|SYMPOSIUM ON PELVIC TRAUMA
|Year : 2014 | Volume
| Issue : 1 | Page : 43-47
Neglected pelvic fractures: An overview of literature
Ramesh Kumar Sen1, Tarun Goyal2, Sujit Kumar Tripathy3
1 Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Orthopaedics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Web Publication||6-Jun-2014|
Ramesh Kumar Sen
Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Despite numerous advancement in surgical techniques and better understanding on pelvic injuries, it is not uncommon to see neglected pelvic fractures in India. The pelvic injuries are either neglected by the patients themselves by late presentation or poor compliance to treatment or sometimes even neglected by the surgeons by inadequate treatment. The usual manifestations of neglected pelvic fractures are either a nonunion or a malunion. Pelvic nonunion or malunion results in huge disability to the patients. These disabilities manifest in the form of pain, leg length discrepancy, sitting or standing imbalance and even sexual or excretory dysfunction. Treatment of such old injuries is extremely difficult. Correction of malunion may be performed in stage wise procedure with multiple osteotomy. The nonunion may be treated with bone grafting and plate stabilization. This literature review focused on the manifestations, treatment and residual problem of such pelvic malunions and nonunions
Keywords: Malunion, neglected pelvic trauma, neglected orthopedic injury, non-union, pelvis, pelvis fracture
|How to cite this article:|
Sen RK, Goyal T, Tripathy SK. Neglected pelvic fractures: An overview of literature. J Orthop Traumatol Rehabil 2014;7:43-7
|How to cite this URL:|
Sen RK, Goyal T, Tripathy SK. Neglected pelvic fractures: An overview of literature. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 Sep 20];7:43-7. Available from: http://www.jotr.in/text.asp?2014/7/1/43/134013
| Introduction|| |
Contribution of the road traffic accidents to the global burden of disease is expected to rise from the 9 th to the 3 rd position from 1990 to 2020.  Mortality of a major pelvic fracture is about 10%  and impact of these injuries on future functional impairment is considerable. Disability following these injuries commonly affects individuals in the most productive years of their life. Definitive operative treatment of complex pelvic fractures is often neglected and bony union is presumed, thereby making way for mal-unions and non-unions. As the acute trauma care has improved, more patients with complex pelvic fractures survive the initial injury. Internal fixation following open reduction is the recommended line of treatment for unstable injuries of the pelvic ring. Treatment using conservative means or external fixation often results in inaccurate reduction and high chances of non-union or mal-union in these patients.  If treated by external fixation, about 85% of the type C fractures have been reported to have unsatisfactory outcomes [Table 1]. Thus, most of these disabilities are preventable if treated appropriately at the initial stage.
Non-unions and mal-unions of the pelvic rings are severely disabling injuries, but only limited literature is available on their management. Management of associated life-threatening injuries in these patients often take precedence and the pelvic injury remains neglected, or even major mal-alignments are accepted. These in the longer term lead to pelvic pain or problems of balance while sitting or walking. This review discusses the clinical manifestations, associated injuries and treatment options of neglected pelvic fractures.
| Pain, sitting and standing imbalance|| |
Inadequately managed unstable pelvic fractures may lead to considerable morbidity in the longer run. Pain is the most common complaint in patients with late mal-unions and non-unions of the pelvic ring. ,, It may arise from the anterior or the posterior aspect of the pelvic ring, with the problems in the posterior ring being the most common pain generators. Incongruity and instability of the sacro-iliac joint (SIJ) and non-union of the posterior pelvic ring may lead to significant functional impairment. The reasons for pain include a non-union, instability or pressure effect from the mal-aligned bony structure. Less commonly, a neurogenic type of pain due to nerve root compression in lumbo-sacral plexus may be seen. Pain can vary in intensity and even impair activities of daily living in some patients. Pain due to instability and non-union is the most common reason for late surgical treatment of these patients. Pain from the pelvis should be differentiated form other anatomical sites such as the hip and spine. Associated trauma to the hip joint may be a significant contributor to pain. Chronic low back of mechanical origin, from mal-alignments of spine, pelvis or limb may also be a significant cause of pain in these patients. Persistent low back pain is a major long term complaint following pelvic fractures. ,, In series of Mears and Velyvis,  this was seen in 51% of the patients. Interestingly 62% of these patients also had lumbar spinal injuries at the time of trauma, which may be difficult to differentiate from pelvic pain in these patients.
Difficulty in sitting is a common complaint after a pelvic fracture non-union and mal-unions. This is secondary to sitting imbalance or pressure from a prominent bony projection. Sitting imbalance may arise from asymmetry of the ischial tuberosities. In series by Mears and Velyvis  this asymmetry was due to vertical displacement and mal-rotation of hemi-pelvis in saggital plane in almost equal number of patients. Prominent bony projections such as those resulting from posterior displacement of the hemi-pelvis or pelvic rotations may cause pressure symptoms while sitting or lying down. With cranial migration of the hemi-pelvis or bilateral pelvic wings the prominence of the sacrum or the coccyx may also be a cause of difficulty in sitting. 
Leg-length discrepancy can be a result of a vertically unstable fracture or a saggital mal-rotation. There may be an associated two-column fracture of the acetabulum resulting in a limb-length discrepancy. This may result into a fixed pelvic obliquity. Internal or external rotation of the hemi-pelvis may also result in internal or external rotation of the foot while walking respectively.
Pennal and Massiah  were first to describe the pelvic non-unions in their series of 32 patients with pelvic fracture non-unions. Vertical shear fractures had the highest incidence of non-union. Inadequate immobilization, premature weight bearing and gross mal-positioning of the fracture ends were the most common reasons for non-union. Mears and Velyvis  studied 204 patients with non-unions and mal-alignments following pelvic fractures [Table 2]. Most common complaints in these patients were pain, pelvic instability, sitting imbalance and apparent limb-length discrepancy. Stable pelvic fractures fared much better than the unstable fractures in terms of long-term clinical outcomes. Majority (>80%) of patients with pelvic non-unions had significant pain due to instability. 
|Table 2: Classification of pelvic non-unions and mal-alignments (Mears and Velyvis)|
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Hefzy et al.  studied the effect of a simulated open book injury on opening of the SIJ in human cadavers. They found that degree of opening up of the SIJ in an open book type of injury can be predicted from the amount of opening up of the pubic symphysis.  Thus if pubic symphysis is left open as in neglected pelvic fractures, the SIJ are also incongruous to a similar degree. There was no vertical movement of the hemi-pelvis in an open book type of injury, but it was found to displace inferiorly and posteriorly on the side of the injury.
| Sexual and excretory dysfunction|| |
Sexual and excretory dysfunction is an important cause of long term disability following pelvic fractures. Wright et al. studied a cohort of 298 patients with pelvic fractures and found incidence of sexual and excretory dysfunction of 21% and 8% respectively.  This was significantly higher than the incidence in other patients sustaining trauma with no pelvic fractures. A strong gender specific association was seen between the fracture configuration and the dysfunction. A four-fold higher risk of sexual and excretory dysfunction was seen in males with SIJ injuries. In females presence of symphyseal diastasis increased the risk of sexual and excretory dysfunction by 4.8 and 12% respectively.
Dysparunia may be seen in females with displaced pelvic fractures, with incidence of dysparunia correlating with the initial displacement of the pelvic fracture.  Impingement of the vaginal wall by the displaced fragment or the medially displaced ischial tuberosity is an important cause of dysparunia.
Vallier et al.  studied 31 females in reproductive age group who had pregnancies after healed pelvic fractures. They concluded that fracture patterns, minor mal-alignments and internal fixation hardware are not an indication for cesarean delivery. Though the incidence of cesarean delivery was much higher in these patients, it was generally related to patient or obstetricians preference. They recommended for suitable trial of labor in these patients. Lateral compression (LC) injuries may reduce the dimensions of the pelvic rings complicating normal fetal passage. Three women in their series, who had delivered normally, had reduction in pelvis dimensions by 1.2-2.2 cm due to LC injuries. No objective measurements to allow for a normal vaginal delivery exist in these patients and a case for cephalo-pelvic disproportion may be ruled out before allowing a vaginal delivery by the obstetrician, though this is not common in minor displacements or internally fixed fractures.
| Management of late complications|| |
Symptomatic pelvic non-unions and mal-unions often need surgical treatment. Conservative treatments have been tried to equalize the leg-length difference and sitting imbalance. These include shoe raises and pelvic pad for sitting imbalance. Surgical correction is the treatment of choice if appropriate expertise is available. Cause of pain and other symptoms in these patients is important to evaluate before any surgical intervention is undertaken. Much more pre-operative planning is needed in these patients with pelvic non-unions and mal-unions compared to acute fractures. Choice of surgical approach, sequence of surgeries in multiple procedures, extent of soft-tissue releases and osteotomies if needed and modalities of fixation have to be planned in advance. Due attention is needed to protect the neurovascular structures from soft tissue dissection and manipulation during the surgery. Most surgeons use neural monitoring using somatosensory evoked potentials during the procedure.
| Pre-operative planning|| |
Clinical evaluation should include measurement of limb-length discrepancy and pelvic obliquity. Site of pain and its relation to various activities will help to decide the cause of pain. Non-union, mal-union and instability are important causes of pain in these patients. Plain radiographs with special views are the initial imaging modality for pelvic fractures. These views include standard antero-posterior view, inlet and outlet views and 45° oblique views of the pelvis. Stress testing under radiographs or single-leg weight bearing films can sometimes be used for evaluation of instability following pelvic injuries.
Computed tomography (CT) scan with 3D reconstruction has become a modality of choice for detailed study of the pattern of bony injury in pelvis trauma. CT guided intra-articular injection of lignocaine into the SIJ may help to localize the site of pain in complex pelvic injuries. A significant improvement in pain with intra-articular injection would indicate that stabilization or fusion of the SIJ will result in a significant improvement of pain. Technetium bone scan is also frequently used investigation for evaluation of the SIJ. Increased uptake may correlate with SIJ as the cause of posterior pelvic pain.
| Surgical treatment|| |
Prevention of the pelvic deformities and instability is better than the treatment of these complications. Goal of surgical treatment of an acute, displaced pelvic fracture should be anatomical reduction and stable internal fixation, once the hemodynamic stability has been achieved. External fixation alone is insufficient to maintain reduction of unstable pelvic fractures and often results in symptomatic mal-unions. Injuries involving both the anterior and posterior arches of the pelvic ring may need both anterior and posterior procedures to achieve union, depending upon the degree of instability. Insufficient fixation or premature mechanical loading may lead to non-unions of the pelvic rings. Such non-unions are poorly tolerated and are a source of pain. Additional surgical procedures for stabilization of the pelvic ring and improving the biological environment for healing may be needed [Table 3].
|Table 3: Summary of operative treatment of late pelvic non-unions and malunions|
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Non-union in the anterior ring usually need additional plate fixation of the fractures with bone grafting (BG). Management of the posterior ring non-unions are more complicated. The ilio-sacral and ilio-lumbar ligaments are unhealed and arthrodesis is the recommended treatment, though the results may be sub-optimal. The disrupted ligaments may often cause soft-tissue interposition at the fracture site. Treatment of mal-union is much more complicated. Insufficient reduction of the sacral injuries may be well tolerated, if the initial vertical displacement of the SI articulation is <1 cm.  Reduction of these mal-unions is complicated and there is a danger of lumbo-sacral plexus injury. If the pain is the main symptom and is attributable to non-union, in situ fixation may be carried out.
Reduction of pelvic mal-unions and non-unions require extensive soft tissue releases. Multi-stage surgical procedures are generally required [two-stage or three stages [Table 3]. The surgical procedure itself is challenging, with prolonged surgical duration of 6-8 h and may need large volumes of blood transfusion. , Deformities involving isolated internal and external rotation of the pelvic ring are the ones easiest to correct. , These can usually be approach through single anterior incision. A study done by Oransky and Tortora  corrected rotational deformity (axial plane deformity) using only anterior approaches. Frigon and Dickson  advocated a single stage reconstruction of the pure internal or external rotation deformities of the pelvic ring using anterior approach. A Pfannensteil's incision was used for anterior soft-tissue releases followed by distraction or compression of the pelvic ring, which was stabilized using the same incision. Posterior stabilization could be combined using percutaneous SI screws.
Isolated posterior displacement of the hemi-pelvis is also easier to correct. Deformities in saggital and coronal plane and vertical displacements are most difficult to correct. There is a very high chance of neural injuries in such injuries.
Current literature is deficient on surgical treatment of neglected pelvic fractures. Mears and Velyvis  treated surgically 204 patients for non-unions of the pelvis. Pain was the most common symptom, present in all but one patient. Constant or severe pain was present in 64% of the patients. They used standard surgical approaches and their extensions for surgical correction as were used for primary fracture fixation. Principles of surgical treatment were similar to non-unions or mal-alignments in other bones. These include debridement of the non-union site, approximation of the fracture ends, BG of the gaps and stable internal fixation. Mears and Velyvis used multistage procedures under single anesthesia in complex pelvic deformities to carry out anterior and posterior releases. They used a supplementary curvilinear incision in patients with limb-length discrepancies, extending from the iliac crest to the inferior aspect of the lateral sacrum to release the SIJ and other contracted posterior structures. In two-column acetabular fractures with secondary incongruity and limb-length discrepancy, a pelvic osteotomy was used, extending from the greater sciatic notch to the iliac crest, which was rotated to correct the limb-length. They also used surgical excision of the more inferior ischial tuberosity in three patients who were unsatisfied after the surgical procedures for correction of the limb-length discrepancy, with good outcomes. Union was seen in 96% of the patients.  All patients with pre-operative pelvic instability showed symptomatic improvement. Anatomical reduction was seen in 50% with another 35% showing satisfactory reduction. The surgical procedures had good success rates in improvement of pain with 69% of the patients having only no or only slight pain after recovery (compared to only 9.5% patients before the surgery). Out of 66 patients with sitting imbalance, 92% patients were satisfied following the surgery.
Matta et al.  in their study have recommended a three-staged reconstruction as the most common surgical approach for the late pelvic mal-unions. They treated 37 patients with pelvic non-unions and mal-unions. This could be carried out in anterior-posterior-anterior or posterior-anterior-posterior sequence. The first stage involved soft-tissue releases and mobilization of the fracture site in one side of the hemi-pelvis. Second stage involved additional releases, mobilization and reduction of the fracture site in the opposite side of the pelvis (anterior or posterior). The final stage involved reduction and fixation. Extensive soft-tissue releases including release of the posterior ligament complex may be necessary to achieve reduction. Nerve injuries were seen in three patients following the surgery. Satisfactory results were reported in 32 of the 37 patients.  Simple non-unions without deformities may be addressed by simple one or two-staged procedure targeting the non-union site. Unilateral injuries of the pelvic ring have a fair chance of correction. In bilateral injuries of the pelvic ring, Matta et al.  have recommended that the correction of the deformities may be difficult and the aim of treatment may sometimes be limited to addressing the non-union site and accepting the mal-union due to the bilateral injuries. Similar three stages procedures for surgical correction have been used by other authors. ,
van den Bosch et al. operated 11 cases of non-unions of the pelvic ring.  Pain was the most common symptom seen in all the patients. Following surgery improvement in pain and functional status was seen in 9 of the 11 patients (82%).
| Iatrogenic neural damage|| |
The gluteal nerve, lateral femoral cutaneous nerve and L5 nerve roots are the most commonly involved nerves during surgical treatment of these pelvic fractures and should be identified and protected. Mears and Velyvis  had used intra-operative somato-sensory evoked potential monitoring of pudendal and sciatic nerves during the surgical procedure. Iatrogenic lumbo-sacral plexopathy or sciatic nerve palsy was seen in eight patients. There was complete recovery on five patients in 6 months. van den Bosch et al. in their study reported one case (9%) of neuropraxia of the lateral femoral cutaneous nerve of thigh in the series of 11 cases of pelvic fracture non-unions treated operatively.  Oransky and Tortora  reported neural damage in L5/S1 nerve roots in 6 of the 55 patients operated for pelvic non-unions and mal-unions.
| Conclusion|| |
Pelvic fractures following high velocity trauma are a major contributor to the long-term morbidity and mortality. Patients who suffer from major pelvic trauma would often have sustained a major life-threatening event. Disability from the pelvis fracture may often be realized later in the course of recovery. Motivation for treatment may be low both on the part of the patient and the treating surgeon, as the patient is trying to compromise with the poor quality of life and the surgeon is often fraught with the fear of poorer results.
Early operative treatment of pelvic fractures provides the highest chances of good function. Neglected pelvic fractures result in poor outcomes in long run. Surgical treatment of these late presentations is difficult and fraught with complications, though this is the only way reasonable function can be restored in majority of these patients. These procedures should be carried out by experienced surgeons as the procedure is difficult and complication rates are high. Individualized planning has to be made for each patient based on fracture pattern, before any such surgical intervention is planned.
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[Table 1], [Table 2], [Table 3]