From the Research
A right-sided iliac fracture with SI joint involvement treated by plating is a serious orthopedic injury requiring surgical fixation, and the most recent and highest quality study 1 supports the use of anterior intrapelvic plating for sacroiliac joint fixation. The procedure begins with patient positioning in a supine or lateral position under general anesthesia. After sterilization, the surgeon makes an incision along the iliac crest to expose the fracture site. The fracture fragments are then carefully identified and reduced to their anatomical position. For the SI joint component, the surgeon exposes the joint and ensures proper alignment. Specialized pelvic reconstruction plates are selected and contoured to match the patient's anatomy, with studies suggesting that large fragment plates can be used with an area overlying the sacrum of 360 mm3 1. These plates are secured with screws across both the iliac fracture and the SI joint to provide stability, with the screws in the sacrum advised to incline medially about 30° directing to the true pelvis 2. The surgeon verifies proper reduction and hardware placement using intraoperative imaging. The wound is then irrigated, closed in layers, and dressed. Postoperatively, patients typically remain non-weight bearing on the affected side for 8-12 weeks, followed by progressive weight bearing as healing progresses, as seen in a case report of a patient with a comminuted displaced iliac fracture and superior and inferior pubic rami fractures who underwent open reduction and internal fixation with osteosynthesis plating 3. Physical therapy is essential for regaining strength and mobility. This procedure is necessary because pelvic fractures involving the SI joint are inherently unstable and can lead to chronic pain and disability if not properly stabilized, with studies showing that minimally invasive adjustable plates can provide favourable radiographic and functional results 4. The plates provide the mechanical stability needed for proper bone healing while maintaining the crucial alignment of the SI joint, which is essential for normal weight transfer between the spine and lower extremities. Some key considerations in the surgical approach include avoiding iatrogenic injuries to the lumbar nerves, with anatomical evidence suggesting that the horizontal distance from L4, L5 nerve roots to the sacroiliac joint decreases gradually from the top to the bottom 2. Overall, the goal of surgical treatment is to return the patient to their prefracture state, with the most recent study 1 providing quantitative evidence for the area available on the sacrum for reduction and plating using the anterior intrapelvic approach.
Some key steps in the procedure include:
- Patient positioning and sterilization
- Incision and exposure of the fracture site
- Reduction and alignment of the fracture fragments
- Selection and contouring of pelvic reconstruction plates
- Securing the plates with screws across both the iliac fracture and the SI joint
- Verification of proper reduction and hardware placement using intraoperative imaging
- Wound closure and postoperative care
It is also important to consider the potential complications and challenges associated with this procedure, including:
- Iatrogenic injuries to the lumbar nerves
- Difficulty in achieving proper reduction and alignment of the fracture fragments
- Limited access to the sacroiliac joint
- Risk of infection and other postoperative complications
However, with proper technique and attention to detail, the outcomes of this procedure can be excellent, with patients achieving significant improvements in pain and functional ability, as seen in the case report of a patient who underwent open reduction and internal fixation with osteosynthesis plating 3.