AP Compression



< 2.5 cm diastasis


Sacrospinous ligament intact



EUA of APC-1 injury demonstrating < 2.5 cm instability




Sagi et al J Orthop Trauma 2011

- EUA of 14 APC-1 fractures

- 50% deemed unstable and to actually be APC-2 fractures




1.  Anterior pelvic ring injury > 2.5 cm pubic diastasis

- anterior plate through Pfannenstiel incision

- anterior external fixation


2.  Posterior SI joint disruption

- reduction and posterior stabilisation

- usually with SI screws

- if comminuted may need sacro-iliac plates (anterior or posterior)


Pelvic APC ORIF 1Pelvic APC ORIF 2Pelvis APC ORIF 3


Pfannenstiel approach / Plating Pubic Symphysis


Vumedi video pubic symphysis plate


AO surgery reference pubic symphysis plate




Set up

- supine on radiolucent table

- foley catheter to decompress bladder


Incision 2 cm above pubis

- through fat and fascia

- split linea alba between rectus

- identify and protect bladder


Pfannenstiel 1Pfannenstiel 2

Incision 2 cm above pubis                                    Identify linea alba and develop plane between rectus

Pfannenstiel 3Pfannenstiel 4Pfannenstiel 5

Identify and protect bladder posteriorly


Reduction techniques

- during the reduction care must be taken to avoid trapping bladder or urethra in the symphysis when closing the clamp

- assistant may apply pressure over each iliac crest or an external fixator can be applied

- large pointed reduction clamp can be placed onto each pubic tubercle or through holes drilled in the bone

- expose the medial obturator foramen and application of pelvic reduction forceps thru the medial aspect of the foramen


Superiorly applied plate

- pelvic reconstruction plate


Pelvis Pubic Symphysis Plate 1Pelvis Pubic Symphysis Plate 2Pubic symphysis plate

Post-operative XRs: AP, outlet and inlet views


Outcomes of pubic symphysis plating


Morris et al CORR 2012

- 148 patients with pubic symphysis plating

- hardware breakage in 63 patients

- 60% of these patients asymptomatic

- 5 patients required revision for failure of fixation or symptomatic instability


Tseng et al Arch Orthop Trauma Surg 2022

- 9 patients with implant failure including plate breakage

- no difference in functional outcomes


Baron et al Injury 2021

- 58 patients with APC fractures treated with anterior plate versus anterior external fixation

- Majeed score of 70 with external fixation

- Majeed score of 79 with plate

- non significant


Sacro-iliac screws


Vumedi video percutaneous SI screws


AO surgery reference percutaneous SI screw



Radiolucent table with image intensifier

- 45o cephalad and caudal / inlet and outlet views


Must reduce SI joint

- reduce vertically with traction on limb / outlet view

- reduce AP usually via anterior plate or external fixation / inlet view


Guide wire insertion into body of S1

- anatomic safe zone

- between S1 foramen and superior ala on outlet view (outlet view)

- between neural canal and anterior body  (inlet view)


Insert 6.5 mm partially threaded cannulated screw, to aid compression


Pelvis Sacroiliac Screws InletPelvis Sacroiliac Outlet


Post operative


Check screw position with CT

Protected weight bear for six weeks


CT SI screwCT SI screw 2CT SI screw 3




Zwingmann et al Arch Orthop Trauma Surg 2013

- systematic review of SI screws inserted using image intensifier versus navigation

- SI screw malposition in 2.6% cases using inlet / outlet views

- SI screw malposition in 0.1% cases using CT navigation


Malpositioned SI screw


Khaled et al Eur J Trauma Emerg Surg 2015

- 50 patients with one screw, 37 patients with 2 screws

- no difference in outcomes between one or two screws


Kim et al Injury 2020

- systematic review of plates versus SI screws

- no difference in complications or nonunion rates

- implant loosening more common with SI screws

- higher functional outcomes with SI screws




L5 nerve root

- injured with anterior cortical perforation with screw


Mason et al Eur Spine J 2013

- 55 patients with SI screws

- one patient with L5 radiculopathy

- one patient with S1 nerve root injury


Outcomes of APC fractures


Lybrand et al J Orthop Trauma 2017

- 35 APC-2 and 19 APC-3

- trends towards between outcomes with ACP-2

- worse outcomes in patients with higher ISS

- worse outcomes with residual displacement > 15 mm

- APC-2: EQ5D 82, Majeed 77

- APC-3: EQ5D 74, Majeed 81