|SYMPOSIUM ON PELVIC TRAUMA
|Year : 2014 | Volume
| Issue : 1 | Page : 37-42
Long term outcome of surgical treatment of fractures of pelvis
Ajai Singh, Rajeshwar N Srivastava, Shah Wali, Abhishek Agarwal
Department of Orthopaedics, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||6-Jun-2014|
King George's Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
With the advances in the trauma management, the protocol of the treatment of fractures of pelvis has evolved with control of mortality and morbidity, which is associated with these fractures. The goal of management is to achieve anatomical reduction with stable fixation of these fractures with optimum functional outcome. Despite of the better understanding of the pathophysiology of these fractures and advances in the surgical techniques to fix these fractures, the long term outcomes of these fractures are not predictable. Though in majority of patients, we may achieve the pelvic stability and pain free walking, but still we are not able to define a reproducible approach to achieve the optimum functional outcomes in all the patients with fractures of pelvis. The present paper deals with a systematic review of available literature related with controversies related with all aspect of surgical treatment of these fractures including various methods of management, various methods of fixation, techniques of fixation, determination of type and amount of pelvic stablisation and evaluation of long term functional outcome and its correlation with various factors.
Keywords: Fracture pelvis, long term outcome of fracture pelvis, surgical treatment of fracture pelvis
|How to cite this article:|
Singh A, Srivastava RN, Wali S, Agarwal A. Long term outcome of surgical treatment of fractures of pelvis. J Orthop Traumatol Rehabil 2014;7:37-42
|How to cite this URL:|
Singh A, Srivastava RN, Wali S, Agarwal A. Long term outcome of surgical treatment of fractures of pelvis. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 May 27];7:37-42. Available from: http://www.jotr.in/text.asp?2014/7/1/37/134011
| Background|| |
Pelvic fractures account for 1-3% of all skeletal fractures and about 2% of orthopaedic hospital admissions.  The frequency of pelvis fractures occurs in a bimodal pattern, with peak observed in persons aged 20-40 years and later in persons aged older than 65 years.  The incidence of instability related to pelvic fractures ranges between 13-17% of all cases.  It has been stated that the death as a result of pelvic fracture occurs in less than 1% of the patients admitted with this injury.  The risk factors for increase in mortality and morbidity risk associated with fractures of pelvis has been identified as the age of the patient, females, mode of injury (impact force) and crash characteristics (lateral impacts by a heavy vehicle).  Mortality from pelvic trauma varies from 40-60% among patients in shock, and upto 90% in patients considered to be in extremis.  Those patients with pelvic trauma who reach hospital, mortality is reported to be between 7.6-19%. ,,,, The mortality associated with open pelvic fractures is as high as 50%.  Adam et al..  reviewed 392 deaths resulting from motor vehicle collision and concluded that one of the cause of under reporting of mortality from pelvic trauma may be due to those individuals who do not survive long enough to reach the hospital.
Important anatomic considerations
The pelvic ring is a major supportive structure permitting bipedal erect walking in human beings. Various important neurovascular components including the autonomous nerves supplying the reproductive organs and visceral structures (bladder, urethra) reside within the pelvic cavity. These structures are at risk not only at the time of injury, but also at the time of surgical intervention. Therefore any neurovascular insult can lead to painful walking, paresthesia, muscle weakness and sexual dysfunction as a long term disability after fractures of the pelvis.
Pelvic fracture classification
The most frequently used pelvic fracture classifications were proposed by Burgess et al.,  which is based on the direction of force (lateral compression, anterior compression, vertical shear and combined) and degree of displacement of fracture fragments. This classification system is of little use in predicting the outcome and prognosis of these fractures. It has been observed that a large proportion of patients with severe pelvic fracture do not have immediate complications such as hemorrhage, while approximately 50% of the patients with pelvic fractures with significant hemorrhage do not have any significant radiological injury. 
According to the type of trauma, the fractures of the pelvis can be divided as high energy trauma fractures or low energy trauma fractures.  Though the high energy trauma pelvic fractures are less common than low energy pelvic trauma, but these are associated with other systemic and musculoskeletal injuries in more than two-third of patients. The rate of surgical fixation of high energy trauma pelvic fractures is two times higher than low energy trauma pelvic fracture.  During a long term follow-up, mortality associated with high energy trauma pelvic fractures were reported to be approximately 10% at 1 year, 20% at 2 years and 50% at 5 years.  Unlike high energy pelvic fractures, the mortality has been rarely related to the trauma itself in lower energy pelvic fractures. 
Statement of problem of haemorrhage related with pelvic trauma
The major life threatening bleeding is associated with all the three common injury patterns resulting in pelvic fractures, i.e. anteroposterior compression, lateral compression, and vertical shear injuries. Usually, most bleeding in pelvic fracture occurs due to presacral venous plexus injury or musculature injury, but arterial injury can result into catastrophic bleeding. It would be very important to diagnose the bleeding early as the treatment of each cause would be different- early fixation of factures, to facilitate the tamponad effect of venous bleeding and arterial embolosation. The hemorrhage may be complicated with impaired coagulation. 
Hemorrhage risk based on pattern of injury/fracture
Hamill et al.  tested the hypothesis that pelvic fracture injury pattern are associated with the need for pelvic arterial embolosation. They observed that though a correlation existed, it was not strong enough to change the indications of angiography. It was also observed that pelvic fracture in elderly is more likely to cause significant haemorrhage, regardless of force patterns/vectors.  However Cook et al.  noted in their retrospective study of 150 consecutive patients with unstable fractures of pelvis that the morphology of these fractures was not the reliable guide to associated vascular injury.
Management of unstable pelvic fractures/hemorrhage
The urgent management of the patient with pelvic fractures, which is complicated by hemorrhage remains a diagnostic and therapeutic challenge. We need an urgent, comprehensive but aggressive approach to treat them. A team should composed of anaesthesiologist, emergency medicine physicians, interventional radiologists and orthopaedic and trauma surgeons. One can diagnose the thoracic and/or abdominal sources of major bleeding by portable bed side upright chest radiograph and either by portable ultrasound or diagnostic peritoneal lavage (DPL). Evers et al.  recommended pelvic angiography before laparotomy in hemodynamically unstable patients with pelvic fracture, unless the DPL is grossly positive. Literature  has described a number of treatment modalities, including pneumatic antishock garments, laprotomy and pelvic packing, celiotomy with bilateral hypogastric artery ligation, transcatheter embolotherapy and external fixation of pelvis.
Surgical management of soft tissue injuries associated with fracture of pelvis
Management of lower urinary tract injuries
Bjurlin et al.  reviewed 1400 patients with pelvic fracture and documented about 4% urinary bladder injury and 2% urethral injuries in his series. It was observed that a urethral injury is not only documented in male patients, but also in female patients with pelvic injuries. One must examine the vagina to observe any blood per urethra with or without any laceration. Even without any obvious external urethral injury one must rule out it by placing a urinary catheter smoothly. The suprapubic cystostomy with delayed repair of posterior urethral disruption is a time tested approach. The current consensus amongst the urologists is that fibrotic strictures of the urethra may take months for stability. It has also been demonstrated that the long term presence of suprapubic catheter delays or even prevents definitive surgical fixation of pelvic fracture. This delay in the definitive management of these fractures or even inability to fix these fractures in time may result into long term disability. Hadjizacharia et al.  concluded that patients undergoing immediate endoscopic repair developed voiding in an average time of 35 days in comparison to 229 days in patients going to delayed repair with significantly lower incidence of stricture formation with formal procedure (14% vs. 100%). It has been now established that early realignment of disrupted urethra with early repair may lead to significantly long term improved sexual function.  These observations thus favor the early expeditious diagnosis and realignment of urethral disruption with avoidance of suprapubic cystostomy. A rare associated bladder neck injury with pelvic fracture may lead to long term incontinence which may be dealt with implantation of an artificial sphincter.  Koraitim  evaluated the results of treatment modalities of urethral injuries complicating the fractured pelvis. He reviewed 100 male patients with urethral injuries following pelvic fractures. Seventy-three of them were managed by delayed repair with suprapubic cystostomy, 23 by primary urethral realignment and 4 by primary suturing of urethral ends. He observed that urethral stricture was an inevitable consequence (97% of the cases) after suprapubic cystostomy. The study also concluded that the frequency of the stricture was reduced to 53% by primary realignment but this procedure produced impotency in a 36% cases. It was noted that fibrotic strictures were formed in about 49% of cases of primary suturing of the urethra, but the same series of patients impotency was complicated in about 56% of cases with or without incontinence in 21% of cases. After observing the long term results, it may be concluded that suprapubic cystostomy should be the treatment modality for an incomplete urethral rupture with minimum urethral distraction and in those patients who are critically ill. With the wide separation of urethral ends which may or may not be associated with injury of the bladder neck or rectum, partial alignment should be performed. There is no specific indication for primary suturing of the urethra. Laparoscopies bladder repair has been reported  but enough long term data are not available to analyze the value of this procedure.
Management of perineal injuries associated with open pelvic fracture
Open pelvic fractures are often associated with perineal lacerations, which may involve the anus, rectum, vagina and urethra and direct communication with fracture site. This communication may decompress or contaminate the fracture hematoma early, leading to sepsis or even multiple organ failure. The vaginal laceration should be repaired immediately. The injured anal sphincter should be approximated to the degree possible. An early diverting colostomy may be required to avoid septic complications. The long term outcome and recovery rate are poorer in these types of pelvic fractures than the close fracture without associated with these injuries.  Chronic disability, impaired role performance and poor physical function are reported in the series of long term outcome of open pelvic fracture.  Though less common, long term complications associated with these fractures may include fecal or urinary incontinence, impotence dyspareunia and non-healing fractures. 
Management of pelvic fractures
The stable pelvic fractures are best treated with bed rest. Once the instability is diagnosed the open reduction and internal fixation of both anterior and posterior element of the pelvic ring are the gold standard treatment.  The early and definitive fixation of posterior elements is a vital step for early rehabilitation of these patients and maximizing the chances of pain free walking.  The long term outcome of conservative treatment of displaced and unstable pelvic fractures is poor and associated with life long disability.  The early aggressive combination treatment protocol involving external and internal techniques has become standard to counter the associated disability, but fixation within the first 24 h is sometimes questioned as it is often accompanied by other injuries. , As per present trends available, it may be concluded the internal fixation performed even between 6 days to 2 weeks will not compromise the long term outcome. 
Disruption pubis symphysis
The amount of instability between the pubic bones determines the treatment modality of pubis symphysis disruption. Several authors have recommended surgical stabilization when pubis diastasis is more than 2.5 cm, , but letournel recommended symphysis stabilization even if disruption measures more than 1.5 cm.  The external fixation or open reduction and internal fixation are the treatment options available for the management of pubic symphyseal disruptions. In the presence of suprapubic cathetors, the external fixators are indicated for small symphysis. ,, Though external fixators are easy to apply but their maintenance is very cumbersome with a high chance of pin site infection. Early open reduction and internal fixation of the symphysis are preferably done by reconstruction plate. Berner et al.  managed significant symphyseal disruptions by internal fixation with unsatisfactory functional outcomes in 21% cases.
Pubic rami fractures
The treatment options for pubic rami fractures include external fixation, , percutaneous screw fixation , and open reduction, and open reduction and internal fixation by 3.5 mm pelvic reconstruction plate. ,
Iliac wing fractures
Severely displaced or comminuted iliac wing fractures, associated with bowel herniation within fracture, associated with significant skin abnormality, significant closed degloving injuries, open pelvic fractures and associated with unstable pelvic ring injuries are some of the indications of surgical management of these fractures. 
The fractures of posterior ileum extending from iliac crest into the greater sciatic notch associated with an articular dislocation of the anterior sacroiliac joint are described as crescent fractures. , These fractures are treated by direct reduction of iliac fracture with indirect reduction of the sacroiliac joint. Iliosacral screw may also be used to augment the fixation. 
Sacral fractures usually are treated by indirect techniques unless a need for forminal decompression is present or inability to secure an acceptable reduction of fractures.  Sacral stabilization is done with transiliac bars, transiliac screws, transiliac plate or iliosacral screws.
Sacroiliac joint disruption
The incomplete disruption of sacroiliac joint can be managed by nonoperative methods or with an external fixator. Complete disruption or dislocation of SI joint can be managed by open reduction and internal fixation by 3.5 or 4.5 mm pelvic reconstruction plates.  Use of ilisacral screws is being popularized for stabilization of the SI joint.  Rargnarsson et al.  reported on 21 patients with SI joint disruption treated with internal fixation with plate and screws. They observed long term poor functional outcome in about 14% of those patients in which post-operative radiological position remained unchanged with that of preoperative position. It was further observed that one of the reasons for the poor results in cases of SI disruption could be the residual displacement of more than 10 mm. 
Long term outcome and prognosis of management of pelvic fractures
It has been demonstrated that stabilization of unstable pelvic ring within first 8 h of admission improves the long term outcomes and survival rate.  Injury pattern and amount of displacement and its replacement have been correlated with outcome.  Disruption of SI joints is associated with poorer results than when compared with either sacral or iliac wing fractures. , Posterior displacement of pelvic fragments of 5 mm has been identified as leading to poorer patient outcomes.  Semba et al.  reported a correlation of primary anterior and posterior displacement exceeding 10 mm with severe low backache. It was also established that limb length discrepancy more than 2.5 cm also has been associated with poor results.  Permanent neurological injury, which is associated with unstable pelvic ring injuries in about 20% of patients contributes to poorer long term outcome. , Templeman et al.  noted that even sacral fractures complicated by neurological involved are associated with compromised outcome. It has been documented that the neurological injuries associated with pelvic fractures recover as late as 4 years.  Suzuki et al.  studied the correlation of long term functional outcome of patients with unstable pelvic ring fractures with various factors such as an injury severity score, fracture location or fracture type. They concluded that there is no correlation between them. They also discovered a close correlation between neurologic injury and functional outcome.
Fixation of the anterior part of the ring is considered unnecessary by many surgeons although all biomechanical tests show inferior stability compared to extensive fixation of the whole pelvic ring. The only external fixation of anterior part of the pelvis does not produce enough stability in type C unstable pelvic fractures, which may lead to suboptimum long term functional results.  Hirvensalo et al.  described an anterior low-middle incision for an anterior extraperitoneal approach to fix the anterior and lateral parts of the ring. This approach was combined with a lateral incision on the lateral crest for fractures of the wing and with posterior approach for SI injuries. They observed that the complications were fewer with this new technique. Ong et al.  described internal fixation of unstable pelvic ring injuries by modifying Stoppa approach in a series of five patients. They observed good long term functional outcome in three of five patients. They concluded that this modified Stoppa approach offers excellent visualization of quadrilateral plate and anterior column as well as the posterior element also in some cases.
Mardanpour et al.  reviewed 38 patients with unstable pelvic fractures, who were treated with open reduction and internal fixation of the unstable pelvic ring. They observed excellent to good results in 75% of cases. No sexual dysfunction was reported in their series. They had not reported any relationship between functional outcome and the site of fracture.
Holdsworth et al.  reported that about 50% of their patients with unstable pelvic ring fractures managed by open reduction and internal fixation returned to their original job. Mardanpour et al.  reported that 67% of their patients with operated unstable pelvic fractures returned to their original work. In a study  of closed pelvic fractures managed by early internal fixation, it was observed that patients are more likely to be discharged rather than to rehabilitation or skilled care (P < 0.05) and have greater functional outcomes and improved mobility. In a study  of unstable pelvic ring fractures repaired with open reduction and internal fixation, 76% of the patients returned to work. Sickness impact profile score (SIP) at 1 year after injury indicated that 77% of these patients had only mild disability, while 23% had a moderate disability.
Lau et al.  retrospectively compared non-operated elderly pelvic fractures with those operated. There was no difference in walking status at 3 months. They observed that the walking deteriorated in all surgically as well as non-operatively managed patients with pelvic fracture by the end of 1 year, whereas mortality was significantly less in operative case as compared to non-operated cases by the end of 1 year. To date, there is no RCT compares operative to conservative management in fragility fractures of the pelvis.
Giannoudis et al.  concluded that percutaneous screw fixation of fractures of the pelvis was a newer procedure. They concluded that only experienced surgeons with proper knowledge of the anatomy should undertake this technique. Although inadequate reduced fractures treated by this technique are not having a better outcome compared with an anatomical open reduction, but certainly have significantly lesser complications.
| Conclusions|| |
Most patients with fractures of pelvis survive their injuries. If not, the mortality is usually due to concomitant injuries. Control of hemodynamics instability with infection, diagnosis, early fixation of unstable fractures and early start of rehabilitation are vital for optimum functional outcomes. These patients require a coordinated approach by various health professionals throughout their treatment and even after the discharge. With early intervention and prevention of problems through collaborative efforts, these patients can return to the community with fruitful and constructive life.
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