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Posterior Surgical Approach for Pelvic Frx

- See: Kocher Langenbock for Acetabular Frx

- Discussion:
    - position pt prone, on a radiolucent table;
    - vertical incision placed 2 cm lateral to posterosuperior spine;
    - mobilize gluteal muscles from their origins on iliac wing & sacrum;
    - mobilize piriformis from greater sciatic notch to allow palpation can be performed anteriorly along sacrum and sacroiliac joint;
         - reflect posterior portion of gluteus from posterior iliac wing;
         - maximus origin is also reflected from sacrum;
    - greater sciatic notch must be exposed for assessment of the reduction;
    - w/ sacral frx, frx is visualized on posterior sacral lamina;
    - place pointed reduction forceps from sacrum to iliac wing for reduction;
    - palpation thru greater sciatic notch as well as visualization of the most inferior portion of the SI joint give keys to reduction;
    - flouroscopy is needed used to place screws perpendicular to iliac wing across the SI joint into the sacral ala;
         - screws are directed toward the S1 vertebral body;
    - complications of posterior approach:
         - posterior incisions in acute trauma situation have resulted in unacceptably high rate of skin necrosis;
         - even w/o posterior incisions, there may be skin breakdown in many pts w/ severe unstable vertical shear injuries;
         - at surgery, gluteus maximus muscle is often torn from its insertion leaving no underlying fascia to nourish skin