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SURGICAL REVIEW

The Functional Outcome of Surgically Treated Unstable Pelvic Ring Fractures

*M. Maru, M.B.Ch.B, MRCS
S.P. Lazarides MB BS, MD, BC(Ortho);, P. Gill, MD FRCS;, A. Cross, FRCS;, G. Dekiewiet, FRCS;, A. Nanu, FRCS,

*Clinical Fellow, Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, SR4 7TP, United Kingdom.
†Consultant Orthopaedic Surgeons, Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, SR4 7TP, United Kingdom

Address for Correspondence
M Maru, Clinical Fellow,
Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, SR4 7TP, United Kingdom.
' :01915656256
E-mail: mmarus2000@yahoo.com

 

ABSTRACT

Eighteen patients with unstable pelvic fractures, treated from 1998 to 2003 were retrospectively reviewed. The mean patients’ age was 39 years (range 17 to 79). Thirteen patients were men and 5 women. The commonest cause was a road traffic accident (N=14). There were 6 type-C and 12 type-B fractures according to Tile’s classification. One of the fractures was open. Fifteen patients sustained additional injuries; four patients had lumbosacral plexus involvement.  External fixation as a definite management was applied to one fracture; surgical reduction was scored from the post-operative radiographs and Majeed’s score was used to assess the clinical outcome. The mean follow-up was 51.7 months (range 15 to 77 months). Nine patients required admission to ITU post-operatively. One patient developed superficial infection. The mean hospital stay was 27 days (range 5 to 50 days). All the patients had either good or excellent radiological reduction, however 5 of them had a fair functional outcome according to Majeed’s criteria. One patient died 2 years after surgery from causes unrelated to pelvic injury and we were unable to trace 2 patients. One patient with type-C3 fracture underwent hip resurfacing, 2 years following surgery.  Four patients complained of pelvic pain on mild exertion and two had sexual dysfunction. Seven patients returned to their original job, however the level of pain affected their performance accordingly. 

The management of unstable pelvic fractures is challenging; initial haemodynamic stabilisation takes preference and significantly reduces mortality. Associated injuries are common and they might further compromise the functional outcome. Open reduction and internal fixation yields a satisfactory outcome, however rehabilitation period is prolonged.

Keywords:   Pelvic fractures, unstable fractures, clinical outcome.

J.Orthopaedics 2005;2(2)e2

 

Introduction

Pelvic fractures are relatively rare injuries; their incidence in trauma patients is quoted to range between 3 % and 8.2 % and instability occurs in 13 % to 17 % of cases (1).

Because of the large force that is required to disrupt the pelvis, pelvic fractures are indicative of high-energy transfer to the patient and therefore, often combined with other injuries (1). Road Traffic Accidents (RTA) is the commonest cause of major pelvic ring injuries, followed by falls from a height, athletic or crush injuries (2). The mortality rate of haemodynamically unstable patients with pelvic fractures may be as high as 40 to 50 %, therefore prompt resuscitation that may involve several specialties is essential (2). Open reduction and internal fixation of the unstable pelvic ring fractures has been suggested to provide the best stability of fixation and the best clinical outcome (7,8), however rehabilitation period is prolonged.

The purpose of this study was to evaluate the morbidity and functional outcome of surgically treated unstable pelvic fractures in our department.

 

Patients and method

A retrospective study was conducted on eighteen patients who underwent surgical intervention for unstable fractures of the pelvic ring between 1998 and 2003. Instability was defined according to Tile’s classification (3).

The case notes were studied and demographic and clinical data was recorded, which included; age, gender, mechanism of injury, type of fracture, associated injuries, definitive surgery, postoperative ITU admission, hospital stay and complications.

The quality of surgical reduction was scored from the post-operative radiographs by implementing the scoring system that was introduced by Pohlemann et al (9).

The clinical outcome at the time of follow up was assessed via the scoring system introduced by Majeed (10); the current job status was also recorded.

Nine patients were transferred directly to our Accident and Emergency Department and the remaining nine patients were referred from surrounding trusts, as our unit acts as the referral centre for these injuries. Four of the nine patients who were transferred directly to our hospital arrived with signs of hypovolaemia; following initial fluid resuscitation and stabilization of the pelvic ring with an external fixator at the A&E department, three of them underwent an urgent laparotomy following urgent abdominal ultrasound which indicated free fluid in the peritoneal cavity. Surgical stabilisation of the pelvic ring with a combination of techniques was carried out as an emergency procedure within 6 hours of arrival in seven patients; the remaining two patients underwent surgery within 24 hours of admission. The remaining nine patients were referred by surrounding hospitals within an average of 4 days from the time of their injury and presented with stable vital signs on admission to our Unit. The ISS of patients who were directly transferred to our A&E had a mean value of 30 (range 16-62). 

The mean patients’ age was 39 years (range 17 to 79 years). Thirteen patients were men and five women. Road traffic accidents were the cause of pelvic fracture in 14 patients, followed by fall from a height in 3 patients and injury from a falling object in one patient. There were 6 type-C and 12 type-B fractures according to Tile’s classification (3). One of the fractures was open communicating with the vagina.   Two patients who underwent urgent laparotomy were found to have a ruptured spleen. Four patients had urological injuries; two had sustained bladder tears and the other two kidney lacerations resulting in one nephrectomy. Nearly half the patients had associated long bone fractures. One patient with comminuted fracture of the humerus had additional rupture of the axillary artery and brachial plexus injury; the damage to axillary artery was successfully repaired but the brachial plexus had only partially recovered at the time of follow up. Neurological injury of the lumbosacral plexus was identified in four patients at the initial evaluation; 3 were combined motor and sensory deficits affecting the L4, L5, and S1 nerve roots and the remainder was an isolated sensory deficit of the S1 and S2 nerve roots. (Table 1)

Nine patients had fixation of the symphysis pubis as well as the sacro-iliac (SI) joint. Three patientsunderwent internal fixation of the acetabulum and sacro-iliac joint and another three had fixation of the sacro-iliac joint that was combined with external fixation in two patients. One patient had fixation of the symphysis pubis whereas in another one that was combined with external fixation. External fixation as definitive treatment was applied for eight weeks in one patient. All patients received Cefuroxime perioperatively. Prophylaxis against Deep Venous Thrombosis included low molecular weight heparin (Enoxaparin 20mg sc) for the time of hospitalisation and thrombo-embolic deterrent stockings for six weeks following surgery. Seven patients required admission to ITU postoperatively with an average stay of 3.5 days (range 2-7 days). The average stay in hospital was 27 days (range 5 to 50 days). (Table 2)

The mean follow-up was 51.7 months (range 13 to 77 months). The data regarding the clinical outcome were collected via a questionnaire that was posted to patients along with a pre-paid self-addressed envelope. Those who did not reply were conducted by phone.  Analysis of the data was performed in Excel 2002.

Table I

           

No (N=18)

Age

Gender

Mechanism of injury

Type of Fracture

Neurological

injury

Associated injuries

 1

27

 F

 RTA

B2

 S1, S2, sensory

 Retroperitoneal bleed,

Vaginal laceration,

 # radius, # ankle

2

29

M

RTA

C3

 

# mandible, # os calcis

3

44

M

Fall From hgt

B2

 

Head injury, # tibia

4

38

F

Falling object

B2

 

# 2 ribs,                         splenic laceration

5

40

F

RTA

B2

L5, S1

Bladder tear, # forearm

6

17

M

RTA

B2

 

 

7

55

M

RTA

C3

 

Kidney contusion, # forearm (open)

8

24

M

RTA

B3

 

Intracerebral bleed,    flail chest

9

52

M

RTA

C1

L4, L5

Kidney laceration, splenic laceration, # wrist,

10

43

M

Fall From hgt

B1

 

 

11

40

M

RTA

B3

 

#  humerus,  # tibia, axillary artery injury, brachial plexus injury.

12

39

M

Fall From height

B2

 

# ribs, Pneumothorax, # humerus, # femur

13

35

M

RTA

C3

 

# femur, # ankle

14

41

F

RTA

B3

 

Ruptured urethra

15

42

M

RTA

C3

L5, S1

Bladder tear

16

36

M

RTA

B3

 

# 2 ribs, Pneumothorax

17

79

F

RTA

B2

 

# humerus, # wrist

18

21

M

RTA

C1

 

# calcaneous, head injury

 

TABLE II

Serial No   (N=18)

Type of fracture

Type of fixation

ITU stay

(days)

Hosp. Stay

(days)

Complications

Radiological score

Clinical outcome

 1

 B2

 External fixation, ORIF symphysis  pubis

 7

 31

 Nil

 Excellent

 Good

2

C3

Fixation SI joint,

Acetabular Recon.

2

39

Nil

Good

Excellent

3

B2

Fixation SI joint,

ORIF Pubic Rami

 

7

Pneumonia

Excellent

Good

4

B2

External Fixation

 

14

Paralytic ileus

Good

Good

 

5

 

B2

 

External fixation

Fixation SI joint

 

 

28

 

Errectile dysfunction

 

Excellent

 

Good

6

B2

Fixation SI joint, ORIF Pubic Symphysis

2

18

Nil

Good

Excellent

7

C3

Fixation SI joint  Acetabular Recon.

 

20

Superficial infection

Excellent

Fair

8

B3

ORIF Pubic Symphysis

4

25

Nil

Excellent

Excellent

9

C1

Fixation SI joint, ORIF Pubic Symphysis

4

30

Paralytic ileus

Good

Fair

10

B1

Fixation SI joint, ORIF Pubic Symphysis

 

5

Nil

Excellent

Excellent

11

B3

Fixation SI joint, ORIF Pubic Symphysis

 

37

Small PE

Good

Good

12

B2

External Fixation Fixation SI joint

4

39

MRSA at pin site

Excellent

Excellent

13

C3

Fixation SI joint, Acetabular Recon.

 

50

Nil

Good

Fair

14

B3

Fixation SI joint, ORIF Pubic Symphysis

4

40

Errectile dysfunction

Excellent

Excellent

15

C3

Fixation SI joint, ORIF Pubic Symphysis

 

38

Paralytic ileus

Good

Fair

16

B3

Fixation SI joint, ORIF Pubic Symphysis

2

14

Nil

Excellent

Lost to f-up

17

B2

Fixation SI joint

3

32

Pneumonia

Good

Died 2y post-op

18

C1

Fixation SI joint, ORIF Pubic Symphysis

 

35

Nil

Excellent

Lost to f-up

 

Results

One patient died 2 years following surgery from causes not related to pelvic injury. We were unable to trace 2 patients; therefore 15 patients were available for follow up.

Complications: The commonest postoperative complication was paralytic ileus, which occurred in 3 patients, followed by pneumonia in 2 patients. One patient developed small pulmonary embolus that was treated successfully; there was not any clinically detected Deep Vein Thrombosis. Bladder rupture occurred in two patients and was repaired without sequelae, following transurethral catheterisation. Two patients reported erectile dysfunction in the early post-operative period; one of them had associated urethral damage. Both patients regained normal erectile function within a year following their injury. All fractures united and there were not implant failures. Two patients developed superficial infection, which were successfully treated by oral antibiotics.  There were no deep infections.

Radiological results: Two patients with type-C fractures had excellent radiological reduction with anterior displacement of symphysis pubis of less than 5mm, while the remaining 4 patients had good radiological reduction with residual displacement of symphysis pubis between 6mm and 10mm. Eight patients with type B fractures had excellent radiological score and the remaining four had good radiological reduction.

Clinical outcome: According to Majeed’s score, excellent and good clinical outcome was achieved in 6 and 5 patients respectively. Four patients had a fair result with activity related intense pain being the main complaint; all had initially sustained a C-type injury and eventually had to change their original jobs. Four patients complained of a slight limp and pain on mild exertion. Two female patients complained of dyspareunia; they both had residual displacement of the symphysis pubis, of more than 5mm, following surgical reduction and one had also sustained a vaginal laceration at the time of injury. One patient with an associated acetabular fracture (C3-type) underwent hip resurfacing arthroplasty 2 years after surgery, due to intense, continuous pain at rest with radiological evidence of osteoarthritis.

Outcome evaluation: The study revealed that radiological result was superior to the clinical result and that residual anterior displacement of symphysis pubis beyond 5mm following fixation is likely to lead to residual symptoms. However, this could not be statistically proved due to small number of patients that were reviewed. All neurological injuries involving the lumbosacral plexus were fully recovered at the time of follow-up. The brachial plexus injury however, recovered only partially. Seven patients with B-type fractures were pain-free at the time of study as opposed to one patient with C-type fracture. Seven patients returned to their original job, however the level of pain influenced their performance accordingly.

 

Discussion

Pelvic fractures are relatively rare injuries; their incidence in trauma patients is quoted to range between 3 % and 8.2 % and instability occurs in 13 % to 17 % of cases (1). The commonest cause of a pelvic ring disruption is a Road Traffic Accident (2) and that involved 70% of our patients. Because of the large force that is required to disrupt the pelvis, pelvic fractures are indicative of high-energy transfer to the patient and therefore, often combined with other injuries (1,17).  

Patients with major pelvic injuries need a multidisciplinary approach and should be treated in well-equipped and staffed centres. Stabilisation of vital parameters is the first goal, and a standardised trauma protocol for diagnostic policy as well as for surgical treatment should be followed routinely (17). Associated intra-abdominal injuries should be evaluated by emergency abdominal ultrasound to diagnose or exclude intra-abdominal bleeding (17). Ultrasound was sufficient to diagnose intra-abdominal haemorrhage in both our patients with splenic lacerations, however laparotomy was unnecessary in the third patient.  

Haemodynamically unstable patients with pelvic fractures have a mortality of 40 to 50% and this increases markedly if there is associated head injury (2). Some authors attribute this high mortality to exsanguinating haemorrhage within the pelvis, others are for the opinion that massive bleeding from pelvic fractures is uncommon and that mortality is related to associated injuries (4). External fixation can be applied in 15 minutes by an orthopaedic surgeon or a physician credentialed in this procedure (18). This method reduces the relative volume of a fractured pelvis, thereby reducing the potential space for haemorrhage. If the patient remains unstable despite the resuscitation efforts, should undergo angiographic embolisation or be brought to operating theatre for surgical intervention (18). None of the 4 haemodynamically unstable patients who were transferred to our A&E department required angiographic embolisation, however three of them underwent an urgent laparotomy following initial stabilization of the pelvic ring by an external fixator. Two were found to have sustained splenic lacerations and in the third a retroperitoneal haematoma was burst into the peritoneal cavity. The vital signs of the fourth patient were stabilised after application of a pelvic sling in the A & E department.  

The incidence of an open, unstable pelvic ring disruption with connection occurring between the fracture and skin, rectum or vagina is 3.5 to 4.5% (1). Brenneman et al (ref) reported that morbidity and mortality of the patients with open pelvic fractures were higher than in patients with closed injuries and Kobak et al (ref) reported death due to sepsis in a patient with open fracture. One female patient of ours had an open fracture that was communicating with the vagina; that was treated successfully without complications.

The mortality rate in this small series of unstable pelvic fractures was zero; the fact that the only patient with serious brain injury recovered fully and the open fracture was communicating with the vagina rather than the rectum, as well as the prompt multidisciplinary approach of haemodynamically unstable patients may explain this favourable outcome, which comes in contradiction with the recent literature ( 17).

Associated injuries occurred in most of our patients (15 out of 18 patients). Corovessis et al  reported that concomitant injuries have negatively affected the clinical outcome of unstable pelvic fractures despite the good radiographic score of surgical reduction. The presence of associated injuries has certainly increased morbidity in our group of patients and negatively affected the functional outcome in the case of a brachial plexus injury, a calcaneal fracture and a vaginal laceration.  Four out of eighteen patients (22%) had an associated acetabular fracture and one patient underwent a hip resurfacing for progressed hip osteoarthritis within 2 years of injury. 

The incidence of neurological injuries in this study was 22% which is comparable with that reported in the literature. Three patients with combined motor and sensory neurological deficits affecting the L4, L5, S1 nerve roots were fully recovered at the time of follow-up. One patient with isolated sensory deficit of S1 and S2 nerve roots was still complaining for perineal dysaesthesia and dyspareunia, 29 months following injury. The small number of patients in this study may be a reason for the most favourable potential for recovery of the neurological injury at the L4, L5, and S1 nerve roots, as compared with the literature  (10,20). Early rigid stabilisation of both anterior and posterior pelvic ring injury, which is what was performed in our patients, has been suggested as a potential reason for favourable prognosis of these injuries. 

Stabilisation of the unstable pelvic ring injuries can be achieved by external and/or internal fixation (17). External fixation can be applied fast resulting in reduced haemorrhage in the intrapelvic space by tamponade (18). Open reduction and internal fixation of the unstable pelvic ring fractures provides the best stability of fixation as well as best clinical outcome (7,8). Unstable type-B1 injuries should be fixed (17) whereas type-B2 and B3 fractures could be treated non-operatively, because the pelvis has the elasticity to restore to a near normal position (19).

Some of the reported long-term morbidity of an unstable pelvic ring fracture include chronic pelvic pain, impaired function of the pelvis for sitting and weight bearing that results from pelvic non-union, pelvic malunion and leg length discrepancy (6).

 Non-union or leg length discrepancy of more than 1cm did not occur in our patients but displacement of symphysis pubis of more than 5mm was associated with residual symptoms such as pain and dyspareunia in 2 females. The small number of patients did not allow us to derive statistically significant correlation between the two parameters.

Our study shows that the antibiotic prophylaxis used in the unit is effective as only one patient developed superficial infection.  The deep venous thrombosis (DVT) prophylaxis is also effective as no patient developed clinical deep venous thrombosis. 

Even though the review of literature shows several studies have supported this both in biomechanical studies and clinical trials there is a lot of controversy about the long-term outcome of unstable pelvic injuries. Berner in 1982 reported a rate of 16% unsatisfactory functional, and 17% unsatisfactory radiological result in a group of 42 patients treated non-operatively after combined disruptions of the pubic symphyses and the sacro-iliac joint. (11) After treatment of a similar injury with open reduction and internal fixation, the rate of unsatisfactory functional rating was zero and 10% in the radiological rating.

Rargnarsson in 1993 reported on 21 patients after SI joint disruption treated with internal fixation using plating (12). He stated the radiological position of the pelvic ring as “unchanged to the post-operative radiographs”, a rate of 14% poor functional results were reported.

One of the reasons for the poor result previous studies have postulated is that a residual displacement of 10mm and more was critical for a significant increase of residual pain (13). Semba et al also reported a correlation of primary anterior and posterior displacement exceeding 10mm being correlated with a markedly higher incidence of severe low back pain. (13) Holdsworth in 1948 reported that 50% of the patients they studied returned to their original job (14). Our study showed that 7 patients returned to their original jobs. In the largest series of patients treated with open reduction and internal fixation of unstable posterior pelvic injuries, 67% returned to their former jobs without restrictions (15). Another study where all fractures were reduced operatively to less than 10mm of residual displacement; 35% of patients had neurologic injuries, and another 23% had associated injuries inhibiting normal gait.  Females with pelvic fractures tended to have increased urinary complaints and dyspareunia, which were shown to correlate with residual displacement of >5mm. (16)

Our study has shown that anatomical restoration of the pelvic ring correlates with higher probability of a good clinical outcome.

 

Conclusions 

Pelvic fractures are challenging injuries to manage. Stabilisation of vital parameters takes preference and significantly reduces mortality. Associated injuries are common and often have a substantial effect on the patient’s psychological status. Rehabilitation period is prolonged; however proper management yields a satisfactory outcome. Further analysis and studies including a larger number of patients are required to identify the prognostic factors for the late sequelae. This preferably should be a valid statistical analysis of outcomes of patients treated nonsurgically, by external fixation or by internal fixation in a randomised prospective study with standardised indications for surgery. A standardised trauma protocol for diagnostic policy as well as for initial and definitive surgical treatment should be followed routinely.

 

References

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2) Moreno C, Moore EE, et al: Haemorrhage associated with major pelvic fracture: A multispeciality challenge. J Trauma 26:987-994,1986
3) Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg 1988; 70B:1
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6) Smith J, Western journal of Medicine. San Francisco: Feb 1998; 168:124-6
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8) Tile M. Fractures of the pelvis and acetabulum. Baltimore: Williams and Wilkins, 1984
9) Pohlemann T et al. Outcome after pelvic ring injuries. Injury 1996; 27 Suppl2: B31-8
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11)Berner W, Oestern H-J 1982; 85:377-387
12) Rargarsson B, Oleurd C. Anterior square-plate fixation of sacroiliac disruption. Acta Orthop.Scand.1993;64(2):138-142
13) Semba R, Yasukawa K, Gustillo R Critical analysis of results 53 Malgaigne fractures of pelvis.J.Trauma,1983;23(6):535-537
14) Holdsworth FW: Dislocation and fracture dislocation of pelvis.J Bone Joint Surg Br 30;461-466,1948
15)Tornetta P, Dickson K, Matta JM: Outcome of rotationally unstable pelvic ring injuries treated operatively.Clin Orthop 39:147-151,1986
16) Copeland CE,Bosse MJ, McCarthy ML: Effect of trauma and pelvic fracture      on female genitourinary, sexual and reproductive function.J Orthop Trauma 11:73-81,1997
17) Van Veen IH, van Leeuwen AA, van Popta T, van Luyt, Bode PJ, Vugt AB: Unstable pelvic fractures: a retrospective analysis. Injury.1995 Mar; 26(2): 81-5
18) Coppola T, Coppola M: Emergency department evaluation and treatment of pelvic fractures. Emerg Med Clin of North Am.2000 Feb; 18(1): 1-27,
19) Tile M.Pelvic ring fractures: should they be fixed? J Bone Joint Surg 1988;70B: 1
20) Helfet DL, Koval KJ, Hissa EA et al:Intraoperative somatosensory evoked potential monitoring during acute pelvic fracture surgery. J Orthop Trauma 9:28-34,1995

 

 This is a peer reviewed paper 

Please cite as :

M Maru: The Functional Outcome of Surgically Treated Unstable Pelvic Ring Fractures
J.Orthopaedics 2005;2(2)e2

URL: http://www.jortho.org/2005/2/2/e2

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