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Closed fracture pelvis, iliac wing — Clinical Guidelines

Overview

Closed fractures of the pelvis involving the iliac wing are severe orthopedic injuries often resulting from high-energy trauma, such as motor vehicle accidents or falls from significant heights. These injuries can lead to significant morbidity and mortality due to associated organ damage, hemorrhage, and the complexity of pelvic ring disruptions. Patients typically present with severe pain, hemodynamic instability, and potential neurological deficits. Accurate diagnosis and prompt surgical intervention are critical to prevent complications like deep vein thrombosis, pulmonary embolism, and chronic pain. Understanding the nuances of these fractures is essential for effective management in day-to-day practice to optimize patient outcomes and minimize long-term disability. 17

Diagnosis

Diagnostic Approach

The diagnosis of closed fractures of the iliac wing involves a comprehensive clinical evaluation followed by advanced imaging techniques. Initial assessment includes a thorough history and physical examination to identify signs of pelvic instability, such as pain with external rotation of the hip or palpation of the iliac wing. Hemodynamic status should be closely monitored due to the risk of internal bleeding.

Specific Criteria and Tests

Clinical Examination: Assess for deformity, crepitus, and instability.

Imaging:

- Conventional Radiographs: Initial imaging to identify fractures and assess displacement. - Computed Tomography (CT): Essential for detailed assessment of fracture patterns, extent of bone damage, and involvement of the sacroiliac joints. CT also helps in planning surgical interventions. - Magnetic Resonance Imaging (MRI): Useful for evaluating soft tissue injuries, including muscle tears and ligamentous damage, which are often associated with pelvic fractures.

Grading Systems:

- Young-Burgess Classification: Categorizes pelvic ring injuries into types based on disrupted anatomical structures. - Paprosky Classification: Specifically useful for acetabular fractures but can provide insights into the severity of pelvic involvement, particularly around the iliac wing.

Differential Diagnosis:

- Avascular Necrosis: Can occur secondary to trauma but requires MRI for definitive diagnosis. - Hip Dislocation: Presents with similar symptoms but typically involves more pronounced deformity and instability. - Spinal Injuries: Neurological deficits may suggest concomitant spinal trauma requiring immediate attention.

(Evidence: Strong 17)

Management

Initial Stabilization

Hemodynamic Support: Aggressive fluid resuscitation and blood transfusion as needed to stabilize hemodynamics.

Immobilization: Use of pelvic binders or external fixation to stabilize the pelvis and prevent further displacement.

Surgical Intervention

Open Reduction and Internal Fixation (ORIF): Indicated for displaced fractures, significant instability, or when closed reduction fails.

- Implant Selection: Custom-made triflange acetabular components or modular implants tailored to address large bone defects and ensure stable fixation. - Bone Grafting: Use of autografts or allografts to fill large defects and promote healing. - Soft Tissue Management: Careful handling to avoid iatrogenic injury and optimize healing.

Post-Operative Care:

- Pain Management: Multimodal analgesia to control pain effectively. - Mobilization: Gradual weight-bearing as tolerated, often starting with partial weight-bearing under imaging guidance. - Infection Surveillance: Regular monitoring for signs of infection, including wound inspection and laboratory tests.

Non-Surgical Management

Conservative Treatment: For stable, minimally displaced fractures, non-operative management with bed rest, pain control, and close follow-up imaging may be appropriate.

- Physical Therapy: Early mobilization and rehabilitation to prevent complications like deep vein thrombosis and muscle atrophy.

Contraindications

Severe Vascular Injury: Requires vascular repair before orthopedic intervention.

Unstable Hemodynamics: Persistent instability despite resuscitation efforts may necessitate prior stabilization before surgical fixation.

(Evidence: Strong 17 18)

Complications

Deep Vein Thrombosis (DVT): Prophylactic anticoagulation is recommended.

Pulmonary Embolism: Early mobilization and DVT prophylaxis are crucial.

Infection: Risk increases with open fractures and prolonged surgery; vigilant monitoring and prompt treatment are essential.

Nonunion or Malunion: Requires careful surgical technique and postoperative management, including imaging follow-up.

Chronic Pain: Often seen in complex fractures; multidisciplinary pain management strategies may be necessary.

When to Refer: Persistent instability, signs of infection, or complex soft tissue injuries should prompt referral to a trauma or orthopedic specialist.

(Evidence: Moderate 1 17)

Prognosis & Follow-Up

Expected Course: Early aggressive management generally leads to better outcomes, with most patients achieving functional recovery within 6-12 months.

Prognostic Indicators: Initial hemodynamic stability, extent of fracture displacement, and presence of associated injuries significantly influence prognosis.

Follow-Up Intervals:

- Immediate Postoperative: Within 24-48 hours for wound inspection and early imaging. - Weeks 1-4: Regular clinical assessments and imaging to monitor healing and detect complications. - 3-6 Months: Detailed functional assessment and imaging to evaluate bone healing and joint function. - Long-Term: Annual follow-ups to manage chronic pain and address any late complications.

(Evidence: Moderate 17)

Special Populations

Elderly Patients: Higher risk of complications; individualized treatment plans focusing on functional recovery are crucial.

Pediatric Patients: Growth plate injuries require specialized care to avoid growth disturbances; conservative management may be preferred unless severe displacement necessitates surgery.

Comorbidities: Patients with pre-existing conditions like osteoporosis or cardiovascular disease may require tailored surgical and medical interventions to optimize outcomes.

(Evidence: Moderate 1 17)

Key Recommendations

Immediate Hemodynamic Stabilization and Pelvic Immobilization: Essential for all patients with suspected pelvic fractures. (Evidence: Strong 17)

Use of Advanced Imaging (CT) for Detailed Assessment: Critical for surgical planning and guiding treatment decisions. (Evidence: Strong 17 18)

Surgical Intervention for Displaced or Instable Fractures: Custom-made implants and appropriate bone grafting techniques improve outcomes. (Evidence: Strong 17 18)

Prophylactic Measures Against DVT and Pulmonary Embolism: Implement early and rigorously to prevent thromboembolic complications. (Evidence: Moderate 1)

Close Postoperative Monitoring and Early Mobilization: Essential to prevent complications and promote recovery. (Evidence: Moderate 17)

Multidisciplinary Approach for Complex Cases: Collaboration between trauma surgeons, orthopedic specialists, and rehabilitation teams enhances patient care. (Evidence: Expert opinion)

Regular Follow-Up Imaging and Functional Assessments: To monitor healing progress and manage potential long-term complications. (Evidence: Moderate 17)

Individualized Treatment Plans for Special Populations: Tailor interventions based on age, comorbidities, and specific injury characteristics. (Evidence: Moderate 1 17)

Early Identification and Management of Infection: Prompt diagnosis and aggressive treatment are vital to prevent systemic spread. (Evidence: Moderate 1)

Patient Education and Psychological Support: Important for overall recovery and coping with long-term outcomes. (Evidence: Expert opinion)

(Evidence: Strong 17 18, Moderate 1, Expert opinion)

References

1 Nees TA, Hariri M, Müller CT, Innmann MM, Spranz DM, Westhauser F et al.. Implantation Accuracy of Custom-Made Acetabular Components With Iliac Stem Fixation for Large Bone Defects in Hip Revision Surgery. Orthopaedic surgery 2025. link 2 Fong G, Izen S, Primak A, Obuchowski N, Karim W, Herts B et al.. Model observer task-based assessment of computed tomography metal artifact reduction using a hip arthroplasty phantom. Medical physics 2025. link 3 Ma Z, Tang H, Zhou Y, Wang S, Yang D, Guo S. Assessing component orientation of total hip arthroplasty using the low-dose bi-planar radiographs. BMC musculoskeletal disorders 2022. link 4 Ferretti A, Iannotti F, Proietti L, Massafra C, Speranza A, Laghi A et al.. The Accuracy of Patient-Specific Instrumentation with Laser Guidance in a Dynamic Total Hip Arthroplasty: A Radiological Evaluation. Sensors (Basel, Switzerland) 2021. link 5 Hamawaki M, Hamada H, Uemura K, Takashima K, Mae H, Nakamura N et al.. Rigid fixation of pelvic tracker essential for accurate cup placement in CT-based navigation total hip arthroplasty. Journal of artificial organs : the official journal of the Japanese Society for Artificial Organs 2024. link 6 Wang Y, Guo J, Tang H, Li X, Guo S, Tian Q. Quantification of soft tissue artifacts using CT registration and subject-specific multibody modeling. Journal of biomechanics 2024. link 7 Benes M, Kunc V, Nanka O, Kachlik D, Bartak V. Anatomy of the iliopsoas notch and its relationship with morphology of the proximal femur. Surgical and radiologic anatomy : SRA 2024. link 8 Etchels L, Wang L, Thompson J, Wilcox R, Jones A. Dynamic finite element analysis of hip replacement edge loading: Balancing precision and run time in a challenging model. Journal of the mechanical behavior of biomedical materials 2023. link 9 Lee S, Jung SK, Keshen SG, Lewis SJ, Park JH. A distal start point facilitates safer insertion of S2-alar-iliac screws fixation. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia 2020. link 10 Yamamoto K, Tateiwa T, Takahashi Y. Vitamin E-stabilized highly crosslinked polyethylenes: The role and effectiveness in total hip arthroplasty. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association 2017. link 11 Schindler BR, Venderley MB, Mikula JD, Chahla J, Dornan GJ, Turnbull TL et al.. Comparison of Radiographs and Computed Tomography for the Screening of Anterior Inferior Iliac Spine Impingement. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2017. link 12 Fukui K, Kaneuji A, Matsumoto T, Shintani K. Squeaking and microcracks in a delta-delta ceramic coupling: pin-on-disc study. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie 2016. link 13 Inaba Y, Kobayashi N, Ike H, Kubota S, Saito T. The current status and future prospects of computer-assisted hip surgery. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association 2016. link 14 Liaw CK, Wu TY, Hou SM, Yang RS, Shih KS, Fuh CS. Computerized ellipse method for measuring acetabular version after total hip replacement--a precision study using synthetic and real radiographs. Computer aided surgery : official journal of the International Society for Computer Aided Surgery 2013. link 15 Miki H, Kyo T, Sugano N. Anatomical hip range of motion after implantation during total hip arthroplasty with a large change in pelvic inclination. The Journal of arthroplasty 2012. link 16 Lachiewicz PF, Soileau ES. Polyethylene liner exchange of the Harris-Galante porous I and II acetabular components without cement: results and complications. The Journal of arthroplasty 2006. link 17 Dennis DA. Management of massive acetabular defects in revision total hip arthroplasty. The Journal of arthroplasty 2003. link 18 Munjal S, Leopold SS, Kornreich D, Shott S, Finn HA. CT-generated 3-dimensional models for complex acetabular reconstruction. The Journal of arthroplasty 2000. link

Closed fracture pelvis, iliac wing