Journal of Orthopaedics 14 (2017) 530–536

Contents lists available at ScienceDirect

Journal of Orthopaedics
journal homepage: www.elsevier.com/locate/jor

Review article

Management of the open book APC II pelvis: Survey results from pelvic
and acetabular surgeons in the United Kingdom
James R. Gill* , Colin Murphy, Ben Quansah, Andrew Carrothers
Department of Trauma and Orthopaedics, Cambridge University Hospitals, Addenbrooke’s, Cambridge, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history:
Received 12 June 2017 The results of this questionnaire show that the opinion of pelvic and acetabular surgeons in the UK and
Accepted 6 August 2017 Republic of Ireland vary as to the best method of fixation for APC II pelvic injuries. A single anterior plate
Available online 9 August 2017 and single sacroiliac joint (SIJ) screw was the most popular fixation method, chosen by 34%. 74% favour a
single, opposed to two orthogonal anterior plates. Posterior fixation supplementing anterior plating is
Keywords: preferred by 63% of surgeons, 58% use a single versus 42% two SIJ screws. Case by case assessment and
Open book pelvis intraoperative screening to assess stability is essential when considering whether to stabilise the SIJ.
APC II © 2017 Prof. PK Surendran Memorial Education Foundation. Published by Elsevier, a division of RELX
Tile B1
India, Pvt. Ltd. All rights reserved.
Pubic symphysis diastasis
Anterior plating
Orthogonal double plating
Sacroiliac joint screw
Symphyseal plating

1. Introduction Various fixation techniques are recognized for the treatment of

pelvic ring injuries involving disruption of the pubic symphysis.
The purpose of this questionnaire was to determine the Fixation techniques for pubis symphysis diastasis include cerclage
variation and preferred treatment of an open book pelvis, wiring,6 suture osteosynthesis, single or double plate and screw
classification APC II type injury, by specialist pelvic and acetabular constructs, and box plate constructs. The most common manage-
surgeons across the United Kingdom (UK) and Republic of Ireland ment for this type of injury is open reduction of the diastasis across
(ROI). the pubic symphysis and internal fixation 7–12 where a plate is fixed
The optimal operative fixation of APC II open book pelvic to the pubic bones, which maintains reduction while allowing the
injuries remains controversial. Open book pelvis injuries are disrupted pubic symphysis and pelvic ligaments to heal.
common in patients who have suffered blunt trauma,1–3 yet there Historically external fixation has been considered an acceptable
is no clear consensus on the optimal method of fixation. Popular method of definitive fixation.13 Open reduction of the diastasis and
classification systems for pelvic injuries include the Young and internal fixation using a plate placed on the anterior aspect of the
Burgess classification,4 which is based on the force vector causing pubic symphysis allows improved comfort and the avoidance of
the injury and the Tile 5 and AO/OTA classifications which are pin-tract complications and neurovascular issues associated with
based on the stability of the injury. The Young and Burgess Anterior external fixators, and have been shown to be biomechanically 14
Posterior Compression II (APC II), Tile B1 and AO/OTA 61-B all and clinically 10 superior. Orthogonal plating using two plates
approximate to the same injury. The injury pattern consists of placed superiorly and anteriorly across the pubic symphysis
disruption and diastasis of the pubic symphysis, disruption of the perpendicular to each other offers greater construct stiffness. The
sacrotuberous, sacrospinous and anterior sacroiliac ligaments but theoretical disadvantage of orthogonal double plating is greater
crucially the posterior sacroiliac ligaments remain intact so there is soft tissue stripping with the inherent adverse effects on bone and
only partial disruption of the posterior arch. This injury therefore symphyseal healing.
has vertical stability but is rotationally unstable. Design-specific symphyseal plates with locking capability are
now available, but evidence for benefit of this technique for acute
pelvic symphysis disruption have not been conclusively
demonstrated.15–17 Concerns have been expressed regarding the
common modes of failure associated with locked-plate constructs
* Corresponding author. in this setting. 18 One of the most contentious areas in the
E-mail address: [email protected] (J.R. Gill).

http://dx.doi.org/10.1016/j.jor.2017.08.004
0972-978X/© 2017 Prof. PK Surendran Memorial Education Foundation. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
 J.R. Gill et al. / Journal of OrthopaedicsJ Orthop. 14 (2017) 530–536 531

management of APC II pelvic injuries is whether to stabilise the

posterior pelvis. Theoretical benefits to stabilisation of the
posterior pelvis with one or more SIJ screws include improved
stability of both the SIJ and symphysis pubis.
Recently a new technique has been developed which uses
spinal pedicle screws to create a subcutaneous ‘external’ fixator
construct called INFIX.19,20 INFIX has reopened the debate with
encouraging results equivalent to internal fixation for some types
of pelvic fractures. INFIX has the advantage over external fixators of
obviating the risk of pin-tract infection and irritation,21–23
however there have been reports of nerve injury complications.24-
–26
Clinical studies will be required to assess the outcome of the use
of INFIX for stabilisation of open book pelvis injuries. At the time of
design of this study INFIX was an emerging technique and so will
not be assessed further by this questionnaire.
As far as the authors are aware this is the first survey of its kind
to assess surgeons preferred management of APC II pelvic injuries Fig. 2. AP radiograph of APC II, Tile B1, AO/OTA 61-B open book pelvis injury.
across the UK and ROI.
c. Single anterior plate and sacroiliac joint screw fixation (one
2. Methods screw)
d. Single anterior plate and sacroiliac joint screw fixation (two
A short questionnaire was prepared using the online question- screws)
naire tool; Surveymonkey (www.surveymonkey.com). An invita- e. Orthogonal double plating and sacroiliac joint screw fixation
tion to complete the electronic questionnaire was sent to the email (one screw)
addresses of sixty-four pelvic and acetabular surgeons in the UK f. Orthogonal double plating and sacroiliac joint screw fixation
and ROI. All responses were anonymized in order to encourage (two screws)
open participation.
Surgeons were presented with the following case of a typical 3. Do you prefer locking or standard plates?
pelvic injury accompanied by a diagram of the injury and an AP a. Standard plate
plain film radiograph of the pelvic injury [Figs. 1 and 2]: b. Locking plate
The open book pelvis, classification APC2, Tile B1, OTA/AO 61-
B type [Figs. 1 and 2], isolated, closed, neurovascularly intact and 4. If a locking plate is used, is it used in locking mode or as a
haemodynamically stable, in a young male with no co- conventional plate?
morbidities. a. Not applicable
The surgeons were then asked to complete the following b. Locking mode
multiple choice questions related to the clinical scenario. c. Conventional plate mode
Questionnaire
1. How many pelvic fractures are you responsible for treating 5. Regarding weight bearing status immediately post
each year: operatively (on the affected side), would you typically allow?
a. 1–5 a. Full weight bearing
b. 6–10 b. Partial weight bearing
c. 11–15 c. Non weight bearing
d. 16–20
e.>20 6. Please indicate the time frame until full weight bearing
status allowed on the affected side?
2. What would be your preferred operative management for a. 0–4 weeks
the described injury? b. 4–8 weeks
a. Single anterior superior plate c. 8–12 weeks
b. Orthogonal double plate
3. Results

A total of 38 (59%) pelvic and acetabular surgeons responded to

the questionnaire. The experience of the surgeons responding
demonstrated a high volume of pelvic and acetabular practice for
the majority of responders; 63% surgeons treat greater than 20
pelvic fractures a year [Graph 1]. Surgical management preferences
varied considerably; the most popular method of surgical fixation
chosen by 34% of surgeons was single anterior plating augmented
with a single SIJ screw, the second most popular chosen by 24% was
single anterior plating without posterior fixation [Graph 2]. In total
74% use one anterior plate, while 26% prefer two orthogonal
anterior plates with or without any form of SIJ fixation. Anterior
plating alone was the preference of 37% of surgeons, while 63%
prefer anterior plating in combination with SIJ screw fixation. Of
Fig. 1. Diagram of OTA 61-B open book pelvis: Incomplete disruption of posterior the surgeons that use SIJ screw fixation; 58% prefer a single SIJ
arch, partially stable.
532 J.R. Gill et al. / Journal of OrthopaedicsJ Orthop. 14 (2017) 530–536

Graph 1. Responses to question 1. Number of pelvic injuries treated per year by each survey respondent.

Graph 2. Responses to question 2. Preferred operative management for the described injury.

screw while 42% prefer two SIJ screws. Surgeons which use two weeks post operatively [Graph 4]. See Table 1 for a full breakdown
orthogonal anterior plates are less likely to stabilise the posterior of the results.
pelvis compared to those that use a single anterior plate; 50%
versus 68%. 95% of respondents preferred standard plates over 4. Discussion
locking plates for the pubic symphysis. 20% of surgeons report
using locking plates in non-locking mode. Regarding weight The results of this questionnaire show that opinion is divided
bearing status on the affected side immediately post operatively amongst consultants who have a specialist interest in pelvic and
11% of surgeons allow full weight bearing, 46% partial weight acetabular trauma regarding a number of facets of the manage-
bearing and 43% non-weight bearing [Graph 3]. There was no ment of APC II pelvic injuries. There is lack of consensus on type of
correlation between early full weight bearing and chosen method fixation and post-operative weight bearing status. This is due to a
of fixation. When asked the time frame until full weight bearing is paucity of high level evidence to guide decision making. Much of
permitted on the affected side; 10.8% allow full weight bearing the evidence comes from biomechanical studies often with
within 0–4 weeks, 29.7% within 4–8 weeks and 59.5% within 8–12 conflicting results and relatively small case series which include
 J.R. Gill et al. / Journal of OrthopaedicsJ Orthop. 14 (2017) 530–536 533

Graph 3. Responses to question 5. Weight bearing status on the affected side immediately post-operatively.

Graph 4. Responses to question 6. Time frame until full weight bearing status allowed on the affected side?.

a spectrum of pelvic injuries. Reasons for the lack of evidence limited evidence to suggest there is benefit to using one compared
include relative low frequency with which any specific type of to two orthogonal symphyseal plates. Numerous authors have
pelvic injury occurs and evolving surgical techniques and implants. conducted case series which suggest that stabilisation of pubic
Key areas of debate highlighted by the survey include the use of a symphysis diastasis is satisfactorily performed with a single
single anterior plate versus two orthogonal anterior plates and anterior plate. 10,15–17, 27,7,8 The results of biomechanical studies
whether posterior stabilisation with a SIJ screw is necessary. vary in their conclusions regarding the use of orthogonal double
plating. Biomechanical studies conducted by MacAvoy et al. 28 and
4.1. Single anterior plate versus two orthogonal anterior plates Simonian et al.29 showed no significant difference in the stability of
fixation of simulated open book pelvis fractures fixed with a single
The survey showed there was a preference for fixation with a versus two perpendicular anterior plates whereas Ponson et al.30
single anterior plate versus two orthogonal anterior plates. There is showed that orthogonal double plating increased stiffness of
534 J.R. Gill et al. / Journal of OrthopaedicsJ Orthop. 14 (2017) 530–536

Table 1
Responses to questionnaire.

1. How many pelvic fractures are you responsible for treating each year?
a. 1–5 3
b. 6–10 1
c. 11–15 6
d. 16–20 3
e. >20 25
Total number of responses to question 1 38
Percentage response to question 1 100%

2. What would be your preferred operative management for the described injury?
a. Single anterior superior plate 9
b. Orthogonal double plate 5
c. Single anterior plate and sacroiliac joint screw fixation (one screw) 13
d. Single anterior plate and sacroiliac joint screw fixation (two screws) 6
e. Orthogonal double plating and sacroiliac joint screw fixation (one screw) 1
f. Orthogonal double plating and sacroiliac joint screw fixation (two screws) 4
Total number of responses to question 2 38
Percentage response to question 2 100%

3. Do you prefer locking or standard plates?

a. Standard plate 36
b. Locking plate 2
Total number of responses to question 3 38
Percentage response to question 3 100%

4. If a locking plate is used, is it used in locking mode or as a conventional plate?

a. Not applicable 27
b. Locking mode 1
c. Conventional plate mode 7
Total number of responses to question 4 35
Percentage response to question 4 92.1%

5. Regarding weight bearing status immediately post operatively (on the affected side), would you typically allow?
a. Full weight bearing 4
b. Partial weight bearing 16
c. Non weight bearing 15
Total number of responses to question 5 35
Percentage response to question 5 92.1%

6. Please indicate the time frame until full weight bearing status allowed on the affected side?
a. 0–4 weeks 4
b. 4–8 weeks 11
c. 8–12 weeks 22
Total number of responses to question 6 37
Percentage response to question 6 97.4%

fixation in a simulated Tile C1 pelvic model. The theoretical pelvis injuries whose fixation included fixation of the posterior
disadvantage of double plating is increased soft tissue stripping. In pelvis with a SIJ screw. Neither Morris 18 nor Van de Bosch 35 (Van
a case series by Putnis et al. use of single versus two orthogonal den Bosch EW & Van der Kleyn R, 1999) were able to show an
anterior plates was dictated by persistent intra-operative instabil- advantage to using posterior stabilisation. Morris et al. 18 found
ity after single plating and poor bone quality. 31 that rate of anterior fixation failure was not related to the presence
or absence of posterior fixation. Van de Bosch et al. 35 reported no
4.2. Posterior stabilisation with SIJ screws difference in functional outcome between patients treated with
combined anterior and posterior internal fixation and those
There is long standing controversy regarding whether APC II treated with anterior fixation alone. Putnis et al. advocate posterior
pelvic injuries require stabilisation of the posterior pelvis in fixation if there is >1 mm of SIJ displacement.31 Of the surgeons
addition to internal fixation of the pubic symphysis, this is which use SIJ screws 58% prefer a single SIJ screw. There is little in
reflected in lack of consensus in survey respondents. 63% of the literature to guide surgeons on this, the only literature
responders use SIJ screws with this pattern of injury. A number of identified that addresses the use of one versus two SIJ screws
cadaveric biomechanical studies have been conducted which both relates to unstable pelvic injuries opposed to the partially stable
support and refute the use of posterior pelvis stabilisation. Van de APC II injury which the questionnaire in this publication pertains
Bosch et al. concluded “the addition of a single sacroiliac screw in a to. In a case series of unstable Tile B and C pelvic injuries analyzed
Tile B1 fracture did not provide significant additional rotational or by Khaled et al. 36 no difference in functional outcome was
translational stability”, 32 In contrast in separate studies Simonian identified with the addition of a second SIJ screw. A number of
et al. 33 and Dujardin et al. 34 both concluded that anterior plate biomechanical studies have looked at the use of different
fixation of the pubis symphysis alone did not significantly modify configurations of SIJ screws. Zhang et al. 37 created finite element
SIJ motion whereas with SIJ screws, SIJ motion was significantly models of unstable Tile type B and C pelvic injuries and concluded
reduced, in the case of Simonian with one and Dujardin with two the use of a single S1 screw should be adequate for a type B
SIJ screws. A number of authors have published results of dislocation. Sagi et al. 12 conducted a cadaveric biomechanical
retrospective case series of patients who sustained open book study simulating a vertically unstable APC III pelvic injury and
 J.R. Gill et al. / Journal of OrthopaedicsJ Orthop. 14 (2017) 530–536 535

concluded that once an S1 SIJ screw had been properly placed there responded, despite great care being taken to contact all pelvic and
was no additional benefit to supplementary SIJ screws. Pelvic and acetabular surgeons in the UK and ROI there is no society or
acetabular surgeons are mindful of the potential risks associated register so some will undoubtedly have not received the survey.
with SIJ screws. These complications are well described, and
potentially extremely serious, 7,38–43 and the judicious use of SIJ 5. Conclusions
screws among responders may reflect the surgeons assessment of
risks and benefits for this particular injury in the specific case The results of this questionnaire provide a snapshot of the
presented. current practice of pelvic and acetabular surgeons in the UK and
The ideal method of stabilising the pubic symphysis may not ROI and shows that consensus is varied for the best method of
just be a case of which construct provides the most stable fixation. definitive fixation and post-operative weight bearing regimen for
Collinge et al.44 conducted a retrospective review of Tile B and C an APC II pelvic injury. Classification of pelvic injuries is not always
pelvic injuries treated with anterior plating with or without straightforward and therefore as suggested by a number of survey
posterior fixation. There was a high incidence of failure of fixation respondents and advocated by the senior author, case by case
which resulted in pubic symphyseal space widening, yet only one assessment and intraoperative screening to assess stability is
case required revision surgery. Collinge et al. question whether essential when considering whether to stabilise the SIJ. Bio-
fixation failure may represent return to more physiological motion mechanical and clinical studies are required to assess single versus
at the pubic symphysis. two orthogonal plate pubic symphysis constructs and anterior
plating versus anterior plating with posterior stabilisation in APC II
4.3. Locking plates versus standard plates pelvic injuries.

Standard plates were favoured over locking plates by 95% of Conflict of interest
respondents. As yet there is no evidence to support the use of
locking plate fixation of the symphysis pubis diastasis. Moed None.
et al.,45 Daily et al.17 and Prasarn et al.16 all conducted separate
biomechanical studies comparing locking plates to non-locking Acknowledgements
plates for symphysis pubis diastasis fixation and none found a
significant difference in stability. Moed et al. also published a The authors would like to thank all the surgeons who
report of 6 cases of locking plate failure for fixation of the pubic participated in this survey and made this study possible.
symphysis.45 In contrast to this Hamad et al. published a case series
of 11 occurrences of pubic symphysis diastasis fixed with locking References
plates and reported all patients to be asymptomatic and none
requiring revision surgery.46 There is concern that failure of locking 1. Pohlemann T, Tscherne H, Baumgärtel F, et al. Pelvic fractures: epidemiology,
therapy and long-term outcome. Overview of the multicenter study of the
plate fixation could result in significant bone stock destruction as Pelvis Study Group. Unfallchirurg. 1996;3:160–167.
the construct fails en masse. Some locking plates are ergonomically 2. Demetriades D, Karaiskakis M, Toutouzas K, Alo K, Velmahos G, Chan L. Pelvic
contoured for the pubic symphysis so are chosen for their fit rather fractures: epidemiology and predictors of associated abdominal injuries and
outcomes. J Am Coll Surg. 2002;195(1):1–10.
than use as an angularly stable device. The authors believe this 3. Bircher M, Giannoudis PV. Pelvic trauma management within the UK: a
explains why 20% of survey respondents reported using locking reflection of a failing trauma service. Injury. 2004;35(1):2–6.
plates in non-locking mode. 4. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain
radiography in early assessment and management. Radiology. 1986;160
(2):445–451.
4.4. Post-operative weight bearing status 5. Tile M. Acute pelvic fractures: I. Causation Classif. 1996;4(May (3)):143–151.
6. Varga E, Hearn T, Powell J, Tile M. Effects of method of internal fixation of
symphyseal disruptions on stability of the pelvic ring. Injury. 1995;26(March
The results of the questionnaire showed there is neither
(2)):75–80.
consensus for post-operative weight bearing status on the affected 7. Tile M. Pelvic ring fractures: should they be fixed? Bone Joint J. 1988;70(1):1–
side immediately post operatively nor for the duration until full 12.
weight bearing is permitted. There is limited evidence to support 8. Lange RH, Hansen Jr. STJr.. Pelvic ring disruptions with symphysis pubis
diastasis. Indications, technique, and limitations of anterior internal fixation.
decision making regarding post-operative weight bearing status. Clin Orthop Relat Res. 1985;(December (201)):130–137.
Meissner et al. conducted a biomechanical study that advocated 9. M Tile, T Hearn, M Vraha, Biomechanics of the pelvic ringin Fractures of the
early partial weight bearing on pubic symphysis diastasis which pelvis and acetabulum. 3rd [ed.] DL Helfet, JF Kellam, Ms Tile M. Philadelphia,
2003. pp. 32–45.
underwent plate fixation.14 Specimens loaded with 100% of the 10. Matta JM. Indications for anterior fixation of pelvic fractures. Clin Orthop Relat
forces acting on the pubic symphysis during walking, simulating Res. 1996;(August (329)):88–96.
full weight bearing led to early failure, however specimens loaded 11. Webb LX, Gristina AG, Wilson JR, Rhyne AL, Meredith JH, Hansen Jr STJr. Two-
hole plate fixation for traumatic symphysis pubis diastasis. J Trauma. 1988;28
with 50% of the acting forces, simulating partial weight bearing, (June (6)):813–817.
cycled to simulate 6 weeks of mobilisation did not result in failure. 12. Sagi HC, Ordway NR, DiPasquale T. Biomechanical analysis of fixation for
The post-operative weight bearing protocol used in a case series vertically unstable sacroiliac dislocations with iliosacral screws and
symphyseal plating. J Orthop Trauma. 2004;18(March (3)):138–143.
published by Aggarwal et al. for APC II injuries was immediate toe 13. Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective
touch weight bearing for six weeks with a mobility aid, followed by classification system and treatment protocols. J Trauma. 1990;30(7):848–856.
partial weight bearing for six weeks, with unrestricted weight 14. Meissner A, Fell M, Wilk R, Boenick U, Rahmanzadeh R. Comparison of internal
fixation methods for the symphysis in multi-directional dynamic gait
bearing after 3 months,47 this is in line with the most popular
simulation. Unfallchirurg. 1998;101(January (1)):18–25.
response to the survey. Outside the rigidity of discrete multiple 15. Grimshaw CS, Bledsoe JG, Moed BR. Locked versus standard unlocked plating
choice questions in real life the authors suspect surgeons decide of the pubic symphysis: a cadaver biomechanical study. J Orthop Trauma.
upon weight bearing status based on factors such as patient age, 2012;26(July (7)):402–406.
16. Prasarn ML, Zych G, Gaski G, et al. Biomechanical study of 4-hole pubic
weight, patient compliance, injury pattern, bone density, pre- symphyseal plating: locked versus unlocked constructs. Orthopedics. 2012
trauma mobility, type and quality of fixation. Jul;1(35 (7)):e1028–32.
There are several elements of this study design which could 17. Daily BC, Chong AC, Buhr BR, Greeson CB, Cooke FW. Locking and nonlocking
plate fixation pubic symphysis diastasis management. Am J Orthop (Belle Mead
introduce a risk of bias. They include; varying case load and NJ). 2012;41(December (12)):540–545.
experience of respondents, not all surgeons who were contacted
536 J.R. Gill et al. / Journal of OrthopaedicsJ Orthop. 14 (2017) 530–536

18. Morris SAC, Loveridge J, Smart DKA, Ward AJ. TJS, Chesser, Is fixation failure pelvis. An understanding of instability and fixation. Clin Orthop Relat Res. 1994;
after plate fixation of the symphysis pubis clinically important. Clin Orthop (December).
Relar Res. 2012;470:2154–2160 [Bristol, UK : s.n.]. 34. Dujardin FH, Roussignol X, Hossenbaccus M, Thomine JM. Experimental study
19. Vaidya R, Colen R, Vigdorchik J, Tonnos F, Sethi A. Treatment of Unstable Pelvic of the sacroiliac joint micromotion in pelvic disruption. J Orthop Trauma.
Ring Injuries with an Internal Anterior Fixator and Posterior Fixation: Initial France: University Hospital of Rouen; 2002 [s.n., 2002 Feb.].
Clinical Series. [Jan 26]. 35. Van den Bosch EW, BSc, Van der Kleyn R, Hogervorst M, Van Vugt AB.
20. Gardner MJ, Mehta S, Mirza A, Ricci WM. Anterior pelvic reduction and fixation Functional outcome of internal fixation for pelvic ring fractures. J Trauma
using a subcutaneous internal fixator. J Orthop Trauma. 2012;. Injury Infect Crit Care. 1999;Vol. 47(2) [Leiden, Netherlands: s.n.].
21. Chaus GW, Weaver MJ. Anterior subcutaneous internal fixation of the pelvis: 36. Kleyn O, Khaled MA, Soliman L. Functional outcome of unstable pelvic ring
placement of the INFIX. Oper Tech Orthopaedics. 2015;25(July (4)):262–269. injuries after iliosacral screw fixation: single versus two screw fixation. Eur J
22. Vigdorchik JM, Esquivel AO, Jin X, Yang KH, Onwudiwe NA, Vaidya R. Trauma Emerg Surg. 2015;41(August (4)):387–392.
Biomechanical stability of a supra-acetabular pedicle screw internal fixation 37. Wahed Y, Zhang C, Peng P, Du Routt ML. Biomechanical study of four kinds of
device (INFIX) vs external fixation and plates for vertically unstable pelvic percutaneous screw fixation in two types of unilateral sacroiliac joint
fractures. J Orthopaedic Surg Res. 2012;27(September). dislocation: a finite element analysis. Injury. 2014;45(December (12)):2055–
23. Cole PA, Gauger EM, Anavian J, Ly TV, Morgan RA, Heddings AA. Anterior pelvic 2059.
external fixator versus subcutaneous internal fixator in the treatment of 38. Routt Jr. MLJr., Lynch T, Mills WJ. Iliosacral screw fixation: early complications
anterior ring pelvic fractures. J Orthop Trauma. 2012;. of the percutaneous technique. J Orthop Trauma. 1997;11(November (8)):584–
24. Apivatthakakul T, Rujiwattanapong N. Anterior Subcutaneous Pelvic Internal 589.
Fixator (INFIX), Is It Safe? A Cadaveric Study. . 39. Marmor M, Lynch T, Matityahu A. Superior gluteal artery injury during
25. Hesse D, Kandmir U, Solberg B, et al. Femoral Nerve Palsy After Pelvic Fracture iliosacral screw placement due to aberrant anatomy. Orthopedics. 2010;33
Treated with INFIX: a Case Series. :138–143. (February (2)):117–120.
26. Vaidya R, Kubiak EN, Bergin PF, et al. Complications of anterior subcutaneous 40. Templeman D, Schmidt A, Freese J, Weisman I. Proximity of iliosacral screws to
internal fixation for unstable pelvis fractures: a multicenter study. Clin Orthop neurovascular structures after internal fixation. Clin Orthop Relat Res. 1996;
Relat Res. 2012;. (August (329)):194–198.
27. Sagi HC, Papp S. Comparative radiographic and clinical outcome of two-hole 41. Oh CW, Kim PT, Kim JW, et al. Anterior plating and percutaneous iliosacral
and multi-hole symphyseal plating. J Orthop Trauma. 2008;22(July (6)):373– screwing in an unstable pelvic ring injury. J Orthop Sci. 2008;.
378. 42. Schweitzer D, Zylberberg A, Córdova M, Gonzalez J. Closed reduction and
28. MacAvoy MC, McClellan RT, Goodman SB, Chien CR, Allen WA, van der Meulen iliosacral percutaneous fixation of unstable pelvic ring fractures. Injury.
MC. Stability of open-book pelvic fractures using a new biomechanical model 2008;39(August (8)):869–874.
of single-limb stance. J Orthop Trauma. 1997;11(November (8)):590–593. 43. van den Bosch EW, van Zwienen CM, van Vugt AB. Fluoroscopic positioning of
29. Simonian PT, Routt Jr MLJr, Harrington RM, Tencer AF. Box plate fixation of the sacroiliac screws in 88 patients. J Trauma. 2002;53(July (1)):44–48.
symphysis pubis: biomechanical evaluation of a new technique. J Orthop 44. Collinge C, Archdeacon MT, Dulaney-Cripe E, Moed BR. Radiographic changes
Trauma. 1994;8(December (6)):483–489. of implant failure after plating for pubic symphysis diastasis: an
30. Ponson KJ, Hoek van Dijke GA, Joosse P, Snijders CJ, Agnew SG. Improvement of underappreciated reality? Clin Orthop Relat Res. 2012;470(August (8)):2148–
external fixator performance in type C pelvic ring injuries by plating of the 2153.
pubic symphysis: an experimental study on 12 external fixators. J Trauma. 45. Moed BR, Grimshaw CS, Segina DN. Failure of locked design-specific plate
2002;53(November (5)):907–912. fixation of the pubic symphysis: a report of six cases. J Orthop Trauma. 2012;26
31. Putnis SE, Pearce R, Wali UJ, Bircher MD, Rickman MS. Open reduction and (July (7)):e71–e75.
internal fixation of a traumatic diastasis of the pubic symphysis: one-year 46. Hamad A, Pavlou G, Dwyer J, Lim J. Management of pubic symphysis diastasis
radiological and functional outcomes. J Bone Joint Surg Br. 2011;(January). with locking plates: a report of 11 cases. Injury. 2013;44(July (7)):947–951.
32. Van den Bosch EW, Van Zwienen CM, Hoek Van Dijke GA, Snijderst CJ, Van Vugt 47. Aggarwal S, Bali K, Krishnan V, Kumar V, Meena D, Sen RK. Management
AB. Sacroiliac screw fixation for tile B fractures. J Trauma. 2003;(November). outcomes in pubic diastasis: our experience with 19 patients. J Orthop Surg Res.
33. Simonian PT, Routt Jr. MLJr., Harrington RM, Mayo KA, Tencer AF. 2011;6(May (17)):21.
Biomechanical simulation of the anteroposterior compression injury of the