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Sacroiliac Joint Dislocation

Sacroiliac Joint Dislocation occurs as a result of an anteriorly or posteriorly directed force to the pelvis associated with symphysis pubis disruptions or rami fractures.

Sacroiliac Joint Dislocation Types

Incomplete Sacroiliac Joint disruptions of the SI joint typically are characterized by rupture of the anterior SI ligaments with a concurrent symphyseal disruption of less than 2.5 cm. These injuries are not associated with vertical instability and may be managed non-operatively, with an external fixator or open reduction and internal fixation.

Complete Sacroiliac Joint disruptions of the SI joint are associated with rupture of the anterior and posterior SI joint ligaments. A rotationally and/or vertically unstable pelvis characterizes these injuries. Because of the poor results with persistent SI joint subluxations and dislocations, surgical reduction and stabilization is recommended.

See Also: Pelvic Anatomy
See Also: Sacral Fractures

Dislocated SI Joint Symptoms

Patient with dislocated SI joint presents with pelvic pain.

Physical Examination should include assessment of the hemodynamic status and should perform detailed neurological exam. Abdominal assessment to look for distention, rectal exam and examine urethral meatus for blood should be included also.

SI Joint Dislocation imaging

SI Joint Dislocation Treatment

Dislocated sacroiliac joint treatment can be performed from either the supine or prone position.

Supine Position

Stabilization in the supine position usually is achieved using the lateral window of the ilioinguinal surgical exposure. After debridement of the joint space, the dislocation is reduced. Care must be taken with exposure across the SI joint to avoid excessive medial dissection to prevent injury to the L5 nerve root. Distal ipsilateral femoral traction, Schanz pins within the ilium, tenaculum clamps, Farabeuf clamps, pelvic reduction clamps and a femoral distractor used in compression may all be helpful in reducing SI joint Dislocations.

See Also: Ilioinguinal Approach to Acetabulum

Stabilization is achieved with either 3.5 or 4.5 mm pelvic reconstruction plates placed perpendicular to one another across the SI joint. Plates should be contoured carefully to avoid distraction at the inferior portion of the SI joint. The S1 nerve root is at risk when drilling and inserting a screw within the sacral ala, and fluoroscopic guidance is recommended.

See Also: Anterior Approach to Sacroiliac Joint

SI Joint Dislocation Treatment

Prone Position

Stabilization of SI Joint Dislocation from the prone position uses a vertical paramedian dorsal surgical exposure; however, one must be wary of significant wound problems that may develop using posterior exposures in a compromised soft tissue envelope. Unlike anterior surgical exposures, reduction of the SI joint is performed indirectly because visualization is compromised as the joint is brought into reduction.

Reduction is verified manually by palpation of the anterior aspect of the SI joint through the greater sciatic notch and radiographically with intra-operative fluoroscopic imaging. Reduction of the dislocated ilium to the sacrum may be assisted with clamps placed through the greater sciatic notch clamping the posterior iliac wing to the sacral ala. Stabilization is obtained with combinations of transiliac plates using either pelvic reconstruction or dynamic compression plates, transiliac screws and iliosacral screws. Use of iliosacral screws has gained popularity for stabilization of SI joint Dislocations.

Percutaneously placed iliosacral screws have been used after both open and closed reduction of SI joint Dislocations. Iliosacral screws may be placed in either the prone or supine position with good results. When using percutaneous techniques for posterior ring stabilization, it is helpful to reduce and stabilize the anterior pelvic ring injuries, which indirectly reduce the posterior ring, thereby allowing for safe iliosacral screw placement.

Careful examination of plain radiographs and CT scans is essential in evaluating sacral morphology and planning for safe iliosacral screw placement. Cannulated iliosacral screws are inserted under fluoroscopic guidance using inlet, outlet and lateral sacral images. Others prefer solid iliosacral screw placement, with which the tactile sensation of the drill bit engaging into the sacral ala and sacral body is used to assist with fluoroscopic imaging in safe placement of iliosacral screws. Still others favour CT scan-guided placement of iliosacral screws. Each technique has its advantages and associated potential problems but each demands that the surgeon understand the local anatomy and achieve accurate reductions.

Dislocated sacroiliac joint treatment

References & More

  1. Goldstein A, Phillips T, Sclafani SJ, et al. Early open reduction and internal fixation of the disrupted pelvic ring. Journal of Trauma 1986;26:325–33. Pubmed
  2. Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clinical Orthopaedics and Related Research 2000;375:15–29. Pubmed
  3. Kellam JF. The role of external fixation in pelvic disruptions. Clinical Orthopaedics and Related Research 1989;Apr:66–82. Pubmed
  4. Simpson LA, Waddell JP, Leighton RK, et al. Anterior approach and stabilization of the disrupted sacroiliac joint. Journal of Trauma 1987;27:1332–9. Pubmed
  5. Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. Journal of Orthopaedic Trauma 1997;11:584–9. Pubmed
  6. Moed BR, Ahmad BK, Craig JG, et al. Intraoperative monitoring with stimulus-evoked electromyography during placement of iliosacral screws. An initial clinical study. Journal of Bone and Joint Surgery (American) and Related Research 1998;80:537–46.
  7. Routt ML Jr, Simonian PT, Agnew SG, Mann FA. Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. Journal of Orthopaedic Trauma 1996;10:171–7.
  8. Templeman D, Schmidt A, Freese J, Weisman I. Proximity of iliosacral screws to neurovascular structures after internal fixation. Clinical Orthopaedics and Related Research 1996;Aug:194–8.
  9. Ebraheim NA, Rusin JJ, Coombs RJ, et al. Percutaneous computed-tomography-stabilization of pelvic fractures: preliminary report. Journal of Orthopaedic Trauma 1987;1:197–204.
  10. Nelson DW, Duwelius PJ. CT-guided fixation of sacral fractures and sacroiliac joint disruptions. Radiology 1991;180:527–32.
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