SUPPLEMENT ARTICLE
Anterior Pelvic Ring: Introduction to Evaluation and
Management
Geoffrey S. Marecek, MD* and John A. Scolaro, MD, MA†
Summary: The evaluation and management of pelvic ring injuries
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continues to evolve. Historic treatment was primarily nonsurgical,
which yielded to open surgical treatment as the benefits of restoring
pelvic anatomy and stability became clear. The development of
percutaneous techniques for pelvic ring fixation enabled surgeons to
reduce and stabilize certain injuries without the need for large open
surgical dissections. Although percutaneous iliosacral screw fixation of
sacral fractures and sacroiliac disruptions is the standard for most
posterior pelvic ring injuries, the evaluation and treatment of anterior
pelvic ring disruptions remains a controversial topic among surgeons
who treat these injuries. Universally accepted indications for anterior
pelvic ring stabilization do not exist, and there is little comparative data
to support one surgical technique over another. In fact, some believe
that for many injuries, the anterior ring rarely requires fixation after
stable fixation of the posterior pelvic ring. The purpose of this work is
to present a brief history on management of the anterior pelvic ring as
a component of pelvic ring disruptions and briefly review the anatomy
of the anterior pelvic ring. Finally, we will introduce the current
techniques available for anterior pelvic reduction/stabilization and
present information on evaluation of anterior ring stability as a means
of guiding treatment.
Key Words: anterior pelvic ring, pelvis, instability, ramus, fracture,
disruption
(J Orthop Trauma 2018;32:S1–S3)
HISTORY
Similar to other areas of orthopaedic trauma, management
of pelvic ring injuries has moved from nonsurgical or limited
external stabilization/traction to internal fixation. Before routine
implementation of internal fixation techniques, anterior external
fixation was used as definitive treatment for many lateral
compression (LC) and anterior posterior compression (APC)
type injuries.1,2 Internal fixation techniques were used with
increasing frequency between the 1980s and 1990s, commonly
with plates and screws.3 In the mid-90s, percutaneous techniques
for the anterior and posterior pelvic ring were described, which
fundamentally changed management of pelvic ring injuries.4–6
Accepted for publication May 29, 2018.
From the *Department of Orthopaedic Surgery, University of Southern California,
Keck School of Medicine, Los Angeles, CA; and †Department of Orthopaedic
Surgery, University of California, Irvine, Orange, CA.
The authors report no conflict of interest.
Reprints: John A. Scolaro, MD, MA, Department of Orthopaedic Surgery,
University of California, Irvine, 101, The City Drive South, Building
29A, Pavilion III, Orange, CA 92868 (e-mail: jscolaro@uci.edu).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000001249
J Orthop Trauma  Volume 32, Number 9 Supplement, September 2018
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Injuries to the posterior pelvic ring through the sacrum
or sacroiliac joints have historically been given priority with
regard to stabilization. Many believed that in the setting of a
pelvic ring injury, stabilization of the posterior elements alone
would be sufficient. A single surgeon experience of pelvic ring
injuries published in 1996 noted, “Many anterior fixations are
not necessary . and add to the potential risks of pelvic sur-
gery. Properly performed posterior fixation is sufficient in most
cases.”7 Although stable and accurate posterior ring fixation
remains important, a recognition that each injured pelvic ring
element is a potential site of instability and deformity has
driven improved evaluation and fixation of the anterior pelvis.
Recent literature on the pelvic ring has focused primarily
on the development of anterior pelvic intramedullary techniques
and on evaluating and predicting pelvic stability after injury.
Alternative techniques, such as anterior subcutaneous fixation
(ASF), bridge plating,8 and unique bridge fixators,9 have also
been described as a means of stabilizing the anterior pelvic ring.
Future biomechanical and clinical investigations will continue
to improve the body of literature on the topic and improve care.
ANATOMY
The pelvic ring consists of 2 innominate bones, the
sacrum, and multiple ligamentous attachments between them.
Fractures and/or ligamentous injuries within the ring may result
in instability. The anterior pelvic ring includes the 2 superior
and inferior rami and their anterior midline junction at the pubic
symphysis, a non-synovial amphiarthrodial joint.10 The relevant
surgical anatomy along the superior ramus will be discussed.
The medial surface of each pubic bone is covered with
a thin layer of hyaline cartilage and stabilized by anterior and
posterior ligamentous structures. The main stabilizing liga-
ments are the superior and inferior arcuate ligament. Moving
laterally, the pubic tubercle is a prominence that serves as
the attachment of the inguinal ligament. Multiple muscle
attachments exist near the symphysis, including the rectus
abdominus, pyramidalis, adductor longus, and the upper border
of the gracilis and adductor brevis. Lateral to the symphysis,
the pectineal line is a ridge along the superior ramus. Fibers of
the pectineal ligament and origin of the pectineus muscle are
found here. If present, vascular communications between the
external iliac and obturator or inferior epigastric system exist
here.11 Continuing laterally along the pelvic brim, the iliopec-
tineal fascia is a vertical thickening of fascia that inserts onto
the iliopectineal eminence. This fascia separates the true pelvis
from the false pelvis and the eminence represents the location
where the ilium and pubis fuse. Medial to the fascia, the fem-
oral artery and vein course over the superior ramus. Lateral to
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Marecek and Scolaro J Orthop Trauma  Volume 32, Number 9 Supplement, September 2018
the eminence is a broad shallow depression where the iliacus
and psoas major muscles, as well as the femoral nerve, pass.
The obturator neurovascular bundle course below the superior
ramus within the obturator canal but is in close opposition to
the caudal cortical limit of the superior ramus along the supe-
rior lateral aspect of the obturator foramen.
Comprehension of the relevant surgical anatomy of the
anterior pelvic ring is essential as trauma, surgical exposures,
and implant placement can all result in injury. Although
traumatic injury is unable to be prevented, iatrogenic injury
must be avoided.
ANTERIOR PELVIC RING
STABILIZATION TECHNIQUES
Techniques for stabilization of the anterior pelvic ring
can be grouped into 3 main categories: plate fixation,
intramedullary fixation, and spanning fixation. Each will be
described in greater detail within the body of this supplement
but will be introduced here.
Plate and screw fixation of the symphysis pubis is
routinely performed in the setting of traumatic symphyseal
widening. Plate fixation can also be used for ramus fixation or
to span both an injured ramus and symphysis pubis.12 In most
instances, plate and screw fixation requires a formal open sur-
gical approach to the injured element(s) of the anterior ring.
Although this technique allows direct visualization of the
injury, and can be used regardless of osseous morphology, it
does leave a surface implant in place, which may be undesirable
in some clinical scenarios. Flexible 3.5-mm reconstruction-style
plates and standard cortical screws are most frequently used.
Intramedullary fixation uses the osseous fixation path-
way (OFP) of the superior ramus that exists between the pubic
symphysis and supra-acetabular region.13 It can be used for
simple and complex rami fractures but is not used for fixation
across a symphyseal disruption. Screws are placed in an ante-
grade or retrograde direction; terminology that refers to
whether screw insertion begins in the supra-acetabular region
or near the pubic symphysis, respectively. Unless a reduction
requires an open approach, intramedullary fixation has the
advantage of leaving a small biological footprint; it also does
not leave a surface implant on the bone. Anatomical variation
exists and some patients do not possess a safe corridor for
intramedullary fixation due to the size and/or shape of the
OFP. The technique also requires an understanding of not only
the relevant anatomy of the bony pelvis and surrounding soft
tissue structures but also their fluoroscopic representations.
Finally, spanning fixation describes both pelvic external
fixation and ASF. Both external fixation and ASF provide an
indirect reduction to the anterior pelvic ring.1,14,15 External fix-
ation can be used for provisional or definitive stabilization and
can be used in both APC or LC type injuries. External fixation
pins are commonly placed in 1 of 2 positions: (1) between the
inner and outer tables of the ilium within the gluteus medius
pillar16 or (2) anteriorly, starting about the anterior inferior iliac
spine and heading posteriorly within the OFP in the supra-
acetabular region toward the sciatic notch or posterior superior
iliac spine.17 ASF uses the anterior supra-acetabular pin trajec-
tory exclusively. External fixation and ASF also leave a limited
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Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
biological footprint and can be used when osseous morphology
or surgical field contamination prohibit internal fixation. Both
techniques do have associated morbidity and limitations.14,18
Anterior pelvic ring fixation can be accomplished in
multiple ways. Before considering the various techniques,
proper evaluation of anterior pelvic ring stability is performed
to determine both the need and the type of fixation applied.
ASSESSMENT OF STABILITY
Mechanical instability is obvious in certain cases (Fig. 1,
widely displaced ring). However, for many cases, identifying
and quantifying instability is challenging (Figs. 2A–C). Phys-
ical examination of the patient is a critical first step, as patients
with pelvic ring instability are often reluctant to move in bed,
intolerant of pelvic compression, and difficult to mobilize.
Radiographs and computed tomography scans are com-
monly used studies to begin evaluation of the pelvic ring but
both are static images that may not demonstrate maximum or
potential displacement of the ring.19 Some surgeons have at-
tempted to identify markers of mechanical instability that can
predict later displacement. Bruce et al20 reviewed 117 LC type
injuries managed nonoperatively. Patients with complete sacral
fractures displaced more than 1 cm in any plane during treat-
ment in 50% of cases. Anterior ring injuries were important as
patients without ramus fractures did not displace, whereas those
with unilateral or bilateral ramus fractures displaced in 8.8%
and 39% of cases, respectively. However, the functional impact
of this displacement is unknown. Moreover, these data provide
an estimate of the risk of displacement but cannot determine the
presence of mechanical instability in any given patient.
Consequently, surgeons have turned to dynamic assess-
ments of mechanical stability in equivocal cases. Sagi et al21
described a 15-step examination under anesthesia (EUA) to
identify mechanical instability in LC and APC type injuries
that was used to direct treatment preoperatively and intraoper-
atively. In many cases, a simple internal rotation or external
rotation force is sufficient to identify the presence of instabil-
ity, although the surgeon may desire more information from
the remainder of the examination. In a later study, Whiting
FIGURE 1. Anteroposterior (AP) radiograph of pelvic ring with
obvious mechanical instability.
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J Orthop Trauma  Volume 32, Number 9 Supplement, September 2018
FIGURE 2. A 60 year old woman who sustained a fall at home. She was discharged from an outside hospital and was walking several
days after injury when she presented with this AP radiograph (A) and axial CT scan (B). One week later, mechanical instability was
evident on repeat AP pelvis (C).
et al22 subsequently documented the results of nonoperative
treatment in patients with negative EUA. The study included
patients with LC1, LC2, and APC1 injuries who were per-
mitted weight-bearing as tolerated after a negative EUA. Pa-
tients had a maximal increase in displacement of 2 mm at the
final follow-up and achieved uneventful union.
Dynamic evaluation can help guide decision-making
intraoperatively. There is frequently debate about the role of
anterior ring fixation after adequate posterior stabilization.7
Avilucea et al23 proposed a sequential examination for
mechanical instability after posterior ring fixation. Half of the
74 patients demonstrated mechanical ring instability after pos-
terior fixation and received anterior ring fixation, whereas those
patients who were deemed stable did not. All patients who
received fixation went on to uneventful union. Of the 36 pa-
tients who did not receive fixation, only 9 with bilateral ramus
fractures had early displacement up to 12 mm. The study high-
lights the frequency with which mechanical instability persists
after isolated posterior fixation and that special consideration
may be given to patients with bilateral ramus fractures.
CONCLUSIONS
The management of the anterior pelvic ring has evolved
a great deal but remains controversial. Not only are the
indications for fixation of the anterior ring debated but
multiple options for fixation also exist. The anterior pelvic
ring, composed of the pubic symphysis and bilateral superior
and inferior rami provide important contributions to ring
structure, with each disruption representing a potential loca-
tion of instability. Static imaging provides information about
injury location and pattern but recent evidence has reinforced
the fact that pelvic instability is dynamic and that appropriate
measures should be taken to identify and then address it.
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Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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