Assessment of the posterior pelvic ring during examination under anesthesia changes surgeons’ classification and treatment decisions of anterior posterior compression pelvic ring injuries

Abstract Purpose Traditionally, examination under anesthesia (EUA) focuses on displacement of the anterior pelvic ring and may fail to detect or localize sacroiliac (SI) joint diastasis in patients with anterior-posterior compression (APC) pelvic injuries. This study evaluates the effect of directly observing sacroiliac (SI) diastasis during EUA, compared to observing only the anterior pelvic ring (AP EUA), on changes in classification and treatment plan. Methods Four hundred international pelvic surgeons were invited to participate in an online survey, with one month between two surveys. All surveys included the same 10 cases of APC injuries. One part included AP EUA images, and the other included additional SI EUA images. Questions regarding classification and treatment were asked, including the need for anterior and posterior fixation, and the side of SI joint fixation. The change in management after the addition of SI EUA images was assessed. Results One hundred six pelvic trauma surgeons completed the survey with AP EUA images, and 99 also completed the survey with SI EUA images. The addition of SI EUA imaging resulted in a 37% change in classification, with APC1 decreasing from 17% with AP EUA to 10% with SI EUA, APC2 remaining 67%, and APC3 increasing from 17 to 23%. Treatment decisions changed in 29% of all cases. There was an increase in the combined anterior and posterior fixation, from 56 to 74%. Improved lateralization (choice of right or left SI joint fixation) was seen in 4 cases. Conclusion In this survey, the addition of SI EUA images according to the modified protocol changed surgeons’ perception of pelvic ring instability and the subsequent treatment strategy chosen. SI EUA images provide surgeons with information that prompts the addition of an SI joint fixation, resulting in an 18% increase in the use of combined anterior and posterior fixation. SI EUA images also improved injury localization, helping surgeons identify which sacroiliac joint required stabilization.