The relative merits and indications for operative management of Young-Burgess lateral compression type 1 (LC1) pelvic ring injuries (AO/OTA 61-B1/B2) continues to be debated [[1], [2], [3]] and wide variation in operative decision making exists [4]. Despite this, the prevalence of operative management is growing due to some evidence showing an ability to improve acute pain, ambulation, and functional outcomes [[4], [5], [6], [7], [8], [9], [10], [11], [12]]. Whilst the debate has largely focused on surgical indications, less considered has been the importance of anterior ring stability and if surgery is performed, does fixation matter and is there a gold standard?

Central to the decision to operate on LC1 fracture patterns has been determination of fracture instability [13]. This has been based mainly on radiographic parameters, examination under anaesthesia (EUA) [[14], [15], [16]], or failure of a ‘trial of mobilization’ [4,17]. Fracture displacement [8,17] and fracture patterns have been used independently or in conjunction for decision making [[18], [19], [20], [21], [22]]. The consensus for instability has been defined as >1 cm of displacement on stress imaging [16,23]. Surgery, if successful, should provide the pelvic ring with sufficient stability to maintain structure and function under physiologic load to prevent displacement and deformity [24]. Theoretically, greater construct stability could correlate with improvements in acute pain, ambulatory ability, functional outcomes and potentially fracture healing. If a surgical construct cannot maintain reduction or stability of the pelvic ring, the question that could be asked is: what benefit did surgery have?

Fixation of unstable LC1 injuries typically includes posterior iliosacral and/or trans-sacral screws based on sacral fracture pattern and bone quality [7,12,20,25], with large variance in the surgical management of the anterior ring [4,6,7,9,20,26]. Treatment of the anterior ring injury may include no fixation [4,7,9,18,20,27,28], indirect fixation in the form of external fixators [7,28,29], or InFix devices [14,30], and internal fixation with percutaneously applied screw fixation being the most popular modern construct [28], but also the most technically challenging [31]. In some circumstances, open reduction and internal fixation (ORIF) may be applied, with added morbidity from the open approach [7,8,28]. Each of these anterior fixation options has strengths and weaknesses, but there is a dearth of literature discussing outcomes between different constructs or comparing outcomes of different percutaneous screw types [5,13]. No consensus exists as to what, if any, fixation to apply [32].

This study used contemporary data and modern implants to ask: In patients receiving surgical fixation of Young-Burgess lateral compression type 1 (LC1) pelvic ring injuries (AO/OTA 61-B1/B2) when the posterior ring has been stabilized, (1) is fixation of the anterior ring required, (2) is indirect or internal fixation favored, and (3) are there differences between long and short percutaneous screws for stabilization of the anterior ring?