Surgical Discussion

Patient positioning:  The patient was first positioned supine for anterior pelvic exposure and fixation, then repositioned prone for posterior wound management and fixation.

Anatomical surgical approach:  Anteriorly, a low midline infraumbilical incision was made to expose the symphysis pubis, with subperiosteal dissection of the rectus sheath and direct visualization of the disrupted symphysis. Posteriorly, a longitudinal midline approach over the sacrum was utilized, incorporating the traumatic wound for I&D. Deep dissection allowed access to the sacral ala and SI joint. A tenaculum clamp was applied percutaneously to achieve reduction of the sacral/SI fracture-dislocation. Iliosacral screws were inserted percutaneously under fluoroscopic control across the SI joint into S1.

The sequence of anterior then posterior fixation allowed unimpeded access to both injury sites. The use of a tenaculum clamp facilitated reduction of the complex posterior injury. No technical interference was encountered between anterior plate fixation and subsequent posterior iliosacral screw placement. The presence of embolic coils did not impede surgical access or reduction maneuvers.

Postoperative protocol:   Early mobilization with protected weight bearing was initiated. Supine positioning was maintained for 48 hours postoperatively, followed by gradual progression to sitting and standing as tolerated. Non-weight bearing on the affected side was maintained for 6 weeks, with progression to partial weight bearing thereafter based on radiographic healing.

Follow up:   Not specified

Orthopaedic implants used:   3.5 mm anterior symphyseal plate, cannulated iliosacral screws