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Todays Role of External Fixation with Pelvic
Fractures
ESTES - EFORT
VIENNA, June 2009
Vilmos Vécsei, Vienna, Austria
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1.) Colostomy, retroperitoneal packing
2.) F.E.
3.) Revision, Reconstruction
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4.) Removal of F.E. after 12w.
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Pelvic Ring Injuries at the University Clinic for
Trauma Surgery Vienna Between 1995-2000 236
Pelvic ring injuries Death on
admission 26 ( 11 ) Polytrauma 156 (
66) Associated pelvic organ injuries 18 (
7,6)
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The main bleeding sources in the pelvic region
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RECONSTRUCTION COMPRESSION
ANGIOGRAPHY RECONSTRUCTION EMBOLIZATION COMPRESSIO
N
The main bleeding sources in the pelvic region
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Is the use of external fixation on the pelvis
today rectified?

• YES
• ACUTE Reduction of volume, Control of
  haemmorhage Stabilization of pelvic floor
• TREATMENT of FX. B-Type, Rotational
  unstable, Hybrid structure advantageous,
  Care and mobilization easier

• NO
• Acute simpler methods avialable
• Complicated
• Reduction unsatisfying
• Bulky, uncomfortable
• Pin-tract infections frequent
• Results not predictable
• Careintensive

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Packing and stabilization
Acute life saving measure
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18 / 64
10 / 36
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Data from 28 cases (01/1993 12/2008)
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Indications for F.E.
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Further indications according to the literature
1982 - 1994

• Provisoric stabilization
• Multifragmentary fx. (both) os pubis
• Open book injury
• Lateral compression
• Unstable fx. Child
• Soft tissue defect
• Decollment

• Comminuted fx. Pelvis
• Def. Stabilization of the anterior ring
• Concommitant injury Abdomen
• Injuries with high risk of local infections
  (i.e. Impalement)

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Rupture of the urinary bladder
Frequency10 - 25
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Pins and bar above the anterior iliac crest
Pin implatation
Key points
Bar configuration
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How to avoid posterior and caudal distraction?
Posterior compression
Effect limited!
Anterior compression
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Pins in iliac crest and supraacetabular bar
combined
Goal To improve stability in general
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Male, 25y. Polytrauma
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Result 8 months after injury
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Pins supraacetbular bar complex
Complex - open pin insertion idicated!
Goal Distraction and
compression where ever needed!
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Direct supraacetabular pin insertion simple,
offers more stability and free access to the
abdomen.
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Data from 28 cases (01/1993 12/2008)
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Comminuted fx. 1978
Osteotomy 2001
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Data from 28 cases (01/1993 12/2008)
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Unsolved problems with ex. fix.

• Mechanically weak performance
• Complex problems complex solutions
• Does not fit all expectations
• Secundary displacement can be expected X-ray
  controls !
• Complementary combined (hybrid) ORIF F.E.
  (highest degree of stability) When, why?

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Data from 28 cases (01/1993 12/2008)
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PROTOCOL FOR EMERGENCY TREATMENT OF COMPLEX
PELVIC FRACTURES
PELVIC TRAUMA
Time after admission 0-5 minutes
External mass bleeding, Crash trauma
Immediate emergency operation
Yes
Laparotomy, Haemostasis, Stabilization pelvic ring
General resucitation (airway,circulation)
Basic investigations (Radiograph chest, pelvis,
Sonography abdomen)
No
Further investigations, Polytrauma managment
Pelvic ring unstable Circulation unstable
Tscherne H. et al. Eur J Surg 2000 276 - 282
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PROTOCOL FOR EMERGENCY TREATMENT OF COMPLEX
PELVIC FRACTURES
Further investigations, Polytrauma managment
PELVIC TRAUMA
Pelvic ring unstable Ciculation unstable
Time after admission 10-15 minutes
Yes
Pelvic C clamp Mass tranfusion
Further investigations, Polytrauma managment
Circulation stabilized
Tscherne H. et al. Eur J Surg 2000 276 - 282
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PROTOCOL FOR EMERGENCY TREATMENT OF COMPLEX
PELVIC FRACTURES
PELVIC TRAUMA
Time after admission 20-30minutes
Surgical haemostasis Exploration Tamponade
Pelvic stabilization
ICU
Circulation stabilized
Angiography Embolization
Tscherne H. et al. Eur J Surg 2000 276 - 282
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Data from 28 cases (01/1993 12/2008)
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Multiple injured 85 (n28)
Results satisfying 85 (n20) Mortality
28,6 (n28) Complications 20 (n20)

Data from 28 cases (01/1993 12/2008)
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Data from 28 cases (01/1993 12/2008)
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Data from 28 cases (01/1993 12/2008)
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Data from 28 cases (01/1993 12/2008)
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CONCLUSIONS

• External fixator is within the frame of acute
  measures one important usefull tool
• It is unsuitable to reduce and keep vertically
  unstable pelvic fx.s for healing time
• Treatment and implantation technique has as a
  prerequisit a skilled and experienced surgeon.

• An either or nor policy in connection with F.E.
  would exclude something advantageous
• How far irregularities of reduction and retention
  can be accepted remain topic of discussion
• ExFix plays an important role furtherhin in the
  pelvis in present and future as well!

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Take care!
Thank you for listening!