Displaced pelvic ring injuries signify significant trauma from a high energy mechanism. The treatment of patients with pelvic fractures begins with the identification and treatment of all potentially life threatening injuries. Only after initial measures are successful is attention focused on the definitive treatment of the pelvic injury. The outcome of these patients, however, is not known for some time, and may be related to coincident injury. This symposium progresses in a manner that reflects the injury timeline.
The first 2 articles review the radiologic assessment of the pelvis in terms of injury pattern and skeletal stability. Next, the most common associated injuries related to the pelvic displacement are addressed. These include neurologic, urologic, and soft tissue problems. These associated injuries must be sought during the resuscitation phase as part of a careful physical examination.
The next 3 articles review the associated hemodynamic and vascular injuries. A review of the hemodynamic considerations is followed by a description of the indications and use of external fixation, which has become a standard part of the resuscitative effort in the multidisciplinary approach to these patients. In patients with continued blood loss after external fixation, angiography is a useful tool in controlling arterial bleeding. This topic is covered next. In addition to arterial injuries, venous injury is common. This can lead to thrombosis and embolic complications. These problems cannot be overemphasized. A thorough review of thromboembolic complications is included with recommendations for screening and routine prophylaxis.
The next group of papers focuses on the technical aspects of reduction and fixation of the pelvic ring. The indications for anterior fixation, its effect on leg length, and the vascular structures at risk during anterior fixation are discussed. This is followed by a set of 3 papers describing the 3 surgical approaches to the posterior pelvis. These include the open posterior, open anterior, and closed percutaneous methods. Each method has advantages and disadvantages and the pelvic surgeon must be capable of using all the methods for specific indications. Two papers then describe the preferred techniques of several authors for fixation of specific injury patterns. The importance of strict and objective documentation of reductions using the 3 standard views of the pelvis is emphasized.
The intermediate term outcome of patients with pelvic ring injuries is addressed in the next 5 papers. This may be the most important section of this symposium and several important points are made clear. It was consistently found that good reductions of the pelvis are attainable, and that with a good reduction late pelvic pain is not common. It is also becoming clearer that the ultimate outcome of a given patient is likely to be determined by his associated injuries. Concomitant neurologic, orthopaedic, and urologic injuries have a profound effect on patients' ultimate result. It is for this reason that standard outcome scores are of lesser value in assessing multiple trauma patients than they are in more isolated and elective problems. Although these patient based scores are important for our understanding of our patients' needs and desires, they are severely limited in their ability to help us decide on treatment. This is referable to the concept of the least common denominator. If a patient has 1 severe injury that is likely to result in a low outcome score, then even poor treatment of his or her other injuries may not further lower his or her score. An example of this would be a patient with a displaced pelvic fracture, a lumbosacral nerve palsy, a urethral disruption, and a complex foot injury. The chances of a patient with this constellation of injuries having a high outcome score is poor. This does not mean, however, that the potential problems from the displaced pelvic injury should be ignored allowing the development of pelvic pain and sitting problems in addition to the other sequelae. For this reason, specific factors related to the pelvic skeletal injury, its reduction, and outcome must be assessed in both objective and subjective ways. This is pointed out in the last article that deals with the complicated problems of malunions and nonunions of the pelvis. This review highlights the need for proper management of displaced pelvic fractures in the acute phase.
pelvic fracture treatment have lead to a maturation of this field. Those of us who are treating these injuries regularly owe a debt of gratitude to them for their vigilant work, teaching, and documentation. I would like to thank all the authors who have contributed to this symposium and to the ongoing challenge that these injuries present. They have made my job easy. I would also like thank Dr. Joel Matta for encouraging my interest in treating patients with pelvic fractures.
Paul Tornetta, III, MD
SUNY Health Science Center, Brooklyn; Brooklyn, NY