骶骨螺钉固定骶髂关节损伤及骶骨骨折 | 妙手书生

Technique of percutaneous transsacral screw
stabilization for sacroiliac joint injury
and sacral fractures

Results of a series of 20 cases

F. LAUDE, Ph. PAILLARD

Hôpital de la Pitié. Boulevard de l'hôpital. 75013 Paris

source：

INTRODUCTION

Displaced lesions of the pelvic ring including either a vertical fracture of the sacrum, or a dislocation of one or both sacroiliac joints, often pose problems of reduction and fixation. [1-5]

These lesions are optimally stabilized with internal osteosynthesis, which is performed, as a rule, by open surgery under visual control. [2, 4-7]

This type of procedure is rarely possible under emergent conditions. Joël Matta and Chip Routt [8] proposed a technique of percutaneous screw fixation. The former advocated the prone position, while the latter preferred the supine position. The advantages of this technique have been well described in the literature with, in particular, a net decrease in blood loss and risk of infection [8, 9] . The intermediate and long-term outcome of these fractures is held to be directly correlated to the quality of the reduction and to the absence of difference in lower limb length. Consequently, reduction of these fractures is the key element [10] . The problem still persists of certain reductions difficult to obtain with closed procedures, limiting the advantages of this technique [1, 2, 11] . Conscious of the advantages of percutaneous osteosynthesis, we propose a new reduction technique, limiting the necessity of an open approach to the fracture. This technique permits anatomical results in certain very displaced fractures, expanding the range of indications for percutaneous screw fixation.

SURGICAL TECHNIQUE

The operation is performed in three stages:

* The reduction is obtained by applying traction in the axis of the femur while blocking the trunk and contralateral limb. Reduction is indispensable before proceeding to the following stage.

* The entry point is determined either on lateral views as proposed by Routt, or in inlet and outlet views as proposed by Matta.

* Hardware placement is guided using AP inlet and outlet views.

- Patient positioning and reduction (Figure 1a)

Figure 1a: Traction on a conventional table. We have adapted a system of traction, which permits straightforward reduction and, above all, maintains it during the entire surgical procedure. The patient is placed in the supine position. Transcondylar traction is applied. The body of the patient is immobilized using several restraints. Only the thigh to which traction is to be applied should be unrestrained. The surgeon should then vary the degree of flexion of the thigh and knee to obtain optimum reduction.

The table base should not hinder displacements of the fluoroscopy C-arm necessary for the outlet views. On certain tables, the patient has to be moved toward the caudal end of the table to achieve adequate films. In large patients, the patient's feet may even extend beyond the table. Transcondylar traction is strongly recommended, because it relaxes the various nerves of the lower limb. In our opinion, hip flexion would also appear to contribute to reduction. The opposite foot is blocked by a support in such a manner that traction in the axis of the lower limbs acts to reduce the fracture of the pelvis.

One may also use an orthopedic table if it is radiolucent. However, on most orthopedic tables, the base blocks outlet views. On the Tasserit table, we add the leg supports to the main square without a countertraction post, placing the buttocks of the patient on these two supports. If the patient is not obese, this poses no problem and patient positioning is much simpler, making outlet views possible. Traction should always be transcondylar. The opposite foot is maintained in the foot support (figure 1b).

Figure 1b: The system of traction can also be set up on an orthopedic table provided that one can pass the C-arm for outlet views. In this image, the patient's buttocks are placed on two supports to leave enough room for the passage of the C-arm. This technique is possible only if the patient is neither too heavy nor too tall.

The quality of the reduction can be assessed on inlet and outlet AP views. Once reduction has been obtained, the pelvic region is rendered accessible and draped.

- Radiological location

The intervention takes place under fluoroscopic guidance.

The entry point of the iliosacral screw can be determined on lateral views, but this is only possible if anatomic reduction has first been achieved. If the reduction is imperfect (persisting displacement greater than 1 cm), open reduction is preferable, if possible.

To obtain adequate lateral X-rays, it is imperative to align two, bilateral anatomical landmarks from each iliac wing (Figure 2).

Figure 2: Lateral film of the sacrum. Lines a1 and a2 correspond to the radiological projection of the sacral ala, and lines b1 and b2 correspond to that of the greater sciatic notches. To obtain a true lateral view of the sacrum it is necessary for line a1 to overlap line a2 and for line b1 to overlap line b2. One may then define the area (in yellow here) where the iliosacral screw should pass. All of this is true only in a reduced pelvis. If the reduction has not been achieved, it is better to turn to an open technique. In the present series, all the patients operated within 48 hours had an excellent reduction. The small inserted image shows the relationships between the L5 nerve root and the bony region that defines line a1 in figure 2 on lateral films of the sacrum.

On a proper lateral X-ray of the sacrum, the two greater sciatic notches should overlap. This landmark was proposed by Routts. In our opinion, it is also helpful to align the radiological projection of the right and left sides of the pelvic inlet.

This second landmark on lateral views is interesting, because not only can it be used to ensure the quality of lateral views, but it also shows the position of the L5 nerve root in the sacrum. The L5 root is situated immediately anterior to this line on lateral views (Figure 2).

The entry point must be always situated below the projection of the pelvic inlet on lateral films.

A fine 10-cm pin is inserted in the outer table of the iliac wing. The image intensifier generally hinders direct placement of the definitive drill bit. Once the image intensifier in position face, one can replace the small pin by the definitive drill bit.

With experience, we remarked that lateral views were not essential and the entry point could be determined on the AP inlet and outlet views. These criteria were well defined by Joël Matta. During the intervention, it may be useful to secondarily verify the proper position of the screws on lateral views.

余分な腎疾患

The entry point into the sacrum having been previously determined, the progress of the screw is verified on AP views. Instead of using true AP films of the sacrum, one should guide screw insertion with inlet views, which correspond to a superior view of the sacrum and outlet views, which show the true front side of the sacrum (figure 3).

Figure 3: The inlet view provides a superior view of the sacrum and the outlet view shows the front of the sacrum. It is important that the base of the table not hinder the passage of the image intensifier. As a rule, the entry point is situated at the intersection of a line prolonging the axis of the femur and a vertical line passing 1 to 2 cm posterior to the anterior superior iliac spine.

These two views are performed by tilting the image intensifier perpendicularly to the major axis of the sacrum for outlet views and aligned with this axis for inlet views. The axis of the sacrum and its angle with the horizontal will have been previously measured on lateral films. It is preferable to place the receiver unit over the patient. Having an image intensifier with a 23-cm receiver also simplifies the procedure.

The progression of the drill bit, then that of the screws are alternately monitored on the two views of the C-arm (Figures 4 and 5).

Figure 4: Progression of the drill bit on inlet views. It should pass immediately anterior to the sacral canal. It is preferable for the screw tract to lie a little too dorsally than a little too ventrally.

Figure 5: Progression of the drill bit on outlet views. The bit should pass between the first sacral foramina and the sacral endplate. There is a risk of passing like a bridge over the sacroiliac joint in case of sacralization of the fifth lumbar vertebra. One should anticipate this problem if on outlet views the proper position of the drill bit is situated very high in the iliac wing. As a rule, the screw should be halfway between the summit of the greater sciatic notch and the superior aspect of the iliac wing. If the proper position of the screw is too close to the summit of the iliac wing, one should be wary and consider inserting the screw between the first and the second sacral foramina in these exceptional cases.

The use of cannulated screws is recommended. It facilitates the surgical procedure. The choice of screws is important. The sacrum is primarily cancellous bone, which does not permit purchase of the same quality as a femoral head. Most of long cannulated screws were developed for osteosynthesis of fractures of the femoral neck. The quality of the cancellous bone of the sacrum is also rather disparate. Near sacroiliac joints, the spongiosa is dense. In the center, it is much less so. This is one of the reasons why screw purchase should, if possible, not stop just beyond the fracture line, but continue and approach the contralateral sacroiliac joint, or even penetrate it. Purchase and stability of the screw are better in this case.

Experience taught us the poor reliability of screws with insufficient thread length. For example, the long screws used for femoral neck fractures are often unsuitable. Their threading being generally less than 25 mm in length, they are incapable of adequately stabilizing a fracture of the sacrum. Ideally, one would need screws from 7 to 8 mm in diameter with relatively "wide thread" "deep thread" "large thread" from 50 to 80 mm in length. Longer screws are also needed, generally sizes between 90 and 150 mm. We believe it is important not to use a pin for a possible cannulated screw. The sensations obtained by using a true drill bit are completely different from those from a pin. With a drill bit, one "feels" the progress of the bit in the cancellous bone of the sacrum. With a pin, one does not feel anything. Unfortunately, most instrument sets offer a threaded pin.

In certain favorable cases, bone drilling can continue into the contralateral sacral ala and beyond the other sacroiliac joint. In this case, one achieves transsacroiliac screw fixation providing purchase in three layers of cortical bone beyond the sacral fracture line. Once the drill bit is in place, the surgeon uses a bone tap 5 mm in diameter and 250 mm in length. Insertion of the cannulated screw using the 3-mm drill bit guide is then straightforward.

This passage of both sacroiliac joints is desirable in case of unilateral or bilateral vertical fracture of the sacral ala (U fracture or H fracture). One can also use bilateral screw fixation.

Reduction of posterior lesions relatively often results in excellent reduction of the anterior lesions. Anterior plate osteosynthesis of lesions of the pubic symphysis is nevertheless a necessary complement of posterior ring stabilization, in our opinion, although it is not necessary to perform the procedure at once. If there is a catheter placed through the bladder dome, waiting a few days to perform the procedure poses no problem. In isolated lesions of the symphysis pubis, the procedure is simple, consisting in the placement of a four-hole plate. Combined lesions of the symphysis and the pubic rami are also managed by screw-plate fixation of the symphysis alone. It is not useful to dash into an ilioinguinal approach, which is much too aggressive. Generally the periosteum on the deep aspect of iliopubic rami is very thick and simple application of tension is sufficient to obtain an excellent reduction.

No patient is placed in traction postoperatively.

THE OPERATIVE SERIES

Figure 6: Fracture of the sacrum of type C1 in the Tile AO classification with dislocation of the sacroiliac joint.

We present a series of 20 patients who had fractures of the pelvis treated by percutaneous sacroiliac screw fixation between March 1995 and January 2000. The same surgeon performed the procedure in eighteen of these patients, and another surgeon performed the other two.

The series included 10 women and 10 men, whose mean age was of 36.1 years (range, 16 to 70 years).

Every case involved high-energy trauma:

• 9 falls
• 6 motorcycle accidents
• 2 car accidents
• 3 pedestrians hit by a car

We classified the lesions according to criteria defined by the AO. We noted:

• 16 type C (11 unilateral lesions, 5 bilateral lesions),
• 4 type B unstable (3 type B1, 1 type B2)

Four times, the lesion of the pelvis was isolated. Overall among the other cases in the series, there were:

キマーゼ阻害剤の皮膚炎

• 4 ipsilateral and 1 contralateral femur fractures
• 3 ipsilateral lower leg fractures
• 5 ipsilateral and 1 contralateral foot fractures
• 1 fracture of the spine with complete paraplegia
• 1 fracture of the spine with incomplete paraplegia
• 2 spinal fractures without neurological deficit
• 3 fractures of the humerus
• 4 fractures of the hand / wrist

Intraoperative blood loss was estimated by the amount of blood transfused, not forgetting that the pelvic injury is often not the only cause of hemorrhaging. Each patient received an average of: 13 packed red blood cell units (range, 0 to 39), 6.7 units of fresh frozen plasma (range, 2 to 15), and 2.7 platelet concentrates (range, 1 to 10).

A single patient had severe gynecological lesions subsequently treated by sphincter reconstruction and tension-free vaginal tape for incontinence.

Among urologic lesions, we noted 1 partial rupture of the bladder, 1 ureteral rupture, 1 urethral rupture and 2 complete ruptures of the bladder (2 AO type C fractures were involved).

Sacral neurological lesions were noted in 6 of the patients immediately after the trauma. Average delay between the accident and surgery was 3 days (range, day 0 to day 31). In seven patients, the surgical procedure was performed the first day after the trauma.

In our series, it is important to distinguish the 14 patients having had reduction by transcondylar traction during the intervention from the 6 patients in whom this method of reducing the pelvic dislocation was not attempted.

The patients can be divided into 2 groups according to the type of osteosynthesis:

• 14 isolated percutaneous sacroiliac screw fixation procedures
• 6 percutaneous sacroiliac screw fixation procedures combined with anterior stabilization.
• 4-hole plate on the pubic symphysis: 4 cases
• 6-hole plate: 1 case
• 1 external fixator was used under emergent conditions because of hemodynamic instability.

We used 4 types of screws: Venable® screws in 4 cases, special Tornier® screws in 4 cases, Asnis II® screws in 4 cases, and Stryker Osteo® (Asnis III) screws in 10 cases.

In 13 cases, only one screw was used. In 9 cases (including revision procedures), two screws were used.

In 17 cases, only one sacroiliac joint was traversed, in 3 cases, both sacroiliac joints were traversed from one side, and, in 2 cases (including revision procedures), each sacroiliac joint was traversed by one screw from each side.

Figure 7: Reduction was obtained as described above. In this exceptional case, before piercing with the drill bit, a square awl was used to push the iliac wing to verify that it could be positioned correctly on the sacroiliac joint.

PATIENT FOLLOW-UP

Eighteen patients had follow-up visits with the authors and one was seen at follow-up by a rehabilitation specialist. All of these patients had recent films of the pelvis. One patient was lost to follow-up, but one-year postoperative films of this patient were available.

Clinically, patients were evaluated using the McGee questionnaire.

Radiologically, five parameters were determined in each hemipelvis. These right and left parameters were marked on the midline and measured in millimeters on preoperative, postoperative and follow-up inlet films -AP films. The midline was defined as the axis of the vertebral column. Inlet and outlet films were also used when they were available . The radiographic parameters were:

• the level of the iliac crests
• the inferior limit of the sacroiliac joint
• the inferior limit of the U fracture
• the level of the pubic spine
• distance between the right and left pubic bones

Figure 8: Progress of the screw, which leads to final reduction. It is indispensable to place a washer on the screw.

COMPLICATIONS

- The position of screws

Control CT was performed postoperatively in 11 patients. In 7 of the 11 patients, the position of the screws was very satisfactory.

The screw passed anterior to the ipsilateral sacroiliac joint in 3 patients, one of whom was reoperated on day one. In 1 patient, the screw passed anterior to the contralateral sacroiliac joint. This case was also included among our operative failures and the patient was reoperated.

- The other complications

There was no infectious, cutaneous, gastrointestinal, or vascular complication even though rare complications have been reported with this technique in the literature [12] .

Regarding neurologic complications, one patient had sciatic involvement. This patient was counted among failed surgeries, because reoperated on day 1 for a poorly positioned screw. At present, the patient has completely recovered.

RESULTS

In our opinion, it is indispensable to distinguish the cases in which reduction was achieved by traction from the patients in whom we were not able to use the surgical protocol that we have just described.

- Patients with reduction by traction

Radiological results

Figure 9: Inlet X-ray after osteosynthesis. Good recovery of the oval shape of the inner pelvis is clearly visible on this film. The diastasis of the symphysis is almost completely reduced. The patient was reoperated 2 weeks later for screw plate fixation of the symphysis pubis.

The 14 patients who had intraoperative traction all had excellent immediate postoperative reduction of their posterior lesions. Imaging after the intervention showed, in some cases, an incomplete reduction of the anterior lesions.

In 3 of the 14 patients who had closed reduction, a complement of anterior osteosynthesis was performed. All 3 patients had excellent immediate and long-term radiological results.

Among the eleven patients who had unstable fractures for which isolated posterior osteosynthesis was performed, the excellent reduction persisted in six.

Secondary displacement occurred in 4 patients. It was less than 1 cm in one, between 1 and 2 cm in two cases, and was 2.5 cm in one patient (figure 10a, b, c).

In 2 cases, secondary displacement was accompanied by hardware failure. In these 2 cases Venable® screws were involved. The screws twisted forcing us in one of the two cases to reoperate the patient and try other screws (Asnis II), which also failed to maintain the reduction.

Clinical results of the 3 patients having had combined posterior and anterior osteosynthesis

We saw these 3 patients at follow-up. They all had only moderate pain during intense activities

自然治癒にきびの薬最高のにきび治療

Clinical results of the 11 cases of isolated posterior fixation

This subgroup of 11 patients included the patient lost to follow-up. Among the 10 remaining patients, 5 had type C1 lesions, 3 type C2 lesions, 1 a type C3 lesion and 1 a type B2 lesion.

Enumeration of results:

• Regarding pain: 7 very good or good results (6 pain free), 1 painful during intense activities, 1 painful in prolonged sitting positions, and 1 moderately painful when beginning to move
• Regarding the use of analgesics: 2 of the 10 were taking medication for pain at follow-up.
• Regarding the resumption of activity: Six patients returned to normal activities, two of which with mild impairment. Four were unable to resume normal activities, but two of the latter were unable because of neurological involvement (1 motor deficit caused by spinal injury and 1 caused by sacral lesions), and one because of foot sequelae of an associated trauma.
• Regarding hip mobility: All were found normal, with the exception of one patient who had a mild impairment of rotation, because of an underlying femur fracture treated with nails.
• Regarding pain in the sacroiliac joint and pubic palpation: 1 patient had persistent pain in the sacroiliac joint.
• Regarding motor function: 7 had normal motor function, 1 was paraplegic and 2 had motor deficit because of associated plexus lesions.
• Regarding ambulation: 5 walked normally, 2 walked with canes (1 because of neurologic sequelae), 1 limped slightly, 1 was paraplegic, and 1 patient had severe walking impairment, because of the foot injury.

It is noteworthy that long-term functional results appear to depend on the quality of reduction and its conservation. This has previously been observed by Joël Matta [7].

- Patients not reduced by traction

Six patients had fixation without attempted reduction by transcondylar traction.

In 3 of these 6 patients, we were confronted by lesions that we classified 'type B', which were not initially vertically displaced. We proposed osteosynthesis to these patients because of severe sacroiliac joint diastasis, which could not be reduced by anterior osteosynthesis. The follow-up films of these 3 patients were unchanged with regard to the immediate postoperative films. In three cases, the screws were removed 1 year after the intervention.

Clinical outcome in these 3 cases was good.

In 3 patients, despite the absence of initial reduction, we performed percutaneous screw fixation.

These 3 cases were all failures:

• 70-year-old woman crushed by a bus, type C1 lesions with extensive Morel-Lavallee degloving lesions involving the pelvis, thighs and low back. There was severe preoperative neurological involvement. These extensive degloving injuries prevented us from using an external fixator. The patient had emergent screw fixation without traction because of hemodynamic instability. The osteosynthesis permitted successful vascular treatment, but malunion occurred with cephalad displacement and external rotation of the iliac wing. We should have reoperated the patien t quickly and reduced the lesions. The patient's general status during the month that followed the accident did not permit this procedure. At follow-up, the patient had severe pain, limb shortening with a difference of 3 cm, was unable to resume previous activities, walked with two canes, and took opioid analgesics daily. Two years after the accident the patient fell and fractured the greater trochanter, which was treated by screw plate fixation. This patient had severe neurologic sequelae.

• 35-year-old man with a type C1 fracture of the iliac wing. The indication of  percutaneous surgery was probably not judicious, because of the length of the fracture line in the iliac wing. The patient was operated without traction and initial reduction was poor. The patient was reoperated at two months postop at the stage of malunion. At that time, reduction was obtained in an open procedure. Although severe urological problems persisted, the final orthopedic and radiological outcome was good.

• 33-year-old woman with lesions of type C1, also operated without traction with insufficient reduction. This was the only patient in the series, for whom incertitude existed regarding a possible neurological complication, which was not observed at follow-up. The patient was reoperated at day one, this time with transcondylar traction and preoperative reduction. The initial films were good, but this result was not maintained. The final functional result was good in spite of a malunion with cephalad displacement of the iliac wing of 15 mm. Regarding neurological involvement, the patient had completely recovered at follow-up.

DISCUSSION

The management of type B fractures is generally straightforward at present. Most of these patients fuse spontaneously and confinement to bed is usually sufficient for healing. If there are lesions of the pubic symphysis, the use of an anterior plate generally suffices. However, one should be wary of certain type B injuries that are, in fact, type C. If there is doubt, reinforcement using posterior screw fixation is recommended. In some cases, screw fixation can also replace an external fixator. In our only case, we were able to remove a poorly tolerated external fixator and replace it with a posterior screw.

The management of the unstable pelvic fractures (certain of type B and all of type C) was, in contrast, much more informative.

Percutaneous screw fixation of these unstable fractures does not appear feasible in our opinion if reduction is not obtained first. In every case in which it was applied, the reduction technique that we developed permitted highly satisfying reduction of the initial lesions. The consistency with which reduction was obtained was probably due to the fact that we almost always performed it within the first 2 days. In one patient who had had a gastrograffin enema, and whom we were not able to operate before the 8th day, the reduction was more difficult to obtain and was not quite as good. The necessity of early screw fixation has previously been suggested by Routh [9] .

In our opinion, if reduction is not obtained, this technique should be avoided. As early as 1972, Slatis and Huitiven [13] reported poor results when the lack of reduction exceeds 2 cm. Rout considers as acceptable a defect in reduction of approximately 1 cm.

At the beginning of our experience, we had only Venable screws, which are not cannulated. The purchase of these screws in the cancellous bone of the sacrum is excellent, because the threading is very long. The good compression of the fracture provided by these screws allowed us to obtain spectacular results not only in posterior lesions, but in anterior lesions, as well. Reduction of posterior lesions very often led to a quite satisfactory or even anatomical reduction of the anterior lesions [7] . At that time, it seemed possible to treat every fracture by isolated posterior synthesis. Unfortunately, although this strategy was successful in some cases, certain constructs failed rather quickly with, for example, a twisted screw.

Using the other types of screws, we did not always achieve comparable reduction of the anterior lesions. Therefore, in certain cases, we added an anterior plate to strengthen the construct. All the patients who had this treatment had an excellent radiological result at follow-up. The patients who had isolated posterior osteosynthesis all had good immediate reduction, as well, but the construct failed leading to malunion of the pelvis in one out of two. These modifications did not compromise the intermediate-term outcome in our series. Nonetheless, such hardware failure is undesirable, especially when the initial result is good.

For this reason, we now advocate adding anterior osteosynthesis to the posterior fixation, if possible, as recommended by Keating et al. [14] .

Anterior osteosynthesis is quite straightforward when a simple symphysis dislocation is involved, in which case a four-hole plate is sufficient. When pubic symphysis dislocation is associated with pubic ramus fracture, we perform osteosynthesis only on the pubic symphysis. The periosteum on the deep aspect of the pubic rami is typically intact and reduction is obtained spontaneously [7] .

Many current publications on the subject are focused on preoperative electromyographic or computed tomographic means allowing safer screw fixation by limiting vascular and neurologic risks [15, 16] .

We think that preoperative CT studies may be useful in certain patients with anatomical variations of the sacrum and for certain fractures provided that one can perform the maneuvers necessary for the reduction.

However, we still believe that the principal assets of the surgeon are good knowledge of the anatomy and the sensation of progression of the drill bit in the sacrum.

CONCLUSION

Percutaneous sacroiliac screw fixation is, in our opinion, a reliable and reproducible technique. The treatment of unstable fractures of the pelvis (type C in the AO classification) appears to be the best indication. The patient is operated in the supine position on a radiolucent table with a system of traction. Reduction of lesions is indispensable before proceeding with screw fixation. If reduction is not obtained, it is preferable to use another technique of osteosynthesis. The patient should be operated as soon after the trauma as possible, ideally within 24 hours. The procedure can even be performed under emergent conditions if there is vascular failure and advantageously replaces an external fixator.

If one follows the guidelines recommended above, the risk of iatrogenic lesions is low. Complications occurred in the present series every time we failed to obey these restrictions.

Although reduction of posterior lesions very often results in a reduction of the anterior lesions, further stabilization with anterior osteosynthesis is often desirable. We prefer plate fixation for lesions of the symphysis pubis. Osteosynthesis of fractures of the pubic rami is not necessary.

The low rate of postoperative complications, the good functional results aside from a few understandable failures, justify continued use of this method.

Percutaneous screw fixation is not a goal in itself. It is, in our opinion, more important to stress the quality of the reduction obtained, the percutaneous screw fixation only being useful to maintain this reduction. If the reduction is not achieved by closed procedures, one should opt for another reduction technique.

REFERENCES

1. ROUTT, M.L., JR., P.T. SIMONIAN, and W.J. MILLS, Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma, 1997. 11(8): p. 584-9. 2. TEMPLEMAN, D., et al., Internal fixation of displaced fractures of the sacrum. Clin Orthop, 1996 (329): p. 180-5. 3. OLSON, S.A. and A.N. POLLAK, Assessment of pelvic ring stability after injury. Indications for surgical stabilization. Clin Orthop, 1996(329): p. 15-27. 4. LETOURNEL, E., Pelvic fractures. Injury, 1978. 10(2): p. 145-8. 5. LETOURNEL, E., Surgical fixation of displaced pelvic fractures and dislocations of the symphysis pubis (excluding acetabular fractures). rev Chir Orthop, 1981. 67(8): p. 771-82. 6. LEIGHTON, R.K. and J.P. WADDELL, Techniques for reduction and posterior fixation through the anterior approach. Clin Orthop, 1996(329): p. 115-20. 7. MATTA, J.M. and P. TORNETTA, 3rd, Internal fixation of unstable pelvic ring injuries. Clin Orthop, 1996(329): p. 129-40. 8. ROUTT, M.L., JR., et al., Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma, 1995. 9(3): p. 207-14. 9. ROUTT, M.L., JR. and P.T. SIMONIAN, Closed reduction and percutaneous skeletal fixation of sacral fractures. Clin Orthop, 1996(329): p. 121-8. 10. COLE, J.D., D.A. BLUM, and L.J. ANSEL, Outcome after fixation of unstable posterior pelvic ring injuries. Clin Orthop, 1996(329): p. 160-79. 11. ROUTT, M.L., JR., et al., Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma, 1996. 10(3): p. 171-7. 12. ALTIN, M.A. and Z.H. Gundogdu, Ureteral injury due to Kirschner wire in a five-year-old girl. A case report. Turk J Pediatr, 1994. 36(1): p. 77-9. 13. HUITTINEN, V.M. and P. SLATIS, Fractures of the pelvis. Trauma mechanism, types of injury and principles of treatment. Acta Chir Scand, 1972. 138(6): p. 563-9. 14. KEATING, J.F., et al., Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma, 1999. 13(2): p. 107-13. 15. TONETTI, J., et al., Percutaneous iliosacral screw placement using image guided techniques. Clin Orthop, 1998(354): p. 103-10. 16. BARRICK, E.F., Entrapment of the obturator nerve in association with a fracture of the pelvic ring. A case report. J Bone Joint Surg Am, 1998. 80(2): p. 258-61. These are our most popular posts: 股関節 画像問題 - MES「医学の知識共有場」: アルファベット O. obturator foramen：閉鎖孔. 戻る☞MES HOME ... pelvic ring：骨盤 輪. pelvic ear：骨盤耳. peauricular sulcus of the ilium：腸骨の耳介前方溝. pubic sprs：恥骨棘. pelvic fracture：骨盤骨折. Pelvis Lauensteins projection：ラウエン ... read more 骶骨螺钉固定骶髂关节损伤及骶骨骨折 25 Apr 2012 ... Displaced lesions of the pelvic ring including either a vertical fracture of the sacrum, or a dislocation of one or both sacroiliac ..... BARRICK, E.F., Entrapment of the obturator nerve in association with a fracture of the pelvic ring. read more 2005 classification of common acetabular fractures 百度文库 5 Mar 2011 ... 髋臼骨折 髋臼骨折隐藏 ... In the evaluation of the five most common acetabular fractures, assessment of the obturator ring, followed by the iliopectineal and ilioischial lines and iliac wing, for fracture allows accurate ... read more 27. レジンとシリコーンを応用した Obturator (第60回日本補綴歯科学会 ... 1973年12月30日 ... 下顎骨体骨折整復後に生じたOpen-biteの補綴的修復 11. ORingを応用した新しい スタッド・アタッチメント : 第3報 とくに鉤歯お.. 21. ORing を応用した新しい stud attachment (第2報) (.. 27. レジンとシリコーンを応用した Obturator (第60回 ... read more 登録: コメントの投稿 (Atom) ブログ アーカイブ ▼  2012 (28) ►  6月 (4) ▼  5月 (13) 寝る前のガムは、虫歯にならない?!キシリトールとリカルデント、この違いは何?：悩み解消生活カタログ ... 骶骨螺钉固定骶髂关节损伤及骶骨骨折 | 妙手书生 坐骨神経痛 | バートカイロプラクティック 嗅覚について 愛のループアラートウィークリー：集。が受信さ23 -グローバルa Nnouncenents、イベント... 妊娠中の腰痛（尾てい骨痛） | OKWave 早朝高血圧など隠れた高血圧が危険｜病気・症状について｜テルモ　一般のお客様向け情報 うつ病の症状、特徴、兆候 Amazon.co.jp： 送料無料★永久磁石と遠赤のダブルのハーモニー「コリ」「寒さ」『マグネッカ... Alibaba Manufacturer Directory - Suppliers, Manufa... 耳鳴 Self-ish Prank Blog: 日記 アーカイブ よくあるご質問（出張施療の流れ・準備いただくこと・本当に無痛？・何回で改善可能？・骨盤痛も改善するの？) ►  4月 (11) 自己紹介 john 詳細プロフィールを表示 「シンプル」テーマ. Powered by Blogger.