Surgical Discussion

Patient positioning:  For anterior pelvic fixation and bladder repair, the patient was positioned supine. For posterior sacral ORIF, the patient was repositioned prone.

Anatomical surgical approach:  The anterior approach utilized a Pfannenstiel incision to access the symphysis pubis and pubic rami, with subperiosteal dissection of the rectus abdominis and exposure of the retropubic space for reduction and fixation. For posterior sacral ORIF, a midline longitudinal incision was made over the sacrum, with subperiosteal elevation of the paraspinal musculature to expose the sacral fracture. A tenaculum clamp was applied for direct reduction, followed by percutaneous insertion of iliosacral screws under fluoroscopic guidance.

The case was notable for initial successful multidisciplinary management of both hemodynamic instability and intraperitoneal bladder injury, allowing for staged surgical intervention. Despite accurate anterior pelvic reduction and fixation, postoperative imaging revealed worsening posterior sacral displacement, necessitating subsequent posterior open reduction. The use of a tenaculum clamp facilitated direct anatomical reduction of the sacral fracture prior to iliosacral screw fixation. The presence of an embolic coil from prior angioembolization did not impede surgical access or hardware placement. This case demonstrates that initial anterior pelvic ORIF does not complicate or preclude subsequent routine posterior pelvic ORIF in complex unstable ring injuries.

Postoperative protocol:   Postoperative protocol included restricted weight bearing for 8 weeks, early passive range of motion exercises for the lower extremities, and progressive mobilization as tolerated after radiographic evidence of healing.

Follow up:   Not specified

Orthopaedic implants used:   Anterior pelvic reconstruction plate, iliosacral cannulated screws, tenaculum reduction clamp