Pelvic Fracture Surgery.
Edited By: M.L. Chip Routt, Jr., M.D.
Last updated Wednesday, January 12, 2005
SummaryOverview 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.Types 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. Similar conditions 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. Young males are often at risk, due to
their high velocity lifestyles.Diagnosis 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.Medications 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.Surgical options 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.Effectiveness 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.Urgency 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.Risks 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.Managing risk Complications are managed aggressively and according to the patient's overall clinical condition.Preparation 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.Surgical team 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.Facilities 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.
Technical details 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.Anesthetic 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. Hospital discharge 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.
Convalescent assistance 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.Physical therapy Six weeks after the operation, therapy includes weight bearing,
strengthening, and stretching activities. Aquatic programs are helpful
for some people.Rehabilitation options 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. Surgery for pelvic fracture at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4288 (outside the Seattle area: 800-440-3280) to make an appointment.
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