Fractures
of the pelvis
Fractures of the pelvis are relatively common in osteoporotic elderly
patients. In this age group they are low-energy injuries and may, in fact, be
pathological fractures. A careful check should be made for abnormalities which
might suggest a benign lyric lesion or a metastatic tumour. In young patients, a
pelvic fracture is associated with very high-energy accidents and carry a
mortality of up to 20 per cent. This is because of the associated injuries. The
pelvis is a stable ring, made up of bones and ligaments. If there is a displaced
fracture of the pelvis then it must be broken in at least two places, and the
ring is likely to be unstable. Unstable pelvic fractures carry a very poor
prognosis because they are associated with torrential retroperitoneal bleeding
from the pelvic veins. Immediate temporary stabilisation of the pelvic ring may
be life-saving by helping the pelvic veins to clot off through tamponade, and by
reducing the chance of movement displacing the clot. Pelvic fractures are also
associated with damage to the rectum, the vagina and the urethra (especially in
the male). A careful examination of all these structures should be performed in
any patient with a significant pelvic fracture.
Classification
of pelvic fractures
These fractures do not disrupt the structure of the ring and occur
either following a direct blow or as a traction injury of an epiphysis. In
fractures of the sacrum a careful check should be made for nerve damage as the
sacral nerves are likely to be involved.
Fractures of the coccyx can occur when the patient falls on to their
backside. The fracture is very painful but usually settles after a few weeks. If
it does not, then treatment is very difficult as coccydynia (pain in the coccyx)
seems to be associated with a neurotic personality. Neither injection of the
fracture site with local anaesthetic and steroids nor excision of the coccyx
reliably relieves the pain.
Traction
injuries
The origin of rectus femoris can be avulsed when, for example, a patient
kicks a heavy wet football. Similarly, in Fig. 23.1 the adductor tubercle can be
avulsed if the leg is forcibly abducted. Both of these fractures settle with
rest.
Fracture
of the iliac wing
The iliac wing can be broken following direct trauma, or indeed when
harvesting bone graft (Fig. 23.1). No active treatment is necessary.
Single
fractures of the ring
These fractures are by definition undisplaced and commonly
Fractures
in or around the acetabulum
A fall from a great height on to the feet or a direct blow to the
greater trochanter can fracture the pelvis around the acetabulum. The femoral
head can be driven centrally through the floor of the acetabulum into the pelvis
(the central acetabular fracture) (Fig. 23.3). Alternatively, either the front
wall (the anterior pillar) or the back wall (the
Treatment.
Fractures around the acetabulum can be treated nonoperatively with skeletal
traction for 6—8 weeks. Although this method of treatment is uncomplicated and
safe, the results are poor if there is a displaced intra-articular fracture.
Traumatic
osteoarthritis of the hip is inevitable, and subsequent treatment with an
arthrodesis or even a joint replacement will be required within a few years.
This may, however, be the only option if the patient’s overall condition is so
poor that major surgery is dangerous, or if the relevant surgical expertise is
not available. The alternative is surgical reconstruction of the pelvis using
plates bent to the contour of the surface of the pelvis and screws to stabilise
fractures. This type of surgery is both difficult and complex, and carries a
significant morbidity and mortality to the patient through blood loss and damage
to the nerves around the pelvis. If, however, a stable congruent surface to the
acetabulum can be recreated the prognosis to the patient is very good indeed.
Double
fractures of the ring
Displaced fractures of the pelvis must by definition involve a fracture
through two parts of the pelvic ring. It is not always possible to see the
second fracture line as it may pass through the sacral iliac joint. These
fractures are very high energy and are intrinsically unstable (Fig.
23.5). They
are associated with a high mortality because of associated injuries and the
massive retroperitoneal haemorrhage involved. Therefore for the reasons
described above, they may need stabilising immediately with an external fixator
to reduce haemorrhage when the patient is turned (Fig.
23.6).
They
are also associated with damage to the nerves of the sacral plexus as well as
injuries to the pelvic organs, particularly the male urethra.
Treatment.
Initially these patients may be too sick to embark on a formal reduction and
stabilisation of the pelvic ring (Fig. 23.7). The operation therefore may have
to be delayed for up to 10 days. Beyond that the operation becomes difficult
because callous formation prevents fracture reduction.