Beruflich Dokumente
Kultur Dokumente
DOI 10.1007/s00068-012-0225-7
ORIGINAL ARTICLE
Received: 2 May 2012 / Accepted: 27 August 2012 / Published online: 25 September 2012
Springer-Verlag 2012
Abstract
Purpose Spinopelvic dissociation is a rare high-energy
injury pattern in adults associated with high morbidity and
an increased rate of neurological deficits. The purpose of
this article is the conception of fracture type-associated
treatment recommendations.
Methods This article is based on our own experience with
spinopelvic dissociations and a review of the current
literature.
Results Bilateral vertical plus an optional transverse
fracture component configures spinopelvic dissociations as
U- or H-shaped, with the result of a spinopelvic dissociation. Y-, T- or II-shaped fractures do not
necessarily belong to this entity but can be subsumed to
this entity in a wider sense. The surgical treatment of these
injuries remains challenging. Initial haemodynamic stabilisation represents the main goal of primary care until
definitive treatment can be performed. Anatomical reduction is demanding and even more complex in fracture areas
with large comminution. Surgical treatment options depend
on the fracture type, including transsacral screws, sacral
Pelvic trauma
Introduction
Less than 10 % of sacral fractures occur solely, as they are
combined injury patterns with other fractures of the pelvic
ring. Spinopelvic dissociations are usually associated with
high-energy trauma in adults. They are also observed in
elderly patients with osteoporotic bone after low-energy
traumas. Due to its anatomical localisation and configuration, the sacrum encounters two major forces of opposite
direction [1]. The vertical stress causes a bilateral intraforaminal fracture, resulting in an instability, which, in turn,
provokes the sacrum to pivot out of the posterior pelvic
ring. This creates a horizontal fracture, normally in the S1
to S2 junction, known as a weak area in the bony structure
of the sacrum causing the spinopelvic dissociation. They
represent a heterotopic entity of different soft tissue and
bony injuries [2]. Therefore, the term traumatic spinopelvic dissociation was proposed by Bents et al. [3] to
differentiate this entity from lumbosacral fracture dislocations or bilateral sacroiliac joint dislocations. However,
fully bilateral transforaminal fractures might also be added
to that entity of spinopelvic dissociations, as they lack a
bony connection to the pelvis. Additionally, the sacrotuberous and the sacrospinous ligaments might be torn.
123
518
Discussion
Classification system
The most simple classification for sacrum fractures was
developed by Denis et al. [4], which categorised fractures
into three types based on the anatomical relationship to the
sacral neural foramina. The vertical fracture line in spinopelvic dissociations occurs mostly in zone 2 according to
the Denis classification. Based on biomechanical considerations, Roy-Camille et al. [1] introduced the first classification for these fractures (Fig. 1). They distinguished
three different types of fractures: type 1 as a flexion fracture
W. Lehmann et al.
Fig. 1 Schematic representation of the spinopelvic dissociation forms described by Roy Camille et al. [1] and extended by Strange-Vognsen and
Lebech [5]
123
essential, other forms that are also attributed spinopelvic dissociations can be sufficiently addressed with alternative osteosyntheses
518
Discussion
Classification system
The most simple classification for sacrum fractures was
developed by Denis et al. [4], which categorised fractures
into three types based on the anatomical relationship to the
sacral neural foramina. The vertical fracture line in spinopelvic dissociations occurs mostly in zone 2 according to
the Denis classification. Based on biomechanical considerations, Roy-Camille et al. [1] introduced the first classification for these fractures (Fig. 1). They distinguished
three different types of fractures: type 1 as a flexion fracture
W. Lehmann et al.
Fig. 1 Schematic representation of the spinopelvic dissociation forms described by Roy Camille et al. [1] and extended by Strange-Vognsen and
Lebech [5]
123
essential, other forms that are also attributed spinopelvic dissociations can be sufficiently addressed with alternative osteosyntheses
519
(Table 1). As spinopelvic dissociations are usually combined with other life-threatening injuries, the majority of
patients are sedated or intubated on hospital admission,
allowing no neurological status examination. Therefore,
the neurological status often remains unknown in the phase
of definitive treatment. However, if radiological imaging
reveals obliteration of the spinal canal or neural foramina,
timely intervention and decompression are mandatory.
Recent studies have shown that early fixation within
24 h is particularly important, because it reduces morbidity
and length of intensive care unit stay [24]. The definition
of the length of time of that early period has changed
within the last several years. While the damage control
orthopaedics principle should still be applied, we do not
continue to insist on a 3- to 4-day time period between
early care and definitive treatment, as earlier studies recommended [25].
Basically, we can distinguish between open and minimally invasive procedures. Reviewing the literature,
standard procedures are vertebropelvic fixation techniques
[16, 17, 19]: a dorsal tension band plate combined with
iliosacral screws and the distraction spondylodesis with or
without additional sacroiliacal screw, so called triangular
osteosynthesis. This technique of vertebropelvic fixation
was primarily described in 1994 by the groups of Kach
and Trentz (5 cases) and Josten et al. (8 cases) [26, 27].
Schildhauer et al. [19, 28, 29] reported excellent clinical
and biomechanical results. Compared to unlocked plating
of sacrum fractures, locked plating did not show relevant
advantages [3032]. In regards to minimally invasive
methods, iliosacral screw fixation can be performed as
percutaneous osteosynthesis, and either one or two screws
can be inserted unilaterally or bilaterally (Fig. 3). Furthermore, the technique of vertebropelvic fixation can be
carried out in a less invasive method, described as less
invasive lumbopelvic stabilisation (LILS) by Keel et al.
[33]. Sabourin et al. [23] reported a shortening osteotomy
and sacro-sacral plating in limited access surgery [2]. The
problems with the minimally invasive procedures are the
limited possibility for reduction and the impossibility of
decompressing neuronal structures. Konig et al. [34]
recently published a series of three patients in whom the
sacral fractures were reduced and fixed percutaneously
with iliosacral screws. In our experience, the use of isolated screws is indicated in cases of severe soft tissue
injury, which does not allow a standard open surgical
procedure. However, severely displaced fractures should
generally be treated by open reduction so as to allow
anatomical reduction. Based on current knowledge, triangular osteosynthesis seems to be the safest method [28].
Anatomical reduction and fixation of sacral fractures can
be challenging, especially when facing a large comminution zone.
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520
W. Lehmann et al.
Fig. 3 ac Computed
tomography (CT) scan of a type
II fracture. d Post-operative
AP view. Due to the severe soft
tissue trauma on the back, the
stabilisation on the dorsal side
was done minimally invasively
with percutaneous screws and
small incisions for the
reduction. e, f Digital
subtraction angiography
showing the bleeding out of the
arteria obturatoria (red arrow)
before and after coiling of the
vessel, respectively
Surgical techniques
Reviewing the biomechanical datasets, triangular stabilisation seems to be the most stable method of fixation.
In the early phase of treatment, closed reduction in the
prone position with hyperextension of the hip joint and
applied extension is worth a try [35]. Yet, the goal is an
123
MoI mechanism of injury, CS clinical series, RCS retrospective clinical study, CR case report, SA suicide attempt, F fall, CI crush injury, RTA road traffic accident, GS gun shot, N/A not
available, AB abnormal, N/M not mentioned, N normal, ND neurological deficit, IS iliosacral screws, SB sacral banding, TF triangular fixation, SPF spinopelvic fixation
SPF
SPF
AB (1)
N/M (1)
AB (1)
AB (1)
N/M
21
U-shape
U-shape
X-Ray
CT
CI (1)
RTA (1)
CR (1)
Rhee et al. [14]
26
CR (1)
Vilela et al. [16]
23
TF (3)
N/M
N(2), AB (2)
N (2)
N (2), AB (2)
AB (2)
AB (3)
9
N/M
3
U-shape
U-shape
U-shape
CT
X-ray
X-ray
SA (3), RTA (1)
AF (1), CI (1)
SA (2), CI (1)
CS (4)
CR (2)
Hunt et al. [17]
Hussin et al. [15]
30
18
CS (3)
Mouhsine et al. [18]
31
SPF (19)
N (10), ND (8),
1 lost FU
AB (19)
N/M
N/M
X-ray
F (10), RTA (7),
CI (2)
RCS (19)
Schildhauer et al. [19]
34
IS (13)
N (2), ND (11)
N (2), AB (9),
N/A (2)
4
U-shape
U-shape
X-ray
X-ray
SA (3), F(4),
RTA (6)
SA (7), F (1)
29
RCS (8)
RCS (13)
Nork et al. [20]
31
521
IS (3)
N (1), ND (2)
AB (2), N/A (1)
6
U-shape
CT
AF (1), RTA (1),
SA (1)
CS (3)
Konig et al. [2]
22
MoI (no.
of cases)
Mean age
(years)
Study type
(no. of cases)
Authors, references
Primary
diagnostic
imaging
Fracture
type
Mean time to
surgery (days)
Neurostatus
pre-op.
Neurostatus
post-op.
Type of surgery
123
522
W. Lehmann et al.
123
Summary
Spinopelvic dissociations are rare injuries commonly
associated with high-energy trauma in adults. They are also
described in elderly patients after low-energy trauma. The
most common method to address these injuries is spinopelvic fixation. The biomechanical data suggest that
spinopelvic stabilisation combined with iliosacral screw
placement, defined as triangular osteosynthesis, provides
the most fixation stability. However, spinopelvic injuries
are a heterogenic entity requiring fracture-defined fixation
523
methods. U- and H-type fracture configurations represent the most unstable forms of spinopelvic dissociations
and commonly require triangular fixation. II-, Y- and
T-type fractures usually provide more intrinsic fracture
stability and might be addressed by transsacral screws only.
In summary, these patients do not have a good prognosis
and suffer long-term physical and neurological impairment.
Conflict of interest
None.
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