Percutaneous iliosacral screw (IS) fixation for pelvic ring injuries with the use of an O-arm imaging system has been associated with decreased procedure time and improved accuracy of IS screw placement compared with the use of fluoroscopic guidance. Specifically, patients with sacral dysmorphism require identification of safe bony sacral corridors, using specific anatomical measurements, to decrease the likelihood of complications such as screw perforation. Intraoperative computed tomography imaging and navigation can aid in safe and accurate IS screw fixation in patients with difficult anatomy.