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To report on the early complications related to the percutaneous placement of iliosacral screws for the operative treatment of displaced posterior pelvic ring disruptions.Prospective, consecutive.Level-one trauma center.One hundred seventy-seven consecutive patients with unstable pelvic ring fractures. One hundred two male and seventy-five female patients ranging in age from eleven to seventy-eight years (mean, thirty-two years).Operative procedures were performed urgently according to the patient's clinical condition. Anterior pelvic reductions and fixations were performed by using internal and external fixation techniques. Accurate closed or open reductions of the posterior pelvic ring disruptions were accomplished by using a variety of surgical techniques dependent on the specific pattern of pelvic ring disruption. Closed manipulative reductions of the posterior pelvic ring were attempted for all patients. Open reductions were necessary in those patients with unacceptable closed manipulative reductions as assessed fluoroscopically at the time of operation (more than one centimeter in any field of fluoroscopic imaging).Plain inlet and outlet radiographs were obtained postoperatively at six weeks, three months, and twelve months. A pelvic computed tomography scan was performed postoperatively to assess fracture or dislocation reduction and the implant safety. Annual follow-up pelvic radiographs were obtained. Residual pelvic deformities were quantified based on these imaging modalities.There were no posterior pelvic infections. Minimal blood loss was associated with this technique. Complications occurred due to inadequate imaging, surgeon error, and fixation failure. Fluoroscopic imaging was inadequate due to obesity or abdominal contrast in eighteen patients. Five screws were misplaced due to surgeon error. One misplaced screw produced a transient L5 neuropraxia. Fixation failures related to either crandiocerebral trauma, delayed union, noncomplicance, and a deep anteror pelvic polymicrobial infection secondary to a urethral tear occurred in seven patients. There were two sacral nonunions that required debridement, bone grafting, and repeat fixation prior to healing.Iliosacral screw fixation of the posterior pelvis is difficult. The surgeon must understand the variability of sacral anatomy. Quality triplanar fluoroscopic imaging of the accurately reduced posterior pelvic ring should allow for safe iliosacral screw insertions. Anticipated noncompliant patients or those with craniocerebral trauma may need supplementary posterior pelvic fixation. Low rates of infection, blood loss, and nonunion can be expected.