Review Question - QID 219165

This patient sustained a Young and Burgess anterior-posterior compression (APC) II injury. Even with the anatomic restoration of the pelvic ring, long-term outcomes are below population norms primarily due to chronic pain and sexual dysfunction (erectile dysfunction in men and dyspareunia in women).

Pelvic ring injuries can occur in the setting of high-energy trauma in young patients or low-energy, ground-level falls in the elderly. The Young and Burgess classification (Illustration A) characterizes these injuries based on the force vectors placed on the pelvis at the time of injury and the resultant predictable fracture patterns. In general, many high-energy pelvic ring fractures that require operative fixation result in diminished patient-reported outcomes due to chronic pain. However, APC injuries are specifically notorious for the risk of sexual dysfunction due to the anterior pelvic diastasis traction injury on the pudendal nerve. Some studies report sexual dysfunction in up to 90% of males and dyspareunia in 60% of females. Initial symphysis diastasis, associated bladder disruption, the need for plate fixation of the symphysis, and final symphysis alignment >5mm from anatomic reduction are all associated with dyspareunia in females. Further, the rate of subsequent C-sections is higher in this patient cohort, although this has been attributed to patient and obstetrician preference.

Wojahn and Gardner provided a comprehensive review article regarding fixation principles and strategies involving the anterior pelvic ring. The authors discuss that open reduction and plating is the preferred operative technique for injuries involving symphyseal diastasis because it allows for anatomic reduction, improved stability, carries low morbidity, and rarely requires implant removal. They note that external fixation remains viable for patients with open perineal wounds, urologic/rectal injuries, suprapubic catheters, or any other injuries where internal implants would be at increased risk for infection. The authors conclude that appropriate posterior fixation remains critical, regardless of the fixation strategy employed for the anterior pelvic ring.

Langford and colleagues present an updated review article regarding the indications and techniques for the definitive surgical management of pelvic ring injuries. They discuss that contemporary management employs primarily percutaneous reduction and fixation in the supine position. The authors further discuss various operative techniques and review relevant intraoperative fluoroscopic imaging. They conclude that even with anatomic restoration of the pelvis, long-term outcomes are below population norms primarily due to chronic pain and sexual dysfunction.

Metze and colleagues performed a retrospective review of 77 male patients who sustained a pelvic ring injury at their institution and the risk for associated sexual dysfunction. 61% of patients reported some form of limitation in sexual function with persistent, long-term erectile dysfunction in 1/5 of all patients. The authors noted patients with pubic diastasis, distraction injuries, and concomitant posterior pelvic ring injuries are at an increased risk for and severity of sexual dysfunction. The authors conclude that these complications are important to detect early on, as some potential urologic treatment options are time sensitive with earlier intervention resulting in better outcomes.

Figure A demonstrates a Young and Burgess APC II injury on plain AP pelvic radiographs. A subsequent CT scan confirmed bilateral anterior sacroiliac (SI) joint diastasis. Figure B demonstrates intraoperative fluoroscopic imaging after anterior symphyseal plating and bilateral posterior percutaneous SI screw fixation. Illustration A is a depiction of the Young and Burgess classification reported in the Langford article.

Incorrect Answers:
Answer 2 & 3: Anterior pelvis instability would be appreciably avoided with symphyseal plating. Anterior symphyseal plating hardware failure is commonly reported if there is any unaddressed posterior pelvic injury (i.e. anterior SI joint widening without posterior fixation). However, even in the setting of symphyseal plating hardware failure, the residual instability is rarely symptomatic. Further, failed symphyseal plating hardware is seldom symptomatic requiring removal.
Answer 4: The L5 nerve roots lie directly anterior to the sacral ala, placing them at risk during percutaneous screw fixation of the SI joints. However, injury to the L5 nerve roots would result in the loss of hallux dorsiflexion, not ankle plantar flexion weakness.
Answer 5: Thigh adduction weakness could be seen if the obturator nerve is injured from drill bit/screw penetration through the obturator foramen during symphyseal plating. However, this is an infrequent complication often avoided by appropriate ORIF techniques (i.e. avoidance of plunging and excessive screw lengths).