Appendix C: Pelvic Stabilization Technique

External Fixation of the Pelvis (Iliac Crest Technique)

1. Clinical Indications

a. Unstable pelvis fracture not amenable temporizing stabilization with pelvic sheet or binder

b. Temporizing stability of proximal femur fractures that require pelvic pins given their location

c. Significant perineal or rectal wounds that preclude use of a binder

2. Damage control surgery without fluoroscopy. If fluoroscopy is available, and the surgical team is appropriately trained and comfortable with this technique, supra-acetabular pins should be placed under radiographic guidance. 

3. Key Anatomy

a. Anatomic landmark for safe pin placement using the Iliac Crest Technique is two fingerbreadths posterior to the anterior superior iliac spine (ASIS) which is palpable in nearly everyone.

4. Steps

a. Mark an incision approximately two fingerbreadths posterior to the ASIS along the iliac crest.

b. Sharply dissect down to expose the iliac crest. You may dissect soft tissues off to expose inner and outer tables of the iliac crest.

Figure 1.  Incision placed two fingerbreadths posterior to ASIS along the iliac crest.                                                         Source: COTS+

c. Place first pin two fingerbreadths posterior to ASIS and place second one posterior to that.

d. Repeat the same steps on the contralateral hemipelvis.

e. Assemble frame and manipulate pelvis to achieve a closed reduction prior to tightening the frame.

Figure 2. Two pins are placed in each iliac crest, followed by frame assembly, pelvis reduction, and tightening of all clamps.        Source: COTS+

5. Pearls/Pitfalls

a. There are several tricks that can be used to ensure appropriate trajectory of iliac crest pins:

i. Aim towards the contralateral greater trochanter

ii: Place a second pin resting along the inner table of the pelvis to help demarcate the slope of the iliac crest.

iii: Dissect soft tissues off the inner and outer table. Place thumb and index finger around the crest.  Aim the pin in that trajectory to ensure it is staying within the narrow corridor of bone.

Figure 3. Use additional pin or fingers to palpate ilium and guide trajectory of pin between inner and outer tables of the ilium.                                                             Source: COTS+