SUPPLEMENT ARTICLE
The Use of External Fixation for the Management of the
Unstable Anterior Pelvic Ring
Christopher Lee, MD and Marcus Sciadini, MD
Summary: The objective of this article was to highlight the
indications and various methods of external fixation for management
Downloaded from https://journals.lww.com/jorthotrauma by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3+5UxwP5IFlBD9KwJYCFGgxWp17zOrfICl/C95nwBsgc= on 05/20/2020
of the unstable anterior pelvic ring. Although most often used
temporarily in the setting of significant hemorrhage from a pelvic ring
fracture, external fixation remains an option for definitive stabilization
of select pelvic ring injuries. Classically, the iliac crest frame has been
used, although use of the supra-acetabular frame has gained favor due
to its superior bone purchase and improved biomechanics. Common
complications from external fixation include pin site infections, loss of
reduction, and the “external fixator deformity.”
Key Words: external fixation, unstable pelvic ring, anterior ring
(J Orthop Trauma 2018;32:S14–S17)
INTRODUCTION
The management of pelvic ring injuries can be complex,
requiring a multidisciplinary approach for treatment.1 Anterior
pelvic ring injuries can manifest as symphyseal dislocations,
ramus fractures, or combinations of both.2 Functional recovery,
treatment options, and residual deformity varies widely
between fractures classified as stable and unstable.3–5 Anterior
pelvic ring instability results from significant disruption of the
pubic symphysis (often defined as greater than 2.5 cm of sym-
physeal diastasis, although the significance of this absolute
number has recently been called into question6) and/or ramus
fractures combined with posterior ligament equivalent disrup-
tions, including complete sacral fractures.7 Various options for
anterior fixation have been proposed, including anterior exter-
nal fixators with use of supra-acetabular and/or iliac wing pins
and internal fixation in the form of plates and screws.
INDICATIONS FOR EXTERNAL FIXATION
The routine use of external fixation for stabilization of
the anterior pelvic ring has declined in recent years. As
recently as 2 decades ago, external fixators were used often in
the treatment of anterior ring injuries. External fixation has
maintained a role at trauma centers, especially in the
resuscitative phase of treatment, owing to its ease and
Accepted for publication May 29, 2018.
From the Department of Orthopaedic Surgery, R Adams Cowley Shock
Trauma Center, Baltimore, MD.
The authors report no conflict of interest.
Reprints: Marcus Sciadini, MD, Department of Orthopaedic Surgery, R
Adams Cowley Shock Trauma Center, 22S. Greene St, Baltimore, MD
21201 (e-mail: MSciadini@umoa.umm.edu).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000001251
S14 | www.jorthotrauma.com J Orthop Trauma  Volume 32, Number 9 Supplement, September 2018
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
efficiency in the application of fixators for symphyseal
disruptions and ramus fractures.8 However, the risk of pin
site infections, interference with abdominal access, the cum-
bersome nature of the frame—especially with sitting upright
—and inability to accurately control posterior ring instability
in addition to the widespread use of pelvic sheeting or binders
for provisional pelvic stabilization during acute resuscitation
has limited their use in modern pelvic fixation.9
Currently, the primary role of anterior pelvic external
fixation is stabilization of the anterior pelvic ring when open
reduction and internal fixation is precluded. This may occur in
the presence of bladder rupture where contamination of plate
and screw constructs is increased, open/contaminated wounds,
or wounds potentially contaminated due to anterior laparotomy
incisions. Patients presenting with refractory hemodynamic
instability indicated for pelvic packing may undergo external
fixation in conjunction with this emergent procedure, as
external fixation provides pelvic volume control with packing
to allow for tamponade of pelvic bleeding. Additional patient
and injury-specific considerations may also drive consideration
of external fixation, including certain complex and comminuted
anterior ring injury patterns that may not be amenable to open
reduction and internal fixation and morbidly obese patients with
a large anterior pannus, in whom the risk of wound complica-
tions associated with open instrumentations is deemed unac-
ceptably high.
Special consideration can be made when treating females
of childbearing age. As internal fixation can prevent relaxation
of the pelvic ring at the time of delivery, this may necessitate
cesarean section. External fixation provides temporary stabiliza-
tion of the pelvic ring with no residual fixation to inhibit
relaxation of the pelvic ring at the time of delivery.10 In the study
by Vallier et al, there was a trend toward increased caesarean
delivery in women with retained internal fixation.11
BIOMECHANICAL CONSIDERATIONS FOR
EXTERNAL FIXATION
Prudent decisions regarding stabilization of pelvic ring
injuries require knowledge of mechanical stability differences
with respect to internal and external fixation. McBroom and
Tile found that all existing external frames would stabilize the
pelvic ring sufficiently, provided the posterior osseous
ligamentous hinge remained intact. However, no external
frame could provide adequate stability for mobilization of
a patient with the posterior hinge disrupted. They additionally
found that internal fixation provided greater stability to the
pelvic ring than external fixation.12
J Orthop Trauma  Volume 32, Number 9 Supplement, September 2018
Hearn and Tile demonstrated that no significant differ-
ence exists in controlling external rotation of the hemipelvis
when comparing anterior internal and external fixation.13
However, vertical displacement was resisted to a greater
extent with use of anterior internal fixation as opposed to
external fixation.14 Furthermore, pure symphyseal disruptions
treated with anterior external fixation have been reported to
have an increased incidence of mechanical failure in compar-
ison to internal fixation, with obesity additionally increasing
the risk of mechanical failure.15
External Fixation Treatment Methods
Two common methods exist for the placement of anterior
pelvic external fixation: iliac crest pins and supra-acetabular
pins. The classic iliac crest frame traditionally involves the use
of two or three 5-mm partially threaded Schanz pins placed in
to each iliac wing starting at the iliac crest and bound together
by an anterior frame.16 It is important to place the most anterior
pin at least 2 cm dorsal to anterior superior iliac spine (ASIS) to
avoid injuring the lateral femoral cutaneous nerve. In the study
by Rupp et al, a thick zone of bone was identified 2–3 cm
posterior to the ASIS and extending 6–8 cm posteriorly along
the crest. This region of bone was found to be hourglass-shaped
and followed the superior gluteal ridge to the acetabular region
with a maximal thickness of 4 cm, which would minimize risk
of cortical perforation along the tables of the ilium.17 Histori-
cally, the technique involved dissection into the internal iliac
fossa to help guide trajectory of the pins and minimize perfo-
ration. The most significant advantage of this technique is that
it can be performed without fluoroscopic guidance and can be
performed expeditiously. However, intraoperative fluoroscopy
can be used to ensure proper placement of the pins, with an
outlet view demonstrating whether the pin is out of the crest,
and an obturator oblique view showing whether the pins remain
between the inner and outer tables. The iliac crest pin frame,
however, uses pins placed in inferior-quality bone, and recent
biomechanical studies have shown inferior ability to resist
internal and external rotation. Furthermore, the less ideal vector
for closure of the unstable ring occasionally causes an abduc-
tion moment not seen in the supra-acetabular frame.18–23
The supra-acetabular frame uses 2 pins placed from the
anterior inferior iliac spine to the posterior ilium in the robust
bone of the sciatic buttress.24,25 The placement of these pins
requires intraoperative fluoroscopy, beginning first with an
obturator oblique outlet view to visualize the “tear drop”
(represents the inner and outer tables of the ilium and the
top of the greater sciatic notch inferiorly) for the start site
followed by an iliac oblique to demonstrate that the pin is
proximal to the hip joint and directed toward the sciatic but-
tress superior to the greater sciatic notch. The final necessary
view is the obturator oblique inlet, which demonstrates place-
ment of the pin within the inner and outer tables of the pelvis
(Fig. 1).26 As these pins extend back to the posterior inferior
iliac spine, they offer some, albeit minimal, control of the
posterior ring. Supra-acetabular pin placement can be associ-
ated with injury to the lateral femoral cutaneous nerve and hip
capsule, with Haidukewych et al showing the mean distance
from pin insertion site to the lateral femoral cutaneous nerve
being 10 mm, and as close as 2 mm, and the mean superior
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Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
External Fixation for the Unstable Pelvic Ring
extent of the hip capsule being 16 mm, ranging from 11 to
20 mm.27 The starting point and trajectory for these pins is
traditionally described as being identical to those employed
by the insertion of “Lateral Column-2 (LC-2) screws,” in-
serted for fixation of a posterior iliac “crescent” fracture.
However, the trajectory may be modified and directed more
toward the greater sciatic notch to provide more clearance for
hip flexion and facilitate a seated posture for those patients
being treated definitively in an anterior frame. Additionally,
iliac crest pins can be added to a supra-acetabular frame to
increase mechanical stability.19
A third option, the subcristal pelvic external fixation
frame is less common. The starting point of the subcristal pin
lies medial to the center of the palpable ASIS and just lateral
to the inner cortex of the ilium. The pin is placed toward the
iliac tuberosity between the 2 iliac cortices. Intraoperative
fluoroscopy can be used to confirm intraosseous placement of
the pin in the iliac crest, although it is not needed. Solomon
et al reported low complication rates while allowing for easier
pin placement and less interference with hip flexion.28
COMPLICATIONS
Postoperative infection after external fixation of the
unstable anterior ring usually manifests as pin tract infections.
Pin tract infection rates have varied in the literature, with recent
reports suggesting an 18% rate while some historical literature
suggesting up to a 50% incidence of pin tract infections.29
These can typically be managed with appropriate release of
the skin around the pins and dressing changes as necessary.
Antibiotics may be warranted with persistent drainage or the
development of cellulitis. Persistent infections can cause pin
loosening, at which point the pin must be removed and the pin
tract debrided.30
Loss of reduction can occur with use of external fixation,
especially when used for definitive fixation (Fig. 2). In the
study by Tosounidis et al, type B pelvic ring injuries displaced
to a lesser extent at final follow-up than type C pelvic ring
injuries. However, increased displacement at final follow-up
did not correlate statistically with functional outcomes.31
The application of external fixation for the unstable
anterior pelvic ring can also exacerbate the deformity of the
ring injury. Dickson et al reported on the presence of the
FIGURE 1. A, Iliac oblique view to demonstrate placement of
the supraacetabular pin just cranial to the sciatic buttress. B,
Obturator oblique inlet view demonstrating placement of the
pin within the inner and outer tables of the ilium.
www.jorthotrauma.com | S15
Lee and Sciadini J Orthop Trauma  Volume 32, Number 9 Supplement, September 2018
FIGURE 2. A, Sixty-eight year-old female status
post a motorcycle accident presenting with an
Anterior Posterior Compression (APC) II pelvic ring
injury with extraperitoneal bladder rupture. B,
Status post anterior external fixation with a su-
praacetabular frame and SI/S2 transiliac transacral
screws. C, One week post-op showing loss of
reduction of the anterior ring. D, Six week post-op
showing progressive loss of anterior ring reduc-
tion despite concentric reduction of the posterior
ring. E, CT scan showing loss of anterior ring
diastasis. F, CT scan showing maintained posterior
ring reduction.
“external fixator deformity,” defined as worsening of flexion,
internal rotation, or both with application of an anterior fix-
ator in the setting of complete posterior ring disruption. They
recommended caution when applying the external fixator and
suggested adjusting the reduction vector to circumvent the
worsening deformity. Additionally, the authors recommended
sheeting or binder placement around the greater trochanters
before external fixation to help reduce the pelvis while limit-
ing the occurrence of pelvic deformity.32
CONCLUSIONS
Pelvic ring injuries can vary in severity and deformity.
Although external fixation of the unstable anterior pelvic ring
has largely given way to internal fixation, there remain
indications for its use. In the setting of acute hemodynamic
instability requiring pelvic packing, external fixation maintains
a crucial role in stabilization of the patient. The 2 most
common methods used have been the classic iliac crest frame
and the fluoroscopy-dependent supra-acetabular frame. Like all
treatment options, complications remain. Pin site infections
remain the most commonly reported complication, although
this is often managed with minimal effort. In summary,
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external fixation remains a viable form of treatment for the
unstable anterior pelvic ring, and as such should remain in the
armamentarium of the surgeon.
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