Percutaneous iliosacral screw fixation has become a cornerstone in the management of unstable posterior pelvic ring injuries. Its minimally invasive nature reduces soft tissue trauma, blood loss, and postoperative morbidity while providing excellent mechanical stabilization. Yet even well-established procedures can produce rare but devastating complications when anatomy, fracture morphology, or implant trajectory are less than ideal.
The case reported by Drossel and colleagues highlights one such complication and, more importantly, demonstrates how careful multidisciplinary planning can transform a potentially catastrophic event into a successful clinical outcome.
A 58-year-old woman sustained multiple traumatic injuries after a fall from height, including an unstable posterior pelvic ring fracture that was initially treated elsewhere with percutaneous sacroiliac screw fixation. Following transfer for further management, postoperative imaging raised concern that the sacroiliac screw had been placed well anterior to its intended osseous corridor. Contrast-enhanced computed tomography demonstrated intimate contact between the screw and the left external iliac vein, while duplex ultrasonography identified extensive ipsilateral deep venous thrombosis, strongly suggesting venous injury or compression.
The management dilemma was substantial. Simple screw removal risked sudden exsanguinating hemorrhage if the screw was tamponading a venous perforation. Open vascular exposure would require a highly invasive operation with significant morbidity. Leaving the screw in place carried ongoing risks of bleeding, thrombosis, pain, and nonunion.
Rather than choosing either extreme, the treating team assembled specialists from traumatology, vascular surgery, and angiology to design a hybrid solution. Before revision surgery, an inferior vena cava filter was inserted because of the existing deep venous thrombosis. Intravascular imaging and venography were performed, balloon occlusion catheters were positioned to control potential bleeding, and the screw was carefully removed under continuous angiographic visualization within a hybrid operating suite. As anticipated, contrast extravasation immediately confirmed perforation of the external iliac vein. Coil embolization of the screw tract successfully controlled the bleeding, after which a correctly positioned sacroiliac screw was inserted during the same procedure.
The patient's recovery was remarkably favorable. Postoperative CT confirmed appropriate screw placement without active hemorrhage. The inferior vena cava filter, which had captured organized thrombus, was subsequently removed, illustrating its protective role against pulmonary embolism. At follow-up, the patient demonstrated maintained fixation, satisfactory mobility, and good functional recovery without recurrent vascular complications.
Beyond presenting an unusual complication, this report emphasizes several broader lessons. Accurate preoperative planning remains essential, particularly in patients with sacral dysmorphism or complex pelvic anatomy. Although conventional fluoroscopy remains widely used, the authors review growing evidence supporting three-dimensional navigation to reduce malposition rates and improve screw trajectory. Equally important, this case reminds surgeons that when complications do occur, individualized decision-making and close collaboration across specialties frequently provide safer and less invasive alternatives than traditional open revision.
Rare complications often teach the most enduring lessons. This report expands the literature on vascular injuries during sacroiliac fixation while providing a practical roadmap for managing one of the most feared technical complications in pelvic trauma surgery. It demonstrates that thoughtful interdisciplinary collaboration, advanced imaging, and endovascular techniques can successfully convert a potentially fatal intraoperative event into an excellent clinical outcome.
Clinical Take-Home Message
Careful preoperative imaging, meticulous screw trajectory planning, and early recognition of implant malposition are essential during sacroiliac fixation. When vascular injury is suspected, multidisciplinary management in a hybrid operating environment can allow minimally invasive treatment that avoids major open surgery while safely controlling potentially life-threatening hemorrhage.
Multiple-Choice Question
A 58-year-old woman undergoes percutaneous sacroiliac screw fixation for an unstable pelvic ring fracture. Postoperative imaging demonstrates that the screw has perforated the left external iliac vein. Which of the following management strategies was successfully used in this case report?
A. Immediate open laparotomy with direct venous repair before screw removal
B. Observation with anticoagulation alone because the patient was hemodynamically stable
C. Hybrid minimally invasive management using angiographic guidance, temporary vascular protection, screw removal, coil embolization of the injured venous tract, and reinsertion of a correctly positioned sacroiliac screw
D. Immediate removal of the screw in the operating room without vascular imaging or endovascular preparation
Correct Answer: C
Explanation
Answer C is correct.
The authors employed a carefully planned interdisciplinary approach involving trauma surgery and angiology in a hybrid operating room. An inferior vena cava (IVC) filter was first placed because of extensive deep venous thrombosis, followed by venography and intravascular imaging. Balloon catheters were positioned to allow vascular control before the misplaced screw was removed under fluoroscopic guidance. Removal confirmed perforation of the external iliac vein with contrast extravasation. Coil embolization of the screw tract successfully controlled the bleeding, after which a new sacroiliac screw was accurately inserted. The patient recovered without vascular complications.
Why the Other Answers Are Incorrect
A. Immediate open laparotomy with direct venous repair before screw removal
Although open vascular exposure was considered, it was rejected because of its substantial surgical morbidity and the possibility of performing an unnecessary laparotomy if no significant vascular injury were present. The multidisciplinary team instead selected a less invasive hybrid strategy.
B. Observation with anticoagulation alone because the patient was hemodynamically stable
Observation would have left the patient at continued risk for catastrophic hemorrhage, persistent venous injury, thrombosis, pain, and pseudarthrosis. Definitive management was required.
D. Immediate removal of the screw without vascular imaging or endovascular preparation
Simply removing the screw could have resulted in uncontrolled life-threatening bleeding because the screw was likely tamponading the injured vein. Endovascular preparation with angiographic monitoring and vascular control was essential to safely manage the complication.
Teaching Pearl
When vascular injury is suspected after sacroiliac screw fixation, the safest management may not be immediate screw removal. Thorough imaging, multidisciplinary planning, and hybrid endovascular–orthopedic techniques can minimize morbidity while safely treating potentially fatal complications.
Journal of Medical Case Reports is the world's first international, PubMed-listed, medical journal devoted to publishing case reports from all medical disciplines and will consider any original case report that expands the field of general medical knowledge, and original research relating to case reports. The journal is open access, and strongly endorses the CARE guidelines for case reports, requiring authors to submit populated CARE checklists with submissions to improve transparency in reporting.