LONG-TERM FUNCTIONAL PROGNOSIS OF POSTERIOR INJURIES IN HIGH-ENERGY PELVIC DISRUPTION

Objective: This study sought to identify the long-term functional resu lts of various posterior pelvic lesions and to determine whether such injuries benefit from exact reduction. Design: Consecutive cohort of p atients admitted for pelvic disruption between 1980 and 1990, Setting: University hospital. Patients: Eighty-eight pelvic fractures in eight y-eight patients were classified according to the instability and anat omy of the posterior injury. Simple fractures of the pubic rami, minim ally displaced fractures with pubic diastasis of less than 2.5 centime ters, and fractures without other pelvic lesions (type B1 lesions, sta ge 1 in the Tile classification) were all excluded. Patients with sequ elae of associated lesions that could render functional evaluation dif ficult were also excluded. Interventions: The initial status of the pa tient and the type of fracture determined the treatment. In the antero posterior compression injuries group, an external fixator using the do uble-frame Hoffmann device was applied in twenty-eight cases to reduce a large external horizontal displacement, either immediately to contr ol bleeding or later as definitive treatment when anterior internal fi xation was not possible. Anterior internal fixation with a plate was u sed six times to repair a symphyseal disruption. In vertical shear inj uries, tibial skeletal traction was used for six weeks as an attempt t o stabilize vertical instability. In ten patients, traction alone was used. In other cases, traction was used in conjunction with an externa l fixator or internal pubic fixation, In impacted lateral compression injuries, simple bed rest for six weeks was used in cases of stable le sions. Skeletal traction was applied in ten patients of this group bec ause of a potential vertical instability, particularly in cases with a comminuted sacral lesion. Main Outcome Measures: Anatomic diagnosis a nd evaluation of the reduction were made using anteroposterior, inlet, and outlet radiographs of the pelvic ring, To assess reduction, verti cal, anteroposterior, and rotatory displacement was measured. Function al results were qualified based on the injury pattern and the quality of the final reduction and were then quantified according to the gradi ng proposed by Majeed. Results: Functional results varied according to injury anatomy, with fractures of the iliac wing and sacroiliac (SI) fracture-dislocations having the best prognosis, The quality of reduct ion did not affect the functional results. Conservative methods such a s skeletal traction and external fixation generally gave satisfactory functional results. Conversely, however, pure SI lesions were associat ed with poor functional results, especially if reduction was not exact .Conclusions: This study shows that when the posterior injury is a fra cture of the iliac wing or a mixed fracture with SI propagation, a lon g-term satisfactory functional result can be obtained without an exact reduction even in cases of vertical instability. Simple methods are u sually sufficient, and it seems unnecessary to propose more aggressive treatment. It is important, however, to recognize that SI fracture-di slocations (17 percent in this series) seem to be quite different from pure SI disruptions in terms of persistent pain, Moreover, it appears that exact reduction of pure SI lesions is critical for good function al results, something that is difficult to obtain with conservative pr ocedures. Sacral fractures represent a special problem for the surgeon because of the frequency of fair results in which neurologic lesions whose pathophysiology is poorly known seem to be responsible.