Pelvic Fracture

What Is a Pelvic Fracture?

Our pelvis is ring-shaped. The two halves consist of the ilium, ischium, and pubis, which grow together in development. The two halves are connected at the back by the sacrum (the extension of the spine), whereby the joint (sacroiliac joint) is additionally stabilized by strong ligaments. The pelvic halves are held together in front by fibrocartilage, the symphysis.

The pelvis is subjected to considerable stress daily, from carrying our weight to several times that weight through certain sports. From this, it can be seen that extreme force is required for a pelvic fracture to occur.

In the case of pelvic fractures, the specialist in trauma surgery/sports traumatology distinguishes injuries that involve loss of stability (pelvic ring fracture, symphysis fracture, acetabular fracture) from those that do not (e.g., fracture of the coccyx).

What Are the Causes of a Pelvic Fracture?

The enormous energy required to fracture a pelvis is usually released as part of a polytrauma (injury to several vital organs), e.g., as a result of a traffic accident.

However, childbirth can also lead to a dangerous rupture of the symphysis. This is facilitated by the normal expansion of the symphysis area in preparing the body for birth. However, symphysis rupture is also possible due to trauma.

Fractures in the acetabular area of the hip joint (acetabulum) usually occur indirectly due to excessive force transfer from the thigh to the acetabulum.

Pelvic injuries without loss of stability, such as a coccyx fracture, occur due to a fall on stairs, for example.

Pelvic Fracture Symptoms

The symptoms depend on the type of pelvic fracture. There may be a loss of stability in the pelvis. Due to the open bone surfaces, a large amount of blood can be lost quickly because the bone is the place of blood formation and is well supplied with blood. In addition, usually, other organs, such as the spleen, intestines, liver, nerves, are damaged after a traffic accident involving a pelvic fracture.

The leg-supplying vessels and nerves and the excretory organs for stool and urine also proceed in the pelvis area. As a result, symphysis rupture after childbirth is accompanied by severe pain on movement and strain.

Fracture of the acetabulum results in pain on the affected side, which may be accompanied by malalignment of the leg. Weight-bearing on the leg is no longer possible in this case of fracture. Fractures without loss of stability, such as the coccyx fracture, are manifested by severe pain.

How Is a Pelvic Fracture Diagnosed?

The suspicion of a pelvic fracture usually arises at the accident scene due to the course of the accident and the signs of injury. During the physical examination, an experienced emergency physician or trauma surgery specialist should check the stability of the pelvis once. Multiple examinations may result in a large amount of blood loss. After the physician's assessment, emergency treatment, including stabilization of the pelvis, is started.

Symphysis blast is clinically visible by the changes on the pelvis. However, the exact width of the blast is determined by radiographs taken by a radiologist.

The acetabular fracture is revealed by the symptoms the patient described. Physical examination of active and passive range of motion and pain onset also provide further clues. The location and exact nature of the fracture gap can be identified by computed tomography. Three-dimensional reconstruction of the data on the computer helps in this process. Minor fractures are usually identified by clinical examination and radiologic imaging.

Pelvic Fracture Treatment and Surgery

Emergency pelvic ring fracture treatment primarily stabilize vital signs (blood pressure, pulse, respiration). To prevent significant blood loss and allow transport of the casualty, a pelvic cramp can be applied to press the pelvis, and thus the bleeding bone surfaces together.

Once the emergency treatment has been carried out (usually by various specialist teams such as urologists, abdominal surgeons, etc.), the definitive treatment of the pelvic fracture can begin. If the pelvis is stable, it can be treated conservatively, with 1-2 weeks of bed rest.

Unstable or partially stable pelvic fractures are treated with plates and screws (plate osteosynthesis). In the case of polytrauma, an external fixator, i.e., a metal frame outside the body that is fixed to the pelvis by several metal rods, can be used temporarily. It offers the possibility of strong compression of the pelvic fracture and low blood loss.

Symphysis ruptures can be treated conservatively after birth with a tight belt around the hip. However, surgical treatment is carried out in case of a symphyseal burst due to an accident (if it is more than 3 cm wide).

The acetabular fracture is also treated with plates and screws but is among the most challenging procedures. It is essential to restore the joint surface without the slightest differences in height. Otherwise, premature wear of the joint (osteoarthritis) may occur. If the fracture pieces are not displaced (dislocated) by the fracture, surgery is not always necessary.

Healing Process and Prognosis

It takes several weeks for a bone to heal completely. During this time, significant rest is advised at the beginning. Over time, increasingly more load can be applied to the hip. In the meantime, physiotherapeutic treatment is important so that the full range of motion can be regained at the end and there are no deficits due to excessive resting of muscles and tendons.

Hip fracture is always associated with an increased risk of premature joint wear, which in some cases may require the implantation of an artificial hip joint years later.

Sources:

http://www.fallsammlung-radiologie.de/ct_beckenringfraktur.html

http://www.awmf.org/leitlinien/detail/ll/012-019.html

Winker, Karl-Heinrich (2011): Facharzt Orthopädie Unfallchirurgie. Munich: Urban & Fischer.

Grifka, Joachim (2011): Orthopädie und Unfallchirurgie. Für Praxis, Klinik und Facharztprüfung; mit 155 Tabellen. Berlin [u.a.]: Springer.