCLUSIONS: The most frequent cause of pelvic malunion or nonunion was inadequate treatment. To reduce the number and the percentage of disabilities, it is necessary that specialised centres provide patients with early treatment that is adequate and definitive.

[Percutaneous management of hemorrhages in pelvic fractures].

PURPOSE: To report our experience in the control of haemorrhage with the transcatheter embolisation technique. MATERIALS AND METHODS: Between 1999-2001, we treated 56 patients with important pelvic trauma. Forty-two were victims of car accidents and 14 of falls from great altitudes. Twenty presented acute symptoms due to blunt pelvic trauma, with massive bleeding, not treatable by drugs and blood transfusion. Diagnosis of pelvic haemorrhage was made with CT. When high-flow haemorrhage was found, the patient was referred for angiography. Embolisation was achieved after a diagnostic arteriography, with bilateral transfemoral approach and selective catheterisation of the internal iliac arteries. RESULTS: Technical success was achieved in 100% of cases: all the haemorragic sites were found and embolised. In only one patient with severe shock was it impossible to locate the site of contrast material extravasation on the first day; the patient was successfully treated on the second day with improvement of the clinical conditions. The obturator artery was involved in five cases, the gluteal artery in eleven. In eighteen patients, use of an angiographic catheter was sufficient to treat the haemorragic sites. Percutaneous control of the haemorrhage was obtained by using Gelfoam, Ivalon and coils. CONCLUSIONS: Percutaneous haemorrhage control is safe and effective, and not as costly or dangerous as the surgical option. We regard it as the treatment of choice in multiple trauma patients with important and high-flow pelvic haemorrhage.