Pelvic Fractures

Definition/description

A pelvic fracture is a breakdown of the pelvic bone structure. The anatomical ring is formed by the fused bones of the iliac ischium and pubic bone attached to the sacrum. Pelvic fractures can be caused by low energy mechanisms or high energy impacts. They range in severity from relatively benign Life-threatening unstable fracture injuries.

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Clinically Relevant Anatomy

The pelvis is the entire structure formed by the two hip bones (sacrum and coccyx), with the lower part of the coccyx attached to the sacrum. The paired hip bones are the large curved bones that form the outside and front of the pelvis. Each adult hip bone is made up of three separate bones Comes together in the late teens. These bony components are the ilium, ischium, and pubic bone. [2]

Pelvic stability depends on the integrity of the posterior weight-bearing sacroiliac complex and the transmission of weight-bearing forces from the spine to the lower extremities. The sacroiliac joint (between the sacrum and ilium) transmits the forces of the upper body and spine to the hip joint and lower extremities, and vice versa. This joint also acts as a shock absorber. Some muscles affect sacroiliac joint motion and stability by attaching to the sacrum or ilium or by attaching ligaments to the strong anterior and posterior sacroiliac ligaments. two-thirds of the muscle The joint includes the posterior superior ligament portion, and one third of the joint includes the anterior synovial portion. [3] [4]

The pelvis contains sliding tilt and rotation motion components.

The main neurovascular and part of the bowel bladder and reproductive organs pass through the pelvic ring. The pelvis protects these vital structures from injury. It also acts as an anchor for the hip thigh and abdominal muscles.

Epidemiology/Etiology

Pelvic fractures occur after low and high energy events. The incidence of pelvic fractures is highest among those between the ages of 15 and 28. Among people under the age of 35, pelvic fractures occur more frequently in men than in women. Pelvic fractures are more likely in people over age 35 More women than men [5]. In young adults, pelvic fractures are primarily the result of high-energy mechanisms. In older adults, they are caused by minor trauma, such as a fall from a low position. Older adults with osteoporosis have higher risk factors.

Low energy fractures are usually stable fractures of the pelvic ring. High-energy pelvic fractures are common after motor vehicle crashes, motorcycle crashes, motor vehicle strikes of pedestrians, and falls. Those high energy pelvic fractures are one of the leading injuries leading to death. this Coma shock and head and chest injuries were predictors of death. [6] (Level of Evidence: 2B) The video clip below provides a detailed summary of the etiology and treatment/complications of pelvic fractures.

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Characteristics/Clinical Presentation

Pelvic fractures should always be considered when there is a history of major trauma. Pelvic fractures can be identified by tenderness, bruising, swelling, and crepitus of the pubic bone, buttocks, and sacrum. Other presenting factors are: hematuria, rectal bleeding, hematoma, and Abnormalities of the nerves and blood vessels in the legs. Physical examination findings may include abnormal lower extremity position and pelvic deformity or instability. With avulsions, there is usually pain associated with contraction of the affected muscle. [8]

A distinction must be made between high-impact unstable fractures and low-impact stable pelvic fractures. This can be done by identifying the circumstances of the trauma. Patients with unstable fractures are often unable to stand while those with stable fractures are able to stand Often walk alone.

Pelvic fractures can be classified by a variety of classification systems. The two most commonly used systems are the Tiles classification and the Young-Burgess classification.

Tile’s classification of pelvic fractures is based on the integrity of the posterior sacroiliac complex. [twenty three]

• Type A: rotationally and vertically stable with intact sacroiliac complex. Type A fractures are mostly treated nonoperatively.
  o A1: avulsion fractures
  o A2: Stable iliac wing fracture or slightly displaced pelvic ring fracture
  o A3: Transverse sacrum or coccyx fracture
• Type B: partial disruption of the posterior sacroiliac complex due to rotational instability and vertical stabilization caused by external or internal rotational forces.
  o B1: open-book injuries
  o B2: lateral compression injuries
  o B3: bilateral rotational instability
• Type C: complete destruction of the posterior sacroiliac complex with rotational instability and vertical instability. These unstable fractures are often caused by high-energy trauma, such as falls from a motor vehicle or crush injuries.
  o C1: unilateral injury
  o C2: Bilateral injury with rotational instability on one side and vertical instability on the opposite side
  o C3: Bilateral injury, bilateral vertical instability

70 – 80% of pelvic injuries are type A or B fractures. [4]

Young and Burgess’ classification of pelvic fractures is based on the mechanism of injury. [9][10][11]

• Anterior posterior compression
• Lateral compression
• Vertical shear
• Complex: any combination of the three main modes

The Young and Burgess classification system is limited because it provides little guidance for treatment. [12]

Differential Diagnosis

Pelvic fractures rarely occur as a single injury. They should be distinguished from or may be accompanied by many diseases, such as:[13][14][15][16]- Avascular necrosis of the femoral head- Cancer- Hip dislocation- Hip fracture- Osteomyelitis- Osteoporosis- Genitourinary system injury-Intestinal injury- Muscle Injury – Neurovascular Injury – Bladder Injury – Urethral Injury

Diagnostic Procedures

The diagnosis of pelvic fractures is primarily made by medical imaging. Imaging tests can determine where the fracture is, how much bone is affected, and whether the injury damaged surrounding soft tissue, such as tendons, ligaments, blood vessels, or nerves:[17]

• X-ray: front and rear views entrance view and exit view
• CT scan 
• Ultrasound
• Bone scans

Severity and associated injuries can be investigated by:[18]

• Urinalysis
• Measurement of hemoglobin and hematocrit: to measure blood loss
• Retrograde urethrography
• Arteriography
• Cystography

Outcome measures

To measure the prognosis of patients with pelvic fractures, a number of questionnaires can be used. They can be classified as disease-specific or patient-specific outcome measures. [19]

Disease specific:

– Harris Hip score- Mayo Hip scores

Patient specific:

– Oxford Hip Score – SF-36- WOMAC- iHOT

Examination

Because high-energy trauma can damage major organ systems, the workup for pelvic fractures should begin with the investigation of life-threatening injuries. The abdominal perineal genital rectum and lower back must be examined very carefully. [8] High energy fractures are often accompanied by Other organs were severely injured. [10] When life-threatening injuries are ruled out, the examination should include inspection and palpation of the pelvis to identify crepitus and determine pelvic stability. It is necessary to check whether there are related injuries. some hurt Potentially associated pelvic injuries include soft tissue, urethral, skeletal, neurovascular, and nervous system injuries.

Soft tissue injuries such as hematoma abrasions and lacerations often accompany pelvic ring injuries. Hematomas located laterally to the scrolabia and inguinal region suggest intrapelvic hemorrhage [13]. Perineal-rectal and vaginal tears indicate severe injury, which may indicate contamination with urine or feces. Omori et al. It was concluded that the risk factors for major bleeding were: lactate level AO/OTA classification and CT contrast medium pelvic extravasation. They Created a New Effective Predictive Score for Major Bleeding In pelvic ring fractures. [14] Pelvic fracture Urethral injury is a rare but potentially devastating result of a pelvic fracture. Symptoms of urethral injury are blood at the external urethral opening, high (not palpable) prostate in men, and swelling of the perineum and genitals. pelvis Fractures are often accompanied by bladder rupture. Destruction may be intraperitoneal or extraperitoneal or both. Gross hematuria occurs in patients with bladder rupture. [15]

Pelvic fractures are often associated with bone damage. It is necessary for the clinician to examine the spine and extremities. Limb length differences or internal/external rotational deformities may be present.

Because many structures span the pelvis, injury to the pelvis may result in damage to the neurovascular structures. Vascular injury is more common than arterial injury. Both can cause bleeding. Vascular damage urgently requires treatment. [16]

Sometimes there is also nerve damage. Commonly injured nerve roots are L5 and S1. Sometimes the L4 (severe pelvic injury) or S2-S5 nerves (sacral injury) are also damaged. Clinicians should carefully detect these nerve injuries by neurological examination.

Medical Management

Pelvic fractures should be considered in the context of polytrauma management and not in isolation. The treatment and management of each patient requires careful individualized decision-making. [3] The medical treatment of pelvic fractures consists of many components. first if necessary Resuscitation must be performed. The patient and fracture should then be stabilized. Once medical management is complete, rehabilitation can begin.

Stabilization of pelvic fractures has historically been managed nonoperatively. Recently, surgery has increased in the treatment of unstable pelvic fractures. Surgical treatment of unstable pelvic ring injuries allows early mobilization, thereby reducing complications Immobilized. Stability may also be important for patient survival and may be desirable to improve long-term functional outcome. It corrects and prevents significant pelvic deformities, thereby improving clinical outcomes for patients [20].

In emergencies, fractures will be stabilized with external fixators (for anteroposterior injuries) or “C-clamps” (for vertical shear injuries). Final fixation can be done at the front or rear and internally or externally. most plates or screws for stability fracture. Rommens et al. (2015) concluded that more research is needed to find the optimal treatment for each instability type. [twenty one]

Other methods used to treat pelvic fractures are traction herringbone cast pelvic slings and turnbuckles.

Physical Therapy Management

Physical therapy is an important part of low-energy and high-energy pelvic fracture rehabilitation.

• Low energy injuries are usually treated conservatively. This includes bed rest for pain control and physical therapy. [8]
• High-energy injuries, especially unstable fractures, must be minimized by surgical treatment. Physical therapy afterward includes the same treatments as for low-energy fractures.

Early mobilization is important because prolonged immobilization can lead to many complications, including respiratory and circulatory dysfunction. Physical therapy can help patients get out of bed as quickly as possible.

The goal of a physical therapy program should be to provide patients with optimal functional recovery by improving functional skills, self-care skills, and safety awareness. [22] The main goals are to improve pain levels, strength, flexibility, healing speed and motion of the hip and spine as well as leg. Another important goal is to reduce the time required to return to activity and exercise. The strength of rehabilitation depends on whether the fracture is stable or unstable.

In patients undergoing surgery, physical therapy begins after 1 or 2 days of bed rest. It starts with small movement transfer training and movement training. The following exercises can be started immediately after surgery and should be performed at least four times per day (unless otherwise stated). The number of repetitions is a guideline and may vary for each patient. [twenty three]

Plantarflexion and dorsiflexion of feet Sit up or lie down. Keeping your legs straight, move your feet up and down at the ankles, point your toes, and relax. Repeat 10-15 times per hour.

Hip abduction moves your legs out to the sides, then back to the center. Repeat 10 times on both sides.

Quadriceps Contraction Lay your legs flat on the bed. Push your knees down to straighten your legs, then tighten your thigh muscles and hold for 5 seconds. Repeat 5-10 times.

Knee extension: Lie on your back. Place a rolled towel under your knees. Tighten your thigh muscles, straighten your knees, and lift your heels off the floor. Hold the leg straight for five seconds, then lower it gently. Repeat 10 times on both sides.

Knee stretch: Sitting Once you are comfortable in a chair or wheelchair: Pull your foot up, tighten your thigh muscles, and straighten your knee. Hold this position for five seconds. Repeat 10-15 times per hour.

Short-term goals for patients after surgery: independence through transfer and wheelchair mobility. Depending on the patient’s medical condition, these goals can be achieved within 2 to 6 weeks. The physical therapy program can continue in the hospital or at home. Home-based programs include Basic range of motion stabilization and strengthening exercises designed to prevent contractures and reduce atrophy.

During the non-weight-bearing state, patients perform isometric exercises until fatigue with gluteal and quadriceps range-of-motion exercises and upper-body resistance exercises (eg, shoulder and elbow flexion and extension). repeat times can Varies from patient to patient. [twenty four]

Once weight bearing is resumed, physical therapy includes gait training and resistance training of the trunk and extremities, as well as cardiovascular training (such as treadmill or bicycle training). Stability exercises and mobility training should also be kept in the program. [25] The spa is also good and helpful if available. [twenty four]

Mobility exercises can help restore hip, knee, and ankle range of motion after immobilization. Gait training should start with walking between the parallel bars. Afterwards, the patient should learn how to walk with a walker or crutches. Balance and proprioception training should also included in rehabilitation. Resistance training should be gradual to improve muscle strength in the hips and legs. In the final phase, functional exercises should be included in order to provide the patient with optimal functional recovery.

The video clip below shows a good progression of physical therapy, but not for the elderly and infirm.

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For older adults with pelvic fractures, the rehabilitation process focuses on optimizing their quality of life. Rapid mobility and adequate pain relief are the main goals of treatment [27] and assessment of the home environment to assess the need for safety aids such as guardrails Slopes add lighting and remove loose cushions. Appropriate walking aids should also be provided. A falls prevention outpatient program may be helpful.

Zidden et al. (2010) investigated the long-term effects of home rehabilitation programs. They concluded that a year after the rehabilitation process began, most patients felt they were not fully recovered compared to their pre-fracture conditions. [28] should have More investigations are needed to describe the short- and long-term effects of rehabilitation for pelvic fractures.

Key Research

Few studies have focused on optimal conservative management of pelvic fractures. Most studies focus on medical management. More evidence is needed to define optimal physical therapy regimens.

Clinical Bottom Line

The type of pelvic fracture should first be determined. Medical management and further rehabilitation depend on whether the fracture is stable or unstable. If the fracture is unstable, surgery is often required. Pelvic fractures should be considered in the context of polytrauma management Rather than being isolated due to the complexity of the injury that caused the pelvic fracture.

In patients undergoing surgery, physical therapy begins after 1 or 2 days of bed rest. Physical therapy starts with non-weight bearing exercises. Only when the fracture is sufficiently stable should weight-bearing exercises be started. Walking aids will be necessary and must be tapered off.

We can conclude that the treatment and management of each patient requires careful individualized decision-making and therefore consider this the main idea of pelvic fractures.