Tile examined whether traumatic pelvic ring disruptions should be stabilized at operation, weighing patient survival against the natural history of each injury type.
Review article built on 494 pelvic fractures treated over 5 years at Sunnybrook Medical Centre, Toronto, plus laboratory testing of fixation constructs.
Methods
Design
Review article
Author's Sunnybrook Medical Centre series, Toronto
Laboratory testing of fixation constructs
Patients
494 pelvic fractures over 5 years
Author's earlier natural‑history series (Tile et al. 1982, Tile 1984): 218 displaced pelvic ring fractures, mean follow‑up 5.6 years (range 2 to 18)
Basis
Pelvic ring stability: rotational and vertical
Key Findings
Of 494 pelvic fractures, only about 19% needed any stabilization, and only 5% needed internal fixation.
In Tile's earlier 218‑patient series, 60% of patients with vertically unstable disruptions continued to have pain.
In that series, non‑union occurred in 3.5% and malunion with more than 2.5 cm of leg‑length discrepancy in 4%.
In that series, permanent nerve injury affected 12 patients (5.5%) and permanent urethral damage 6 (2.5%).
In earlier laboratory testing of a vertically unstable injury, every anterior fixation construct failed under a 20 kg load and posterior internal fixation was far superior.
Mortality tracked the Injury Severity Score and stayed at 10% despite earlier, more aggressive resuscitation with early external fixators.
Board pearl
In an open‑book injury, a symphyseal gap over 2.5 cm implies that the sacrospinous and anterior sacroiliac ligaments are torn.
Tile classification of pelvic ring fracturesTile, J Bone Joint Surg Br 1988
Type A
Stable
A1
Fractures of the pelvis not involving the ring
A2
Stable, minimally displaced fractures of the ring
Type B
Rotationally unstable, vertically stable
Open book over 2.5 cm: external fixation, or symphyseal plating when a laparotomy is done without contamination. Under 2.5 cm usually needs no stabilization.
B1
Open book. Stage 1: symphysis gap under 2.5 cm, no posterior lesion. Stage 2 (one side) or 3 (both): wider gap, implying sacrospinous and anterior sacroiliac ligament disruption
Without posterior fixation: two symphyseal plates at right angles.
C1
Unilateral
C2
Bilateral
C3
Associated with an acetabular fracture
Authors' conclusion
Most pelvic fractures, even those referred to major trauma units, are relatively stable and may be managed by simple techniques. Posterior internal fixation should be reserved for those cases with a difficult vertically unstable pelvis; this often does badly with traditional methods.
Tile examined whether traumatic pelvic ring disruptions should be stabilized at operation, weighing patient survival against the natural history of each injury type.
Review article built on 494 pelvic fractures treated over 5 years at Sunnybrook Medical Centre, Toronto, plus laboratory testing of fixation constructs.
Methods
Design
Review article
Author's Sunnybrook Medical Centre series, Toronto
Laboratory testing of fixation constructs
Patients
494 pelvic fractures over 5 years
Author's earlier natural‑history series (Tile et al. 1982, Tile 1984): 218 displaced pelvic ring fractures, mean follow‑up 5.6 years (range 2 to 18)
Basis
Pelvic ring stability: rotational and vertical
Key Findings
Of 494 pelvic fractures, only about 19% needed any stabilization, and only 5% needed internal fixation.
In Tile's earlier 218‑patient series, 60% of patients with vertically unstable disruptions continued to have pain.
In that series, non‑union occurred in 3.5% and malunion with more than 2.5 cm of leg‑length discrepancy in 4%.
In that series, permanent nerve injury affected 12 patients (5.5%) and permanent urethral damage 6 (2.5%).
In earlier laboratory testing of a vertically unstable injury, every anterior fixation construct failed under a 20 kg load and posterior internal fixation was far superior.
Mortality tracked the Injury Severity Score and stayed at 10% despite earlier, more aggressive resuscitation with early external fixators.
Board pearl
In an open‑book injury, a symphyseal gap over 2.5 cm implies that the sacrospinous and anterior sacroiliac ligaments are torn.
Tile classification of pelvic ring fracturesTile, J Bone Joint Surg Br 1988
Type A
Stable
A1
Fractures of the pelvis not involving the ring
A2
Stable, minimally displaced fractures of the ring
Type B
Rotationally unstable, vertically stable
Open book over 2.5 cm: external fixation, or symphyseal plating when a laparotomy is done without contamination. Under 2.5 cm usually needs no stabilization.
B1
Open book. Stage 1: symphysis gap under 2.5 cm, no posterior lesion. Stage 2 (one side) or 3 (both): wider gap, implying sacrospinous and anterior sacroiliac ligament disruption
Without posterior fixation: two symphyseal plates at right angles.
C1
Unilateral
C2
Bilateral
C3
Associated with an acetabular fracture
Authors' conclusion
Most pelvic fractures, even those referred to major trauma units, are relatively stable and may be managed by simple techniques. Posterior internal fixation should be reserved for those cases with a difficult vertically unstable pelvis; this often does badly with traditional methods.