Pubic Rami Fracture with Disruption of the Sacroiliac Joint (Malgaigne Fracture)
First described by French Surgeon Joseph-Francois Malgaigne, vertical shear fractures of the pelvis are rare injuries often seen from high-energy trauma, typically falls from a height or a planted foot in a motor vehicle crash. They are characterized by an injury to the sacroiliac joint as well as ipsilateral vertically oriented pelvic rami fractures. There is complete disruption of the strong stabilizing ligaments of the posterior pelvic ring, including the sacrotuberous, sacrospinous, and anterior/posterior sacroiliac ligaments, resulting in complete sacroiliac joint instability and vertical displacement of the hemi-pelvis. Examination of the genitourinary system and neurovascular status is critical. Aggressive resuscitation and stabilization should occur during the hospitalization, and multiple services, including general surgery, urology, and orthopedic surgery, may be necessary for optimal management. Classification is described using the Young and Burgess Classification. Unlike other pediatric pelvic ring injuries, those affecting the sacroiliac joint, particularly with vertical instability, often require surgical stabilization. Successful and maintained reduction of the sacroiliac joint is essential for good long-term outcomes. Definitive surgical management should occur within the first week, once the patient has been adequately resuscitated, preoperative imaging and planning have been completed, and all personnel and equipment is available. Blood products should be available during the procedure. There are various percutaneous and open fixation methods available. Obtaining excellent fluoroscopic images is necessary. Understanding the available osseous corridors for screw placement is critical to avoiding iatrogenic nerve root injury. Poor outcomes are correlated to malreduction of the sacroiliac joint, leg length discrepancy, as well as associated neurologic or genitourinary injuries.
References and Suggested Reading
- Routt ML, Simonian PT, Mills WJ (1997) Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma 11(8):583–589Google Scholar
- Routt ML, Simonian PT, Grujic L (1999) The retrograde medullary superior pubic ramus screw for the treatment of anterior pelvic disruptions. J Orthop Trauma 1:35–44Google Scholar