Pelvic Ring Fractures

Topic updated on 07/31/16 8:43pm
  • Mechanism typically high energy blunt trauma
  • Mortality rate 15-25% for closed fractures, as much as 50% for open fractures
    • hemorrhage is leading cause of death overall  
      • closed head injury is the most common for lateral compression injuries 
    • increased mortality associated with
      • systolic BP <90 on presentation
      • age >60 years
      • increased Injury Severity Score (ISS) or Revised Trauma Score (RTS)
      • need for transfusion > 4 units  
  • Associated injuries
    • chest injury in up to 63%
    • long bone fractures in 50%
    • sexual dysfunction up to 50% 
    • head and abdominal injury in 40%
    • spine fractures in 25%
  • Prognosis
    • high prevalence of poor functional outcome and chronic pain
    • poor outcome associated with
      • SI joint incongruity of > 1 cm
      • high degree initial displacement
      • malunion or residual displacement
      • leg length discrepancy > 2 cm
      • nonunion
      • neurologic injury
      • urethral injury
  • Pediatric pelvic ring fractures
    • children with open triradiate cartilage have different fracture patterns than do children whose triradiate cartilage has closed
      • if triradiate cartilage is open the iliac wing is weaker than the elastic pelvic ligaments, resulting in bone failure before pelvic ring disruption
      • for this reason fractures usually involve the pubic rami and iliac wings and rarely require surgical treatment 
  • Osteology
    • ring structure made up of the sacrum and two innominate bones
    • stability dependent on strong surrounding ligamentous structures
    • displacement can only occur with disruption of the ring in two places
    • neurovascular structures intimately associated with posterior pelvic ligaments 
      • high index of suspicion for injury of internal iliac vessels or lumbosacral plexus 
  • Ligaments  
    • anterior 
      • symphyseal ligaments 
        • resist external rotation
    • pelvic floor 
      • sacrospinous ligaments
        • resist external rotation
      • sacrotuberous ligaments
        •  resist shear and flexion
    • posterior sacroiliac complex (posterior tension band)
      • strongest ligaments in the body
      • more important than anterior structures for pelvic ring stability 
      • anterior sacroiliac ligaments
        • resist external rotation after failure of pelvic floor and anterior structures
      • interosseous sacroiliac 
        • resist anterior-posterior translation of pelvis
      • posterior sacroiliac 
        • resist cephalad-caudad displacement of pelvis
      • iliolumbar
        • resist rotation and augment posterior SI ligaments
Physical Exam
  • Symptoms
    • pain & inability to bear weight
  • Physical exam
    • inspection
      • test stability by placing gentle rotational force on each iliac crest
        • low sensitivity for detecting instability 
        • perform only once 
      • look for abnormal lower extremity positioning
        • external rotation of one or both extremities  
        • limb-length discrepancy
    • skin
      • scrotal, labial or perineal hematoma, swelling or ecchymosis
      • flank hematoma
      • lacerations of perineum
      • degloving injuries (Morel-Lavallee lesion) 
    • neurologic exam 
      • rule out lumbosacral plexus injuries (L5 and S1 are most common)
      • rectal exam to evaluate sphincter tone and perirectal sensation
    • urogenital exam
      • most common finding is gross hematuria
      • more common in males (21% in males, 8% in females)
    • vaginal and rectal examinations
      • mandatory to rule out occult open fracture
  • Radiographs
    • AP Pelvis 
      • part of initial ATLS evaluation
      • look for asymmetry, rotation or displacement of each hemipelvis
      • evidence of anterior ring injury needs further imaging   
    • inlet view  
      • X-ray beam angled ~45 degrees caudad (may be as little as 25 degrees) 
        • adequate image when S1 overlaps S2 body
      • ideal for visualizing: 
        • anterior or posterior translation of the hemipelvis
        • internal or external rotation of the hemipelvis
        • widening of the SI joint
        • sacral ala impaction
    • outlet view  
      • X-ray beam angled ~45 degrees cephalad (may be as much as 60 degrees)
        • adequate image when pubic symphysis overlies S2 body
      • ideal for visualizing:
        • vertical translation of the hemipelvis
        • flexion/extension of the hemipelvis
        • disruption of sacral foramina and location of sacral fractures
    • radiographic signs of instability 
      • > 5 mm displacement of posterior sacroiliac complex
      • presence of posterior sacral fracture gap
      • avulsion fractures (ischial spine, ischial tuberosity, sacrum, transverse process of 5th lumbar vertebrae)
  • CT 
    • routine part of pelvic ring injury evaluation 
    • better characterization of posterior ring injuries
    • helps define comminution and fragment rotation
    • visualize position of fracture lines relative to sacral foramina
Classification & Treatment
  • Tile classification 
    • A: stable
      • A1: fracture not involving the ring (avulsion or iliac wing fracture)
      • A2: stable or minimally displaced fracture of the ring
      • A3: transverse sacral fracture (Denis zone III sacral fracture)
    • B - rotationally unstable, vertically stable
      • B1: open book injury (external rotation)
      • B2: lateral compression injury (internal rotation)
        • B2-1: with anterior ring rotation/displacement through ipsilateral rami
        • B2-2-with anterior ring rotation/displacement through contralateral rami (bucket-handle injury)
      • B3: bilateral
    • C - rotationally and vertically unstable
      • C1: unilateral
        • C1-1: iliac fracture
        • C1-2: sacroiliac fracture-dislocation
        • C1-3: sacral fracture
      • C2: bilateral with one side type B and one side type C
      • C3: bilateral with both sides type C

  • Young-Burgess Classification   
Anterior Posterior Compression (APC)
APC I Symphysis widening < 2.5 cm Non-operative. Protected weight bearing
APC II Symphysis widening > 2.5 cm. Anterior SI joint diastasis  . Posterior SI ligaments intact. Disruption of sacrospinous and sacrotuberous ligaments.  Anterior symphyseal plate or external fixator +/- posterior fixation

APC III Disruption of anterior and posterior SI ligaments (SI dislocation). Disruption of sacrospinous and sacrotuberous ligaments.
 associated with vascular injury q q
Anterior symphyseal multi-hole plate or external fixator and posterior stabilization with SI screws or plate/screws
Lateral Compression (LC)
LC Type I Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture. 

Non-operative. Protected weight bearing (complete, comminuted sacral component. Weight bearing as tolerated (simple, incomplete sacral fracture). 
LC Type II Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture).  Open reduction and internal fixation of ilium
LC Type III Ipsilateral lateral compression and contralateral APC (windswept pelvis). 
Common mechanism is rollover vehicle accident or pedestrian vs auto. 
Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference. 
Vertical Shear (VS)
Vertical shear Posterior and superior directed force. 
Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%
Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference.

Bleeding & Initial Treatment
  • Bleeding Source
    • intraabdominal 
    • intrathoracic 
    • retroperitoneal
    • extremity (thigh compartments)
    • pelvic
      • common sources of hemorrhage
        • venous injury (80%)
          • shearing injury of posterior thin walled venous plexus
        • bleeding cancellous bone
      • uncommon sources of hemorrhage
        • arterial injury (10-20%) 
          • superior gluteal most common (posterior ring injury, APC pattern)
          • internal pudendal (anterior ring injury, LC pattern)
          • obturator (LC pattern)
  • Treatment
    • resuscitation
      • PRBC:FFP:Platelets ideally should be transfused 1:1:1
      • this ratio shown to improve mortality in patients requiring massive transfusion
    • pelvic binder/sheet   
      • indications
        • initial management of an unstable ring injury 
      • contraindications
        • hypothetical risk of over-rotation of hemipelvis and hollow viscus injury (bladder) in pelvic fractures with internal rotation component (LC)
        • no clinical evidence exists of this complication occurring
      • technique 
        • centered over greater trochanters to effect indirect reduction
        • do not place over iliac crest/abdomen
          • ineffective and precludes assessment of abdomen
        • may augment with internal rotation of lower extremities and taping at ankles
        • transition to alternative fixation as soon as possible 
          • prolonged pressure from binder or sheet may cause skin necrosis
        • working portals may be cut in sheet to place percutaneous fixation
    • external fixation
      • indications
        • pelvic ring injuries with an external rotation component (APC, VS, CM)
        • unstable ring injury with ongoing blood loss
      • contraindications
        • ilium fracture that precludes safe application
        • acetabular fracture
      • technique 
        • theoretically works by decreasing pelvic volume 
        • stability of bleeding bone surfaces and venous plexus in order to form clot
        • pins inserted into ilium 
          • supra-acetabular pin insertion
          • single pin in column of supracetabular bone from AIIS towards PSIS
            • obturator outlet view 
              • helps to identify pin entry point
            • iliac oblique view 
              • helps to direct pin above greater sciatic notch
            • obturator oblique inlet view 
              • helps to ensure pin placement within inner and outer table
            • AIIS pins can place the lateral femoral cutaneous nerve at risk  
            • pedicle screws with internal subcutaneous bar may be used
          • superior iliac crest pin insertion
          • multiple half pins in the superior iliac crest
            • place in thickest portion of ilium (gluteal pillar)
            • may be placed with minimal fluoroscopy 
        • should be placed before emergent laparotomy 
    • angiography / embolization
      • indications
        • controversial and based on multiple variables including:
        •  protocol of institution, stability of patient, proximity of angiography suite , availability and experience of IR staff
        • CT angiography useful for determining presence or absence of ongoing arterial hemorrhage (98-100% negative predictive value)
      • contraindications
        • not clearly defined
      • technique
        • selective embolization of identifiable bleeding sources
        • in patients with uncontrolled bleeding after selective embolization, bilateral temporary internal iliac embolization may be effective
        • complications include gluteal necrosis and impotence
Definitive Treatment 
  • Nonoperative
    • weight bearing as tolerated
      • indications
        •  mechanically stable pelvic ring injuries including
          • LC1 
            • anterior impaction fracture of sacrum and oblique ramus fractures with < 1cm of posterior ring displacement 
          • APC1
            • widening of symphysis < 2.5 cm with intact posterior pelvic ring q
          • isolated pubic ramus fractures
          • parturition-induced pelvic diastasis
            • bedrest and pelvic binder in acute setting with diastasis less than 4cm
  • Operative
    • ORIF
      • indications
        • symphysis diastasis > 2.5 cm 
        • SI joint displacement > 1 cm
        • sacral fracture with displacement > 1 cm
        • displacement or rotation of hemipelvis
        • open fracture
        • chronic pain and diastasis in parturition-induced  diastasis or acute setting >6cm
      • technique
        • for open fractures aggressive debridement according to open fracture principles
    • diverting colostomy
      • indications
        • consider in open pelvic fractures
          • especially with extensive perineal injury or rectal involvement
  • Anterior ring stabilization
    • single superior plate
      • apply through rectus-splitting Pfannenstiel approach
      • may perform in conjunction with laparotomy or GU procedure
  • Posterior ring stabilization
    • anterior SI plating 
      • risk of L4 and L5 injury with placement of anterior sacral retractors  
    • iliosacral screws (percutaneous)
      • good for sacral fractures and SI dislocations
      • safe zone is in S1 vertebral body
        • outlet radiograph view best guides superior-inferior screw placement  
        • inlet radiograph view best guides anterior-posterior screw placement
      • L5 nerve root injury complication with errors in screw placement   
      • entry point best viewed on lateral sacral view and pelvic outlet views  
      • risk of loss of reduction highest in vertical sacral fracture patterns  
    • posterior SI "tension" plating
      • can have prominent HW complications
  • Anterior and posterior ring stabilization
    • necessary in vertically unstable injuries 
  • Ipsilateral acetabular and pelvic ring fractures
    • reduction and fixation of the pelvic ring should be performed first 
  • Neurologic injury
    • L5 nerve root runs over sacral ala joint
    • may be injured if SI screw is placed to anterior 
  • DVT and PE
    • DVT in ~ 60%, PE in ~ 27%
    • prophylaxis essential
      • mechanical compression
      • pharmacologic prevention (LMWH or Lovenox)
      • vena caval filters (closed head injury)
  • Chronic instability
    • rare complication; can be seen in nonoperative cases
    • presents with subjective instability and mechanical symptoms
    • diagnosed with alternating single-leg-stance pelvic radiographs 
Urogenital Injuries
  • Present in 12-20% of patients with pelvic fractures
    • higher incidence in males (21%)
  • Includes
    • posterior urethral tear
      • most common urogenital injury with pelvic ring fracture 
    • bladder rupture
      • may see extravasation around the pubic symphysis 
      • associated with mortality of 22-34%
  • Diagnosis 
    • made with retrograde urethrocystogram
    • indications for retrograde urethrocystogram include
      • blood at meatus
      • high riding or excessively mobile prostate
      • hematuria
  • Treatment
    • suprapubic catheter placement 
      • suprapubic catheter is a relative contraindication to anterior ring plating
    • surgical repair
      • rupture should be repaired at the same time or prior to definitive fixation in order to minimize infection risk
  • Complications
    • long-term complications common (up to 35%) 
      • urethral stricture - most common
      • impotence
      • anterior pelvic ring infection
      • incontinence


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Qbank (37 Questions)

(SBQ12.7) Which of the following is an appropriate initial step in the management of a multiply injured patient with an unstable pelvic ring fracture and hemodynamic instability? Topic Review Topic

1. Application of an external fixator
2. Pelvic angiography
3. Pelvic packing
4. Application of a pelvic binder
5. Percutaneous Iliosacral screws

(OBQ12.3) A 7-year old boy presents to the emergency room following a ATV accident with complaints of left pelvic pain. In the emergency room he is alert and oriented and is hemodynamically stable. On physical exam he is unable to bear weight on his left lower extremity. There is no tenderness to palpation at the posterior pelvis. A radiograph is performed and shown in Figure A and CT examination shows the posterior ring is stable and age-appropriate. What is the most appropriate treatment for this injury pattern? Topic Review Topic
FIGURES: A          

1. Nonoperative management with weight bearing as tolerated
2. Percutaneous sacroiliac screw
3. Pelvic external fixation
4. Anterior pelvic ring plating
5. Anterior and posterior pelvic ring plating

(OBQ12.143) A 37-year-old male is struck by a car while walking at night. He is hemodynamically unstable at initial evaluation in the trauma bay. Advanced Trauma Life Support protocols are started, and an initial survey is completed. A chest radiograph and a pelvis AP radiograph (Figure A) are obtained. What is the most appropriate next step? Topic Review Topic
FIGURES: A          

1. The patient should be taken directly to the OR for percutaneous placement of a pelvic external fixator
2. Dedicated inlet and outlet views of the pelvis to better classify the fracture
3. Continued resuscitation and immediate CT of the chest, abdomen and plevis
4. Emergent trip to interventional radiology for pelvic embolization
5. Immediate application of pelvic binder, continued resuscitation and re-evaluation of hemodynamic status

(OBQ12.236) Alternating single-leg-stance radiographs are most helpful for evaluation of which of the following diagnoses? Topic Review Topic

1. Leg length discrepancy
2. Pelvic ring instability
3. Femoroacetabular impingement
4. Hip abductor weakness
5. Lumbosacral instability

(OBQ11.30) A 23-year-old male is an unrestrained driver in a motor vehicle accident and sustains an unstable pelvic ring fracture. During fluoroscopic-aided fixation, a lateral sacral view is used for proper placement of which of the following fixation methods? Topic Review Topic

1. Anterior column percutaneous screw placement
2. Posterior column percutaneous screw placement
3. Posterior iliosacral plating
4. Supra-acetabular pin placement
5. Percutaneous iliosacral screw placement

(OBQ11.31) A 23-year-old female is an unrestrained driver in a motor vehicle collision, sustaining the injury shown in Figure A. She subsequently undergoes reduction and percutaneous bilateral iliosacral screw placement. Which of the following is the most likely neurologic complication associated with percutaneous iliosacral screw insertion? Topic Review Topic
FIGURES: A          

1. Weakness in knee extension
2. Decreased patellar reflex
3. Weakness in great toe extension
4. Weakness in ankle plantar flexion
5. Decreased Achilles reflex

(OBQ11.165) A 32-year-old male sustains an APC-III pelvic ring disruption after a motor vehicle collision. Which of the following imaging techniques best describes the correct utilization of intraoperative flouroscopy for percutaneous iliosacral screw placement across S1? Topic Review Topic

1. Inlet view helps best guide superior-inferior orientation
2. AP pelvis best guides anterior-posterior screw orientation
3. AP pelvis best guides superior-inferior screw orientation
4. Outlet view best guides anterior-posterior screw orientation
5. Outlet view best guides superior-inferior screw orientation

(OBQ11.181) Which of the following descriptions is true regarding APC-II (anterior-posterior compression) pelvic injuries as classified by Young and Burgess? Topic Review Topic

1. Pubic symphysis diastasis, intact anterior sacroiliac ligaments, intact sacrotuberous ligament, intact posterior sacroiliac ligaments
2. Pubic symphysis diastasis, torn anterior sacroiliac ligaments, intact sacrotuberous ligament intact posterior sacroiliac ligaments
3. Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments
4. Pubic symphysis diastasis, torn anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments
5. Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, torn posterior sacroiliac ligaments

(OBQ11.248) A 23-year-old male is involved in a motor vehicle accident and sustains a left open femur fracture, right open humeral shaft fracture, and an LC-II pelvic ring injury. Which of the following best describes the radiographic findings associated with this pelvic injury pattern using the Young-Burgess Classification system? Topic Review Topic

1. Crescent fracture located on the side of impact
2. Widened anterior SI joint, disrupted sacrotuberous and sacrospinous ligaments with intact posterior SI ligaments
3. Complete SI disruption with lateral displacement
4. Sacral compression fracture on side of impact with transverse pubic rami fractures
5. Open-book injury with contralateral sacral compression fracture

(OBQ10.96) A 35-year-old male involved in a high-speed motor vehicle collision presents to the trauma bay hypotensive and with a clinically unstable pelvis. A pelvis radiograph is shown in Figure A. He is placed in a pelvic binder, and his blood pressure normalizes temporarily. An abdominal CT demonstrates free fluid and air in the intraperitoneal cavity, and a laparotomy is indicated. What is the most appropriate next step in orthopaedic management? Topic Review Topic
FIGURES: A          

1. Percutaneous SI screw placement
2. External fixation placement
3. Pubic symphysis plating
4. Posterior pelvic plating
5. Anterior sacroiliac plating

(OBQ10.144) Of all the pelvic ring injury types, anteroposterior compression type III pelvic ring injuries have the highest rate of which of the following? Topic Review Topic

1. Head injury
2. Pulmonary injury
3. Traumatic amputation
4. Need for transfusion
5. Upper extremity fractures

(OBQ10.148) A 34-year-old female presents to the trauma bay with hemodynamic instability following a motor vehicle collision. A chest radiograph shows a left-sided hemothorax and her pelvis radiograph is shown in Figure A. Which of the following is the next most appropriate step in managment? Topic Review Topic
FIGURES: A          

1. Circumferential pelvic sheeting
2. Retrograde urethrogram to evaluate for associated urologic injury
3. Emergent transport to OR for pelvic anterior external fixator placement
4. CT scan to assess for occult femoral neck fracture
5. Bedside posterior pelvic C-clamp application

(OBQ10.205) A 25-year-old male is involved in a motor vehicle accident and sustains the injury seen in Figure A. He is intubated in the field and receives 2 liters of LR and continues to be tachycardic and hypotensive. A massive transfusion protocol is initiated. Which of the following is true regarding the transfusion of packed red blood cells, platelets, and fresh frozen plasma? Topic Review Topic
FIGURES: A          

1. PRBC should be transfused until Hgb>8
2. PRBC, platelets, and FFP should be transfused in equal ratios
3. Platelets and fresh frozen plasma should be given when INR >1.4, platelet count <100,000
4. FFP is not needed unless INR>1.5
5. Platelets should not be transfused unless platelet count <10,000

(OBQ09.40) What risk factor leads to the highest rate of postoperative loss of reduction in unstable posterior pelvic ring injuries? Topic Review Topic

1. Type of anterior fixation
2. Male sex
3. Usage of a transiliac bar
4. Vertical sacral fracture
5. Sacroiliac joint fracture-dislocation

(OBQ08.41) What nerve is most at risk when applying the external fixator shown in Figure A using a minimally invasive fluoroscopic technique of pin insertion? Topic Review Topic
FIGURES: A          

1. Ilioinguinal nerve
2. Obturator nerve
3. First branch of the femoral nerve
4. Lateral femoral cutaneous nerve
5. Superior gluteal nerve

(OBQ08.80) Risk of postoperative fixation failure for the injury seen in figure A has been associated with what variable? Topic Review Topic
FIGURES: A          

1. Anterior pelvic ring fixation method
2. Vertical nature of sacral fracture
3. Iliosacral screw length
4. Number of iliosacral screws
5. Age > 50

(OBQ08.152) A 24-year-old male sustains the injury seen in Figure A after being thrown from a motorcycle at a high speed. Which of the following fixation methods has been shown to be the most stable fixation construct for this injury? Topic Review Topic
FIGURES: A          

1. Posterior bridge plating and anterior ring external fixation
2. Percutaneous iliosacral screw and anterior ring external fixation
3. Percutaneous iliosacral screw and anterior ring internal fixation
4. Transiliac screw
5. Two percutaneous iliosacral screws

(OBQ08.188) For a patient with an unstable pelvic fracture, the amount of blood tranfusions required in the first 24 hours has shown to be most predictive for what variable? Topic Review Topic

1. Length of hospital stay
2. Association with neurological deficit(s)
3. Length of intensive care stay
4. Cardiac collapse
5. Mortality

(OBQ08.205) During percutaneous iliosacral screw placement for an unstable pelvic ring injury, use of the lateral sacral fluoroscopic image is critical to help avoid iatrogenic injury to what structure? Topic Review Topic

1. L4 nerve root
2. L5 nerve root
3. S1 nerve root
4. Sacroiliac joint cartilage
5. External iliac artery

(OBQ08.207) A 32-year-old male is involved in a motor vehicle collision and sustains the injury seen in Figure A. What is the most common urological injury associated with this injury pattern? Topic Review Topic
FIGURES: A          

1. Testicular torsion
2. Posterior urethral tear
3. Bladder denervation
4. Testicular rupture
5. Renal hematoma

(OBQ07.133) A 41-year-old woman is brought to the emergency department after she was the unrestrained driver in a rollover motor vehicle accident. She was placed in a cervical collar and intubated at the scene. Her blood pressure is 80/40 and pulse is 140. She has obvious open fractures of the right forearm and left ankle. On exam, the lower extremities are externally rotated and the pubic symphysis is widened and unstable. Intravenous access is obtained and radiographs are pending. What is the most urgent next step in management? Topic Review Topic

1. Lateral radiograph to clear the cervical spine
2. External fixator application to the left ankle in the operating room
3. External fixator application to the pelvis in the operating room
4. Pelvic binder application
5. Reduction and splinting of the right forearm

(OBQ05.98) Based on the Young and Burgess classification of pelvic ring injuries, an anterior-posterior compression type II injury does not result in disruption of which of the following? Topic Review Topic

1. pubic symphysis
2. anterior sacroiliac ligaments
3. posterior sacroiliac ligaments
4. sacrospinous ligament
5. sacrotuberous ligament

(OBQ05.213) A 27-year-old woman gives birth by normal spontaneous vaginal delivery. Two weeks after delivery she reports anterior pelvic pain and a radiograph is obtained (Figure A). What is the next step in management? Topic Review Topic
FIGURES: A          

1. Pelvic external fixator
2. Open reduction and reconstruction plating of the symphysis
3. Protected weightbearing and binder as needed and observation
4. Open reduction and wiring of the symphysis
5. Symphysiotomy

(OBQ05.229) What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window? Topic Review Topic

1. External iliac artery
2. Pudendal nerve
3. Corona mortis
4. L5 nerve root
5. Ilioinguinal nerve

(OBQ04.60) A 40-year-old male laborer sustained a fall from height and has isolated pelvic pain. He is otherwise hemodynamically stable. A radiograph is shown in Figure A. A stress examination under anesthesia does not show any further anterior diastasis or posterior pelvic ring displacement. Computed tomography reveals no asymmetry of the sacroiliac joints. What is the most appropriate management of this injury? Topic Review Topic
FIGURES: A          

1. protected weight-bearing and pain control
2. open reduction and internal fixation
3. skeletal traction followed by open reduction and internal fixation
4. pelvic external fixation
5. pelvic external fixation followed by sacroiliac screws

(OBQ04.158) A 31-year-old male sustains an ipsilateral displaced transverse acetabular fracture, pubic rami fractures, and a sacroiliac joint dislocation. What structure should be reduced and stabilized first? Topic Review Topic

1. Pubic rami
2. Posterior column
3. Anterior column
4. Sacroiliac joint
5. Quadrilateral plate

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