Surgical Discussion

Patient positioning:  The patient was positioned supine on a radiolucent operating table to facilitate access to the pelvis and proximal femur, with the affected limb in traction via a distal femoral pin.

Anatomical surgical approach:  Percutaneous iliosacral screw fixation was performed through small lateral gluteal incisions, with blunt dissection to the outer table of the os ilium. Under fluoroscopic guidance, guidewires were advanced across the sacroiliac joint into the S1 body, followed by cannulated screw insertion. For the proximal femur, a longitudinal incision was made proximal to the greater trochanter, splitting the fascia lata and gluteus medius fibers to access the piriformis fossa. A guidewire was inserted into the medullary canal, followed by sequential reaming and insertion of an intramedullary nail.

Intraoperative imaging was challenging due to osteopenic bone, fracture comminution, and interference from abdominal packing. Accurate identification of safe osseous corridors for iliosacral screw placement required multiple fluoroscopic projections and careful attention to pelvic landmarks. Bone quality necessitated cautious screw advancement to avoid iatrogenic cortical breach. After pelvic fixation, intramedullary nailing of the proximal femur proceeded without complication. Abdominal packing was removed and laparotomy wound closed after skeletal stabilization. Early mechanical stabilization of both pelvic and femoral injuries was prioritized to optimize survivability in this multiply injured elderly patient.

Postoperative protocol:   Postoperatively, early mobilization with protected weight bearing as tolerated was initiated, with physiotherapy focusing on respiratory function and prevention of decubitus complications. Deep vein thrombosis prophylaxis and close monitoring for systemic complications were instituted.

Follow up:   Not specified

Orthopaedic implants used:   Cannulated iliosacral screws, antegrade intramedullary femoral nail