ISSN 1225-2 대한골절학회지제 25 권, 제 4 호, 2012 년 10 월 J Korean ract Soc 2012;25(4):243-24 원 저 불안정성골반환손상의수술적치료 이상홍ㆍ하상호ㆍ이영관ㆍ조성원ㆍ박상수 조선대학교의과대학정형외과학교실 목적 : 불안정골반환손상의불안정정도및전위정도에따라각기다른고정술을시행하여이에대한치료결과를분석하고자하였다. 대상및방법 : 2005 년 1월에서 200 년 12월까지불안정골반환손상을입은 23명을대상으로 AO/OTA 골절분류를이용하여분류하였다. 수술방법은부분적불안정손상에서는전방금속판고정및후방경피적장-천골나사못고정술, 완전불안정손상에서는전방및후방금속판고정술을시행하였다. 방사선학적평가는 atta 와 Saucedo의기준을사용하였으며, 임상적인평가는 Rommens 와 Hessmann 의기준을이용하였다. 결과 : 방사선학적평가상부분불안정손상에서는후방골반환의전위는약 6.65 mm, 완전불안정손상에서는후방골반환의전위는약 7. mm 호전되었다. 임상적평가에서최종추시상우수 예, 양호 6예였다. 결론 : 불안정성골반환손상의후방불안정정도및전위정도에따라각기다른수술적방법을선택하여양호한결과를얻을수있을것으로생각한다. 색인단어 : 불안정성골반환손상, 후방금속판고정술, 경피적장 - 천골나사못고정술 Operative Treatment of Unstable Pelvic Ring Injury Sang Hong Lee,.D., Sang Ho Ha,.D., Young Kwan Lee,.D., Sung Won Cho,.D., Sang Soo Park,.D. Department of Orthopaedic Surgery, School of edicine, Chosun University, Gwangju, Korea Purpose: To analyze the clinical and radiological results of the different fixation methods according to the type and displacement of unstable pelvic ring injuries. aterials and ethods: Twenty-three patients with unstable pelvic ring injuries from January 2005 to December 200 were classified according to the AO/OTA classification system. When patients had been diagnosed with unstable pelvic ring injuries with partial instability, they were treated by anterior fixation with a plate and posterior percutaneous iliosacral screw fixation. When patients had been diagnosed with unstable pelvic ring injuries with complete instability, they were treated by open reduction and anterior to posterior fixation with a plate through the ilioinguinal approach. The radiological results were evaluated using atta and Saucedo s method, and the clinical results were evaluated using Rommens and Hessmann s method. Results: The outcomes from the radiological evaluation were that the displacement of the posterior pelvic ring were improved by about 6.65 mm in unstable pelvic ring injuries with partial instability. The displacement of the posterior pelvic ring were improved by about 7. mm in unstable pelvic ring injuries with complete instability. The clinical results were excellent in cases and good in 6 cases on latest follow-up. Conclusion: results can be achieved by selecting the treatment method according to the type of unstable pelvic ring injurie and displacement. Key Words: Unstable pelvic ring injury,, Percutaneous iliosacral screw 통신저자 : 이상홍광주시동구필문대로 365, 조선대학교병원정형외과 Tel:062-220-37 ㆍ ax:062-226-337 E-mail:shalee@chosun.ac.kr 접수 : 2012. 2. 2 심사 ( 수정 ): 2012. 3. 10 게재확정 : 2012. 7. 10 Address reprint requests to:sang Hong Lee,.D. Department of Orthopaedic Surgery, Chosun University Hospital, 365, Pilmun-daero, Dong-gu, Gwangju 501-7, Korea Tel:2-62-220-37 ㆍ ax:2-62-226-337 E-mail:shalee@chosun.ac.kr 243
244 이상홍, 하상호, 이영관, 조성원, 박상수 서 불안정성골반환손상은복부및생식기계의내부장기, 주요혈관과신경의손상을가져올수있고이로인한사망률이.6 25% 까지보고되고있어 2,1) 골반환의안정성회복은사망률을감소시킬뿐아니라환자의조기재활과합병증을줄일수있어매우중요하다 26). 골반환손상은그손상기전에따라골절의양상을분류할수있고, 각각의양상에따라보존적치료, 금속판고정술, 경피적나사못고정술, 외고정술등다양한수술방법을선택하고그예후를예측할수있다,26,32). 저자들의경우전후방압박및측방손상으로인한치골결합부이개또는치골지의전위성골절과함께천장관절분리가있는손상은부분불안정성골반환손상으로분류하여전방접근법을통하여치골부위에대한금속판고정술시행및후방골반환손상에대해서는경피적장-천골나사못고정술을시행하였다. 심한전후방또는측방압박손상이나수직전단손상에의하여천장관절의심한불안정성과함께치골지의전위가동반된손상은완전불안정성골반환손상으로분류하여수술 론 중환자의체위변경없이장서혜부도달법을이용하여치골지의골절과천장관절분리부분에대해각각금속판고정술을시행하였고이에대한치료결과를분석하고자한다. 대상및방법 2005 년 1 월부터 200 년 12 월까지본원에서골반환손상에대하여수술적치료를시행한환자중전방금속판및후방경피적나사못고정술을시행한환자들과골반환의전방및후방에각각금속판고정술을시행한환자들중에서최소 1 년이상추시가가능하였던 23 예를대상으로하였으며, 평균연령은 55 세로남자는 예, 여자는 7 예였다. 수상의원인은자동차사고 예, 추락사고 6 예, 보행자사고 5 예, 오토바이사고가 4 예로모두고에너지손상에의한것이었고, 동반손상으로다른부위골절은 예, 방광손상 4 예, 복부장기손상 3 예, 신경학적손상 2 예였다. 단순방사선골반골전후면사진과입구사진및출구사진과함께수술전컴퓨터단층촬영을통하여골절의양 ig. 1. (A, B) A 41-year-old male patient who had an unstable pelvic fracture with symphysis pubis diastasis and sacroiliac joint disruption. (C, D) fixation on symphysis pubis and percutaneous iliosacral screw fixation on sacroiliac joint. (E) After 30 months, he had a complete union and excellent function.
불안정성골반환손상의수술적치료 245 상과전위정도를확인하였다. AO/OTA 골절분류를기준으로 형 예, 형 예, 형 5예, C3형 1예였다. 수술적방법은 AO/OTA 골절분류상 형은부분불안정손상으로분류하였으며 2) 이에대해서는골반환의전방손상에대해서는금속판고정을시행하고후방골반환손상에대해서는환자의체위변경없이경피적장-천골나사못고정술을시행하였다 (ig. 1). AO/OTA 골절분류상,, C3형은완전불안정손상으로분류하여 2) 전방의골반환손상에대하여금속판고정을시행한이후환자의체위변화없이전방접근을위한절개선을후상방으로연장하여장서혜접근법 (ilio-inguinal approach) 을이용하여천장관절손상에대해각각금속판고정술을시행하였다 (ig. 2). 술후환자들에대하여고관절과슬관절은능동적운동을허용하였고, 2주후부터휠체어거동, 6주째에부분체중부하운동, 10 주째에방사선학적인골재형성관찰및임상적으로통증여부에따라서전체중부하거동을허용하였다. 환자의추시는퇴원후 1개월간격으로시행하여골반전후면입구출구방사선사진을확인하고임상 적평가를시행하였다. 방사선적평가는정복의상태에따라 atta 와 Saucedo ) 의기준을이용하여해부학적 (, 골반이대칭이고전위가 4 mm 이내 ), 준해부학적 (nearly, 전위가 4 10 mm 이내 ), 보통 (moderate, 전위가 1 2 cm 사이 ) 그리고불량 (poor, 전위가 2 cm 이상 ) 으로구분하였으며, 임상적평가는 Rommens 와 Hessmann 20) 의기준을이용하여동통, 보행거리에따라우수 ( 동통이없고, 거리제한이없는정상보행 ), 양호 ( 제한된동통, 약간의거리제한이있는다소비정상보행 ), 보통 ( 규칙적인동통, 제한된거리의비정상보행 ), 그리고불량 ( 심한동통, 거리가매우제한된비정상보행 ) 으로구분하였다. 그리고골유합의시기및술후합병증에대하여조사하였다. 결 atta 와 Saucedo ) 에의한방사선학적평가는부분불안정손상 ( 형 ) 에서해부학적정복 6 예, 준해부학적정복 과 ig. 2. (A, B) A 65-year-old female patient who had unstable pelvic fracture with superior and inferior ramus fracture and sacroiliac joint disruption. (C, D) Through the anterior approach, al reconstruction was achieved with the fixation of the anterior and posterior rings. (E) After 53 months, she had a complete union and excellent function.
246 이상홍, 하상호, 이영관, 조성원, 박상수 Table 1. Patient Data Case No. Age Sex Cause of injury Classification (AO/OTA) Associated injury Time to operation after injury (day) ixation of sacroiliac joint Union time (wk) Radiologic result unctional result Complication 1 2 3 4 5 6 7 10 11 12 1 1 20 21 22 23 6 65 54 44 4 25 6 56 70 41 6 72 41 66 52 4 43 34 76 73 53 60 37 all from a height otorbike TA all from a height all from a height all from a height otorbike TA otorbike TA all from a height otorbike TA all from a height C3 Distal radius x. Liver laceration Sacral plexus injury emur x. Distal radius x. Liver contusion emur x. Humerus x. ultiple rib x. Small bowel perforation ultiple rib x. Sacral plexus injury emur x. 3 <24 hr 21 <24 hr 3 5 4 10 7 4 5 1 11 1 23 11 1 1 20 Poor Poor oderate oderate oderate Wound infection DVT CRPS Sciatic nerve palsy SI joint arthritis : ale, : emale, TA: Traffic accident, x: racture, DVT: Deep vein thrombosis, CRPS: Complex regional pain syndrome, SI: Sacro-Iliac. 2 예로나타났고골반환의전위는수술전평균. mm (7 12 mm) 에서수술후평균 3.25 mm (1 6 mm) 로 6.65 mm 호전되었다. 또한완전불안정손상에서해부학적정복 6 예, 준해부학적정복 예, 불량 1 예로나타났고골반환의전위는술전평균.6 mm (10 2 mm) 에서술후평균 5. mm (2 25 mm) 로 7. mm 호전되었다. Rommens 와 Hessmann 20) 의임상적평가는부분불안정손상에서우수 6 예, 양호 1 예, 보통 1 예를보였다. 또한완전불안정손상에서우수 7 예, 양호 4 예, 보통 4 예를보였다. 또한부분불안정손상에서평균.4 주 (10 20 주 ) 에골유합을얻을수있었으며, 완전불안정손상에서.5 주 ( 22 주 ) 에골유합을얻을수있었다. 수술후합병증으로부
불안정성골반환손상의수술적치료 247 분불안정손상에서천장관절에대한경피적나사못고정술시행후 L5 신경근의손상소견이 1 예발생하였으며, 지속적후방골반통증호소하는환자의방사선사진상천장관절의관절염이 1 예발생하였다. 또한완전불안정손상에서수술부위의창상감염이 1 예발생하였고, 복합부위통증증후군 1 예가관찰되었으며, 타장기손상이동반되어수술적처치가 3 주가량지연되었던환자에서심부정맥혈전증 1 예가발생하였다 (Table 1). 고 불안정골반환손상은보존적치료를할경우오랜기간침상생활을해야하며, 시간이경과할수록골절부위의정복이쉽지않고전위가발생할가능이높기때문에추후합병증및장해발생률이높은반면 25), 조기에수술적치료를할경우빠른재활및회복을기대할수있고, 장해발생위험도를줄일수있다 4,11,12). 수술적치료방법은매우다양하고손상의양상에따라적절한치료방법을선택할수있는데, 외고정술은회전력에는불안정하나수직전단력에는안정적인골반환손상에서근본적인치료로사용할수있고 ), 환자의생체징후가불안정한응급상황에서가장빨리시행할수있다는장점이있다. 그러나정복의소실이많고핀부위감염의위험성이있으며환자의불편감으로장기간유지하기어려운단점이있어사용이제한된다 12,,25). Ward 등 31) 은외고정장치가수직전단력에는불안정하기때문에추가적인견인이나후방의금속판고정이필요할수있다고하였으며, 최근에는내고정술이외고정술의단점을줄이고, 생역학적으로안정되며기능적으로우수한결과를보이기때문에여러저자들에의해불안정골반환손상의주된치료법으로사용되고있다 1,20). 후방골반환의내고정술은크게후방접근법과전방접근법으로구분할수있는데후방접근법은천골골절이나천장관절의분리가있을때천추봉 (sacral bar) 이나금속판을이용하며건측의골반에고정시키는방법으로생역학적안정성을가지지만, 과도하게압박되어신경손상의가능성이있고양끝이튀어나와환자가불편감을호소할수있다 7). 또한후방접근법에따른금속판고정술은직접적으로천장관절을볼수없기때문에정확한정복이안될수있고, 수상당시대부분후방의연부조직손상이동반되기때문에심부감염의합병증이발생할가능성이높은것으로알려져있으며,1,25) Kellam 등 ) 은연부조직괴사를 25% 까지보고하였다. 반면전방접근법을통한천장관절전방의금속판고정술은 Simonian 등 24) 이생역학적연구에서우수한고정력을보고하였고, 수술중환자의위치변 찰 화없이한번에치골결합이개및골절에대해서도수술을시행할수있으며, 천장관절을직접볼수있기때문에해부학적정복이가능하여많이사용되고있으며 1,27), in 등 ) 은이러한전방금속판고정술을이용한치료후좋은결과및유용성에대하여보고하였다. 그러나금속판고정시제5 요추신경근및상측둔동맥의손상가능성이있으며, 천골골절부위를잘보기어렵다는단점이있다. 저자들은전위가심한후방골반환손상 예에대하여전방접근법을통한금속판고정술시행한결과충분한고정및만족할만한결과를얻었으나수술후일시적인하지저림증세가 2예에서발생하였고추시관찰중모두회복되었는데이는골절부정복및금속판고정시과도한견인으로인한신경자극에의하여발생하였을것으로판단되었으며향후수술시주의가필요할것으로생각하였다. 최근에는골절부를노출시키지않고유관나사를이용하여제1 천추체및제2 천추체로고정하는방법이많이사용되고있으며 Oh 등 ) 은전방금속판고정및장-천골나사못고정술의유용성을주장하였다. 이는생역학적안정성이있으며 5) 특히전방에금속판고정술을먼저시행하는경우후방골반환손상이간접적으로정복이되기때문에그안정성이더욱증가하는것으로알려져있다 22). 또한절개가적고수술시간이짧기때문에연부조직의문제및출혈이적다는장점이있다. 그러나환자마다천골의해부학적차이가있거나 ), 복부음영이많아정확한영상을얻기어려운경우잘못된위치로의나사못삽입으로혈관, 제5 요추신경근및제1 천추신경근의손상을가져올수있고, 나사못고정력의약화로정복의소실과이로인한불유합혹은부정유합이발생할수있는단점이있다 21,23). 또한 Griffin 등 6) 은경피적나사못고정술이불안정성골반손상에효과적이나천골골절에서는고정실패에대하여주의하여야한다고하였다. 그러나최근에는정확한나사못삽입을위하여전산화단층촬영영상을보면서나사못을삽입하고 30) 더견고한나사못고정을위하여 S1 추체에 2개의나사못을고정하거나, S1 추체와 S2 추체에각각의나사못고정을시행하여좋은결과를얻은연구들이보고되고있다 10). 저자들의경우치골결합부이개를동반한천장관절분리 예 (형) 에대하여 pfannestiel 접근법과 bone hook과 Schanz 나사못을이용하여하방으로견인및정복한후전방골반환에금속판고정을시행하였고이후후방골반환이간접적으로정복이되는것을확인하고장골피질골외측에서 S1추체에경피적장-천골나사못고정술을시행하였다. 이후정복의소실등은발생하지않았으나술후합병증으로 1예에서나사못고정시 S1 천추공으로나사못돌출이발생하였는데하지의저린감및좌골신경마비증상보여즉시나사못을제거하였고이후증상의호전
24 이상홍, 하상호, 이영관, 조성원, 박상수 을보였다. 그리고천장관절분리가동반된, 형의경우장서혜부도달법을통하여전방골반환에금속판고정을시행한후, 천장관절부위에 1 개혹은 2 개의재건금속판을사용하여장골과천골에 2 개이상의나사못고정을시행하였고, 양측성불안정손상인 C3 형의경우전방골반환및천장관절에금속판을고정및추가로외고정기기를 4 주간장착하였다. 수술후에는, C3 의경우최소 4 6 주간안정가료를시행하였다. 수상으로부터수술까지의시간은평균 일이소요되었는데, 대부분골절에의한출혈이멈추고, 술후감염등의위험성을줄이기위하여연부조직의부종이가라앉기를기다려 7 일전후로수술을시행하였고이경우일시적인외고정은시행하지않았다. 수술시간이오래지연되는경우는일시적으로견인이나외고정장치를시행하는것을원칙으로하고있으나본연구에서 1 예는소장파열로외과에서응급수술후복부창상문제로, 1 예는간열상으로절대안정이필요하여외고정을하지못하였다. 환자대부분내원시혈압감소및맥박의증가등불안정한생체징후를보였으나수액및 packed red cell 투여, 그리고측방압박이아닌경우는 pelvic binder 를통해서안정화되었고, 2 예에대해서는회복소견이보이지않아혈관조형술을시행하여혈관손상유무를확인하였다. 술후방사선학적평가에서는 1 예에서해부학적으로불량한정복이발생하였는데 AO C3 형의증례로수상당시 1 등급의간열상이동반되어중환자실에서절대안정후 3 주경과하여수술적치료를시행하였던경우로골반환의후상방전위가관혈적정복으로도용이하지않았으며, 술후천장관절관절염으로보행시지속적인통증으로임상적평가에서도불량의소견을보였다. 임상적평가에서는 3 예에서보통의결과를얻었는데수상당시천골골절이동반되면서요 천추신경총손상으로좌골신경마비증상을보였던 2 예모두최종추시에서도동통및운동장해, 감각이상을호소하였고, 나머지 1 예의경우정복상태는양호하였으나술후복합부위통증증후군으로비특이적인통증을호소하였다. 이를통해수상당시다른장기의손상으로수술적치료가지연되거나신경손상이동반된경우환자의예후에악영향을미칠것으로판단되었고, 이는다른연구에서도비슷한결과를보였다 7,,2). 그외합병증으로 1 예에서수술부위표재성창상감염이발생하였는데술후배뇨장애로배뇨관지속적으로유지하였던경우로항생제치료로호전되었고, 심부정맥혈전증이발생한 1 예의경우헤파린주사및와파린복용으로증상의호전을보였다. 본연구는환자수가적어후방골반환손상의다양한형 태를모두반영하지못하고있으며, 단일수술법이아닌 2 가지수술결과를대상으로하여술후결과를정확하게평가하는것은제한점이있을것으로판단된다. 결 저자들은불안정성골반환손상의후방불안정정도및전위정도에따라 AO/OTA 분류로구분하여, 비교적상하전위가심하지않은 B 형손상대하여전방에금속판고정술을시행하고환자의체위변화없이후방에천장관절에경피적나사못고정술을시행하였다. 상하전위가심한 C 형손상에대하여장서혜도달법을이용한금속판고정술을시행하여양호한결과를얻을수있었다. 불안정성골반환손상에서전위및불안정정도에대한분석후이와같은기준으로수술적방법을선택하여시행함으로써좋은결과를얻을수있을것으로생각한다. 론 참고문헌 1) Atlihan D, Tekdemir I, Ateŝ Y, Elhan A: Anatomy of the anterior sacroiliac joint with reference to lumbosacral nerves. Clin Orthop Relat Res, (376): 236-241, 2000. 2) Bucholz RW: The pathological anatomy of algaigne fracture-dislocations of the pelvis. J Bone Joint Surg Am, 63: 400-404, 11. 3) Bucholz RW, Peters P: Assessment of pelvic stability. Instr Course Lect, 37: 11-127, 1. 4) Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma, 30: 4-56, 10. 5) Comstock CP, van der eulen C, man SB: Biomechanical comparison of posterior internal fixation techniques for unstable pelvic fractures. J Orthop Trauma, 10: 5-522,. 6) Griffin DR, Starr AJ, Reinert C, Jones AL, Whitlock S: Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure? J Orthop Trauma, 20 Suppl 1: S30-36, 2006. 7) Keating J, Werier J, Blachut P, Broekhuyse H, eek RN, O'Brien PJ: Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma, : 107-1, 1. ) Kellam J, curtry RY, Paley D, Tile : The unstable pelvic fracture. Operative treatment. Orthop Clin
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