What is a pelvic fracture?
Depending on the extent of the pelvic injury (severity), a basic distinction is made between two forms:
- Undisplaced or stable fracture, whereby the course of the fracture can sometimes hardly be recognized in normal X-ray images. As with a normal ring, marginal fractures or only fractures in one region (unilateral anterior or posterior) of the pelvic ring are generally stable.
- Complete, total pelvic fracture – usually several parts of the pelvic ring are broken (front and back and/or on both sides). Depending on the accident and the extent of the displacement, organs in the pelvis may also be injured, such as the urinary organs, i.e. the bladder and ureter, but also important blood vessels or nerves.
Pelvic fractures are further classified according to the different sections of the pelvic ring or pelvic girdle. The anatomy of this protective and mediating system of different, firmly connected bones is important: the pelvis consists of a ring formed at the back by the sacrum and ischium, at the sides by the two blades of the ilium, and at the front by the pubic bone.
A further distinction is made depending on which of these structures is affected (localization):
Type A – stable pelvic ring fracture – usually only one, usually not continuous tear, the posterior pelvic ring is stable. The ischium, pubic bone or coccyx are often affected by a tear below the connection to the joint.
Type B – partial interruption of the posterior pelvic ring; stability is usually provided by the intact ligaments.
Type C – unstable pelvic fracture with complete interruption of the anterior and posterior pelvic ring – here, posterior sections of the pelvic girdle are completely affected, making the bone ring unstable. Around 50 percent of those affected suffer further injuries to the body, i.e. polytrauma, which is often life-threatening.
Pelvic fracture: causes and risk factors
Pelvic fractures occur mainly in two age groups – among young adults, i.e. between the ages of 20 and 30, and among the elderly, average age 70.
In young people, the main cause of pelvic fractures is an accident, such as a high-speed motorcycle accident or a fall from a great height(high-speed trauma). The decisive factor here is not only the extent of the force acting on the pelvis, but also the direction from which it hits the bone ring. This usually results in unstable fractures with polytrauma.
Among older people, on the other hand, other risk factors and causes come into play. On the one hand, the dwindling stability of the bones plays a role, i.e. osteoporosis. The bones can therefore break even under slight force. Dizziness and unsteady gait also come into play, which in turn pose a high risk of tripping. A fall from a standing position or falling out of bed can then already result in a pelvic fracture(low torso trauma).
Symptoms of pelvic fracture
Following the accident, certain pains may indicate a pelvic fracture. However, it always depends on the severity of the injury and its localization. A small pelvic tear in the anterior region may even cause hardly any symptoms.
However, a pelvic fracture is usually associated with severe pain.
Typical symptoms of a pelvic fracture include
- Pain in one or both groins
- Pain in the posterior region of the pelvis
- Pain when moving the leg on the side that is affected
- Restriction of movement in the hip joint on the affected side
Swelling and bruising may also occur after a short time. If urinary organs are also affected, the corresponding symptoms occur, such as blood in the urine.
An unstable pelvic fracture in particular is a very serious injury; walking, standing or sitting are no longer possible. Symptoms include The legs may be of different lengths due to the displacement in the pelvis, the pelvis is in a tilted position.
Pelvic fracture: diagnosis with us
If it is a serious sports or traffic accident, the emergency services will be called. In most cases, an unstable pelvic fracture and polytrauma are quickly suspected. He provides first aid on site and on the way to hospital. Caution: In accident victims with suspected unstable pelvic fractures and polytrauma, the fracture edges of the bones may have injured veins and other large vessels in the pelvis. As a result, there is a risk of severe internal bleeding. They must be identified and stopped as quickly as possible, otherwise there is a risk to life. The pelvis must also be stabilized in order to defuse the cause of the bleeding, so to speak.
For a less seriously injured person, i.e. without polytrauma, further examinations and diagnosis are often first carried out in the family doctor’s practice or by specialists in orthopaedics and trauma surgery in a similar way to in hospital – apart from these rescue measures. The description of the course of the accident and the personal health data form the basis of the medical history – which is taken in the practice in the same way as in hospital. This also includes the question of pre-existing illnesses, such as whether older people have already been diagnosed with osteoporosis.
This is followed by a physical examination. We take care of external injuries first, if they are present. We also carefully palpate the pelvic ring to see if there are any abnormalities or instability and where there is pain. In addition, it is checked whether the legs are restricted in their mobility, whether the sensitivity is correct as well as the blood circulation and leg length.
Accurately diagnose pelvic fractures with 3D images
With the physical examination, we can usually already assume which parts of the pelvis are injured. However, imaging procedures are essential to determine the exact damage:
- X-ray examination, namely pelvic overview and oblique images
- 3D images of the pelvis with computer tomography
This makes it possible to identify cracks and fractures, their location, extent and whether neighboring organs have been affected.
If there is a suspicion that neighboring organs have been injured by the hernia or that the urinary tract or bladder have been damaged, a urography is also performed. For this purpose, the kidneys and urinary tract are x-rayed using contrast media.
These diagnostic measures are rounded off with blood tests, which not only provide information on the extent of blood loss and whether there is a risk of shock, but also serve to prepare for surgery. This is because surgery is often the most important treatment measure for pelvic ring fractures.
Pelvic fracture: prevention and prognosis
The best prevention of suffering a pelvic fracture is caution – so please don’t take any risks. This particularly affects the group of 20 to 30-year-olds who are especially at risk of pelvic fractures. Therefore, please observe the speed limits and take the weather conditions into account when driving. Ultimately, speeding only saves a few minutes – and if it causes an accident, everyone involved, whether they want to or not, has to spend a lot of time at once – or, in the worst case, even gamble with their lives or the lives of others. And avoid daring climbs that could endanger your health.
Older people, i.e. the second risk group, should train their balance and sure-footedness as much as possible with daily exercise. There are special gymnastics with balance exercises. In this way, falls can be avoided. However, fall prevention also includes not having any trip hazards in the home – such as thick carpets, high thresholds and the like.
Course and prognosis of a pelvic fracture
Stable pelvic fracture: Anyone who has suffered a fracture of the pelvic ring must first and foremost be patient. Even if it is just a tear, it can take up to eight weeks for it to close. Partial loading is important at first. In the vast majority of cases, the stable pelvic fracture heals in this way without complications or consequences. However, if sufficient mobilization is not possible, either due to severe pain that cannot be controlled with painkillers or insecurity, minimally invasive stabilization procedures should also be considered for these fractures. The risk of complications due to immobility is greater here than with minimally invasive surgery.
Unstable pelvic fracture: In the case of an unstable pelvic fracture, it depends on how many parts of the pelvic ring are affected and whether additional organs have been injured. The treatment plan: Surgery, then no weight-bearing at all for a short time, followed quickly by controlled mobilization. However, it can take many months before the affected person is fully recovered and can put normal weight on their legs.
The age and state of health of those affected also play an additional role here. However, unstable pelvic fractures can lead to complications somewhat more frequently than stable ones. If nerves in the pelvis are damaged, for example, there is a risk of incontinence and men may have problems with erectile function. In the vast majority of cases, however, an unstable pelvic fracture heals without consequences.
Pelvic fracture: treatment usually means surgery
Conservative treatment is only sufficient if the pelvic fracture is stable. This means that those affected do not usually need surgery. Careful and slow mobilization with partial weight bearing under the guidance of physiotherapy are the measures to be taken. Painkillers can also be given during the initial period.
This is not the case with partial or unstable pelvic fractures with complete interruption. Here, surgery is the most important and first therapeutic measure. The surgeon rejoins the bone fragments, fixing them with plates and screws, for example. Depending on the severity and location of the fractures, external fixation is also used for initial treatment. These constructs are fixed to the bone from the outside through the skin as a retaining system, and are then implanted later.
At the USZ, all current modern techniques and implants are used depending on the situation in order to offer you the best possible result. Together with our colleagues in anaesthesia, we adhere to algorithms developed by the USZ before, during and after the operation in order to keep blood loss low during these sometimes major operations, so that the risk of administering foreign blood is significantly minimized.
However, minimally invasive surgical techniques are now also possible. For example, a fracture can be stabilized with long screws through a small incision in the skin. Here at the USZ, we use modern intraoperative 3D navigation, which uses intraoperative computer tomography to show the surgeon the planned screw path and the position of the instruments with an accuracy of 1 mm, so that not only a very secure fixation can be achieved, but also the complication rate can be minimized.
The special group of geriatric patients with unstable fractures, i.e. not fundamentally stable insufficiency fractures, poses a particular challenge. Rapid mobilization is important in order not to lose activity. This is usually only possible with a full load. Therefore, in addition to fracture stabilization, we sometimes use special hip prosthesis models – including minimally invasive ones – to achieve these goals and provide interdisciplinary care for elderly patients, particularly together with the Geriatrics Clinic, in order to maintain mobility.
Details of the treatments