Pelvic Fractures

The pelvis is a relatively stable set of bones that form an oval-shaped structure which holds the spine to the leg bones.

The pelvis is also called the pelvic bone is named so because it is derived from the Latin word for “basin. It is found in almost all vertebrates. It consists of the os coxa, the sacrum, the coccyx and a bone that consists of the ilium, the pubis and the ischium. The ilium flares upward to form the iliac crest. In females and males, the pelvis creates a complete circle that is more triangular in males. In females, it forms the structure of the birth canal.

Fractures of the pelvis are not common. They can be simple as in a broken minor ring or severe, as when the major ring has broken. They can be caused by things as minor as jogging or a fall in the elderly to things as major as an automobile accident. Minor fractures can heal in a month or so without having to undergo surgery. Major fractures need surgery and take a long time to heal. Major fractures can do damage to the internal organs the pelvis is supposed to protect, such as the bladder, the bowel viscera and the uterus in females. Major fractures need emergency surgery plus physical therapy to heal them.

• Stable. The pelvis has only a single break in the pelvic ring. The bones stay in one place and there is minimal bleeding.
• Unstable. There are at least two breaks in the pelvic ring. The bones do not stay in one place or are displaced. There is moderate to severe bleeding.
• Open. There is a break in the skin overlying a fracture site.
• Closed. There is no break in the skin.

There are also two classification categories used to describe pelvic fractures. These are the Tile Classification System and the Young Classification system. The Tile system is based upon how stable the posterior sacroiliac complex is.

In Type A fractures, the sacroiliac joint is intact. There is a stable fracture of the pelvic ring that does not need surgery. In Type B fractures, there are forces in play that disrupts the posterior sacroiliac joint. These are usually unstable. In type C fractures, there is a complete loss of the posterior sacroiliac joint integrity, making it an unstable fracture from side to side and from up and down. Type C injuries happen as a result of a great deal of force, usually from a motor vehicle accident, a fall from a great height or any other injury that severely compresses the pelvis.

In the Young classification of fractures, the fracture is based upon the mechanism of injury. There is:

• Anteroposterior compression injuries
• Lateral compression injuries
• Vertical shear injuries
• A combination of different forces causing the injury

These are then graded:

• Grade I: There is sacral compression on the side of the impact
• Grade II: There is an iliac crest fracture on the side of the impact
• Grade III: There is a contralateral injury to the sacroiliac joint

The most common injury is a lateral compression injury, which occurs in pedestrian injuries as well as side-impact automobile accidents. Shear injuries happen when there are falls from a height.

A typical motorcycling injury is called the open book fracture. It is caused by a great force on the groin, causing the left and right aspects of the pelvis to separate in the front and in the back like an “open book”. This type of fracture usually requires surgical correction before the patient can participate in physical therapy. These injuries can also be the result of a head on automobile accident. The high risk of infection and hemorrhage lead to a higher mortality with this type of injury.

The main symptom of a pelvic fracture is severe pelvic pain, although the degree of pain depends on the severity of the injury. Serious situations involving pelvic fracture are related to the degree of hemorrhage. The primary symptoms of a pelvic fracture besides pain include:

• Bruising of the abdomen
• Pain in the back
• Worsened pain with walking
• Difficulty walking
• Hip pain
• Leg pain
• Pelvic Swelling
• Bloody urine
• Dizziness
• Shock
• Fainting spells
• Incontinence
• Lower abdominal pain
• Numb legs
• Weakened legs
• Pelvic instability
• Bowel incontinence

There are usually great forces involved in getting a pelvic fracture. The most common injuries to the pelvis are caused by:

• Falls from a great height such as with roofers or window washers
• Accidents involving motorcycles
• Motor vehicle accident
• Bicycle accident
• Any accident in which the thigh bone takes a direct hit
• Elderly who fall from a standing position
• Those with osteoporosis can fall and fracture the pelvis
• Sports injuries in sports like soccer, rugby and football

Pelvic fractures can be diagnosed with plain film x-rays, especially the anterior-posterior view. If there is a question of a fracture not seen on plain film, a CT scan of the pelvis can show areas of fracture as well as hemorrhaging areas. Large areas of bleeding can be seen on the CT scanner.

If the patient is going to the operating room because of bleeding and is stable, an angiogram of the pelvic vessels can be seen on plain film or CT scan to show exactly which blood vessels are bleeding and the site of the bleeding.

MRI scan can show pelvic fractures along with the quality of the soft tissue structures. It can show, for example, if the pelvic fracture has punctured the bladder or uterus. Areas of bleeding are less well seen on MRI scan than they are in CT scans.

Stable pelvic fractures can be treated conservatively with minimal weight bearing and pain control. Many fractures, especially those sustained in motorcycle or automobile accidents are unstable and need surgical intervention. Surgery depends on where in the pelvis the fracture occurred.

If the symphysis pubis is disrupted, it is usually because of a posterior or anterior force on the pelvis. If the diastasis of the symphysis pubis is greater than 2.5 centimeters, surgery is usually recommended. Open reduction with internal fixation is usually done although sometimes an external fixator is recommended. An external fixator is left in place for 6-12 weeks. Open reduction and internal fixation involves the use of reconstruction plates and a screw to hold it onto the bone at either end of the plate.

If the pubic ramus is injured, external fixation using percutaneous screw fixation or open reduction and external fixation is used. Intramedullary rods have been used when fixing the ramus a well as plates and screws.

If a force has been applied to the iliac wing and it is fractured, it may be treated nonoperatively as long as the pelvic ring is stable. If it is an open fracture or a comminuted fracture, it needs surgery. Preoperative pelvic angiograms are recommended if the fracture is near the greater sciatic notch. Clamps and pins are used to achieve bony connection. Plates and screws can also be used. Medullary screws should be used for open fractures to decrease the chance of bony contamination.

Crescent fractures are fractures of the posterior ilium between the iliac crest and the greater sciatic notch. There can be an articular dislocation of the joint that makes up the anterior sacroiliac area. These are inherently unstable fractures that need surgical intervention. It is treated with clamps and screws along with reconstruction plates placed in the area of the iliac wing. The SI joint is repaired with the patient in the supine position. It is repaired with special iliosacral screws.

Disruptions of the sacroiliac joint happen because of an anterior or posterior force on the pelvis. It is usually associated with rami fractures or symphysis disruptions. If the dislocation is less than 2.5 cm and there is no instability, it can be managed without surgery. Otherwise, an external fixator can be used. There is always the option of open reduction and internal fixation. Care needs to be taken to avoid injuring the L5 nerve root. In such cases, fluoroscopic equipment is expected. Iliosacral screws are used to stabilize the disruption of the sacroiliac joint.

If the sacrum is fractured, it is usually fixed using surgical methods. Open surgery with the patient in the prone position is done by lifting off the paraspinal muscles and decompressing the fracture. The fracture is then stabilized using trans-iliac bars, trans-iliac screws and trans-iliac plates. The doctor cannot compress the sacrum too hard or there could be an iatrogenic injury to a nerve root. There needs to be electromyographic monitoring in order to make sure that precious nerves are not disrupted.

If a pelvic fracture is stable, they tend to heal well. Those fractures sustained because of a high impact injury such as a motor vehicle accident, can have severe complications such as internal bleeding, organ damage, infection, nerve damage and death.

If the injuries are taken care of, the patient tends to do well. Patients can walk gingerly for several months because the muscles around the fractured area were damaged. With physical therapy, these muscles can improve their function. There can be prolonged impairment of the patient’s mobility and long lasting sexual dysfunction from permanent nerve damage in the pelvic region.

If you or a loved one has suffered a pelvic fracture as a result of someone else's negligence and would like to discuss your legal options with an experienced Sacramento Personal Injury Attorney, contact us online or call us at 916.921.6400 to set up a FREE consultation.