Pelvic Fractures:Low Impact

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Original Editor - Lucinda hampton

Top Contributors - Lucinda hampton and Kim Jackson  

Introduction

Pelvis anterior and posterior, segments highlighted.png

A pelvic fracture is a disruption of the bony structures of the Pelvis. An anatomic ring is formed by the fused bones of the ilium, ischium and pubis attached to the sacrum. A pelvic fracture can occur by low-energy mechanism or by high-energy impact.  Due to the increasing life expectancy we are seeing more low energy/fragility fractures of the pelvis (FFPs). Studies have shown a significant increase in low-energy pelvic ring injuries in ages 60 and older[1]. These kinds of fractures are the result of a low-energy impact or they may even occur spontaneously in patients with severe osteoporosis.

  • Low-energy fractures of the elderly population sustained from a ground level fall frequently result in pelvic fractures that do not damage the true integrity of the ring structure and are often treated non-operatively. These fractures include superior and inferior pubic rami fractures as well as non-displaced sacral alar fractures[1].
  • In some patients, an insidious progress of bone damage leads to increasing displacement, nonunion and persisting instability. New concepts for surgical treatment have to be developed to address the functional needs of the elderly patients.
  • The majority of pelvic fractures encountered in the elderly are stable and amenable to non-operative treatment but they do incur a substantial demand on healthcare resources since they are often associated with a prolonged hospital stay and requirement for rehabilitation.[2]
  • Due to some distinct differences, the established classifications for pelvic fractures do not fully reflect the clinical and morphological criteria of FFPs. Most FFPs are minimally displaced and do not require surgical therapy.[3]

Etiology

Low impact injuries are seen more frequently in elderly and adolescents.

  • In the elderly as a result of falls(e.g. stable fractures of the pelvic ring or insufficiency fractures of sacrum and anterior pelvic ring).
  • It has been estimated that two-thirds of pelvic fractures in older patients are due to low energy trauma, most commonly a result of simple falls.[2]
  • Falls can be caused by:balance problems; vision problems; medication side effects; general frailty; by encountering unintended obstacles such as pets underfoot, slippery floors, or unanchored throw rugs[4][5]
  • In adolescents, typically as a result of athletic injuries (e.g. avulsion fractures of superior or inferior iliac spines or apophyseal avulsion fracture of the iliac wing or ischial tuberosity)

Expected Outcomes/Mortality Rates

  • Low-energy pelvic injuries do not appear to increase rate of mortality (compared to the US population).
  • Fracture pattern, race, sex, discharge disposition and length of stay do not seem to have an effect on mortality.
  • Elderly patients with an average age of 84.5 years and more than two comorbidities had higher rates of mortality; however, these patients are more likely to sustain earlier mortality regardless of low-energy pelvic fracture[1].
  • Pelvic fractures in the elderly are associated with an increase in the standardized mortality ratio at 1 year, even when they are isolated injuries[2]

Treatment

Management is almost invariably non-operative with a short period of initial bed rest and analgesia with mobilization as soon as pain allows. 

  • To facilitate rehabilitation it is important to achieve adequate analgesia (failing to do so hampers regaining mobility, increases the risk of complications and prolongs the hospital stay). Patients with cognitive impairment may find it difficult to communicate analgesic needs and this should be taken into account in their management. Care is needed in choosing analgesic management, opioid medication can increase confusion and non-steroidal analgesics are best avoided due to renal and cardiovascular side-effects.
  • Once the patient has been discharged, routine follow-up of these fractures is not required, the majority are united 6–8 weeks after injury. Although most patients do recover and regain their previous level of mobility, the fracture is a hallmark of frailty.[2].

Physiotherapy

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In pelvic fractures in the elderly population, the rehabilitation process will be focused on optimising their quality of life.

  • Rapid mobilisation and sufficient pain relief are the main objectives of treatment[6] 
  • Appointment of the home to assess the need for eg rails, ramps, increased lighting, removal of loose mats.
  • Appropriate walking aids should be supplied, and gait training.
  • Falls education eg clearing the floors of loose obstacles (eg, throw rugs, mats), placing sticky mats in the shower and on the bathroom floor, installing grab bars or rails for the shower, toilet, and stairs, wearing nonslip house shoes, and preventing pets from walking near your feet[5].
  • falls prevention outpatient program could be of benefit.
  • Reduce pain eg heat therapy,TENS, stretching exercises, strengthening exercises, joint mobilization, manual therapy.
  • Geriatrics physical activity.jpg
    A home rehabilitation program should be implemented. [7] to strengthen and stretch the muscles around hip, upper leg, and core to help prevent future problems, such as fatigue and walking difficulty eg the Otago Exercise Program 
  • Restore their strength 
  • Restore their range of motion (hip, spine, and leg motion)
  • Restore their balance[5]
  • Aid speed of healing
  • Speed up clients return to activity and sport

The goals of the physical therapy program should provide the patient with an optimal return of function by improving functional skills, self-care skills and safety awareness. [8]

References

  1. 1.0 1.1 1.2 Ghassibi M, Boyalakuntla DS, Gentile J. Low-Energy Pelvic Ring Fractures in the Elderly Population: Expected Outcomes and Associated Mortality Rates. Journal of Clinical Medicine Research. 2019 Nov;11(11):725.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6879025/(last accessed 11.10.2020)
  2. 2.0 2.1 2.2 2.3 Musculoskeletal Key Pelvic fractures Available from:https://musculoskeletalkey.com/pelvic-fractures-4/#ch32ref2 (last accessed 11.10.2020)
  3. Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: recommendations for surgical treatment. Injury. 2013 Dec 1;44(12):1733-44.Available from:https://pubmed.ncbi.nlm.nih.gov/23871193/ (last accessed 11.10.2020)
  4. Davis DD, Foris LA, Kane SM, Waseem M. Pelvic Fracture. StatPearls [Internet]. 2020 Jan.Available from:https://www.ncbi.nlm.nih.gov/books/NBK430734/ (last accessed 11.10.2020)
  5. 5.0 5.1 5.2 Phoenix rehab Pelvic Fractures Available from:https://www.phoenixrehabgroup.com/pelvic-fracture-physiotherapy.html(last accessed 11.10.2020)
  6. Oberkircher L, Ruchholtz S, Rommens PM, Hofmann A, Bücking B, Krüger A. Osteoporotic pelvic fractures. Deutsches Ärzteblatt International. 2018 Feb;115(5):70. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5817189/ (last accessed 3.4.2019)
  7. Zidén, Lena, Margareta Kreuter, and Kerstin Frändin. "Long-term effects of home rehabilitation after hip fracture–1-year follow-up of functioning, balance confidence, and health-related quality of life in elderly people." Disability and rehabilitation 32.1 (2010): 18-32
  8. Dutton, Mark. Orthopaedics for the physical therapist assistant. Jones & Bartlett Publishers, 2011. (book)