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Sacroiliac Fracture – Dislocations

- See:
       - Posterior Pelvic Injuries 
       - Sacral Fractures
       - cresent fracture: (iliac fracture) 

- Fixation Techniques:
    - SI joint dislocation: posterior screw fixation:
          - Kellum et al 1987, unstable SI joint dislocations can produce long term pain in 60% that are treated non operatively 
                 - associated leg length descrepancies only worse the symptoms;

    - anterior fixation of SI joint dislocation:
          - A Quantitative Exposure Planning Tool for Surgical Approaches to the Sacroiliac Joint. 

   - bilateral iliolumbar fusion 
          - indicated when there is bilateral unstable posterior pelvic fracture (which precludes wt bearing);
          - How bilateral iliolumbar fusion increases the stability of horizontal osteosynthesis in unstable pelvic ring injuries?

- Older Techniques:
    - transiliac sacral bars:
           - utilizes Harrington rods, w/ compression achieved by tightening of threaded nuts;
           - advantages include technical ease of insertion and limited soft tissue dissection;
           - relative contraindications include iliac wing fractures;
           - cautions: may cause over compression of sacral fractures and it can be difficult to judge adequacy of SI joint reduction;

    - 4.5 mm reconstruction plate: (Albert, et al (1993));
           - indicated for posterior pelvic fractures as well as sacral fractures;
           - reconstruction plate is placed along dorsum of the sacral and thru the posterior iliac spines (transiliac plate fixation);
           - advantages:
                  - low profile, minimal risk to N/V structures, and no need for flouro;
           - patient is placed in the prone position;
           - two incisions are made over the PSIS which are perpendicular to the iliac wings, and one vertical incision is made over the
                  base of the S1 spinous process;
                  - dissections are caarried down to the bony surfaces;
           - predrill the PSIS to assist w/ reconstruction plate insertion;
                  - use the 4.5 drill to make 2-3 drill holes 1 cm lateral to the PSIS;
           - 4.5 mm reconstruction plate is chiseled thru the iliac spine, passed along the dorsum of the sacrum to the opposite PSIS;
           - the recon plate is appropriately contoured;
           - the plate is fixed to the iliac wings using 6.5 mm cancellous screws, w/ two screws inserted into each ilac wing;
           - postop: patients can be bed to chair or touch down wt bearing;
           - ref:
                  - Posterior Pelvic Fixation Using a Transiliac 4.5 mm Reconstruction Plate: a clinical and biomechanical study

- Hazards:
    - wound infection and wound slough:
          - especially common in posterior approaches to the joint when the pelvic frx has occured from crush injuries;
          - carefully note skin abrasions, contussions, and ecchymosis over the PSIS;
          - if the soft tissues are not optimal consider an anterior approach to the SI joint; 
    - malreduction:
          - Removal of an iliosacral screw entrapping the L5 nerve root after failed posterior pelvic ring fixation: a case report.

Internal fixation of pelvic ring fractures.

Stabilization of sacroiliac joint disruption with threaded compression rods.

The crescent fracture: a posterior fracture dislocation of the sacroiliac joint.

The Unstable Pelvic Fracture. Operative Treatment.  

Minimally invasive transiliac plate osteosynthesis for type C injuries of the pelvic ring: a clinical and radiological follow-up.