From the Guidelines
Percutaneous cannulated compression (CC) screw fixation is the preferred surgical approach for managing superior and inferior pubic rami fractures due to its minimally invasive nature and effective stabilization. The procedure begins with patient positioning in the supine position on a radiolucent table with the affected hemipelvis slightly elevated. After administering general anesthesia, the surgical site is prepped and draped. A small incision (1-2 cm) is made over the anterior inferior iliac spine for superior ramus fixation. Under fluoroscopic guidance, a guide wire is inserted through the superior pubic ramus toward the pubic symphysis, carefully avoiding penetration of the hip joint or bladder. For inferior ramus fixation, the entry point is typically at the pubic tubercle with the guide wire directed toward the ischial tuberosity. After confirming proper wire placement with multiple fluoroscopic views, the surgeon measures the required screw length and drills over the guide wire. Partially threaded 6.5-7.0 mm cannulated screws are then inserted over the guide wires, with the threads crossing the fracture site to achieve compression. The surgeon confirms final screw position with fluoroscopy, removes the guide wires, and closes the incisions.
Key steps in the procedure include:
- Patient positioning and preparation
- Guide wire insertion under fluoroscopic guidance
- Screw placement and compression
- Confirmation of final screw position and closure of incisions Postoperatively, patients typically begin toe-touch weight bearing on the affected side for 6-8 weeks, gradually progressing to full weight bearing based on radiographic evidence of healing, as supported by the guidelines for pelvic trauma management 1. This technique provides stable fixation while minimizing soft tissue disruption, reducing blood loss, and allowing for faster rehabilitation compared to open reduction techniques. The goal of internal fixation of unstable pelvic ring injuries, including superior and inferior pubic rami fractures, is to allow early functional rehabilitation and to decrease long-term morbidity, chronic pain, and complications that have been historically associated with prolonged immobilization 1.
From the Research
Step-by-Step Procedure for Managing Superior and Inferior Pubic Rami Fractures with CC Screw Fixation
- The management of superior and inferior pubic rami fractures using CC screw fixation involves several steps, including:
- Preoperative planning: This includes evaluating the patient's osseous anatomy and surrounding soft-tissue anatomy to determine the suitability of percutaneous screw fixation 2.
- Classification of the fracture: The Nakatani classification system can be used to categorize superior pubic ramus fractures according to their location with respect to the obturator foramen 3.
- Screw placement: The screw can be placed in either an antegrade or retrograde fashion, with the retrograde technique being more commonly used 4.
- Fixation technique: The fixation technique can involve the use of partially or fully threaded cannulated screws, or a novel intramedullary splinting implant 5.
- The procedure for CC screw fixation of superior and inferior pubic rami fractures involves:
- Insertion of a guide wire into the medullary canal of the pubic ramus under fluoroscopic guidance.
- Drilling a hole for the screw over the guide wire.
- Insertion of the screw into the hole and tightening it to achieve fixation.
- Verification of the screw placement and fixation using fluoroscopy.
Potential Complications and Considerations
- The potential complications of CC screw fixation of superior and inferior pubic rami fractures include:
- Loss of reduction: This can occur due to collapse of the pubic ramus over the screw or recurrence of an internal rotation deformity of the injured hemipelvis 3.
- Implant failure: This can occur due to the high stresses on the implant or poor bone quality 5.
- Neurologic, vascular, or urologic injury: These complications can occur due to the proximity of the pubic ramus to vital structures 3.
Postoperative Care and Follow-up
- Postoperative care and follow-up are crucial to ensure proper healing and to detect any potential complications early.
- Patients should be followed up regularly with radiographs to assess the healing of the fracture and the stability of the fixation 4.
- Pain management is also an important aspect of postoperative care, and regional anesthesia techniques such as continuous pericapsular nerve group (PENG) block can be used to provide effective pain relief 6.