International Orthopaedics

https://doi.org/10.1007/s00264-021-05005-5

ORIGINAL PAPER

Comparison of iliac crest versus supraacetabular external fixator

in hemodynamically unstable patients with a pelvic ring injury
Xiangquan Chu 1 & Katya E. Strage 1 & Michael Hadeed 1 & Joshua A. Parry 1 & August Funk 1 & Clay Burlew 1 &
Cyril Mauffrey 1

Received: 22 January 2021 / Accepted: 16 March 2021

# SICOT aisbl 2021

Abstract
Purpose External fixation has been widely implemented as a resuscitation strategy in combination with pelvic packing for high
energy, hemodynamically unstable, pelvic ring injuries. The primary aim of this study is to compare urgent iliac crest (IC) versus
supraacetabular (SA) external fixation in the setting of haemodynamic instability.
Methods This is a retrospective review of a prospectively gathered registry at an urban level one trauma centre comparing
placement of pelvic external fixator by SA or IC technique. Outcomes assessed were accuracy of pin placement, duration of
procedure, and the effect on true pelvic circumference depending on type of fracture by Young and Burgess Classification
system.
Results Ninety-three haemodynamically unstable patients with a pelvic fracture included. Pin malpositioning was more common
with IC than SA groups (proportional difference, − 40%; 95% CI, − 57 to − 20%; p < 0.0001). For APC injuries, there was a
larger median reduction in pelvic circumference in the SA group than the IC group (median difference [MD], − 12.85 cm; 95%
CI, − 27 to 0.1; p = 0.0485). In LC injuries, the SA group had an overall increase in pelvic circumference compared to an overall
decrease in IC group (MD, 6.5 cm; 95% CI, 1.5 to 16.8; p = 0.0221). There was no difference in the operating room (OR) time
(mean difference, − 5.4 min; 95% CI, − 32 to 22; p = 0.68).
Conclusions In this clinical setting, we recommend placement of SA external fixator (versus IC) with similar operative times,
fewer pin malpositions, and improved stabilization of pelvic circumference in APC and LC injuries.

Keywords Pelvic external fixator . Pelvis . Fracture . Early appropriate care . Damage control orthopedics . Peritoneal packing

Introduction injuries reported a reduction in early mortality from 52%, in

Pelvic ring fractures represent 3% of all reported skeletal in-
juries [1]. While this is a relatively small percentage, the mor-
tality rate associated with these injuries is disproportionally
high. A 2015 study reported a mortality rate of 32% for pa-
tients with pelvic fractures who present in shock [2]. The
management of high energy pelvic fractures focuses on early
recognition and treatment of potentially fatal haemodynamic
instability. A study from Chiara et al. (2016) comparing peri-
toneal packing in haemodynamically unstable pelvic ring
Level of evidence: Level III
* Cyril Mauffrey
cyril.mauffrey@dhha.org
1
Department of Orthopaedics, Denver Health Medical Center, Denver
Health, 777 Bannock St, MC 0188, Denver, CO 80204, USA
those that did not receive pelvic packing, compared to 20%
with those that did receive pelvic packing [3].
Typically, pelvic external fixation is completed using either
supra-acetabular (SA) pins or iliac crest (IC) (Figs. 1 and 2).
While there are advantages and disadvantages to both, the aim
of both techniques is to be efficient, effectively stabilize the
pelvis and have safe pins trajectories. The goal for stabiliza-
tion of the pelvis varies based on injury classification. Using
the Young and Burgess (YB) classification the goal of
anterior-posterior compression (APC) injuries should be to
stabilize the pelvic ring by reduction of the true pelvic circum-
ference, whereas lateral compression (LC) fractures benefit
from an overall increase in true pelvic circumference by dis-
traction of the compressed pelvic ring. Vertical shear (VS)
fractures rely more on vertical stability than circumferential
stabilization, and combined injuries are multifactorial, and
therefore optimal stabilization is more variable. Recent studies
 International Orthopaedics (SICOT)

Fig. 1 a Clinical x-ray showing a supra-acetabular external fixation for a pelvic ring injury, seen here in conjunction with pelvic packing. b Clinical
image of supra-acetabular pelvic external fixator placement

have shown that SA pins are superior when compared to IC
pins in ensuring “sacroiliac joint stability” in all unstable pel-
vic ring injuries [4]. No studies to date have reviewed external
fixation techniques in the context of different pelvic ring
classifications.
The primary objective of this study is to review our insti-
tution’s experience with both types of pelvic external fixators,
SA and IC pins, to determine if there is a difference in pin
malpositioning, change in true pelvic circumference, or oper-
ative time.
Methods
After institutional review board approval, a retrospective re-
view of all patients who were admitted to a level one trauma
centre between 2010 and 2020 was completed. Inclusion
criteria included patients who underwent external fixation of
the pelvis via IC or SA pins and had pre and post external
fixation computerized tomography (CT) scans available for
review. Exclusion criteria included all patients who were <
18 years old or patients that did not have pre and post external
fixation/packing CT imaging available.
CT scans were analyzed using the PACS system by an
orthopaedic surgeon (QC). The injury patterns were classified
using the YB and Tile classification systems. Measurements
of the pin length outside and inside of the bony corridor were
assessed in the appropriate planes. Data recorded via imaging
included pre external fixation true pelvic circumference, post
external fixator true pelvic circumference, pin malposition,
and number of laps accurately placed in the true pelvis (our
protocol uses three laps in each hemi pelvis placed using the
preperitoneal space aiming for the presacral area within the
true pelvis) (Fig. 3). Change in pelvic circumference was de-
fined as the difference in inner circumference of the true pelvis
measured on the reformatted axial CT scan images before and
after external fixation. Negative values represent a reduction
in pelvic circumference, and positive values represent an in-
crease in pelvic circumference. Pin malposition was defined as
> 2 mm of pin outside of the bony corridor. For the SA group,
this was defined as a distal pin penetrating out of the wing of
the ilium. Pin measurement was calculated by using sagittal
and axial CT reconstructions in two windows using a
referencing line. The referencing line was then rotated in each
sequence until parallel with the pins (Fig. 4). Measurements
for pin positioning were then obtained. Review of the medical
records was used to obtain additional patient and operative

Fig. 2 a Clinical x-ray showing an iliac crest external fixation for a pelvic ring injury, seen here in conjunction with pelvic packing. b Clinical image of
iliac crest pelvic external fixator placement. c Model image of iliac crest pelvic external fixator placement
International Orthopaedics (SICOT)
Fig. 3 Accuracy of pelvic pack placement in true pelvis
data including age, gender, mechanism of injury, and opera-
tive times. Operative time was not recorded for patients un-
dergoing additional procedures at the time of pelvis external
fixator placement and pelvic packing.
The student t-test was used to compare continuous vari-
ables and Fisher exact test to compare discrete variables be-
tween patients treated with SA pins and those with IC pins.
For non-parametrically distributed data, as determined by the
Shapiro-Wilk test, medians and interquartile ranges were re-
ported, for parametric means and 95% confidence intervals
(CI). Mean difference, CI, and p values were calculated to
compare means, and median difference (MD), bootstrapped
CI, and p values were calculated to compare medians.
Proportional difference, 95% CI, and p values were calculated
as a measure of association between proportions. A p value of
less than 0.05 was considered statistically significant.
Statistical analysis of data was conducted using JMP Pro 14
(SAS, Cary, NC) [5].
Fig. 4 Example of measurement
for pin malpositioning
Results
Over a 10-year period from November 2010 to April 2020,
134 patients were identified. Forty-one patients were exclud-
ed, including one patient identified as being < 18 years old, 30
patients who did not have post external fixation CT imaging
available, and ten patients who had incomplete medical re-
cords. A total of 93 patients were included in data analysis.
Patient ages ranged from 18 to 89 years old; median age for all
pelvic fractures was 42 years old (IQR: 28.5–57). Patient char-
acteristics between the two groups, IC and SA, including age,
sex, mechanism of injury, Tile classification, and YB classifi-
cation, were all evaluated (Table 1). Forty-eight percent of
patients did not have records to document the mechanism of
injury. Of those that had a mechanism listed, the most com-
mon cause of injury was motor vehicle accident (MVC), ac-
counting for 37.5% of injuries that had a known cause of
injury.
Using the YB classification, there were 42% (39/93) lateral
compression (LC) injuries, 31% (29/93) anteroposterior com-
pression (APC) injuries, 18% (17/93) combined mechanism,
and 9% (8/93) vertical shear injuries. Using the Tile classifi-
cation, 56% Tile C (52/93) and 44% Tile B (41/93). Fifty-two
percent (48/93) of patients had IC pins and 48% (45/93) had
SA pins. One hundred percent of patients were designated as
OTA Classification 61 [6].
Thirty-six out of 93 patients had pins that were
malpositioned, 78% (28/36) in IC group and remaining 22%
(8/36) in SA group (proportional difference, − 40%; 95% CI,
− 57% to − 20%; p < 0.0001) (Table 2).
A comparison of median change in pelvic circumference
by YB classification is reported in Table 3. For APC injuries,
median change in pelvic circumference in IC group was −
0.35 cm (IQR: − 9.25 to 19.98) and in the SA group −
9.8 cm (IQR: − 17.1 to − 5.45) (MD, − 12.85; 95% CI, − 27
to 0.1; p = 0.0485). For LC fractures, IC group had a median
change in pelvic circumference of − 2.05 cm (IQR: − 4.28 to
0.95) and in the SA group 4 cm (IQR: 1.2 to 11.3) (MD, 6.5;
95% CI, 1.5 to 16.8; p = 0.0221).
 International Orthopaedics (SICOT)

Table 1 Comparison of patient characteristics between the SA and IC groups

Type of DCO external fixator

Patient characteristics (n=93) Iliac crest (IC) (n=48) Supraacetabular (SA) (n=45) p Value

Age, median (IQR) 42.(56.75–29.25) 42 (58.5–27.6)

Sex (n (%)) 0.6670
Female 19 (40%) 15 (33%)
Male 29 (60%) 30 (67%)
Mechanism of injury (n (%)) 0.0799
Auto vs. bike 0 (0%) 1 (2%)
Auto vs. ped 8 (17%) 4 (9%)
Fall from height 3 (6%) 2 (4%)
MCC 5 (10%) 5 (11%)
MVC 14 (29%) 4 (9%)
Other 17 (35%) 28 (62%)
Sleeping 1 (2%) 0 (0%)
Skiing 0 (0%) 1 (2%)
AO letter classification (n (%)) 0.6793
A 0 (0%) 0 (00%)
B 20 (42%) 21 (47%)
C 20 (58%) 24 (53%)
Young and Burgess Classification (n (%)) 0.6248
APC 14 (29%) 15 (33%)
Combined 8 (17%) 9 (20%)
LC 23 (48%) 16 (36%)
VS 3 (6%) 5 (11%)

IQR interquartile range

Continuous variable are presented as medians with associated interquartile range
p Value calculated based on Chi-square model, < 0.05 was considered statistically significant

Of the 93 patients included in the analysis, 9 had incom- pelvic packing and external fixation without additional proce-
plete records, and 66 underwent pelvic packing along with dures, which was the cohort used for the operative time anal-
additional procedures. Eighteen patients underwent isolated ysis. The nine incomplete records were due to an inability to

Table 2 Comparison of outcomes between the SA and IC groups

Type of DCO external fixator

Iliac crest (IC) Supra-acetabular Difference, p Value

(n =48) (SA) (n =45) 95% CI

Pin malposition 28 (58%) 8 (18%) 40%, 57% to 20% <0.0001

(n (%))
Median reduction in true pelvic circumference 4.5 (IQR: 1 to 10) 9 (IQR: 3 to 15) 4.5, −8.7 to 1 0.09
(cm)
Mean operative time 52 (95% CI: 34 to 70) 47 (95% CI: 25 to 67) −5.4, −32 to 22 0.68
(minutes)
Median accuracy of pelvic pack placement 63% (IQR: 33% to 67%) 33% (IQR: 25% to 67%) −17%, −33% to 0% 0.0138
(%)

IQR interquartile range

Continuous variables with non-parametric distribution are presented as medians with associated interquartile range
Continuous variables with parametric distribution are presented as means with associated 95% confidence intervals
p Value < 0.05 was considered statistically significant and are italicized
International Orthopaedics (SICOT)
Table 3 Comparison of median change in true pelvis circumference by YB Classification
Type of DCO external fixator
Young and Burgess (YB) Classification Iliac crest (IC)
[Median (IQR)] (n =48)
APC −0.35 (−9.25 to 19.98)
LC −2.05 (−4.28 to 0.95)
Combined −6.35 (−11.20 to −0.23)
VS 1.9 (−1.20 to 5.00)
All fractures −0.95 (−6.00 to 2.84)
IQR interquartile range
Continuous variables with non-parametric distribution are presented as medians with associated interquartile range
p Value < 0.05 was considered statistically significant and are italicized
find reported operative times in historical data files. Data was
normally distributed and analyzed via parametric analysis
(Shapiro-Wilk 0.5137). The mean time for the IC group un-
dergoing pelvic packing and pelvic external fixator only (n =
10) was 52 minutes (95% CI 34 to 70) compared to 47 minutes
(95% CI 25 to 67) in the SA group (n = 8) (mean difference, −
5.4; 95% CI, − 32 to 22; p = 0.68) (Table 2).
Seventy-one patients had documented pelvic packing
placed in the true pelvis at the time of external fixation.
Median number of packs placed in the true pelvis was six
(IQR: 6 to 6). Median number of laps placed was identical
in both groups, six (IQR: 6 to 6) in the IC group compared
with six (IQR: 6 to 6) in the SA group (MD, 0; 95% CI, 0 to 0;
p = 0.7743). Accuracy of pelvic pack placement was analyzed
by median percentage and was compared to external fixator
type. IC group had median percentage of 63% accurately
placed laps in true pelvis (IQR: 33% to 67%), compared to
33% (IQR: 25% to 67%) in SA group (MD: − 17%, − 33% to
0%, p = 0.0138) (Table 2). There were a total of seven deaths
in the included cohort, four in the IC group (4/48) and three in
SA group (3/45). None of the deaths were a result of exsan-
guination from acute haemorrhage; therefore, mortality anal-
ysis was excluded from the study.
Discussion
Of the 93 patients included, 56% (52/93) were Tile C and 44%
(41/93) Tile B, patients highlighting the injury severity of
patients presenting with haemodynamic instability.
This study shows that SA external fixator has decreased
incidence of pin malposition and better pelvic circumference
stabilization when compared to IC pin external fixator. The
results highlight that IC pins were malpositioned in 58% (28/
48) of all IC external fixators placed, compared to only 18%
(8/45) malpositioned in the SA external fixator group. Not
only did the SA external fixator group have more accurate
Supra-acetabular Median difference p Value
(SA) (n =45) (95% CI)
−9.8 (−17.10 to −5.45) −12.85 (−27 to 0.1) 0.0485
4 (1.20 to 11.30) 6.5 (1.50 to 16.80) 0.0221
9.85 (−8.45 to 14.05) 13.35 (−9.5 to 25.3) 0.2410
−1.25 (−9.43 to 0.33) −4.95 (−1.8 to 13.8) 0.4875
0.05 (−10.33 to 9.00) 1.00 (−5.90 to 6.80) 0.7940
placement of pins but also had a superior pelvic circumference
stabilization. For APC injuries, where the goal for pelvic ring
stabilization is an overall reduction in circumference, SA pins
had a significantly greater median reduction in circumference
of − 9.8 cm, compared to only − 0.35 cm with the IC pins.
Additionally in LC injuries, the SA pins showed a median
increase in pelvic circumference of 4 cm, compared to IC pins
which demonstrated an overall reduction in circumference of
− 2.05 cm. The goal for LC injuries is to relieve the lateral
compression on the pelvic ring, and therefore an increase in
the overall true pelvic circumference is desired, which only
occurred in the SA group. VS and combined injuries rely less
on circumference change for stabilization, and therefore it is
not unexpected that no significant trends were identified in
these two groups.
There were a total of seven deaths in the study. None of
these were due to acute haemorrhage resulting in exsanguina-
tion, and all deaths occurred > 24 hours after injury. Given the
cause of death for all the patients was a result of non-
haemorrhage related cause, while no comparison of mortality
and ex-fix type can be made; it does reinforce that the current
institutional protocol of pelvic external fixation with pelvic
packing, in haemodynamically unstable patients, is an effec-
tive strategy for stabilization.
The SA and IC groups had no difference in operative time.
A major limitation to the use of SA pins is the need for fluo-
roscopy. The current decision between SA and IC pin place-
ment is majority due to surgeon preference. However, the
decision is sometimes determined by the operating table on
which the patient is placed as some OR tables make the use of
fluoroscopy technically difficult, which can be problematic
for SA pin application. Under the assumption that all SA pins
were placed under fluoroscopy compared to the IC pins, there
remains no difference in OR times between the two groups.
Operative times were only included for patients undergoing
pelvic external fixator and pelvic packing without any addi-
tional procedures to ensure accurate comparison of operative

times between the two methods of external fixator application,
IC and SA.
On further analysis of pelvic packing, there was a median
of six packs placed in both groups, which confirms a strong
adherence to our institutional policy of six laps total for pelvic
packing. Accuracy of preperitoneal pelvic packing between
the two groups shows that the IC group had improved accu-
racy of pelvic pack placement over SA group (63% and 33%
respectively).
Pelvic ring injuries follow a bimodal epidemiologic distri-
bution with young patients affected by high energy trauma
and older patients suffering from fragility fractures more com-
monly [7, 8]. The treatment aims, concepts, and the mortality
rates are quite different between those two populations. While
the management of lower energy pelvic fractures in older pa-
tients is aimed at assessment of fracture instability, decision to
fix or not, and medical optimization of bone health, high en-
ergy trauma focuses on urgent pelvic ring stabilization and
haemodynamic resuscitation to decrease mortality [9].
Haemorrhage is the most common cause of mortality in
patients with high energy pelvic ring fractures [10]. The effica-
cy of early pelvic binder or sheet application is unquestionable
[10]. However, there are two more definitive strategies for con-
trol of pelvic fracture related bleeding: pelvic angio-
embolization and pelvic packing. Gansslen et al. compared
these two methods and found that in critically injured, unstable
pelvic fractures, embolization is too time-consuming and thus
the primary approach to these patients should be direct
haemostasis via pelvic packing [11]. The combination, of si-
multaneous pelvic external fixator placement and preperitoneal
pelvic packing in unstable pelvic ring injuries, has lowered the
institutional mortality at our level one trauma centre by 30%
[12]. A central component of the success of preperitoneal pack-
ing is that the pelvic external fixator helps reduce the pelvic
volume and has synergistic hemostatic effects with the
preperitoneal pelvic packs in a confined and stable space.
While our institution has a long history of advocating for
the combination of pelvic external fixation and pelvic pack-
ing, looking at the type of pelvic external fixation placed has
been less well studied. Additionally, comparing these two
application techniques in the context of injury classification
has not been reported in the literature. Stewart et al. conducted
a meta-analysis and compared these two approaches, SA and
IC pins, and found that IC pins are more likely to be
malpositioned than SA pins [13]. The meta-analysis also
showed that SA pins had a biomechanical advantage in ensur-
ing stability of the pelvis and were able to “withstand higher
forces.” Another important benefit to the SA pins is that in
those which fail, they slowly back out of the bone with min-
imal risk to surrounding structures, in comparison to IC pins
which more typically move acutely with the potential risk of
penetrating the pelvic cavity. Alipour et al. directly compared
the two techniques and found significantly fewer overall
International Orthopaedics (SICOT)
complications and lower pin tract infection rates in the SA
group when directly compared to the IC group [14]. Grannis
et al. reported several additional benefits to SA pins over IC
pins including “better access to abdomen for future surgery,
less irritating to soft tissues, less likely to compromise further
surgical incisions” [15].
The limitations in this study include potential for measure-
ments obtained from imaging to have significant variability
depending on the evaluator(s). This was reduced by limiting
this process to one individual who followed a specific de-
scribed and agreed upon protocol for recording different mea-
surements. An additional limitation was the sample size of
patients who died as a result of their injuries.
Historically in orthopaedic trauma, IC pins had been the
standard for pelvic external fixators. Recently, however, there
is a growing body of literature showing significant advantages
to the use of SA pins [13–15]. Although there is no current
consensus or general recommendations for external fixation
techniques, this study found that SA pins were overall supe-
rior in terms of accurate pin positioning as well as overall
stabilization of the true pelvis circumference for unstable pel-
vic fractures. The goal for pelvic ring stabilization is depen-
dent on fracture classification, and SA pins were found to be
superior over IC pins in both APC and LC type injuries for
their respective stabilization goals. Additionally, by using SA
pins, there was no difference in operative time, showing min-
imal downsides to this technique. Future studies should look
at long-term complications of each pin technique, the biome-
chanics of each external fixator in stress views of the pelvis,
varying orthopaedic surgeon comfort with each technique, as
well as prevalence of each technique in residency training. If
going forward, the recommendations steer towards SA exter-
nal fixator placement; it would be prudent to ensure that all
orthopedic surgeons taking trauma call feel comfortable with
SA pin placement for external fixation.
Author’s contributions All authors contributed to the study conception
and design, material preparation, data collection, and analysis. All authors
commented on previous versions of the manuscript. All authors read and
approved the final manuscript.
Availability of data and material All data and materials comply with
current standards.
Code availability Not applicable.
Declarations
Ethics approval This retrospective chart review study involving human
participants was in accordance with the ethical standards of the institu-
tional and national research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
The Human Investigation Committee (IRB) of Denver Health and
University of Colorado, Denver Institutional Board Review approved this
study.
International Orthopaedics (SICOT)
Consent to participate Not applicable.
Consent for publication Not applicable.
Conflict of interest Financial interests—Cyril Mauffrey has the follow-
ing disclosures: Springer, publishing royalties and financial or material
support, and Zimmer, research support. Joshua Parry has the following
disclosures: Depuy Synthes, paid consultant. None of the other authors
have financial interests to disclose.
Non-financial interests—Cyril Mauffrey has the following disclo-
sures: Springer, editorial or governing board; DePuy, A Johnson &
Johnson Company, Honorarium for educational courses; International
Orthopaedics, editorial or governing board; and The European Journal
of Orthopaedic Surgery and Traumatology, editorial or governing board.
Joshua Parry has the following disclosure: The European Journal of
Orthopaedic Surgery and Traumatology, editorial or governing board.
Clay Burlew has the following disclosures: JTrauma, editorial or
governing board, and TSACO, editorial or governing board. None of
the other authors have non-financial interests to disclose.
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