Displaced (misaligned) fractures and dislocations of the pelvic ring can be stabilized with various surgical techniques.
A variety of surgical techniques are used to stabilize pelvic ring disruptions (fractures and/or dislocations). Both external (outside the skin) and internal (located in or on the bone) fixations are advocated. Pelvic stability provides comfort, decreases hemorrhage and facilitates patient mobilization.
Characteristics of pelvic fracture
The pelvis consists of three major bones joined together in a ringed shape and held by strong ligaments (see figure 1). General characteristics of pelvic fracture include severe pain, pelvic bone instability and associated internal bleeding. Pelvic fractures occur due to traumatic events such as falls or automobile or motorcycle accidents.
A variety of pelvic fracture injuries may occur. Zones of typical injury include:
- symphysis pubis dislocation
- pubic ramus fracture
- iliac fracture
- sacroiliac joint dislocation
- sacral fracture
Open wounds such as rectal tears may be in contact with and contaminate these injuries.
No other condition is confused with pelvic fracture.
Incidence and risk factors
Pelvic fractures occur rarely. They are commonly associated with high-energy traumatic events.
Alert and awake patients with pelvic fracture complain of pain. Clinical examination of the unstable pelvis reveals bone instability and associated tenderness. Bone instability or bony mobility occurs after fracture when muscle spasms or other deforming forces are applied to the fracture fragments. X-rays show the disruptions (fractures and/or dislocations) and their displacement (misalignment) patterns. Open associated wounds should be obvious to the doctor.
Analgesics (narcotics, etc.) temporarily and incompletely diminish pain due to pelvic fractures.
Possible benefits of pelvic fracture surgery
Surgery stabilizes the injured pelvic ring, restores normal anatomy, provides patient comfort and allows rehabilitation.
Types of surgery recommended
Displaced (misaligned) pelvic fractures may be stabilized by either internal or external fixations (after accurate realignment of the bone fracture fragments or dislocation sites).
Who should consider pelvic fracture surgery?
Patients with unstable and displaced pelvic ring disruptions should strongly consider surgical realignment and stabilization. The decision to have surgery should be discussed by the patient and physician.
What happens without surgery?
If nothing is done, the fracture fragments may not heal for a variety of reasons and may cause a painful nonunion. If union occurs in a displaced location (malunion), chronic pain may result due to leg length inequality and compensatory scoliosis among other problems. If the pelvic fracture heals in a good location, the patient may have few symptoms as a result.
Pelvic external fixation consists of pins usually inserted into the iliac bones and then connected together by clamps and bars. Internal fixation refers to plates and screws applied directly onto the fracture sites after realignment. Combinations of both techniques are frequently chosen for certain fracture patterns.
The procedure is effective when excellent realignment and stable fixation of the displaced fracture is accomplished. A well aligned and healed pelvic fracture is the best starting point for a successful and long lasting result.
In situations of ongoing hemorrhage associated with the pelvic fracture, delaying surgery can be deadly. Early pelvic stability can be life-saving. Surgery soon after the pelvic fracture avoids the problems associated with prolonged recumbency such as pneumonia, skin ulceration and others.
Bleeding wound infection fixation failure and blood clots are but a few of the associated complications of pelvic surgery. Unfortunately, the pelvis contains major abdominal organs, blood vessels and nerves which further complicate the surgery.
Complications are managed aggressively and according to the patient's overall clinical condition.
Patients with unstable and displaced (misaligned) pelvic fractures are rapidly evaluated while being resuscitated. Preoperative X-rays including CT scans show the pelvic injury sites and the displacement patterns. Laboratory evaluations include serial hematocrit and clotting factor testing.
Orthopedic trauma departments at Level One trauma centers typically designate one or two experienced surgeons as their Pelvic and Acetabular Fracture Team. The surgery should have a good chance for success when performed by a surgical team with such concentrated experience.
Level One trauma centers are the major referal sites for most patients with severe pelvic and acetabular fractures therefore most pelvic surgeries are performed at these facilities.
During the pelvic surgery the bone fragments are realigned using a variety of techniques. After the fractures are realigned, fixation devices such as screws and/or plates are applied to the bone fragments to secure their stability. For some injuries, large surgical wounds are needed to access the fracture site and provide stability. Conversely, some patients have unstable pelvic ring injuries which can be secured using percutaneous (small wound) fixation techniques.
General anesthetics are almost always used for pelvic surgery.
Length of pelvic fracture surgery
The duration of the operation varies according to the complexity of the fracture and clinical condition of the patient.
Pain and pain management
After pelvic fracture surgery, patients usually describe significantly improved comfort. Their surgical wounds hurt for several days, but the pelvic instability pain (which was severe) is gone. Narcotic analgesics (pain relievers) are used only as necessary for the first week or so after surgery.
Use of medications
Initially narcotics are administered intravenously (directly into the bloodstream). Later they are administered by mouth. Most patients use narcotics for seven to ten days after surgery.
Effectiveness of medications
The medication's purpose is to reduce the patient's pain which it usually does.
Important side effects
Narcotic analgesic medications are potentially addictive and may produce a variety of side effects.
Recovery and rehabilitation in the hospital
After the surgery the patient is evaluated and treated by a physical therapist. Most patients use crutches to assist their ambulation for six to twelve weeks.
The first six weeks after operation is "quiet time" for most patients. Only gentle range of motion and light strengthening exercises are prescribed as the pelvic ring injury heals.
Most people who have surgery for a severe pelvic fracture require three to four months of recovery time. As the pelvic injury heals strengthening exercises and a conditioning program are prescribed to facilitate their return to work and other daily activities.
The patient is discharged when:
- comfort is sufficient
- normal bowel and bladder function are accomplished
- he or she is cleared by the physical therapist after training with crutches and
- the surgical wounds demonstrate adequate early healing.
Many people have bilateral pelvic ring injuries (injuries on both sides of the pelvic bone) and/or associated lower extremity fractures which prevent quick rehabilitation. Most of these patients need skilled nursing facility placement after their hospital discharge. If the patient is able to go home, family members or friends are needed to assist the patient almost daily. Even simple tasks such as bathing or showering become difficult. Many patients' families have been quite creative in facilitating their loved one's recovery at home.
Six weeks after the operation, therapy includes weight bearing strengthening and stretching activities. Aquatic programs are helpful for some people.
Various rehabilitation plans are prescribed according to the patient's injuries operation and condition.
Duration of rehabilitation
The therapy is continued until the patient is comfortable performing the exercises at home without the supervision of a physical therapist.
Returning to ordinary daily activities
Some patients can return to work very rapidly even as soon as two weeks after the operation. This is unusual however since most people do not return to their normal activities until 6 to 12 weeks after the surgery.
Long-term patient limitations
The only limitations are according to the patient's comfort and condition. High impact activities are discouraged.
Summary of pelvic fracture surgery for pelvic fracture
Unstable pelvic fractures and dislocations are complex and potentially devastating injuries. Early surgical realignment and stabilization of pelvic fractures decreases related bleeding provides patient comfort and facilitates patient mobility.
Edited By: Trauma Team, UW Orthopaedics & Spo,rts Medicine
Last updated: December 31, 2009