Pelvic fractures represent approximately 3% of all skeletal fractures in the United States. Although the frequency constitutes a small percentage of total orthopaedic injuries, they are associated with the reported mortality rates of up to 50%. Death usually occurs due to blood loss or result of other lethal injuries because pelvic fractures are often caused by extreme trauma. Pelvic fractures can also be caused by low-energy trauma and usually have uneventful healing in the patient. In this article, we will discuss common causes of pelvic fractures and treatment options for them.
In human anatomy, the pelvic region is defined as the area between the abdomen and the lower limbs. It encompasses many anatomical structures (pelvic skeleton, pelvic cavity, pelvic floor, perineum). For the purposes of this article, we will be referring primarily to the pelvic skeleton. This is the series of bony structures at the base of your torso that form a butterfly or ring-like shape connecting the spine to the thigh bones. These bones provide support for your internal organs and a sturdy base for your legs. It includes the coccyx and the sacrum at the back surface, and a pair of ischium bones protruding from the bottom of the pelvic girdle. The sacrum is the large, triangular bone at the base of the spine that joins to the pelvis with ligaments. At the front is the flared crest that you may refer to as your hip bone (Ilium). The ilium connects to the two pubic bones (Pubis) at the front, meeting at a band of cartilage called the pubic symphysis. The ilium, ischium and pubis grow together as we age, usually completing its fusion by puberty. Fracturing any of these bone pairs will cause severe pain. Many blood vessels, large nerves, digestive and reproductive organs are located within the pelvic ring, therefore, a pelvic fracture can be associated with substantial bleeding, nerve injury, and internal organ damage.
Pelvic fractures range widely in severity, typically dependent on their cause. Pelvic fractures are either caused by high-energy trauma or low-energy trauma. High-energy trauma fractures are the result of significant blunt trauma, such as high speed motor vehicle accidents, falls from a height or a crushing injury. These often require emergency medical care, surgery, and a long period of recovery. Nearby internal organs may be affected and require surgery as well.
On the other hand, a mild fracture may heal in several weeks without surgery. These are typically the pelvic fractures caused by low-energy trauma, such as an avulsion fracture or a pathological fracture. Avulsion occurs when a small piece of bone is pulled off at the site where a muscle attaches. Avulsion is most common in teenagers, occurring during sporting activities. It is a relatively minor form of pelvic fracture. A pathological fracture occurs due to a disease process affecting the bone, most commonly due to osteoporosis, which weakens the bones and makes them more vulnerable to fractures. We frequently see these fractures in the elderly due to falls.
If a patient suffers a high-energy trauma, the injury is obvious and will require immediate, high-level intervention at a trauma center. Sometimes people have a low-energy fracture and are unaware of the problem causing the pain. Common symptoms of a low-energy pelvic fracture include; pain or tenderness in the groin, lower back or buttock; swelling and bruising around the site of the injury and nerve damage (which will exhibit as pain, numbness or weakness in the legs). I highly recommend seeking medical attention if you feel any of these symptoms. Though they may signify something other than a pelvic fracture, it is better to learn as soon as possible what is causing these symptoms.
Treatment will depend on the severity of the fracture. In a stable fracture, the bones do not move and will heal without surgical intervention. A patient with this type of pelvic fracture can be seen in my office, although these patients probably will have their initial assessment and treatment at the ER. A clinical assessment will include a thorough history and exam while assessing any wounds, bruising, nerves, altered leg position, and the pelvic organs. The patient may have an X-ray or CT scan to help diagnose the presence of a fracture and show an accurate picture of the fracture.
Rest and the use of crutches or a walker to avoid aggravating the injury would be recommended for up to several weeks depending on the severity and placement of the fracture. It will usually take up to three months for a full recovery. Mobility will likely be limited and the patient will have weight bearing restrictions to allow the injury to heal. Stable pelvic fractures tend to heal well.
An unstable fracture means that two parts of the broken bone move with normal activity. The bones will not heal on their own, so they must be fixed by a surgical procedure. Because a high energy fracture of the pelvis can be life-threatening and involve complex internal injuries, office-based Orthopaedic surgeons do not see these patients initially nor do they perform their follow-up care. Their injury assessment and subsequent treatment will begin in a hospital emergency room or and in a trauma center. Most often, a skilled trauma surgeon will perform any required surgery for a fractured pelvis.
Each patient case is assessed individually and the hospital trauma surgeon will decide what will best benefit the patient. The surgical technique depends on the location and the extent of the fracture. Most surgeries will require placing pins, screws and/or plates in to stabilize the broken areas and allow for healing. Following surgery, the patient will work with an in-home physical therapist during recovery. The therapist will teach strengthening exercises to help the patient return to activities of daily living.
Fractures sustained during a high-energy trauma often have complications unrelated to the actual fracture (infection, internal bleeding, organ damage). If these complications are detected and addressed in a timely manner, the fracture itself usually heals well. The muscles around the pelvis may be damaged and will require a long time to heal and become strong again. A patient may be left with lingering pain and impaired mobility due to the damage of the surrounding nerves and organs.
It is important for patients to keep their doctor apprised of all symptoms, particularly pain levels. Chronic pain has its own complex implications, which may require an interventional pain management consult to appropriately address those issues.
Mark W. McFarland, DO is a Fellowship-trained spine specialist and orthopaedic surgeon. His practice is focused primarily on the care and treatment of injuries and disorders of the spine. Dr. McFarland practices at Orthopaedic & Spine Center in Newport News, VA. For more information on Dr. McFarland or OSC, go to www.osc-ortho.com or contact us at 757-596-1900 for a consultation.