n

Feature Article

Percutaneous Screw Fixation of Crescent

Fracture-Dislocation of the Sacroiliac Joint
Xiaolong Shui, MD; Xiaozhou Ying, MS; Chuanwan Mao, BS; Yongzeng Feng, MD;
Linwei Chen, MD; Jianzhong Kong, BS; Xiaoshan Guo, BS; Gang Wang, MD

abstract

Crescent fracture-dislocation of the sacroiliac joint (CFDSIJ) is a type of lateral com-

pression pelvic injury associated with instability. Open reduction and internal fixation
is a traditional treatment of CFDSIJ. However, a minimally invasive method has never
been reported. The purpose of this study was to assess the outcome of closed reduc-
tion and percutaneous fixation for different types of CFDSIJ and present their clini-
cal outcome. The authors reviewed 117 patients diagnosed with CFDSIJ between July
2003 and July 2013. Closed reduction and percutaneous fixation was performed in 73
patients. Treatment selection was based on Day’s fracture classification. For type I frac-
tures, fixation perpendicular to the fracture line were performed. For type II fractures,
crossed fixation was performed. For type III fractures, fixation was performed with
iliosacral screws. Forty-four patients were treated by open reduction and plate fixa-
tion. Demographics, fracture pattern distribution, blood loss, incision lengths, revision
surgeries, radiological results, and functional scores were compared. All 117 patients
were followed for more than 6 months (mean, 14 months [range, 6-24 months]). Blood
loss, extensive exposure, duration of posterior ring surgery, duration of hospital stay,
and infection rates were lower in the closed group (P<.01). Patients in the closed group
achieved better functional performance (P<.01). There were no significant differences
in reduction quality (P=.32), revision surgery rates (P=.27), and iatrogenic neurologic
injuries (P=.2) between the 2 groups. The authors’ results indicate that closed reduc-
tion and percutaneous fixation is a safe and effective surgical method for CFDSIJ.
[Orthopedics. 2015; 38(11):e976-e982.]

The authors are from the Department of Orthopaedic Trauma (XS, GW), Nanfang Hospital, South-
ern Medical University, Guangzhou; the Department of Orthopaedic Surgery (XS, XY, YF, JK, XG) and
the Department of Radiology (CM), The Second Affiliated Hospital of Wenzhou Medical University,
Wenzhou; and the Department of Orthopaedic Surgery (LC), Second Affiliated Hospital, School of Medi-
cine, Zhejiang University, Hangzhou, China.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: Gang Wang, MD, Department of Orthopaedic Trauma,
Nanfang Hospital, Southern Medical University, 1838 Guangzhou Rd, Guangzhou 510000, China
(13616634588@163.com).
Received: November 9, 2014; Accepted: April 8, 2015.
doi: 10.3928/01477447-20151020-05

e976 Copyright © SLACK Incorporated


P
elvic ring injuries are classified into
3 main groups in the Young-Burgess
classification system: anteroposte-
rior compression, lateral compression, and
vertical shear fractures.1 Lateral compres-
sion injuries represent more than 50% of
all pelvic ring injuries and lead to a rota-
tionally unstable hemipelvis.2-4 A subtype
of lateral compression injury, crescent
fracture-dislocation of the sacroiliac joint
(CFDSIJ), which accounts for approxi-
mately 12% of pelvic ring injuries, was
originally defined as a fracture-dislocation
of the sacroiliac joint. It is associated with
various injuries of the sacroiliac ligament
complex, extending to a posterior ilium as
a crescent fracture, which is still attached
to the sacrum with the ligament complex
of the posterior sacroiliac joint.5-7 Crescent
fracture-dislocation of the sacroiliac joint
is often associated with pubic symphysis
injury or pubic rami fracture in the ante-
rior pelvic ring. Borrelli et al7 first reported
CFDSIJ and introduced open reduction and
internal fixation (ORIF) through a postero-
lateral approach.
Day et al5 divided CFDSIJ into 3 main
types: type I fractures involve less than
one-third of the sacroiliac (SI) joint, re-
sulting in a large and stable fragment of
the posterior crescent-shaped ilium; type
II fractures involve one-third of the SI
joint, resulting in a moderate and stable
fragment; and type III fractures involve
more than one-third of the SI joint, result-
ing in a small and stable fragment. On the
basis of this classification, Day et al5 pro-
posed the principle of surgical treatments
for different types of fractures: ORIF
through an ilioinguinal approach for type
I fractures, ORIF through a posterior sur-
gical approach for type II fractures, and
closed or open reduction and iliosacral
screw fixation for type III fractures.
Open reduction and internal fixa-
tion is the preference in most cases of
CFDSIJ, especially types I and II.5,7,8 It is
well known that pelvic injuries are often
associated with multiple injuries and he-
modynamic instability. However, heavy
NOVEMBER 2015 | Volume 38 • Number 11
blood loss, nerve injury, and incision in-
fection are inevitable in ORIF. Closed re-
duction and percutaneous iliosacral screw
fixation has not been previously reported.
The current authors recommend closed
reduction and percutaneous screw fixation
for all CFDSIJ types. The authors com-
pared this technique with traditional ORIF
in the treatment of CFDSIJ. Long-term ra-
diological and functional outcomes were
compared. Special attention was paid to
loss of reduction, infection, late symp-
toms, and functional recovery.
Materials and Methods
Patients
This study is a retrospective review of
the cases of CFDSIJ performed between
July 2003 and July 2013. The study re-
ceived institutional review board approval,
and informed consent was received from
all patients. All patients were treated at 1
of 2 Level I regional trauma centers. One
hundred twenty-two patients met the fol-
lowing inclusion criteria: (1) patients
without known local or systemic infection;
(2) patients with no medical contraindica-
tion (severe vascular or neurologic injury,
diabetes mellitus); (3) skeletally mature
patients; and (4) patients with an unstable
pelvic injury undergoing internal fixation.
Demographics (age and sex), fracture
classification (Tile9 and Day5 classifica-
tions), Injury Severity Score (ISS),10 and
associated injuries were extracted from
the database. Five patients were lost to
follow-up, leaving 117 patients who par-
ticipated in clinical follow-up at a mean
of 14 months (range, 6-24 months). Sev-
enty-three fractures underwent closed
reduction and percutaneous screw fixa-
tion (group 1), and 44 underwent ORIF
(group 2). Patients in the 2 groups were
well matched for age, sex, and fracture
classification.
Management Protocol
Eight patients with open pelvic inju-
ries and associated abdominal organ in-
juries underwent emergent surgery. Mean
n Feature Article
time from injury to surgery was 3.4 days
(range, 0-8 days). Preoperative traction
was generally performed to correct verti-
cal dislocation of the posterior ring, which
was one of the important signs the authors
required for closed reduction and percuta-
neous fixation.
Surgical Technique
In group 1, closed reduction of frac-
tures was a crucial step. In patients with
displaced rami fracture or pubic sym-
physis dislocation, closed reduction and
screw fixation in the anterior ring was
performed first. External rotation of the
injured side of the pelvis was performed
to reduce the lateral displacement, which
can be done by pushing the ilium outward
through manipulation of the iliac crest
or by externally rotating the ilium with a
5-mm Schanz nail embedded in the ilium
as a handle. Longitudinal traction of the
lower extremities was implemented to re-
duce the vertical dislocation. If closed re-
duction failed, a 5-mm incision was made
at the apex of the fracture and dislocation
intraoperatively. A contact pin was used
to push the proximal dislocated part of
the posterior ilium toward the distal end,
supplemented by longitudinal traction of
the lower extremities.
After successful closed reduction,
fixation perpendicular to the fracture line
was performed with several parallel iliac
screws for type I fractures. The screw di-
rection was from the anterior inferior iliac
spine to the posterior superior iliac spine
in the supine position, or vice versa in
the prone position (referred to as “poste-
rior iliac screws”) (Figure 1). For type II
fractures, crossed fixation was performed
with several posterior iliac screws and
iliosacral screws in the prone position.
Reduction and fixation of SI joint disloca-
tion with sacroiliac screws was performed
first, followed by fixation with posterior
iliac screws (Figure 2). For type III frac-
tures, fixation was performed with several
percutaneous iliosacral screws (Figure 3).
Methods of percutaneous screw fixation
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n Feature Article

for the 3 CFDSIJ fracture types are shown

in Figure 4.
When placing closed iliac screws from
the anterior inferior iliac spine to the pos-
terior superior iliac spine, the entry point
should be at the center of the teardrop
when placing the needle at the outlet of
the obturator, 2 cm away from the acetab-
ular articular surface, to avoid invasion
Figure 1: Preoperative radiograph of a Day type I crescent fracture-dislocation of the sacroiliac joint (a). into the joint cavity. During this process,
Preoperative computed tomography scan (b). Postoperative radiograph showing 2 parallel iliac screws
used for fixation (c).
repeated fluoroscopic examination on the
iliac oblique view should be performed to
ensure the guide pin approaches the supe-
rior greater sciatic notch. When placing
closed iliac screws posteriorly, the entry
point near the central line of the poste-
rior superior iliac spine is identified via
fluoroscopic examination after reduction,
with the guide pin pointing to the anterior
inferior iliac spine during anteroposterior
Figure 2: Preoperative radiograph of a Day type II crescent fracture-dislocation of the sacroiliac joint (a). fluoroscopic examination. The guide pin
Preoperative computed tomography scan (b). Postoperative radiograph showing parallel posterior iliac is inserted 15° outwardly in the transverse
and iliosacral screws used for fixation (c). plane and 30° downwardly in the sagittal
plane. Repeated fluoroscopic examination
should be performed to ensure the guide
pin inserts above the greater sciatic notch.
A second guide pin can be inserted 1 to 2
cm away from the first one.
In group 2, all surgical procedures
were performed through either a postero-
lateral approach or an ilioinguinal ap-
proach. The patients in group 2 underwent
Figure 3: Preoperative radiograph of a Day type III crescent fracture-dislocation of the sacroiliac joint (a). ORIF using 1 to 2 pelvic reconstruction
Preoperative computed tomography scan (b). Postoperative radiograph showing 2 iliosacral screws used plates (Stryker, Mahwah, New Jersey),
for fixation (c). which varied in length. Anterior reduction
and fixation was mandatory in cases with
significantly displaced anterior ring frac-
ture and dislocation.

Outcome Evaluation
Radiographs were obtained before
primary treatment, after fixation, and at
final follow-up. The radiological result
was graded by the maximal residual dis-
placement in the posterior or anterior in-
Figure 4: Axial computed tomography scans showing all 3 types of crescent fracture-dislocation of the jury to the pelvic ring (excellent, 0-4 mm;
sacroiliac joint and methods of percutaneous screw fixation. Day type I: The fracture entered the anterior good, 5-10 mm; fair, 11-20 mm; poor,
third of the sacroiliac joint, and fixation perpendicular to the fracture line was performed with several paral- >20 mm).11 Functional outcome was mea-
lel iliac screws (a). Day type II: The fracture entered the middle third of the sacroiliac joint, and crossed fix-
ation was performed with several posterior iliac and iliosacral screws (b). Day type III: The fracture entered
sured using the scoring system described
the posterior third of the sacroiliac joint, and fixation was performed with several iliosacral screws (c). by Majeed,12 which is based on the clini-

e978 Copyright © SLACK Incorporated

 n Feature Article

cal findings of pain, sitting, sexual inter-

course, walking, and work. Table 1
Patient and Fracture Data
Statistical Analysis
Variable Group 1a Group 2b P
Statistical analyses were performed us-
c
ing Student’s t test, Fisher’s exact test, and Age, mean±SD, y 44±11 41±8 .6
Wilcoxon rank-sum test. A P value of .05 Male sex, No.d 48 27 1.0
was considered significant. ISS, mean±SDc 30.9±3.8 28.1±4.8 .8
Tile type, No.d
Results B 43 26 .78
Demographic and injury severity data C 30 18
were not different in the 2 groups with re- Day type, No.d
gard to age, sex, ISS, fracture characteris-
I 16 9 .65
tics, open fracture, and associated injury
II 37 21
(P>.05) (Table 1).
Surgical procedures and fixation III 20 14

methods were compared between the Open fracture, No.d 3 2 .42

d
2 groups. In group 1, closed reduction Associated injury, No. 7 4 .89
and percutaneous screw fixation was Abbreviation: ISS, Injury Severity Score.
a
performed for anterior ring injury in 54 Closed reduction and percutaneous screw fixation.
b
Open reduction and internal fixation.
patients, and ORIF was performed in 7 c
Student’s t test.
patients; for another 12 patients, inter- d
Fisher’s exact test.
nal fixation was not performed due to
insignificant fracture and dislocation. In
group 2, open reduction and plate inter-
nal fixation was performed for signifi- Table 2
cant displace anterior ring injury in 29 Surgical Data and Fixation Methods
patients. The difference of anterior fixa- Variable Group 1a Group 2b P
tion was not significant (P=.57). There Time to surgery, mean±SD, dc 3.3±2.1 3.6±2.6 .35
were significant differences in the dura- Anterior fixation, No.d 61 29 .67
tion of posterior ring surgery between
Operative time, mean±SD, minc 38±11 69±23 <.01
the 2 groups. Mean operative time was
Blood loss, mean±SD, mLc 23±3 186±19 <.01
38 minutes (range, 25-55 minutes) for
Incision length, mean±SD, cmc 1.9±0.8 10.1±2.3 <.01
closed reduction and percutaneous fixa-
c
tion (P<.01) and 69 minutes (range, 45- Hospital stay, mean±SD, d 5.2±1.4 9.0±2.5 <.01
a
105 minutes) for ORIF. Closed reduction and percutaneous screw fixation.
b
Open reduction and internal fixation.
Mean intraoperative and postopera- c
Student’s t test.
tive blood loss in group 1 (23±3 mL) was d
Fisher’s exact test.
much less than that in group 2 (186±19
mL) (P<.01). Mean incision length of the
posterior wound in group 1 (1.9±0.8 cm) Postoperative infections or incision follow-up. These 5 patients underwent re-
was shorter than that in group 2 (10.1±1.3 problems were observed in 2 patients in vision surgery. Reoperation rates between
cm) (P<.01). Mean hospital stay in group group 1 and 8 patients in group 2. The in- the 2 groups were not significantly differ-
1 (5.2±1.4 days) was much shorter than fection rate in group 1 was significantly ent (P=.27). Iatrogenic neurologic inju-
that in group 2 (9±2.3 days) (P<.01) lower than that in group 2 (P<.05). Pa- ries were observed in 2 (12.2%) patients
(Table 2). Mean displacement remaining tients recovered after treatment consisting in group 1 and 3 (19%) patients in group
postoperatively was 4.2±1.8 mm in group of dressing changes and antibiotics. Two 2. Massive vascular damage was not seen
1 and 3.6±1.1 mm in group 2. Reduction patients in group 1 and 3 patients in group in either group. The rates of neurologic
quality was comparable between the 2 2 experienced redislocation of the SI joint injury were not significantly different be-
groups (P>.05) (Table 3). and recurrent pain during postoperative tween the 2 groups (P=.39) (Table 4).

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n Feature Article

osteoarthritis, or instability of the SI joint.

Table 3 A number of surgical techniques have been
described for the reduction and fixation of
Radiological Results After Initial Reduction
SI fracture dislocations.5,7,8,13,14 Day et al5
No. of Displacements Remaining After Reduction
described the CFDSIJ classification system
Excellent Good Fair Poor based on the extent and location of SI joint
Group (0-4 mm) (5-10 mm) (11-20 mm) (>20 mm) Pc
involvement. For type I and II fractures,
1a 45 26 2 0 .527
open reduction and plate fixation is the pre-
2b 34 10 0 0
ferred choice. For type III injuries, fixation
a
Closed reduction and percutaneous screw fixation. with iliosacral screws is performed.5,15
b
Open reduction and internal fixation.
c
Wilcoxon rank-sum test. In recent years, tremendous progress
has been made with the percutaneous
technique for pelvic fractures.16-21 Repair
of SI joint dislocation and sacral fracture
Table 4 using percutaneous iliosacral screw inser-
Clinical Outcomes and Iatrogenic Injuries tion has been described. Routt et al22,23
described a retrograde medullary supe-
No.
a
rior pubic ramus screw for the treatment
Variable Group 1 Group 2b P
of anterior pelvic ring disruptions. Some
Infectionsc 2 8 .004
authors have reported pubic symphysis
Neurologic injuriesc 2 3 .363 screws for the treatment of pubic symphy-
Revision surgeriesc 2 3 .363 sis dislocation.24,25 To the current authors’
a
Closed reduction and percutaneous screw fixation. knowledge, a systematic evaluation of a
b
Open reduction and internal fixation. percutaneous internal fixation technique
c
Fisher’s exact test.
in CFDSIJ is still lacking.
For type I fractures, percutaneous fixa-
tion is performed with 1 to 2 iliac screws
from the anterior inferior iliac spine to
Table 5
the posterior superior iliac spine or from
Radiological Results After Fracture Healing the posterior superior iliac spine to the
No. of Displacements Remaining After Reduction anterior inferior iliac spine. Anatomical
Excellent Good Fair Poor and imaging studies suggest that the iliac
Group (0-4 mm) (5-10 mm) (11-20 mm) (>20 mm) Pc bone is thicker in the posterior superior
a
1 25 31 15 2 .629 iliac spine than in the anterior inferior
2b 14 18 9 3 iliac spine, which can accommodate 1 to
a
Closed reduction and percutaneous screw fixation. 2 six- to eight-mm screws.26 Clinical find-
b
Open reduction and internal fixation. ings suggested that the fracture line in the
c
Wilcoxon rank-sum test.
large posterior crescent iliac is often per-
pendicular to the line linking the posterior
superior iliac spine to the anterior inferior
The radiological outcomes after frac- Discussion iliac spine.27 Therefore, fixation with can-
ture healing were compared between the Crescent fracture-dislocation of the nulated screws in this type of fracture can
2 groups (Table 5). Mean displacement at sacroiliac joint is a relatively uncommon be perpendicular to the fracture line. Si-
final follow-up was 6.5±1.6 mm in group type of lateral compression injury.2-5 The monian and Routt28 reported satisfactory
1 and 8.3±2.7 mm in group 2 (P=.12). main purpose of surgical intervention is biomechanical results with this fixation.
The functional outcomes showed that to achieve early reduction and fixation of For type II fractures, because crescent
functional recovery was better in group 1 the associated fracture or dislocation of the fractures are relatively large, the current
than in group 2 (P<.01) (Table 6). Mean pelvic ring. This treatment can facilitate authors used crossed fixation with ilio-
functional score was 86±17 in group 1 and early mobilization and reduce disabilities sacral screws and posterior iliac screws.
81±19 in group 2. caused by posterior traumatic nonunion, After correcting the vertical dislocation,

e980 Copyright © SLACK Incorporated


reduction and fixation with iliosacral
screws for SI joint dislocation should be
performed before posterior iliac screw fix-
ation because iliac fracture fixation could
interfere with SI joint reduction. Simi-
lar to Day et al,5 percutaneous iliosacral
screw fixation was used in the majority of
type III fractures.
Preoperative heavy-weight (10-20 kg)
traction is important for closed reduction
and internal fixation for CFDSIJ. In cases
where reduction cannot be achieved pre-
operatively, reduction can be performed by
introducing a contact pin percutaneously
above the fracture-dislocation line of the
posterior iliac spine, supplemented by ver-
tical traction in the lower extremities.
Before fixation for fracture-dislocation
of the posterior pelvic ring, reduction and
fixation of the anterior pelvic ring are also
important. Biomechanical experiments
by Simonian and Routt28 suggested that
simultaneous fixation of the anterior and
posterior pelvic rings could make the pel-
vic ring a geometrically unchangeable
system. Furthermore, many injuries were
featured by pelvic rotation dislocation in
horizontal, sagittal, and coronal planes.
Reduction and fixation for anterior pelvic
ring in supine position could help with
correcting rotation dislocation. Therefore,
reduction and fixation of the anterior pel-
vic ring could be essential for closed re-
duction of CFDSIJ.
Insertion of iliac screws from the an-
terior inferior iliac spine to the posterior
superior iliac spine in the supine position
has been reported.27 The current authors
advocate changing the direction from the
posterior superior iliac spine to the ante-
rior inferior iliac spine. This technique
has several advantages, including more
obvious landmarks on the posterior supe-
rior iliac spine and, because posterior iliac
fractures are located posterosuperiorly,
screw length when introduced posteroan-
teriorly is shorter than when introduced
anteroposteriorly, decreasing the possibil-
ity of piercing the iliac cortex and provid-
ing more reliable fixation.
NOVEMBER 2015 | Volume 38 • Number 11
Table 6
Functional Resultsa
No.
Group Excellent (>85) Good (70-84)
1b 35 28
2 c
13 11
a
According to Majeed.12
b
Closed reduction and percutaneous screw fixation.
c
Open reduction and internal fixation.
d
Wilcoxon rank-sum test.
This study has several limitations.
First, the cases enrolled in this study were
from the retrospective review of a surgeon
in a medical institute. Second, follow-
up time was relatively short (mean, 14
months [range, 6-24 months]). Long-term
outcomes remain to be investigated. Fi-
nally, further biomechanical tests must
be implemented to verify the stability of
screw fixation.
Conclusion
Crescent fracture-dislocations of the
sacroiliac joint account for approximately
12% of pelvic ring injuries.5 Closed re-
duction and percutaneous fixation can be
performed in all types of these fractures,
playing a vital role in the treatment of
pelvic ring fractures. The current authors
compared closed reduction and percutane-
ous fixation with ORIF in the treatment of
CFDSIJ. In this study, there was a similar
distribution of demographic and injury se-
verity data between the 2 groups. Patients
treated with closed reduction and percu-
taneous screw fixation had a lower rate
of iatrogenic injuries, such as blood loss
and extensive exposure, than those who
underwent ORIF. The percutaneous surgi-
cal procedure could simplify the treatment
of pelvic ring fractures and avoid massive
blood loss and incision complications. In
patients with multiple trauma and hemo-
dynamic instability, percutaneous fixation
could increase survival. Compared with
patients in the ORIF group, all patients in
the closed reduction group achieved satis-
n Feature Article
Fair (55-69) Poor (<55) Pd
8 2 <.01
16 4
factory radiological results and functional
outcomes.
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