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Management of Pelvic Organ Prolapse Vincenzo Li Marzi
https://textbookfull.com/product/management-of-pelvic-organ- prolapse-vincenzo-li-marzi/ Axel Gänsslen Jan Lindahl Stephan Grechenig Bernd Füchtmeier Editors
Pelvic Ring Fractures
123 Pelvic Ring Fractures Axel Gänsslen • Jan Lindahl Stephan Grechenig • Bernd Füchtmeier Editors
Pelvic Ring Fractures
Editors Axel Gänsslen Jan Lindahl Department of Trauma Surgery, Orthopedics and Orthopaedics and Trauma Surgery Hand Surgery Helsinki University Hospital Hospital Wolfsburg Helsinki Wolfsburg Finland Germany Bernd Füchtmeier Stephan Grechenig Klinik für Unfallchirurgie Klinik für Unfallchirurgie Krankenhaus Barmherzige Brüder Krankenhaus Barmherzige Brüder Regensburg Regensburg Bayern Bayern Germany Germany
ISBN 978-3-030-54729-5 ISBN 978-3-030-54730-1 (eBook)
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Preface
High-energy pelvic fractures continue to present a serious challenge to trauma care. Over the last five decades, our knowledge has increased on the assessment, trauma mechanisms, clas- sification, and management protocols for this particular, potentially lethal injury. During the 1970s, the patho-anatomical pattern of a lethal vascular injury was revealed in post-mortem studies by Huittinen and Slätis in 1973. At the same time (1972), the first case report by Margolies et al. was published on the use of angiographic embolization in the emer- gency treatment of pelvic fracture-related arterial bleeding. The last decades have been a time of rapid progress in the control of pelvic fracture-related mortality and morbidity. A better understanding of the anatomic features of these fractures and an awareness of potential major, exsanguinating arterial hemorrhage have led to multidisciplinary approaches for controlling bleeding and temporarily stabilizing the pelvic ring. After the wide adoption and successful outcomes of external skeletal fixation devices for the treatment of extremity injuries, interest was focused on the use of these devices in pelvic fracture management first by Carabalona et al. (1973) and Slätis and Karaharju (1975). In the 1980s, the concept of internal fixation was introduced, for both anterior and posterior aspects of the pelvis, based on previous biomechanical studies. The mechanical understanding of the pelvic ring structure, estimated direction of the major force vector, and the degree of pelvic instability lead to the current comprehensive classifica- tion system of pelvic ring injuries, which combines the AO classification and the Orthopaedic Trauma Association’s (OTA) classification system with the Tile classification. The highly difficult pelvic area, including the special three-dimensional bone structure and the pelvic organs and the intrapelvic neurovascular structures, needs a comprehensive under- standing to the peri- and intrapelvic anatomy. Therefore, the connection of anatomy and surgery is the predominant basis of adequately treating patients with pelvic ring injuries. At the entrance of the Institute of Anatomy in Graz, two relevant statements accompany every participant before entering the dissection area. These statements have influenced the authors in numerous courses and ultimately to a significant increase of knowledge in pelvic ring injury treatment: “Ärzte ohne anatomische Kenntnisse gleichen Maulwürfen: Sie arbeiten im Dunkeln und ihrer Hände Tagewerk sind – ERDHÜGEL” “Surgeons without anatomy are like moles: They work in the dark and their hands work are EARTH HILLS.” (Tiedemann)
“Anatomie ohne Klinik ist tot – Klinik ohne Anatomie ist tödlich” “Anatomy without clinic is dead—Clinic without anatomy is deadly.” (Platzer)
Historically, Albin Lambotte (1907 and 1913) was the first who proposed several options for the surgical treatment of different fractures of the anterior and posterior pelvic ring includ- ing screw, plate, and wire stabilization techniques. For symphysis pubis, Lambotte described both screw and plate fixation techniques, and for sacral fractures open posterior iliosacral
v vi Preface
screw fixation and sacral bar fixation techniques. Today, it is widely accepted that internal fixa- tion of all unstable injuries in the anterior and posterior pelvic ring provides superior stability for the whole pelvis and better anatomical results as determined by the quality of reduction and lower malunion rate. The treatment of injuries of the posterior pelvic ring need a demanding understanding of the posterior pelvic ring anatomy, even for experienced surgeons, due to different fracture mor- phology. The close relationship of relevant neurovascular structures and the biomechanical significance of the posterior pelvic ring requires a maximum of anatomical and surgical knowl- edge in order to achieve an optimal long-term outcome, as mild persistent malhealing can lead to relevant clinical impairments. The development of special preoperative, intraoperative, and post-operative radiological techniques now allows a much better understanding of this region for the treating surgeon. Overall, treating a patient with a pelvic ring injury should lead the surgeon to focus on mechanical and hemodynamic stabilization. Therefore, sophisticated clinical–radiological diagnostics with the appropriate evaluation of parameters for an optimal, individual indication, pelvic ring region-specific approaches, and a detailed understanding of detailed reduction and fixation techniques are necessary. During the last decade, a trend to more less invasive techniques can be drawn from the lit- erature. Accordingly, an emphasis in this book was placed on stabilization techniques of spe- cific fracture locations, the relevant intraoperative imaging techniques in a practice-oriented manner and their results of treatment. In addition, specific problems in age extremes (paediatric and geriatric) and in osteoporosis as well as the current knowledge of late deformities are presented in detail. We felt that a text- book that provides a comprehensive overview of these injuries would provide a practical approach to the learner as well as the experienced orthopaedic trauma surgeon.
Wolfsburg, Germany Axel Gänsslen
Helsinki, Finland Jan Lindahl Regensburg, Germany Stephan Grechenig Regensburg, Germany Bernd Füchtmeier Acknowledgements
The authors would like to thank the whole team of the Institute of Anatomy of the Medical University of Graz for years of help and their outstanding anatomical and surgical expertise. In particular, our very special thanks are given to Professor Wolfgang Grechenig, Graz University Hospital and Professor Friedrich Anderhuber (†), former Chair of the Institute of Anatomy, Medical University of Graz, Austria, for having the opportunity to perform anatomi- cal studies with their cadavers and to teach pelvic surgery on their courses with practical exer- cises on human specimens during the last two decades. Additionally, we would like to thank our friends Peter Tesch, Andreas Weiglein, and Georg Feigl. The frequent outstanding discussions and the didactic presentations of the anatomical basis at the institute have considerably enlarged our knowledge in this field and became the basis of our daily practice. Special thanks also to our European friends, especially the support by Bore Bakota, and Mario Steresinic, which led to our increasing knowledge in the field of pelvic ring surgery. It is a great pleasure for us to know you all and to work with you.
vii Contents
Part I Introduction
1 The History of Pelvic Fracture Treatment��������������������������������������������������������������� 3
Axel Gänsslen and Jan Lindahl 2 Surgical Anatomy of the Pelvis ��������������������������������������������������������������������������������� 15 Norbert Peter Tesch, Axel Gänsslen, Jan Lindahl, Wolfgang Grechenig, and Georg Feigl 3 Biomechanics of the Pelvis����������������������������������������������������������������������������������������� 47 Peter Grechenig, Axel Gänsslen, Stephan Grechenig, and Bernd Füchtmeier 4 Classification of Pelvic Ring Injuries ����������������������������������������������������������������������� 63 Christoph Grechenig, Stephan Grechenig, Gloria Hohenberger, Axel Gänsslen, and Jan Lindahl 5 Prehospital Treatment of Suspected Pelvic Injuries ����������������������������������������������� 89 Mario Staresinic, Bore Bakota, Stephan Grechenig, and Axel Gänsslen 6 Inhospital Clinical Examination������������������������������������������������������������������������������� 99 Stephan Grechenig, Christian Pfeifer, and Axel Gänsslen 7 Radiological Diagnostics��������������������������������������������������������������������������������������������� 107 Peter Grechenig, Stephan Grechenig, Bore Bakota, and Axel Gänsslen
Axel Gänsslen and Jan Lindahl 9 Emergency Stabilization: Pelvic Binder������������������������������������������������������������������� 135 Axel Gänsslen, Jan Lindahl, and Bernd Füchtmeier 10 Emergency Management: Pelvic C-Clamp��������������������������������������������������������������� 141 Axel Gänsslen and Jan Lindahl 11 Mechanical Stabilization: DC-Osteosynthesis��������������������������������������������������������� 151 Axel Gänsslen, Bore Bakota, Mario Staresinic, and Gloria Hohenberger 12 Pelvic Packing������������������������������������������������������������������������������������������������������������� 157 Axel Gänsslen and Jan Lindahl 13 Direct Hemorrhage Control: Vascular DC-Treatment������������������������������������������� 171 Jan Lindahl and Axel Gänsslen 14 Emergency Management: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) ����������������������������������������������������������������������������� 179 Axel Gänsslen and Jan Lindahl
Jan Lindahl and Axel Gänsslen 16 Coagulation Management ����������������������������������������������������������������������������������������� 213 Jan Lindahl and Axel Gänsslen 17 Open Pelvic Fractures ����������������������������������������������������������������������������������������������� 215 Jan Dauwe and Axel Gänsslen 18 Morel-Lavallée Lesions����������������������������������������������������������������������������������������������� 235 Bernd Füchtmeier, Franz Müller, Stephan Grechenig, and Axel Gänsslen 19 Pelvic Compartment Syndrome��������������������������������������������������������������������������������� 243 Axel Gänsslen and Stephan Grechenig 20 Traumatic Hemipelvectomy��������������������������������������������������������������������������������������� 251 Bore Bakota, Mario Staresinic, and Axel Gänsslen 21 Urological Trauma ����������������������������������������������������������������������������������������������������� 269 Axel Gänsslen and Stephan Grechenig
Part III Treatment of Pelvic Ring Injuries
22 Principles of Treatment of Pelvic Ring Injuries������������������������������������������������������� 277
Jan Lindahl and Axel Gänsslen 23 Symphyseal Disruption����������������������������������������������������������������������������������������������� 285 Axel Gänsslen, Jan Lindahl, and Wolfgang Grechenig 24 Retrograde Pubic Rami Screw����������������������������������������������������������������������������������� 307 Franz Müller, Bernd Füchtmeier, Axel Gänsslen, and Jan Lindahl 25 External Fixation ������������������������������������������������������������������������������������������������������� 317 Franz Müller, Axel Gänsslen, and Jan Lindahl 26 Subcutaneous Anterior Pelvic Fixation��������������������������������������������������������������������� 337 Bernd Füchtmeier, Franz Müller, and Axel Gänsslen 27 Ilium Fractures����������������������������������������������������������������������������������������������������������� 341 Axel Gänsslen and Jan Dauwe 28 Anterior Plating of the SI Joint��������������������������������������������������������������������������������� 355 Jan Lindahl, Axel Gänsslen, and Peter Grechenig 29 SI Joint: Posterior Reduction and Stabilization������������������������������������������������������� 371 Jan Lindahl and Axel Gänsslen 30 Fracture Dislocations of the SI Joint������������������������������������������������������������������������� 377 Axel Gänsslen and Jan Lindahl 31 Iliosacral Screw Fixation ������������������������������������������������������������������������������������������� 393 Axel Gänsslen, Jan Lindahl, and Philipp Kobbe 32 Local Sacral Plating��������������������������������������������������������������������������������������������������� 437 Axel Gänsslen and Jan Lindahl 33 Lower Transverse Sacral Fractures ������������������������������������������������������������������������� 451 Axel Gänsslen and Jan Lindahl Contents xi
Bernd Füchtmeier, Franz Müller, and Axel Gänsslen 35 Lumbopelvic Fixation������������������������������������������������������������������������������������������������� 473 Jan Lindahl and Axel Gänsslen
Part IV Special Situations
36 Pediatric Pelvic Ring Injuries ����������������������������������������������������������������������������������� 503
Annelie-Martina Weinberg and Axel Gänsslen 37 Avulsion Injuries��������������������������������������������������������������������������������������������������������� 521 Axel Gänsslen and Annelie-Martina Weinberg 38 Fragility Fractures ����������������������������������������������������������������������������������������������������� 535 Franz Müller, Bernd Füchtmeier, Jan Lindahl, and Axel Gänsslen 39 Intraoperative 3D Imaging of the Pelvic Ring��������������������������������������������������������� 543 Benedict Swartman, Jochen Franke, Paul Alfred Grützner, Holger Keil, and Axel Gänsslen 40 Implant Removal��������������������������������������������������������������������������������������������������������� 559 Christian Pfeifer and Axel Gänsslen 41 Infectious Complications After Pelvic Ring Surgery����������������������������������������������� 567 Gloria Hohenberger, Axel Gänsslen, Mario Staresinic, and Jan Lindahl 42 Pelvic Malunion and Nonunion��������������������������������������������������������������������������������� 577 Jan Lindahl and Axel Gänsslen 43 Outcome After Pelvic Ring Injuries ������������������������������������������������������������������������� 603 Axel Gänsslen and Jan Lindahl About the Editors
Axel Gänsslen, MD is a Consultant in Trauma Surgery in the
Trauma Department, Wolfsburg General Hospital Wolfsburg, Germany. Since 2012, he has also been Chairman of the AO Trauma Course—Pelvis and Acetabulum in the Department of Anatomy, University of Graz, Austria. Dr. Gänsslen graduated from Hannover Medical School (MHH) in 1993 and subse- quently undertook a number of residencies in trauma surgery before becoming a Consultant in Trauma Surgery in the Trauma Department of Hannover Medical School in 2006. Since 1994, he has been Regional/International Faculty on more than 100 AO Trauma courses. He is the author of numer- ous papers in peer-reviewed journals as well as 5 books and more than 50 book chapters.
Jan Lindahl, MD, PhD is Head of the Pelvis and Lower
Extremity Orthopaedic and Trauma Surgery Ward at Helsinki University Hospital and Adjunct Professor (Docent) in Orthopaedics and Traumatology at the University of Helsinki, Finland. He graduated from the University of Tampere in 1986 and subsequently completed specializations in Orthopaedics and Traumatology and General Surgery at the University of Helsinki before taking up his current post in 2000. Dr. Lindahl has been chairman of AO Trauma, Finland, since 2010 and is a past president of the Finnish Trauma Association, of which he was a founding member. He has received various awards, including the Hughston Award for best paper published in the American Journal of Sports Medicine in 2006. He is the author of almost 50 original articles and more than 30 book chapters, predominantly on management of injuries of the pelvic ring and acetabulum, fractures of the lower extremities, and knee injuries.
xiii xiv About the Editors
Stephan Grechenig, MD, Priv. Doz. Dr. Med. Univ. is a
resident in Orthopaedic and Trauma Surgery at the Clinic for Trauma Surgery, Orthopaedics and Sports Medicine, Krankenhaus Barmherzige Brüder, Regensburg, Germany. He graduated from Medical School at the University of Graz, Austria, in 2013 and subsequently was a post- doc in Musculoskeletal Biomechanics at the AO Research Institute, Davos, Switzerland, and a resident in Trauma Surgery at the University Medical Center, Regensburg, Germany. He is a member of AO Trauma, the AO Faculty Group, and the German Society for Trauma Surgery (DGU) and is the author of almost 50 PubMed-listed articles.
Bernd Füchtmeier, MD is Head of the Department for
Trauma and Orthopaedic Surgery at the Krankenhaus Barmherzige Brüder, Regensburg, Germany. After graduating from Medical School in Hannover, he undertook extensive training in orthopaedic surgery. Dr. Füchtmeier was appointed as a consultant in the Department of Traumatology, Regensburg University Clinic in 2001 and subsequently became Head of the Section of Pelvic Surgery and Arthroplasty. He gained his habilitation in trauma surgery in 2007. In 2008, he was appointed senior consultant in the Clinic for Trauma Surgery, Orthopaedics, and Sports Medicine at Krankenhaus Barmherzige Brüder. Prior to taking up his current position, he was a consultant at the Center for Musculoskeletal Surgery, Charité University Clinic, Berlin. In 2011, Dr. Füchtmeier was appointed Associate Professor in the Medical Faculty, University of Regensburg. He is a member of the Advisory Board for AO Trauma, Germany. Part I Introduction The History of Pelvic Fracture Treatment 1 Axel Gänsslen and Jan Lindahl
First experiences with pelvic ring fractures were reported in
the nineteenth century by analysis of clinical courses and autopsy findings [1–7].
1.1 Malgaigne´s Fractures
It was not until Malgaigne in 1847, who reported ten pelvic
fracture cases (Fig. 1.1) and defined the double vertical frac- ture of the pelvis [8]. A detailed description of pelvic ring injuries was reported. He distinguished between the follow- ing injuries:
• Sacrum fractures • Iliac crest fractures • Pubic fracture • Fractures of the ischium • Double vertical fractures of the pelvis Fig. 1.1 Dysmorphic sacral bone and left anterior ring fracture from Malgaigne´s textbook
1.2 Sacrum Fractures Isolated sacral fractures most commonly were the result of a direct blow from a fall and hit against the distal sacrum, Only one case was seen in a group of 2358 patients. Two pos- which resulted in an angular deformity of the fracture with sible fracture types were distinguished: an open anterior angle. Malgaigne treated three of these cases [9]. • Isolated sacral fractures Closed digital reduction was recommended by fracture • Sacral fractures as part of a pelvic ring injury manipulation using a finger inserted into the rectum. Additionally, a wooden cylinder or comparable measures can be introduced into the rectum for temporary stabilization of the fracture. A. Gänsslen (*) More complex injuries of the sacrum as part of a pelvic Department of Trauma Surgery, Orthopedics and Hand Surgery, Hospital Wolfsburg, Wolfsburg, Germany ring injury were associated with a high mortality rate. Malgaigne cited a case from Guérétin with a horizontal frac- J. Lindahl Orthopaedics and Trauma Surgery, Helsinki University Hospital, ture and two vertical fractures, potentially representing the Helsinki, Finland first described lumbo-pelvic dissociation injury. Additionally, e-mail: [email protected] he observed one case of a coccyx fracture.
A. Gänsslen et al. (eds.), Pelvic Ring Fractures, https://doi.org/10.1007/978-3-030-54730-1_1 4 A. Gänsslen and J. Lindahl
1.3 Iliac Crest Fractures 1.7 K
nowledge on Pelvic Fracture Treatment Before X-Ray Availability Iliac crest fractures are the result of a direct blow against the ilium. These fractures were often undisplaced or showed Gurlt reported first epidemiological data on pelvic ring inju- intrapelvic displacement. Manual direct or indirect ries in 1862 [10]. In an analysis of 22,616 fractures, treated manipulation was recommended for reduction. The progno- at the London Hospital between 1842 and 1862, 70 pelvic sis was mainly influenced by accompanying injuries of the fractures were reported (0.31%). pelvic region. Rose described eight cases with pelvic ring injuries in a group of 800 adult patients with fractures [11]. Thus, 1% of all fractures are pelvic ring fractures. Considering also iliac 1.4 Pubic Fractures crest fractures, acetabular rim fractures, transverse fractures of the sacrum and coccyx, and one case with a bullet frac- The most common mechanism is a direct injury with differ- ture, 2% of all fractures were pelvic fractures. ent forces acting on the pubic region, but sometimes also an Leisrink analyzed 470 fractures and reported on five pel- indirect mechanism (fall on the buttock) can result in pubic vic injuries (1.1%) [12]. fractures (Fig. 1.1). A high variability of fracture locations In a further analysis from 1880 by Gurlt, 51,938 fractures is possible. The healing potential is good. Concomitant were analyzed from the years 1842–1877 [13]. One hundred bladder or urethral injuries were associated with relevant forty-two pelvic fractures (0.273%) and 15 coccyx fractures mortality. (0.028%) were treated. The majority of these fractures were admitted to a hospital (91.7%).
1.5 Fractures of the Ischium
Pelvic ring injuries are rare with an expected incidence Avulsion injuries and complete ischium fractures with two of 0.3–1% in historical analyses. fracture lines were discussed: one fracture below the acetab- ular level and the other fracture line at the connection between the inferior pubic ramus and the true ischial bone. Treatment is predominantly conservative by bed rest until 1.8 Mechanism of Injury pain was acceptable to allow walking. Typical injury mechanisms included roll-over injuries, crush mechanisms, and fall from a great height [14]. Crush 1.6 Double Vertical Fracture injuries were frequently observed from train or mining injuries. Malgaigne was the first to describe this special entity of pel- vic ring injuries and recognized that these injuries merit spe- cial attention in respect to diagnosis, prognosis, and 1.9 Pathoanatomy treatment. Double vertical fractures of the pelvis were defined as multiple pelvic fractures. Typically, two vertical Rose stated, according to Malgaigne, that every pelvic fracture components are present on one pelvic side, separat- fracture consists of at least two parallel fracture lines in the ing the hip joint (floating acetabulum), leading to hemipelvic pelvis axis [11]. Of these, often, one vertical split is run- cranialization and internal rotation deformity with resulting ning through the symphysis or SI joint. The majority of leg length inequality. detected injuries before his analysis consisted of non-survi- The anterior ring injury was usually an upper and lower vors, and the type of pelvic injury was described during pubic rami fracture, while the posterior injury most often autopsy. was a complete ilium fracture or rarely a sacrum fracture or Theodor Billroth reported on 43 fractures of the pelvis a sacroiliac (SI) joint injury. [15]. Of these, 28 patients survived. He reported one case Compared to the other pelvic injury types, higher forces of a traumatic hemicorporectomy after a train roll-over acted on the pelvis (fall from height, pelvic crush mecha- injury in a 6-year-old child, who died within 1 h after the nisms, etc.). Variable displacement and clinical deformity injury. No relevant bleeding was observed from the tran- were observed. Treatment was stated more difficult in trying sected pelvic vessels. The majority of patients died due to to correct the deformity, which sometimes was performed septical problems. Billroth described the clinical diagnos- using traction methods. tics in detail. 1 The History of Pelvic Fracture Treatment 5
Clinically, a lateral pelvic compression, pressure to the • A postpartum symphyseal widening after primary deliv- symphysis, and rectal exploration allow for detection of ery [20]. bony instability and local pelvic pain. Additionally, after • Symphyseal disruption during labor/sport after forceful exclusion of relevant accompanying injuries, further signs, adductor contraction [21]. indicative of a pelvic injury after major forces acting to the • Geriatric fracture after simple fall on the left body result- pelvic region, include impossible standing and walking. ing in left pubic rami fractures with accompanying obtu- Bladder voiding disturbances were frequently observed, and rator vein injury (cause of death) [22]. Billroth expected a temporary paralysis of the bladder detru- sor nerves and muscles. Areilza (1891) reported on 13 cases after lateral compres- Suspected injury mechanisms included forces, acting by sion forces [23]. These injuries were associated with four anterior-posterior or lateral compression to the pelvic area, crush urethral stretch injuries and three urethral disruptions (all mechanisms from heavy loads, and a fall from a great height. three patients died). Pathoanatomical observations presented typical pelvic In 1895, Katzenelson analyzed part of the literature and injury types: distinguished between five possible injury mechanisms [24]:
• Symphyseal disruption • Eleven cases after frontal force transmission: seven deaths • Ilium fractures (63.6%), five urethral and two bladder lacerations; 60% • Uni- or bilateral double vertical (anterior and posterior) of urethral lesions survived. fractures • Four cases after anterior sagittal force transmission: two • Hemipelvic dislocations deaths (50%), one urethral laceration and two bladder lacerations. Pelvic injuries with additional pelvic organ injuries were • Four cases after lateral force transmission to the hemipel- associated with a high mortality rate. vis: 2× type A2, 2× type C1.2 injuries; three deaths (75%), Conservative treatment is usually necessary for two urethral and two bladder lacerations. 4–8 weeks, and despite some mal-healing, most often, no • Six cases after posterior sagittal force transmission: four relevant subjective complaints were reported. deaths (66.6%), two urethral and two bladder lacerations. • Five cases after muscular contraction: one death (20%) Theodor Billroth already in 1869 described clinical after a fall from 12 m height with bladder laceration examination techniques, typical injury mechanisms, (pubic avulsion), all others with uneventful course. fracture types, and risk factors of mortality, which are still valid today [15].
1.10 Clinical Diagnostics
Several case descriptions were reported in the literature after this overview, and an increasing rate of survivors was Drechsler summarized the knowledge from the nineteenth reported. Interesting results included: century in 1891 [25]. Typical clinical signs, indicative of pel- vic fractures/injuries according to Rose, included: • Complex pelvic trauma with urethral disruption and a lat- eral compression type C injury with bilateral pubic rami • Localized pain on palpation fractures, symphyseal disruption, and a complete transfo- • Bladder voiding disturbance raminal sacrum fracture; death [16]. • Iliopsoas pain and functional disturbance • Open spino-pelvic dissociation injury (symphyseal dis- ruption, crescent fracture, contralateral sacrum fracture Additionally, Drechsler recommended further potential with a transverse component at the S1 level); death signs of a pelvic ring injury: [17]. • Complete posterior hemipelvic dislocation injury after • Local ecchymosis crush injury mechanism [18]. • Bowel disturbances • Complete anterior hemipelvic dislocation after a hit by a heavy load from posterior and lateral [19]; four of six Classical fracture signs, e.g., displacement and crepita- cases in the analyzed literature died (concomitant pelvic tion, were infrequently observed due to the soft tissue mantle organ injuries). around the pelvis. 6 A. Gänsslen and J. Lindahl
1.11 Experimental Analyses Kusmin performed experimental studies on cadaver pel-
ves based on classical clinical injury mechanisms derived Fere performed experimental side impacts on whole body from the literature [14]. cadavers from a height of 50–60 cm. In elderly cadavers, Anterior-posterior/posterior-anterior compression forces anterior ring lesions were frequently observed; sometimes, a resulted in (Fig. 1.2a): symphyseal disruption occurred; with increasing forces, a second injury site was detected at the posterior pelvic ring • Upper pubic ramus fractures at the level of the pubic (ilium, sacrum, or SI joint). In younger cadavers, no injuries tubercle or at the iliopectineal eminence close to or were detected [22]. involving the acetabular cavity.
Fig. 1.2 (a) Anterior-posterior force transmission to the pelvis, resulting in different anterior ring fractures according to Kusmin’s experiments. (b) Lateral force transmission to the pelvis, resulting in different anterior and posterior ring fractures according to Kusmin’s experiments 1 The History of Pelvic Fracture Treatment 7
• Lower pubic ramus fractures near the ischial tuberosity. Historically, the prognosis of pelvic injuries was based on concomitant injuries. The presence of additional intrapelvic Fractures were predominantly observed at thze thin area organ and neurovascular injuries often influenced mortality of the rami or even at their thicker parts. [4, 30]. Excessive expanding forces often (lateral compression forces) resulted in (Fig. 1.2b): In the pre-radiographic era, pelvic fractures were • Anterior SI joint injuries, sometimes associated with an rarely observed and were associated with a high mor- anterior or cranial sacrum displacement. tality rate due to concomitant injuries [8, 11, 31]. • Lateral foraminal fractures of the sacrum. Clinically diagnosed injuries, fractures identified dur- • Lateral sacral avulsion fractures (pelvic floor ligamentous ing autopsy examination, and experimental studies avulsions). identified already the classical injury mechanisms and injury pattern [14, 15, 22, 23]. Forces acting on the ilium resulted in: Richardson first reported a symphyseal wire stabiliza- tion in 1887 [27]. • Anterior ring fractures with/without accompanying uni- A hemipelvic dislocation was identified as a high-risk or bilateral sacrum fractures. injury. • Anterior ring fractures with/without accompanying uni- or bilateral sacrum fractures and additional posterior ilium fracture. 1.14 nowledge on Pelvic Fracture K In fresh cadavers, lateral compression was simulated by Treatment After X-Ray Availability Areilza [23, 26]. With 100–300 kg, a combined symphyseal disruption with ipsilateral pubic rami fractures and second- The discovery of X-rays by Wilhelm Conrad Röntgen in ary SI joint disruption was frequently observed. After force 1895 led to a complete new understanding of injuries. reduction, elasticity of the pelvic girdle led to near anatomic Visualization of the pelvic injury was now possible, and reduction. Additionally, isolated symphyseal disruptions, therefore, treatment changes were introduced and analysis of unilateral pubic rami fractures, and ilium fractures were comparable cases was possible. Additionally, ideas on opera- observed. tive treatment were increasingly published. Areilza further analyzed the effect on pelvic organ inju- ries. Lateral compression forces can result in urethral lesions, especially at the level of the pars membranacea, by tension- The discovery of X-rays led to the development of sur- ing near the pubic aponeurosis. gical pelvic injury stabilization techniques.
1.12 Pelvic Ring Stabilization
Shortly after the introduction of X-rays, the gold standard Richardson described a 5-year-old girl after a roll-over injury in treating pelvic injuries was still conservative treatment, with open pelvic injury, consisting of a vaginal laceration which was described in detail by Cheyne in his book A and separation of the pubic bones (symphyseal disruption), Manual of Surgical Treatment in 1900 [32]. which was treated by pubic wiring. Recovery was uneventful For the next decade, no clear ideas on surgical stabiliza- [27]. tion were presented. Pelvic X-rays led more to a better The potential first pelvic surgery in a fracture case was understanding of injury mechanism and injury pathologies. performed already in the eighteenth century by J. Ph. Maret Fischer in 1909 presented an atypical injury with six persons (1705–1780), but no clear data are available [28]. sustaining different injuries after a sledge trauma during winter time [33]. These six persons were sitting on a sledge while hitting a tree. The first person immediately died at the 1.13 Prognosis scene, while the second and third persons died at day 1 and day 9, respectively. The others survived. Fischer analyzed The prognosis of pelvic fractures was mainly influenced by the dead patients 2 and 3 and could identify the typical additional organ injuries. Especially urethral disruption was anterior-posterior compression injury with bilateral posterior associated with a high mortality [29]. hemipelvic dislocations. 8 A. Gänsslen and J. Lindahl
tions, the following stabilization techniques were proposed
[36, 37]:
• Screw stabilization of transverse sacral fractures
(Fig. 1.4). • Copper-wire stabilization of the pubic symphysis (after reduction) (Fig. 1.5). • Screw osteosynthesis of the pubic symphysis (Fig. 1.5). • Plate stabilization of the pubic symphysis. • Screw stabilization of pubic rami fractures (Fig. 1.4). • Open iliosacral screw fixation (entry point definition in Fig. 1.4). • Sacral bar fixation of the posterior pelvis (Fig. 1.6). • Wire or screw fixation of iliac crest fractures (Fig. 1.6).
Fig. 1.3 Hirschberg´s drawing of a symphyseal wire stabilization It took some time until these ideas were taken over by others. Otto Hirschberg in 1911 described a hemipelvic disloca- Lane in 1914 still did not focus on pelvic stabilizations tion, which was treated by a metallic sling around the pubic [38], and in 1916, Hey-Grooves published extensive ideas in bones for symphyseal stabilization [34], comparable to the treating fractures of the upper and lower extremities, but technique described by Richarson in 1887 (Fig. 1.3). options for pelvic fractures were not described [39]. And Finsterer in 1911 treated a 12-year-old boy in the same even Geiger in 1918, who developed the first fracture table way [35]. He described the technique of osteosynthesis in (Fig. 1.7), which could be used even for traction of pelvic detail. A Pfannenstiel incision was used. After periosteal dis- injuries, did not describe pelvic fracture stabilizations [40]. section, reduction was manually achieved and stabilization Between 1920 and 1922, Block and Haumann proposed iliac was performed using an aluminum bronze wire. The perios- wing traction for hemipelvic dislocations [41, 42] (Fig. 1.8). teum was sutured, and after fascial reconstruction, the skin Bauer in 1927 described the treatment of pelvic fractures was closed. After treatment consisted of a pelvic sling and [43]. It was stated that no specific treatment is necessary for bed rest for 6 weeks. simple fractures as muscular forces support dynamic stabili- Original text: zation and 4–6 weeks of supine bed rest is supposed to be Querschnitt über die Symphyse von einem Leistenring zum sufficient. anderen reichend; Freilegen des oberen Randes der Schambeine, Undisplaced pelvic ring fractures can be treated by towel Incision und Abheben des Periostes auf der vorderen und hin- slinging around the pelvis. teren Fläche. Das rechte Schambein stellt etwas nach rückwärts, aber beide gleich hoch. Es zeigt sich, daß die Trennungslinie, die In displaced fractures, traction or leg pulling is indicated. durch lockeres Bindegewebe verschlossen ist, im unteren Teile A detailed description of conservative treatment of concomi- in der Mitte der Symphyse entsprechend dem Gelenkspalt ver- tant bladder or urethral injuries using a catheter was pro- läuft, während sie an der oberen Seite durch den Knorpel nach posed. In some urethral injuries, direct urethral reconstruction rechts bis zur Knochen-Knorpel-Grenze zieht; der Knochen selbst ist intakt. Es wird nun das rechte Schambein nach vorn was favored. gezogen, der Spalt angefrischt, dann durch beide Schambeinäste The majority of pelvic injuries will heal uneventful equal eine Aluminumbronzedrahtnaht gelegt und fest zusam- to a complete restitution. In particular, patients with poste- mengeknüpft. Naht des Periostes, der Fascie und der Haut. rior pelvic ring fractures and acetabular fractures more often Anlegen eines Beckengurtes, der durch seitliche Gewichte das Becken zusammenschnürt. Reaktionsloser Verlauf; Heilung complained of remaining disturbances. Mal-healing was per primam. Bettruhe durch weitere sechs Wochen. Bei der stated to be relevant in pregnant women. Entlassung zeigt das Becken wieder normale Form, keine Westerborn performed an extensive literature review and Verkürzung. Gang frei, ohne Schmerzen. analyzed 306 cases in detail with different pelvic and acetab- ular fractures [44]. Surgical pelvic ring stabilization was Albin Lambotte (1907 and 1913) was the first who pro- only discussed for symphyseal separations, and it was stated posed several options for the surgical treatment of different that “the surgical treatment of symphyseal disruption as rec- fractures including screw, plate, and wire stabilization ommended by Lambotte is simple, but normally not neces- techniques. For pelvic fractures and symphyseal disrup- sary” (“Die operative Behandlung der Symphysenruptur, die 1 The History of Pelvic Fracture Treatment 9
Fig. 1.4 Drawings from Albin Lambotte: screw fixation techniques for transverse sacral fractures, pubic rami fractures, and definition of the entry point for iliosacral screw fixation
Fig. 1.5 (a) Drawings from Albin Lambotte: reduction and fixation techniques for symphyseal separations. (b) X-ray from Albin Lambotte: wire fixation of a disrupted pubic symphysis 10 A. Gänsslen and J. Lindahl
Fig. 1.6 Drawings from Albin Lambotte: fixation techniques for iliac wing fractures and sacral fractures
Fig. 1.7 Geiger´s traction table, also for reduction of pelvic fractures
u.a. von Lambotte empfohlen wird, ist einfach, aber meist
unnötig”). The first larger series on pelvic ring injuries was pub- lished in 1930 by Wakeley in the British Journal of Surgery still performing conservative treatment [45]. Further results were reported by Magnus (1210 cases) [46] and Noland (185 cases) [47]. The treatment was conservative by traction devices (Fig. 1.9) as also recommended in the book by Hermann Matti on “Die Knochenbrüche und Ihre Behandlung” (Fractures and Their Treatment) [48]. Stabilization of the disrupted SI joint was probably first described by Lehmann in 1934, who presented a case with a Fig. 1.8 Pelvic traction technique according to Block, directly at the screw stabilization [49]. ilium After closed reduction maneuvers, open reduction in the prone position was performed using a posterior curved screw was inserted respecting the upper neuroforamina, approach along the posterior iliac crest with mobilization of resulting in a screw orientation, which was rated non-optimal the gluteus maximus muscle. Under direct visualization, a regarding biomechanical principles. 1 The History of Pelvic Fracture Treatment 11
The first and second AO Manuals were published in 1970
and 1977 and were still focusing on acetabular fracture stabi- lization and hip joint arthrodesis [54, 55].
Since Malgaigne’s analysis of pelvic fracture types,
over the next 100 years, primarily pathological- anatomical analyses and descriptions of the injuries were reported, and clinical results were almost exclu- sively published after nonoperative therapy. Until the 1970s, nonsurgical therapy consisted pre- dominantly of bed rest, manual reduction, and reten- tion in a belt-shaped bandage with or without the use Fig. 1.9 In bed traction proposed by Matti in 1931 of compression or even in the pelvic cast. In addition, so-called Beckenschwebe or traction devices were used. Original text: Technik: Extensionstisch, Bauchlage. Direkter Zug mit Extensionszange an den Femurcondylen der verletzten Seite und—da an der zerrissenen Symphyse ein Gegenlager nicht Johannes Poigenfürst summarized the nonoperative treat- angebracht werden konnte—direkter Gegenzug mit Kirschnerdraht am entgegengesetzten Beckenkamm. Nach ment concepts from the first half of the twentieth century [56]: Anziehen der Extensionsspindel Röntgenkontrolle. Dann Freilegen der Synchondrosis mit einem flachen Bogenschnitt • Isolated functional treatment [46, 57, 58]. unter teilweisem Ablösen des Glut. max. Nun konnte man bei • Use of a specially designed compression apparatus [59, 60]. direkter Sicht die gelungene Reposition kontrollieren. Bei der Verschraubung wurde Rücksicht auf die Zwischenwirbellöcher • Cast fixations [57, 58, 61]. mit ihren Nerven genommen. Die Richtung der Schraube wurde • Reduction and fixation (pull—counter pull) and pelvic dadurch im mechanischen Sinne nicht einwandfrei. Trotzdem sling (Beckenschwebe) [57, 58]. erfüllte die Schraube ihren Zweck, das gute Repositionsergebnis • Pelvic traction [41, 62]. zu erhalten [49]. • Pelvic transfixation (cited in [56]).
Meyer-Burgdorf reported two further cases with open Dommisse in 1960 performed wire wrapping of the pubic (“bloody”) reduction, without describing the technique in symphysis. For this purpose, a metal wire was attached detail [50]. around two screws inserted parallel to the symphysis plane to For the next two decades, still conservative treatment was allow for dynamic stabilization [63]. proposed [51]. Due to rather poor results after nonoperative treatment [64–66], surgical stabilization was now increasingly favored. Plate osteosynthesis of the pubic symphysis was Since the ideas of open reduction and internal fixation increasingly performed [64, 67–69]. Schweiberer stated in of pelvic injuries in 1913, during the next four decades, 1978 that posterior deformities after insufficient reduction conservative treatment was still the predominant should be surgically exposed and stabilized with short treatment. plates [70].
First attempts were made to stabilize the pubic sym-
It took until 1953 when Gordon Whiston published five physis using plates. cases with open reduction and internal fixation of pelvic fractures in the American Journal of Bone and Joint Surgery [52]. The potential techniques were identical to the descrip- tions by Albin Lambotte. It was the merit of Raoul Hoffmann in 1941 to develop In 1965, Maurice Müller, Martin Allgöwer, and Hans the concept of osteotaxis and external fixation [71, 72]. Willenegger published the work Technique of Internal George Pennal reported already in 1958 on the use of exter- Fixation of Fractures [53]. nal fixation in pelvic fractures. Carabalona reported their One part was dealing with “Fractures of the Pelvis” but first results in 1973 [73]. Slätis experimentally analyzed vari- only described the technique of open reduction and internal ous pelvic external fixator constructs [74]. In 1980, clinical fixation using screws of acetabular rim fractures. results were presented [75]. In the 1980s and 1990s, external 12 A. Gänsslen and J. Lindahl
fixation was increasingly used as a standard procedure for fractures that occur through the ilium in a patient who is able to withstand surgical intervention, open reduction and rigid fixa- pelvic ring injuries [76–78]. tion of the iliac fracture will restore anatomic configuration, compression and stability to the pelvic ring and are desirable. If the fracture is in the sacrum or the sacroiliac joint, open reduc- External fixation of pelvic ring injuries became popu- tion is more difficult. lar during the 1970s and 1980s. Attempts have been made to use cancellous type screws in that situation, but as previously indicated, the techniques are dif- ficult and cannot be recommended at this time.
Overall, internal osteosynthesis was infrequently used. In During the next years, based on biomechanical studies the late 1970s and 1980s, some surgeons started to perform performed in Toronto by the group of Marvin Tile, it became plate and screw stabilizations [68, 79–84]. clear that anterior and posterior internal stabilization was In 1978, Emile Letournel gave some basic recommenda- associated with optimal results [84]. tions regarding operative treatment of pelvic fractures [85]: In 1988, Marvin Tile published his landmark paper “Pelvic ring fractures: should they be fixed?” in the British • “The external fixator achieves a good reduction more Journal of Bone and Joint Surgery [87]. dependably than conservative methods” … “secondary Several internal stabilization methods were described, displacement seems to be uncommon.” and the following statements can be cited: • Operative treatment. –– “Allows an anatomical reduction” … “and a rigid fixa- • In open book injuries, a two to four-hole plate should be tion can be obtained to eliminate the need for postop- placed on the superior surface and fixed with fully erative immobilization” threaded cancellous screws. –– “Provides relief of pain and discomfort after the first 2 • For unstable type C injuries, where no posterior fixation days”. is planned, two plates at 90° to each other should be used. The following concepts were proposed by Letournel: • For sacral fractures, two sacral bars from one posterior iliac spine to the other will provide good stability and • An absolute indication is either an injury of the SI joint or compression of the sacral fracture, at no risk to the neural the pubic symphysis. structures. • The symphysis is fixed by a plate. • For sacroiliac dislocations, with or without an iliac frac- • In the presence of additional rami fractures, the plate is ture, we favor an anterior approach to the joint, with plates extended to these fracture areas. across the sacroiliac joint and any iliac fracture. • Sacroiliac injuries should also be accurately repaired. • Iliac fractures may be fixed by plates using standard tech- • The SI joint is approached from posterior using a vertical niques of interfragmental compression; an anterior incision with detachment of the gluteus maximus muscle approach is preferred, especially if a sacroiliac disloca- from the sacral crest. tion is present. • For combined symphyseal and sacroiliac injuries, first, the SI joint is stabilized, and after repositioning of the In 1988, Marvin Tile recommended a clear concept patient, the pubic symphysis is addressed. addressing the anterior and posterior pelvic ring for • Pure anterior fractures should be treated conservatively. partially and completely unstable pelvic ring injuries. • Transiliac or transsacral fractures “were neglected too long and are most often incompletely reduced.” • In transiliac or transsacral fractures, the surgeon should choose between external and internal stabilization meth- In 1989, Joel Matta and Tomas Saucedo added a detailed ods according to his experience. description of useful approaches to address the anterior and posterior pelvic areas and standardized the concept of iliosa- Letournel concluded that “the need to obtain the best cral screw fixation as an additional possible procedure for possible reduction of unstable fractures of the pelvis posterior ring stabilization [88]. seems to have become more generally accepted.”
Tile and Matta are the pioneers for open reduction and In 1980, Marvin Tile stated [86]: internal fixation of pelvic ring injuries. The concepts, In most cases where an adequate posterior reduction cannot be which were developed in the late 1980s, are still today obtained by closed means or maintained with external fixators, of substantial value. open reduction has been advocated. As mentioned previously, in 1 The History of Pelvic Fracture Treatment 13
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58. Böhler L. Die Technik der Knochenbruchbehandlung, 74. Slätis P, Karaharju E. External fixation of the pelvic girdle with a Ergänzungsband. Wien: Verlag Wilhelm Maudrich; 1963. p. 12–3. trapezoid compression frame. Injury. 1975;7:53–6. 59. Narat J. New splint for pelvic fractures. Am J Surg. 1938;42:443. 75. Slätis P, Kraharju E. External fixation of unstable pelvic fractures: 60. Vorschütz. Schraubenzwingenbehandlung bei Symphysenspaltung. experiences in 22 patients treated with a trapezoid compression Zentbl Chir. 1937;48:2755–66. frame. Clin Orthop. 1980;151:73–9. 61. Curry G. Fractures of the pelvis. J Bone Joint Surg. 1939;21-A: 76. Mears D, Fu F. External fixation in pelvic fractures. Orthop Clin 384–6. North Am. 1980;11:465–79. 62. Block W. Beitrag zur halbseitigen Beckenluxation nebst 77. Mears D, Fu F. Modern concepts of external skeletal fixation of the Vorschlägen zur Drahtextension am Beckenkamm. Dtsch Z Chir. pelvis. Clin Orthop. 1980;151:65–72. 1920;160:113–22. 78. Rubash H, Mears D. External fixation of the pelvis. AAOS Instr 63. Domisse G. Diametric fractures of the pelvis. JBJS. Course Lect. 1984;32:329–49. 1960;42(B):432–4443. 79. Berner W, Oestern H-J, Sorge J. Ligamentäre 64. Fink D, Möseneder H. Offene Symphysensprengung mit Beckenringverletzungen. Behandlung und Spätergebnisse primärer Verplattung. Hefte zur Unfallheilkunde. 1974;Heft 124: Unfallheilkunde. 1982;85:377–87. 292–3. 80. Ecke H, Burger H, Hofmann D, Nazari P, Maier K. Stabilitätsprüfung 65. Möseneder H, Fink A, Lippert K. Ergebnisse der konservativen verschiedener osteosyntheseverfahren nach symphysenrup- Behandlung der Symphysenzerreißung. Hefte zur Unfallheilkunde. tur und sprengung der ileosacralfuge. Langenbecks Arch Chir. 1974;Heft 124:207–9. 1984;84:195–9. 66. Slätis P, Huittinen V. Double vertical fractures of the pelvis: a report 81. Ecke H, Hagen P. Operative Möglichkeitenzur Behandlung on 163 patients. Acta Chir Scand. 1972;138:799–807. von Verletzungen des Beckenrings. Krankenhausarzt. 1984;53: 67. Beck E. Beckenfrakturen und Luxationen. Hefte zur 346–52. Unfallheilkunde. 1974;124:156–66. 82. Ecke H, Hofmann D. Indikation und Technik der Osteosynthese 68. Dolati B. Die operative Versorgung der Symphysenruptur. bei Beckenringverletzungen: Zuggurtung. Hefte Unfallheilkunde. Unfallchirurgie. 1985;11:223–7. 1986;181:581–2. 69. Jenkins D, Young M. The operative treatment of sacro-iliac 83. Goldstein A, Phillips T, Sclafani S, Scalea T, Duncan A, Goldstein subluxation and disruption of the symphysis pubis. Injury. J, Panetta T, Shaftan G. Early open reduction and internal fixation 1978;10:139–41. of the disrupted pelvic ring. J Trauma. 1986;26(4):325–33. 70. Schweiberer L, Scheib D. Retroperitoneale Verletzungen: 84. Tile M. Fractures of the pelvis and acetabulum. Baltimore: Williams Wirbelsäule und Beckenfraktur. Langenbecks Arch Chir. & Wilkings; 1984. 1978;347:177–86. 85. Letournel E. Annotation to pelvic fractures. Injury. 1978;10: 71. Hoffmann R. Perkutane Frakturbehandlung. Chirurg. 145–8. 1941;13:101–12. 86. Tile M, Pennal G. Pelvic disruptions: principles of management. 72. Hoffmann R. Ostéotaxis, ostéosynthèse externe par fiches et Clon Orthop. 1980;151:56–64. rotoules. Acta Chir Scand. 1954;107:72–88. 87. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint 73. Carabalona P, Rabichong P, Bonnel F, Peruchon E, Peguret Surg. 1988;70-B:1–12. F. Apports du fixateur externe dans le disjonctions du pubis and de 88. Matta J, Saucedo T. Internal fixation of pelvic ring fractures. Clin l’articulation sacro-iliaque. Montpell Chir. 1973;19:61–70. Orthop. 1989;242:83–97. Surgical Anatomy of the Pelvis 2 Norbert Peter Tesch, Axel Gänsslen, Jan Lindahl, Wolfgang Grechenig, and Georg Feigl
The anatomy of the pelvic region is complex due to the The elastic nature of the pelvic ring structure is based on involved structures, including bones, ligaments, joints, mus- three joints, anterior of the pubic symphysis and posterior of cles, pelvic organs, and neurovascular structures. bilateral sacroiliac joints (SI joints). For the treatment of pelvic ring injuries, the relevant sur- These structures are relevant for load transmission from gical anatomy is of major importance, while detailed ana- the lower extremities via the hip joints to the sacrum and the tomical descriptions of all possible anatomical structures are spine. clinically irrelevant. The pure osseous anatomy is the basic construct for static Thus, the focus of this chapter is to deal with the main stability of the pelvic ring structure, while the joints, together surgical structures, which have to be considered during open, with peripelvic muscles and ligaments, act as dynamic minimal invasive (percutaneous), and even conservative stabilizers. treatment of pelvic ring injuries. Due to the presence of the large iliac wings, a false pelvis is distinguished from the true pelvis (Fig. 2.2), the latter sur- rounding the pelvic organs, the sacral plexus, and the rele- 2.1 Osseous Anatomy vant vascular structures.
The bony pelvic ring consists of the two innominate bones,
resulting from fusion of the pubis, the ilium, and the ischium 2.1.1 Hemipelvis (“Innominate Bone”) and the sacrum with the coccyx (Fig. 2.1). A more detailed description of the osseous anatomy during growth is given in The hemipelvis consists of three bones (Fig. 2.3), which fuse the chapter of pediatric pelvic ring injuries. during puberty and early adulthood. Their connection is the triangular cartilage, which fuses to the bony acetabulum, typically during the 14th–16th year of age. Details regarding acetabular development is extensively described elsewhere [1–3]. N. P. Tesch · G. Feigl Division of Macroscopic and Clinical Anatomy, The hemipelvic development is supported by additional Medical University of Graz, Graz, Austria epiphyseal and apophyseal growth. In the developing skele- e-mail: [email protected]; [email protected] ton, apophyses serve as secondary ossification centers, which A. Gänsslen (*) develop during the second decade of life. They serve as ori- Department of Trauma Surgery, Orthopedics and Hand Surgery, gin and insertion sites of muscles and tendons [1–3]. Hospital Wolfsburg, Wolfsburg, Germany The iliac crest apophysis consists of the anterior superior J. Lindahl iliac spine apo-/epiphysis; the true anterior iliac crest epiphy- Orthopaedics and Trauma Surgery, Helsinki University Hospital, Helsinki, Finland sis, which extends to approximately one-half of the whole iliac crest; and the posterior iliac crest apophysis, which W. Grechenig Department of Orthopaedics and Trauma, develops from the posterior superior iliac spine apophysis Medical University of Graz, Graz, Austria [4]. The true iliac crest epiphyses (anterior and posterior) e-mail: [email protected] typically join close to the middle of the iliac crest.
A. Gänsslen et al. (eds.), Pelvic Ring Fractures, https://doi.org/10.1007/978-3-030-54730-1_2 16 N. P. Tesch et al.
nutrient foramen sacrum
ilium SI-joint
coccyx
pubis
ischium
symphysis pubis symphysis pubis
Fig. 2.1 Bony and articular contributions to the pelvic ring anatomy, the pelvis can be divided into two innominate bones and the sacrococcygeal bone connected by bilateral sacroiliac joints (SI joint) posterior and the symphysis pubis anterior
Fig. 2.2 The whole pelvis can be distinguished into the false pelvis (red) and the true pelvis (blue), the latter contains the relevant pelvic the latter surrounding the pelvic organs and neurovascular structures
The iliac crest apophysis develops in male patients The ischial tuberosity apophysis initiates between 13 between 12 and 15 years (median 14 years), and closure is and 16 years of age, while fusion occurs between 16 and observed between 16 and 23.9 years (median 21.6 years). 18 years of age with complete union between 20 and In females, the apophysis appears between 11.3 and 23 years of age [11]. 15.9 years (median 14.4 years), and closure is found at an Data on fusion of the posterior iliac spines are missing. age of 15.8–25.8 years (median 23.3 years) [5]. Ossification typically starts from anterior to posterior [6, 7]. Clinical Relevance The apophysis of the anterior superior iliac spine (ASIS) Thus, in skeletally immature patients, especially in normally develops at the 16th year of age and fuses around young athletes at the age of 14–17 years, there is a risk of the 25th year of age [8]. injury to these areas, as the physes are the most vulnera- The apophysis of the anterior inferior iliac spine (AIIS) ble areas of the musculotendinous connection to the bone normally develops between the 11th and 15th year of age and due to perpendicular acting forces on the apophyses. fuses between the 16th and 18th year of age [9, 10]. 2 Surgical Anatomy of the Pelvis 17
Morphologically, the fully developed innominate bone 2.1.1.1 Ilium
corresponds to the shape of a figure of eight according to The ilium is the most superior part of the three hemipelvic Mollier [12]. Between the perpendicular orientation of the bones (Fig. 2.4). An upper part and a lower part can be dis- iliac wing plane and the obturator foramen, the acetabulum is tinguished, separated by a ridge on the medial (inner) integrated. Gänsslen et al. extended this view and proposed a surface. This ridge is termed the arcuate line in its anterior three-ring structure of the hemipelvis [13]. The periphery of part, which here forms part of the linea terminalis and the these rings allows implant anchorage. pelvic brim [5].
ilium
pubis
ischium
Fig. 2.3 The hemipelvis fuses during puberty and early adulthood. The medial view of a 7-year-old girl shows the triradiate cartilage formation connecting the pubis, the ischium, and the ilium
tuberculum of the iliac crest iliac crest iliac ligamentous iliac crest raughening
PSIS ASIS iliac fossa
AIIS gluteal lines
iliac fossa ASIS
PIIS iliac part
AIIS SI-joint iliac cortical density
a b c d
Fig. 2.4 Relevant bony landmarks of the iliac bone
18 N. P. Tesch et al.
The upper part of the ilium (Fig. 2.3c, d), belonging to the superior iliac spine (PSIS), respectively. The shape of the false pelvis, presents as a flat, fan-shaped wing-structure and iliac crest is convex on the outer side (Fig. 2.5). Approximately serves as an origin of essential muscle groups for the move- 4–8 cm posterior to the ASIS, a prominent tubercle, the ment of the lower leg (abductors, gluteus maximus, iliacus tuberculum of the iliac crest, becomes visible. This area is muscle). relatively thick and includes a slightly angulated bone corri- The inner (medial) surface of the wing is concave (iliac dor, running from the iliac crest to the supraacetabular region fossa), which is covered by the iliacus muscle. Near the SI (Fig. 2.5, blue). This landmark is of surgical relevance dur- joint, a large nutrient foramen is present (Fig. 2.1). During ing pelvic ring external fixation techniques. Here, the strong surgery, relevant bleeding can occur from here. bone structure allows sufficient holding forces for pin appli- Ebraheim et al. analyzed the location of this foramen and cation in an iliac external fixator [16]. reported its location approximately 12.5 mm lateral to the anter- Inferior to the ASIS at the anterior margin of the ilium, the osuperior sacroiliac joint line and 23.5 mm perpendicular to this anterior inferior iliac spine (AIIS), the attachment area of the line along the pelvic brim parallel to the sacroiliac joint line rectus femoris muscle is an important landmark. [14]. In a further analysis, the nutrient artery was found to cross the SI joint. In average, the nutrient foramen was identified Along the plane from the AIIS to the posterior inferior 88.1 mm medial to ASIS, 20.1 mm above the pelvic brim, and iliac spine (PSIS), a long bone corridor is present (Fig. 2.5, 20.1 mm lateral to SI joint [15]. red), which forms the inferior part of the ilium [16], integrat- ing the acetabular roof. More posterior, the upper margin of At the posterior ilium, a ridge is found directly superior to the greater sciatic notch represents its inferior base. the articulating area with the sacrum. Within the true pelvis, the iliac L-shaped articular surface of the SI joint becomes visible. More posterior, a roughened area for attachment of Clinical Relevance interosseous and posterior sacroiliac ligaments is present. Several investigators analyzed the bone corridor The external (gluteal) surface of the iliac wing presents between the AIIS and PSIS for posterior and anterior with some bony margins (gluteal lines) and roughenings, stabilization techniques using different orientations indicating muscular attachments. The abductors originate [16–21]. Its length is between 10 and 15 cm with a along the anterior and inferior gluteal line, the gluteus maxi- width of 11.4 mm and a height of 23 mm. mus muscle to a large extent along the posterior gluteal line. The superior margin of the ilium is thickened and forms the iliac crest for muscular and fascial attachments of lum- bar, abdominal, and lower leg muscles and fascias. Anterior Parallel and anterior to the SI joint, the strongest bone and posterior, the iliac crest ends at the ASIS and posterior structure, the “iliac cortical density” is a relevant structure
* bone corridor from the AIIS to the PSIS
anterior posterior
Fig. 2.5 Anatomy of the iliac crest with the tuberculum of the iliac crest (*). The lateral view confirms the localization of two relevant bone cor- ridors: supraacetabular corridor (red) and vertical bone corridor (blue), starting at the tuberculum of the iliac crest Another random document with no related content on Scribd: 359 As another instance of Dr. Bosanquet’s unintentional unfairness to his opponents, I would note his positive injustice to Theism as such. What many of us think of (however imperfectly) and believe in as God is invariably to him “a theistic Demiurge in his blankness and isolation.” I do not believe in such an abstract Demiurge any more than I believe in the separate, isolated self that he conjures up to his mind when he thinks of personality. The problem of the twentieth century may well be what Dr. Ward has signalised as the relation of God to the “Absolute” of the Hegelian metaphysicians, but this suggestion simply means to me the discovery on the part of philosophers of terms and concepts more adequate to the Supreme Being than either the Absolute, or the external deity rejected by Dr. Bosanquet. 360 Stéphane Mallarmé, according to Nordau in Degeneration, p. 103. 361 And the general reader must remember that the “whole” is always (with all due respect to his high dialectic ability and his high temper of mind and his scholarship) a kind of ignis fatuus in Dr. Bosanquet’s book, a kind of shadow thrown by the lamps and the tools of his own choosing in his Quixotic search. The “whole” is the “perfected individuality” of the individual who sets out to find truth in this great world of ours with all its real possibilities of gain and loss. It is the completion of the “system” of truth to which the truth-seeker would fain reduce the entire universe, that becomes for him (for the time being) the mere “subject-matter” of his thought. It is, that is to say, in both cases, a purely formal conception—an abstraction, although to Dr. Bosanquet it is the reality implied in the very existence and activity of the individual thinker. But the latter is the case to him only because he looks upon man as existing to think instead of as thinking to exist. 362 That is to say, for the scholar and the lover of Dante and Dante’s world. 363 For he was not merely a “mind,” reflecting “Italy” and “minds” and “experiences.” 364 And that, we might add, is still kept alive by some of our humanists and educators of to-day as the ideal for both primary and secondary education. 365 This is a thing that the beginner is taught in lectures introductory to the study of the philosophy of Kant—in regard to Kant’s relation to the barren, dogmatic formalism of Wolff—a one-sided interpreter of the philosophy of Leibniz. I am quite aware that Dr. Bosanquet does not merely use the Principle of Non-Contradiction in the aggressive, or polemical, manner of Mr. Bradley in Appearance and Reality. The principle of positive coherence at which he aims, begins, to some extent, where Mr. Bradley stopped. But it is still the idea of consistency or inconsistency, with certain presuppositions of his own, that rules his thinking; it determines, from the very outset of his Lectures, what he accepts and what he rejects. 366 See p. 152 and p. 156, note 2. 367 I use this word “must” in a logical as well as in an ethical sense, seeing that all judgment implies a belief in the reality of a world of persons independent of the mere fact of “judgment” as a piece of mental process. 368 See p. 145. 369 On p. 345 the words are: “When we consider the naïve or elementary life of morality and religion”; and on p. 346: “The naïve, or simple self of every-day morality and religion,” and the marginal heading of the page upon which these words occur is “The naïve good self compared to grasp of a fundamental principle alone.” Could anything more clearly indicate what the Kantians call a confusion of categories [in the case in point the categories of “goodness” and the categories of “truth”] or what Aristotle calls a μετάβασις εἰς ἄλλο γένος, the unconscious treatment of one order of facts by the terms and conceptions of another order of facts. To Dr. Bosanquet as the Neo-Hellenist that he is in his professed creed, badness is practically stupidity, and “lack of unification of life,” and “failure of theoretical grasp.” This confusion between goodness and wisdom is again indicated on p. 347 in the words: “A man is good in so far as his being is ‘unified at’ all in any sphere of wisdom or activity.” [This is simply not true, and its falsity is a more unforgivable thing in the case of Dr. Bosanquet than it is in the case of the pragmatists who also tend to make the ‘moral’ a kind of ‘unification’ or ‘effectiveness’ in ‘purpose.’] As a proof of Dr. Bosanquet’s transformation of the facts of the ethical life in the interest of logical theory, we can point to p. 334: “Our actions and ideas issue from our world as a conclusion from its premises, or as a poem from its author’s spirit,” or to p. 53, where it is definitely stated that the “self, as it happens to be,” cannot, in any of its “three aspects,” “serve as a test of reality.” To do the latter, it must, in his opinion, follow the law of the “universal,” i.e. become a logical conception. Now of course (1) it is not the self “as it happens to be” that is chiefly dealt with in ethics, but rather the self as it ought to be. And (2) the ethical self, or the “person,” does not follow the “law of the universal” [a logical law] but the law of right and wrong [an ethical law]. As a proof of the subordination of the facts of conduct to the facts of aesthetics, we may take the words on p. 348 where aesthetic excellence is said to be “goodness in the wider or (‘shall we say’) in the narrower sense.” Now the distinction between ethics and aesthetics is not one of degree, but one of kind. And as another illustration of his tendency to transform ethical facts in the light of a metaphysical, or a logical, theory [they are the same thing to him] we may quote the emphatic declaration on p. 356: “Our effort has been to bring the conception of moral and individual initiative nearer to the idea of logical determination,” or the equally outspoken declaration on p. 353: “But metaphysical theory, viewing the self in its essential basis of moral solidarity with the natural and social world ... cannot admit that the independence of the self, though a fact, is more than a partial fact.” Or the words at the top of this same page: “The primary principle that should govern the whole discussion is this, that the attitude of moral judgment and responsibility for decisions is only one among other attitudes and spheres of experience.” These last words alone would prove definitely the non-ethical character of “Individuality and Value.” The ethical life is to its author only a “quatenus consideratur,” only a possible point of view, only an aspect of reality, only an aspect, therefore, of a “logical system.” Now if the ethical life of the world is to count for anything at all, it may be said that the ethical life is no mere aspect of the life of the self, and no mere aspect of the life of the world, seeing that “nature” in the sense of mere “physical nature” does not come into the sphere of morality at all. It is rather the activity of the “whole self,” or the “normative” reflection of the self as a whole upon all the merely partial or subordinate aspects of its activity, upon bodily life, economic life, intellectual activity, and so on that constitutes the world of morality. 370 See p. 147, and p. 244. 371 Good and evil to Dr. Bosanquet are two quasi-rational systems in active antagonism as claiming to attach different “principles and predicates” to identical data. The essence of their antagonism to Dr. Bosanquet is not, however, that evil is contemplated, as it must be sooner or later, in repentance for example as wrong, but rather that the “evil” is an imperfect “logical striving (p. 351) of the self after unity” which is in “contradiction with a fuller and sounder striving” after the same. The evil self is to him merely the vehicle of a logical contradiction in the self. 372 This is seen in his admission (on p. 351) that the “bad will” no less than the “good will” is a logical necessity, when taken along with his doctrine about mind and body, his doctrine of the “dependence” (p. 318) of the finite individual upon the external mechanical world. Dr. Bosanquet, of course, thinks that even in this apparent Determinism he is justifiably supplementing the ordinary ideas about the “self” as “creative” and “originative” (p. 354), by the wider recognition that I am more or less completely doing the work of the “universe” as a “member” in a “greater self.” And he adds in the same sentence the words that “I am in a large measure continuous with the greater (p. 355) self,” and “dyed with its colours”—a further step in Determinism, as it were, and a step which, with the preceding one to which we have just referred, no critic can fail to connect with the Determinism that we have already found to be implicated in his doctrine of the “self,” and in his general doctrine that the “external” must be frankly accepted as a factor in the universe. 373 By the “spectator” fallacy we mean his tendency to talk and think of the self as it is for a spectator or student, looking at matters from the outside, and not as the self is for the man himself. 374 Wollaston is the English ethical philosopher who, according to Leslie Stephen’s account, thought, after thirty years of meditation, that the only reason he had for not breaking his wife’s head with a stick was, that this would be tantamount to a denial that his wife was his wife. 375 See Idola Theatri by Henry Sturt (the editor of the well-known “Personal Idealism” volume) of Oxford—a book that enumerates and examines many of the fallacies of the Neo- Hegelian school. Mr. Sturt’s first chapter is entitled the “Passive Fallacy,” which he calls, with some degree of justice, the prime mistake of the idealistic philosophy, meaning by this the “ignoring” of the “kinetic” and the “dynamic” character of our experience. 376 It is Natural Theology that is the subject proper of the Gifford Lectures. 377 See p. 149 of Chapter VI. 378 With, we might almost say, the pragmatists and the humanists. 379 This is really their main distinguishing characteristic and merit. 380 See p. 162. 381 “Indeed, I do not conceal my belief that in the main the work has been done.”—Preface. 382 I think that the confession is a praiseworthy one in view of the fact of the prejudice of Rationalism, that philosophy has nothing to do with convictions but only with knowledge. 383 By belief I have understood throughout this book simply man’s working sense for reality, and I am inclined to think that this is almost the best definition that could be given of it—our working sense for reality. It is at least, despite its apparent evasiveness, most in harmony with the pragmatist-humanist inclusion of will elements and feeling elements in our knowledge and in our apprehension of reality. It is also in harmony with the conception of reality which may, in my opinion, be extracted from both Pragmatism and Idealism— that reality is what it proves itself to be in the daily transformation of our experience. By the retention of the term “working” in this attempted definition I express my agreement with the idea that action, and the willingness to act, is an essential element in belief. The outstanding positions in the definitions of belief that are generally given in philosophical dictionaries are, firstly, that belief is a conviction or subjective apprehension of truth or reality in distinction from demonstrable knowledge or direct evidence; and, secondly, that feeling elements and action elements enter into it. I am inclined to think that the sharp antithesis between belief and knowledge, or the tendency of philosophical books to emphasise the difference between belief and knowledge, is a characteristic, or consequence, of our modern way of looking at things, of our break with the unfortunate, medieval conception of faith and of the higher reason. The study of the facts either of the history of religion or of the history of science, will convince us, I think, that it is always belief, and that it still is belief (as the working sense for reality), that is man’s measure of reality, our knowledge about the universe being at all times but a more or less perfect working out of our beliefs and of their implications—of our sense of the different ways in which the world affects us, and of the ways in which we are affected towards it. Nor do I think, as I have indicated in different places, that “reality” can be defined apart from belief, reality being that in which we believe for all purposes, theoretical and practical and emotional. In the conception of reality as a world of intersubjective intercourse in which beings, or persons at different stages of development, share in a common spiritual life, we have attained so far (and only so far) to the truth that is common to an idealism of the type of Dr. Bosanquet’s, and to pragmatist-humanism when properly developed and interpreted. There are, I find, upon thinking of the matter, any number of philosophers and thinkers who interpret belief, in the larger sense of the term, as our complete and final estimate of reality, and as therefore not exclusive of, but inclusive of knowledge in the ordinary sense of the term. 384 He even says in the Abstract of his first lecture upon the “Central Experiences,” that Lord Gifford’s desire that his lecturers should “try to communicate” a “grave experience” is the demand that “introduces us to the double task of philosophy. It [philosophy] needs the best of logic, but also the best of life, and neither can be had in philosophy without the other.” 385 Treatise upon Human Nature, sect. vii. (Green and Grose, i. 547). 386 I had originally the idea of calling this chapter by the more modest title of a note upon “pragmatist elements” in the teaching of Bergson. I have allowed myself to call it a chapter partly for the sake of symmetry, and partly because the footnotes and the criticism (of his Idealism) have carried it beyond the limits of a note. I find, too, (as I have partly indicated in my preface) in the teaching of Bergson so many things that make up almost the very body of truth and fact upon which Pragmatism, and Humanism, and Idealism all repose (or ought to repose) that I quote them directly in my footnotes. They indicate to me the scope and the territory of my entire subject. And they are a confirmation to me of much that I had myself arrived at before I read a line of Bergson. 387 “Our intelligence, as it leaves the hands of nature, has for its chief object the unorganised solid” (Creative Evolution, p. 162); “of immobility alone does the intellect form a clear idea” (ibid. 164). “The aspect of life that is accessible to the intellect—as indeed to our senses, of which our intellect is the extension—is that which offers a hold to action” (ibid. 170). “We see that the intellect, so skilful in dealing with the inert, is awkward the moment it touches the living. Whether it wants to treat the life of the body or the life of the mind, it proceeds with the rigour, the stiffness, and the brutality of the instrument not designed for such use. The history of hygiene or of pedagogy teaches us much in this matter. When we think of the cardinal, urgent, and constant need we have to preserve our bodies and to raise our souls, of the special facilities given to each of us in this field to experiment continually on ourselves and on others, of the palpable injury by which the wrongness of a medical or a pedagogical practice is made manifest and punished at once, we are amazed at the stupidity and especially at the persistence of errors. We may easily find their origin in the natural obstinacy with which we treat the living like the lifeless, and think all reality, however fluid, under the form of the sharply-defined solid. We are at ease only in the discontinuous, in the immobile, in the dead. The intellect is characterised by a natural inability to comprehend life” (Creative Evolution, p. 174). (Italics mine.) 388 “I look and I think I see, I listen and I think I hear, I examine myself and I think I am reading the very depths of my heart. But what I see and hear of the outer world is purely and simply a selection made by my senses to serve as a light to my conduct; what I know of myself is what comes to the surface, what participates in my actions. My senses and my consciousness, therefore, give me no more than a practical simplification of reality in the vision they furnish me of myself and of things, the differences that are useless to man are obliterated, the resemblances that are useful to him are emphasised; ways are traced out for me in advance along which my activity is to travel. These ways are the ways which all mankind has trod before me. Things have been classified with a view to the use I can derive from them” (Laughter, p. 151). “Life implies the acceptance of the utilitarian side of things in order to respond to them by appropriate reactions; all other impressions must be dimmed or else reach us vague and blurred” (ibid. p. 131). These last words give us a glimpse of a very important part of Bergson’s teaching—his idea, namely (Voltaire has it in his Micromégas), that “matter” is greater than our perceptions, that our perceptions reveal to us only those aspects of the physical universe with which we are practically concerned. 389 Some years ago psychologists began to distinguish a “structural” from a “functional” psychology, meaning by the former what is otherwise called Psycho-Physics or (to some extent) Experimental Psychology. 390 Cf. “At first sight it may seem prudent to leave the consideration of facts to positive science, to let physics and chemistry busy themselves with matter, the biological and psychological sciences with life. The task of the philosopher is then clearly defined. He takes facts and laws from the scientist’s hand, and whether he tries to go beyond them in order to reach their deeper causes, or whether he thinks it impossible to go further, and even proves it by the analysis of scientific knowledge, in both cases he has for the facts and relations, handed over by science, the sort of respect that is due to a final verdict. To this knowledge he adds a critique of the faculty of knowing, and also, if he thinks proper, a metaphysic; but the matter of knowledge he regards as the affair of science, and not of philosophy” (Creative Evolution, pp. 204–5). [All this represents only too faithfully what even some of our Neo-Kantians have been saying, and teaching, although there is an error in their whole procedure here.] 391 Schopenhauer’s phrase. See my book upon Schopenhauer’s System. 392 It is chiefly in Matter and Memory (in which, by the way, there are pages and pages of criticism of the rationalism of philosophy that are as valuable as anything we have in philosophy since the time of Descartes—Kant not excepted) that we are to look for the detailed philosophy of sensation and of perception, and the detailed philosophy of science upon which this protest of Bergson’s against the excesses of “conceptualism” rests. I indicate, too, at different places in this chapter some of the other special considerations upon which it rests. The gist of the whole is to be found, perhaps, in his contention that our science and our philosophy of the past centuries have both regarded “perception” as teaching us (somehow) what things are independently of their effect upon us, and of their place in the moving equilibrium of things—the truth being on the contrary (with Pragmatism and Humanism) that our knowledge has throughout a necessary relation to ourselves and to our place in the universe, and to our liberation from matter in the life of the spirit. 393 He expresses this idea in the following way in the Introduction to Matter and Memory: “Psychology has for its object the study of the human mind for practical utility,” whereas in “metaphysics” we see “this same mind striving (the idea, as we say elsewhere, is not free from difficulty) to transcend the conditions of useful action and to come back to itself as to a pure creative energy.” Or in the following sentences from his Creative Evolution: “We must remember that philosophy, as we define it, has not yet become completely conscious of itself. Physics understands its role when it pushes matter into the direction of spatiality; but has metaphysics understood its role when it has simply trodden the steps of physics, in the chimerical hope of going farther in the same direction? Should not its own task be, on the contrary, to remount the incline that physics descends, to bring matters back to its origins, and to build up progressively a cosmology which would be, so to speak, a reversed psychology. All that which seems positive to the physicist and to the geometrician would become, from this new point of view, an interruption or inversion of the true positivity which would have to be defined in psychological terms” (pp. 219–20, italics mine). 394 As an indication of what the acceptance of the dynamic instead of the static view of matter on the part of Bergson means, I cite the phrase (or the conception) on p. 82 of Matter and Memory, the effect that “matter is here as elsewhere the vehicle of an action,” or the even more emphatic declaration on p. 261 of Creative Evolution, “There are no things, there are only actions.” It is impossible, of course, that these mere extracts can convey to the mind of the casual reader the same significance that they obtain in their setting in the pages of Bergson, although it is surely almost a matter of common knowledge about his teaching, that one of the first things it does is to begin with the same activistic or “actionistic” view of nature and matter that seems to be the stock in trade of the physics of our time since the discoveries pertaining to radio- activity, etc. Being only a layman in such matters, I may be excused for quoting from a recent booklet (whose very presence in the series in which it appears is to people like myself a guarantee of its scientific reliability) in which I find this same activistic view of matter that I find in Bergson. “What are the processes by which the primary rock material is shifted? There is the wind that, etc. etc.... There are the streams and rivers that, etc.... There is the sea constantly wearing away, etc.... Then there are ‘subtle’ physical and ‘chemical’ forces. And the action of plants.... Hence by various mechanical, organic, and chemical processes the materials originally scattered through the rocks of the earth’s crust, and floating in the air or water, are collected into layers and form beds of sand, clay, limestone, salt, and the various mineral fuels, including peat and coal” (The Making of the Earth, by Professor Gregory, F.R.S., of Glasgow University: Williams and Norgate). It is only right to state here, or to remind the reader in this matter of a “dynamic” view of matter, that Bergson not only dissipates matter into force or energy or activity (as do the physicists of to-day), but also actually credits the world of matter and life with a kind of consciousness (and why not be courageous about it?) in which what I have already called the “susceptibility of everything to everything else,” or the action of everything upon everything else, becomes credible and intelligible. “No doubt, also, the material universe itself, defined as the totality of images, is a kind of consciousness in which everything compensates and neutralises everything else, a consciousness of which all the potential parts, balancing each other by a reaction which is always equal to the action, reciprocally hinder each from standing out” (Matter and Memory, p. 313). 395 See Chapter III., and also the references to Mach, Ostwald, Poincaré, and others, in the second chapter and elsewhere. 396 “There is no intelligence in which some traces of instinct are not to be discovered, more, no instinct that is not surrounded with a fringe of intelligence” (Creative Evolution, p. 143). 397 “We will not dwell here upon a point we have dealt with in former works. Let us merely recall that a theory [the theory of contemporary physiological psychology] such as that according to which consciousness is attached to certain neurons, and is thrown off from their work like a phosphorescence, may be accepted by the scientist for the detail of analysis; it is a convenient mode of expression. But it is nothing else. In reality, a living being is a centre of action. It represents a certain sum of contingency entering into the world, that is to say, a certain quantity of possible action—a quantity variable with individuals and especially with species. The nervous system of an animal marks out the flexible lines on which its action will run (although the potential energy is accumulated in the muscles rather than in the nervous system itself); its nervous centres indicate, by their development and their configuration, the more or less extended choice it will have among more or less numerous and complicated actions. Now, since the awakening of consciousness in a living creature is the more complete, the greater the latitude of choice allowed to it and the larger the amount of action bestowed upon it, it is clear that the development of consciousness will appear to be dependent on that of the nervous centres. On the other hand, every state of consciousness being, in one aspect of it, a question put to the motor activity and even the beginning of a reply, there is no psychical event that does not imply the entry into play of the cortical mechanisms. Everything seems, therefore, to happen as if consciousness sprang from the brain, and as if the detail of conscious activity were modelled on that of the cerebral activity. In reality consciousness does not spring from the brain, but brain and consciousness correspond because equally they measure ... the quantity of choice that the living being has at its disposal” (Creative Evolution, pp. 266–7). 398 “Instead of starting from affection [or ‘sensation’ in the old sense of the haphazard sensation] of which we can say nothing, since there is no reason why it should be what it is rather than anything else, we start from action, that is to say, from our power of effecting changes in things, a faculty attested by consciousness, and towards which all the powers of the organised body are seen to converge. So we place ourselves at once in the midst of extended images [to Bergson as an idealist things are at the same time images or ideas for a consciousness in other things, or in us, or in beings other than ourselves], and in this material universe we perceive centres of indetermination characteristic of life” (Matter and Memory, p. 67). 399 Cf. the words in the Preface to Matter and Memory: “The whole personality, which, normally narrowed down by action, expands with the unscrewing of the vice in which it has allowed itself to be squeezed,” or the words in the same place about the task of metaphysics being the attempt of the “mind striving to transcend the conditions of useful action.” 400 We refer elsewhere in this chapter to Bergson’s idea that living beings are “centres of indetermination,” that is to say, creatures who hold their place in nature and that of their species by “persisting in their own being” (the language of Spinoza) by acting and reacting upon some of the many forces of nature that act upon them, and by avoiding the action of other forces and other animals. “They allow to pass through them,” he says, “so to speak, those external influences which are indifferent to them; the others isolated become ‘perceptions’ by their very isolation” (Matter and Memory, pp. 28, 29). We also refer to Bergson’s idea that the life-force has expressed itself along different grades of being (mineral, animal, and so on). Both these ideas are a partial explanation of what we mean by the presence of a spiritual activity in both inanimate and animate nature. So also is Bergson’s idea that the purely mechanical explanation either of nature or of life is but a device of the intellect for the purposes of description. More specifically it is expressed, too, in his idea that “Our representation of matter is the measure of our possible action upon bodies; it results from the discarding of what has no interest for our needs, or more generally for our functions” (Matter and Memory, p. 30), or that “Consciousness” is just this choice of “attaining to” or attending to “certain parts and certain aspects of those parts” of the “material universe” (ibid. p. 31), or that “sense-perception” is an “elementary question to my motor activity.” “The truth is that my nervous system, interposed between the objects which affect my body and those which I can influence, is a mere conductor, transmitting, sending back, or inhibiting movement. This conductor is composed of an enormous number of threads which stretch from the periphery to the centre, and from the centre to the periphery. As many threads pass from the periphery to the centre, so many points of space are there able to make an appeal to my will, and to put, so to speak, an elementary question to my motor activity. Every such question is what is termed a perception” (ibid. 40, 41; italics mine). Or, as he puts it, on p. 313, “No doubt the choice of perception from among images in general is the effect of a discernment which foreshadows spirit.... But to touch the reality of spirit we must place ourselves at the point where an individual consciousness, continuing and retaining the past in a present enriched by it, thus escapes the law of necessity, the law which ordains that the past shall ever follow itself in a present which merely repeats it in another form, and that all things shall ever be flowing away. When we pass from pure perception to memory, we definitely abandon matter for spirit.” 401 Bergson is always able to detect the relapses even of “mechanism” and of the mechanical philosophy of science into “finalism,” as when he says on p. 72 of his Creative Evolution, “To sum up, if the accidental variations that bring about evolution are insensible variations, some good genius must be appealed to—the genius of the future species—in order to preserve and accumulate these variations, for “selection” will not look after this. If, on the other hand, the accidental variations are sudden, then, for the previous function to go on, or for a new function to take its place, all the changes that have happened together must be complementary. So we have to fall back on the good genius again to obtain the convergence of simultaneous changes, as before to be assured of the continuity of direction of successive variations.” 402 We must remember that to Bergson evolution has taken place along different lines—those of Automatism (in plant-life), Instinct (in animal life), and Intelligence (in human life and the higher animals), and that along none of those lines are we to fall into the errors either of materialism, or of “Darwinism” (the belief in “accidental variations”), or of the “design-philosophy,” or even of theories like “neo-Lamarckianism” or neo-vitalism. To him all these philosophies are but imperfect and hypothetical attempts to grasp “movement” and “life” which both “transcend finality, if we understand by finality the realisation of an idea conceived or conceivable in advance” (Creative Evolution, p. 236). 403 “Paleyism” or “Miltonism” are still good names for the thing, I have read in some competent book upon Evolution. 404 See below, p. 261. 405 To Bergson concepts are just as hypothetical in the realm of science, as they are to thinkers like Mach and Poincaré, and Professor Ward of Cambridge. See the following, for example, from Matter and Memory (p. 263): “We shall never explain by means of particles, whatever these may be, the simple properties of matter; at most we can thus follow out into corpuscles as artificial as the corpus, the body itself—the actions and reactions of this body with regard to all the others. This is precisely the object of chemistry. It studies bodies rather than matter; and so we understand why it stops at the atom, which is still endowed with the general properties of matter. But the materiality of the atom dissolves more and more under the eyes of the physicist. We have no reason, for instance, for representing the atom to ourselves as a solid, rather than as a liquid or gaseous, nor for picturing the reciprocal action of atoms by shocks rather than in any other way.” Or, the following characteristic passage from the same book (p. 280) in respect of the hypothetical character of the concepts of “pure time” and “pure space”: “Homogeneous space and homogeneous time are then neither properties of things nor essential conditions of our faculty of knowing them; they express, in an abstract form, the double work of solidification and of division, which we effect on the moving continuity of the real in order to obtain there a fulcrum for our action, in order to fix within it starting-points for our operation, in short, to introduce into it real changes. They are the diagrammatic designs of our eventual action upon matter.” 406 Like his celebrated contemporary Eucken, and like many other thinkers of their time, Bergson is profoundly convinced of the one-sidedness of the so-called scientific culture of our day, and of the error of any and all conceptions of education and of social policy that are based upon it. Although I refer below to the limitations of his view that the intellect is adapted only to matter and to mechanical construction, I append the following quotation as symptomatic of his value as a spiritual teacher in our scientific age: “As regards human intelligence (Creative Evolution, pp. 145–6) it has not been sufficiently noted that mechanical invention has been from the first its essential feature, that even to-day our social life gravitates around the manufacture and use of artificial instruments.... This we hardly realise, because it takes longer to change ourselves than to change our tools.... In thousands of years, when seen from the distance, only the broad lines of our present age will be visible, our wars and our revolutions will count for little, even supposing they are remembered at all, but the steam-engine, and the procession of inventions of every kind that accompanied it, will perhaps be spoken of as we speak of the bronze or of the chipped stone of prehistoric times; it will serve to define an age.” 407 I find this in Bergson’s whole attribution of much of our “perceptual” and “scientific” knowledge of things to the “needs of action,” and in the detailed reasons that we attempt on pp. 236–238 to indicate for his polemic against rationalism. 408 This confirmation I find in Bergson’s whole philosophy of perception and sensation referred to on p. 236, and in his idea of a living being as a “centre of action” or “a centre of indetermination.” In fact it is obvious that he is one of the very greatest of the upholders of the “freedom” of the life of the individual, and of the fact that each new individual contributes something new of its own to the sum-total of existence, to the life of its species, and to the life of the world. Of course there is no more an explanation in his teaching of the causes of “variation” or the differences at birth between the off-spring of men and of animals, than there is in the philosophy of Darwin. 409 The idea of this necessity is confirmed in Bergson’s whole philosophy of man’s life as a life of action, as a constant surmounting of obstacles, as a life that reacts in its own way upon the life of nature, upon the life of the human species as such, upon the infinite life and energy and “love” of God—if we may soar to this great thought. See, for example, what he writes in explanation of the “discordance” of which he speaks thus: “Our freedom, in the very movements by which it is affirmed, creates the growing habits that will stifle it if it fails to renew itself by a constant effort: it is dogged by automatism. The letter kills the spirit. And our most ardent enthusiasm, as soon as it is externalised into action, is so naturally congealed into the cold calculation of interest or vanity, the one takes so easily the shape of the other, that we might confuse them together, doubt our sincerity, deny goodness and love.” The explanatory words are the following. [They are quite typical of the kind of philosophy of life that Bergson thinks of as alone worthy of the name of a philosophy of the living. And the reference to “love,” as the highest “dynamic” force in this world of ours, occurs at their close.] “The profound cause of this discordance lies in an irremediable difference of rhythm. Life is general, is mobility itself; particular manifestations of life accept this mobility reluctantly, and constantly lag behind. It is always going ahead; they want to mark time. Evolution in general would fain go on in a straight line; each special evolution is a kind of circle. Like eddies of dust raised by the wind as it passes, the living turn on themselves, borne up by the great blast of life. They are therefore relatively stable, and counterfeit immobility so well that we treat each of them as a thing rather than as a progress, forgetting that the very permanence of their form is only the outline of a movement. At times, however, in a fleeting vision, the invisible breath that bears them is materialised before our eyes. We have this sudden illumination before certain forms of maternal love, so striking and in most animals so touching, observable even in the solicitude of the plant for its seed. This love, in which some have seen the great mystery of life, may possibly deliver us life’s secret. It shows us each generation leaning over the generation that shall follow. It allows us a glimpse of the fact that the living being is above all a thoroughfare, and that the essence of life is in the movement by which life is transmitted” (Creative Evolution, pp. 134–5; italics mine). It is surely needless to point out how much truer to human nature, truer therefore to an important part of reality, this life-philosophy is than the abstractionism of Professor Bosanquet in the preceding chapter. 410 This insistence is, I think, amply confirmed by the very fact of the immediate contact with life and reality indicated in the quotation that is given in the preceding note upon the “motive- awakening,” or the “dynamic” character of the philosophy of Bergson. It is also confirmed in his manifest insistence upon the one fact that all philosophy must assume (and has for ever assumed) the fact of life, the fact of the life and thought of God that underlies all our life and all our thought. 411 This position of the pragmatists is certainly confirmed by Bergson’s entire doctrine of the brain and of the intellect—that their main service is, in the first instance, to interpret the “life” of things, its relation to our own will and to our practical activity. I have suggested, too, in this chapter that it is obviously a characteristic, or a consequence, of the philosophy of Bergson that our highest thought about ourselves and about the world should be relative to, and provocative, of our highest emotion. 412 It is only with some degree of care and reservation that I wish to refer to any apparent confirmation of this idea by Bergson. And, as always, I object to the idea of any ultimate separation or “dualism” between faith and knowledge—faith being implied in all “knowledge.” There is no opposition in Bergson, or in the principles of his philosophy, between faith and knowledge; it is rather his idea that “the faculty of seeing should be made one with the act of willing” (Creative Evolution, 250; his italics), and that “philosophy” should “proceed, with the powers of conceptual thought alone, to the ideal reconstruction of all things, even of life” (C.E. xi.; italics mine). My reasons for finding in his writings a confirmation of the idea that it is indeed our rational and spiritual faith, rather than our demonstrable knowledge, that is to us the measure of truth and reality, are such considerations as the following (in addition to those of the clauses just quoted), his close association between the intellectual and the “volitional,” his general faith in “creative evolution,” in the idea that our “consciousness” means for us “new choices” and (real) “new possibilities,” his faith in the higher intuitions of the mind, in the spiritual nature of man, his belief that the building up of the true philosophy of the future will involve “the collective and progressive effort of many thinkers, of many observers also, completing, correcting, and improving one another” (C.E. xiv.), etc. etc. 413 See below, p. 257, note 1. 414 See p. 14 in reference to Dr. Schiller’s suggestion that “freedom” may “pervade the universe.” 415 “From time to time, however, in a fit of absent-mindedness, nature raises up souls that are more detached from life.... Were this detachment complete, did the soul no longer cleave to action by any of its perceptions, it would be the soul of an artist such as the world has never yet seen” (Laughter, p. 154). 416 Cf. p. 235. 417 Cf. “We must break with scientific habits which are adapted to the fundamental requirements of thought, we must do violence to the mind, go counter to the natural bent of the intellect. But that is just the function of philosophy” (Creative Evolution, p. 31).
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