Pelvic fracture: description
The pelvis is the connection between the spine and the legs and also supports the viscera. It consists of several individual bones that are firmly connected to each other and form the pelvic ring. Basically, a pelvic fracture can occur in different sections of the pelvis.
Pelvic fracture: classification
A distinction is made in pelvic fractures between injuries to the pelvic ring and the acetabulum. The Association for Osteosynthesis (AO) divides the various pelvic ring injuries according to the stability of the pelvic ring. A rough distinction is made between a stable and an unstable pelvic ring fracture.
Stable pelvic ring fracture
Unstable pelvic ring fracture
An unstable pelvic ring fracture is a complete fracture involving the anterior and posterior pelvic rings. Medical professionals refer to this as type B when the pelvis is vertically stable but rotationally unstable. This applies, for example, to the symphyseal fracture – “open-book injury”: the pubic symphysis is torn apart in this case, and the two halves of the symphysis are opened like a book.
Furthermore, a pelvic fracture is called type C if it is a completely unstable pelvic fracture. The pelvis tears due to vertical gravitational forces and is both vertically and rotationally unstable.
Acetabular fracture
An acetabular fracture often occurs in combination with a hip dislocation (“dislocated hip”). In some cases (15 percent), the peripheral nerve of the leg, the sciatic nerve (nervus ischiadicus), is also injured.
Polytrauma
A pelvic fracture is a serious injury. In 60 percent of cases, patients also have injuries to other parts of the body (i.e., they are polytraumatized). In particular, the following injuries may occur in combination with a pelvic fracture:
- Fractures of the peripheral skeleton (in 69 percent of pelvic fracture patients).
- Traumatic brain injury (in 40 percent)
- Chest injuries (in 36 percent)
- Abdominal organ injuries (in 25 percent)
- Spinal cord injury (in 15 percent)
- Urigenital injuries, which are injuries to the urinary and genital tracts (in 5 percent)
Pelvic fracture: symptoms
In addition, contusion marks or bruising may appear on the dependent body parts such as the testicles, labia, and perineum. In some cases, the pelvic fracture may cause the legs to have different lengths.
Unstable pelvic fractures often occur as part of multiple injuries (polytrauma). For example, bloody urine may indicate a bladder injury, which is more common in association with pelvic fractures.
Patients often have their pelvic bones easily dislocated from each other. In extreme cases, the pelvis opens up like a book (“open book”). Walking is no longer possible for a person with such an injury.
Pelvic fracture: causes and risk factors
A pelvic fracture usually occurs as a result of a fall or accident. The cause is considerable direct or indirect force on the pelvis, such as a fall from a great height or a motorcycle or car accident.
The most common pelvic fracture is a sit fracture or pubic bone fracture and is usually harmless. It can occur even in simple falls (such as slipping on black ice).
Unstable fractures are often the result of accidents and falls from great heights. In most cases, other bones and organs are also injured (polytrauma). A bladder injury is particularly dangerous.
Pelvic fracture in older people
Older people over the age of 70 are particularly susceptible to a pelvic fracture because they often suffer from osteoporosis: In this case, the bone is decalcified, the number of bone bellicles decreases, and the bone cortex becomes thinner. Even a small force can then result in a fracture. Patients often have other bone fractures, such as a fracture of the neck of the femur. Women are particularly affected by this.
Pelvic fracture: examinations and diagnosis
- How did the accident occur?
- Was there direct or indirect trauma?
- Where is the possible fracture located?
- How do you describe the pain?
- Were there any previous injuries or previous damage?
- Were there any previous complaints?
Physical Examination
Next, the physician will closely examine the individual for external injuries and palpate the pelvis for irregularities. He will use measured pressure on the pelvic bucket to check if the pelvis is unstable. He palpates the pubic symphysis and performs a rectal examination (examination through the anus) with his finger to rule out bleeding.
The doctor also checks the motor function and sensitivity of the legs to see if any nerves have been damaged. He also checks blood flow to the legs and feet by feeling the pulse on the foot, for example.
Imaging procedures
If a posterior pelvic ring fracture is suspected, additional oblique images are taken during the X-ray examination. This allows a better assessment of the pelvic entrance plane as well as the sacrum and the sacroiliac joints (joints between the sacrum and ilium). Dislocated or displaced fracture parts can thus be localized more precisely.
If a posterior pelvic fracture, acetabular fracture or fracture of the sacrum is suspected, computed tomography (CT) can provide clarity. Precise imaging also allows the physician to more accurately assess the severity of the injury – as well as adjacent soft tissues. For example, CT allows the doctor to see how far a bruise has spread.
Magnetic resonance imaging (MRI) is used to evaluate a fracture in children and older patients. Unlike CT, it does not involve radiation exposure.
If osteoporosis is suspected as the cause of the pelvic fracture, bone densitometry is performed.
Special examinations
In connection with a pelvic fracture, injuries to the urinary tract such as the ureter, bladder and urethra often occur. Excretory urography (a form of urography) is therefore used to examine the kidneys and the draining urinary tract. For this purpose, the patient is injected with a contrast medium via the vein, which is excreted via the kidneys and can be visualized in the X-ray image.
Urethrography is an X-ray imaging of the urethra. It can be used to diagnose urethral tears. To do this, the doctor injects a contrast medium directly into the urethra and then x-rays it.
Pelvic fracture: treatment
A pelvic fracture has a high risk of thrombosis. Treatment for pelvic fracture differs according to how severe the injuries are (the condition of the posterior pelvic ring is important) and the condition of the patient.
A stable type A pelvic injury with an intact pelvic ring can be treated with conservative methods. The patient must first be on bed rest with a pelvic harness for a few days. After that, he may begin to do mobility exercises slowly with a physiotherapist – with adequate administration of painkillers.
The pelvis is stabilized in an emergency – either with an anterior “external fixator” (holding system for immobilizing fractures, which is attached to the bone from the outside through the skin) or a pelvic clamp. If the spleen or liver is also injured, the abdominal cavity is opened on an emergency basis. The surgeon clears out the extensive bruise and stops the bleeding with abdominal drapes. If there is a pubic bone fracture, the pubic bone is re-stabilized with plates.
For joint fractures (such as acetabular fracture), surgery is always necessary to prevent premature joint wear. Surgery of the acetabulum should always be performed in specialized centers, as it is a very demanding procedure. The fractures are fixed with screws and plates or an external stabilizer such as the “external fixator”.
Pelvic fracture: complications
A number of complications can occur with a pelvic fracture:
- Injuries to the bladder and urethra, vagina and anus
- Damage to nerves (such as obturator nerve)
- in men with pubic bone fracture: impotence
- diaphragmatic rupture as concomitant injury
- venous thrombosis (occlusion of veins due to blood clot formation)
The following complications are possible with acetabular fracture:
- post-traumatic arthrosis (depending on the extent of destruction of cartilage and joint)
- heterotopic ossification (conversion of soft tissue into bone tissue): For prevention, the surgical area can be irradiated (two hours before surgery and up to 48 hours afterwards) and anti-inflammatory painkillers of the NSAID type can be given.
- Femoral head necrosis (death of the femoral head), if the trauma was very intense and the femoral head was not supplied with blood for a long time
Pelvic fracture: course of the disease and prognosis
An unstable pelvic fracture also usually heals well with appropriate therapy. Complications such as wound healing disorders, bleeding, secondary bleeding and infections are rare. In some cases, nerves supplying the bladder and bowel may be damaged as a result of the pelvic fracture. The patient may then be unable to hold stool or urine (fecal and urinary incontinence). Likewise, sexual function may be impaired in men.
The therapeutic outcome in unstable pelvic fracture depends largely on the additional injuries. In most cases, however, everyday movements and normal physical exertion are possible again afterwards.