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Pelvic fracture is a disruption of the bony structure of the pelvis, including the hip bone, sacrum and coccyx. The most common cause in the elderly is a fall, but the most significant fractures involve high-energy forces such as a motor vehicle crashes, cycling accidents, or a fall from significant height. Diagnosis is made on the basis of history, clinical features and special investigations usually including X-ray and CT. Because the pelvis cradles so many internal organs, pelvic fractures may produce significant internal bleeding which is invisible to the eye. Emergency treatment consists of advanced trauma life support management. After stabilisation, the pelvis may be surgically reconstructed.
The bony pelvis consists of the ilium (i.e., iliac wings), ischium, and pubis, which form an anatomic ring with the sacrum. Disruption of this ring requires significant energy. When it comes to the stability and the structure of the pelvis, or pelvic girdle, understanding its function as support for the trunk and legs helps to recognize the effect a pelvic fracture has on someone. The pubic bone, the ischium and the ilium make up the pelvic girdle, fused together as one unit. They attach to both sides of the spine and circle around to create a ring and sockets to place hip joints. Attachment to the spine is important to direct force into the trunk from the legs as movement occurs, extending to one’s back. This requires the pelvis to be strong enough to withstand pressure and energy. Various muscles play important roles in pelvic stability.Because of the forces involved, pelvic fractures frequently involve injury to organs contained within the bony pelvis. In addition, trauma to extra-pelvic organs is common. Pelvic fractures are often associated with severe hemorrhage due to the extensive blood supply to the region.
Pelvic fractures are most commonly described using one of two classification systems. The different forces on the pelvis result in different fractures. Sometimes they are determined based on stability or instability.
Tile classification system
The Tile classification system is based on the integrity of the posterior sacroiliac complex.
In type A injuries, the sacroiliac complex is intact. The pelvic ring has a stable fracture that can be managed nonoperatively. Type B injuries are caused by either external or internal rotational forces resulting in partial disruption of the posterior sacroiliac complex. These are often unstable. Type C injuries are characterized by complete disruption of the posterior sacroiliac complex and are both rotationally and vertically unstable. These injuries are the result of great force, usually from a motor vehicle crash, fall from a height, or severe compression.
Young-Burgess classification system
The Young-Burgess classification system is based on mechanism of injury: anteroposterior compression type I, II and III, lateral compression types I, II and III, and vertical shear, or a combination of forces.
Lateral compression (LC) fractures involve transverse fractures of the pubic rami, either ipsilateral or contralateral to a posterior injury.
- Grade I – Associated sacral compression on side of impact
- Grade II – Associated posterior iliac ("crescent") fracture on side of impact
- Grade III – Associated contralateral sacroiliac joint injury
The most common force type, lateral compression (LC) forces, from side-impact automobile accidents and pedestrian injuries, can result in an internal rotation. The superior and inferior pubic rami may fracture anteriorly, for example. Injuries from shear forces, like falls from above, can result in disruption of ligaments or bones. When multiple forces occur, it is called combined mechanical injury (CMI).
Open book fracture
One specific kind of pelvic fracture is known as an 'open book' fracture. This is often the result from a heavy impact to the groin (pubis), a common motorcycling accident injury. In this kind of injury, the left and right halves of the pelvis are separated at front and rear, the front opening more than the rear, i.e. like an open book that falls to the ground and splits in the middle. Depending on the severity, this may require surgical reconstruction before rehabilitation. Forces from an anterior or posterior direction, like head-on car accidents, usually cause external rotation of the hemipelvis, an “open-book” injury. Open fractures have increased risk of infection and hemorrhaging from vessel injury, leading to higher mortality.
A pelvic fracture is often complicated and treatment can be a long and painful process. Depending on the severity, pelvic fractures can be treated with or without surgery.
Surgery is often required for pelvic fractures. Many methods of pelvic stabilization are used including external fixation or internal fixation and traction. There are often other injuries associated with a pelvic fracture so the type of surgery involved must be thoroughly planned.
Pelvic fractures that are treatable without surgery are treated with bed rest. Once the fracture has healed enough, rehabilitation can be started with first standing upright with the help of a physical therapist, followed by starting to walk using a walker and eventually progressing to a cane.
Pelvic fractures can be dangerous to one’s physical health. As the human body ages, the bones become more weak and brittle and are therefore more susceptible to fractures. Certain precautions are crucial in order to lower the risk of getting pelvic fractures. The most damaging is one from a car accident, cycling accident, or falling from a high building which can result in a high energy injury. This can be very dangerous because the pelvis supports many internal organs and can damage these organs. Falling is one of the most common causes of a pelvic fracture. Therefore, proper precautions should be taken to prevent this from happening.
Several precautions may decrease the risk of getting a pelvic fracture. One study that examined the effectiveness of vitamin D supplementation found that oral vitamin D supplements reduced the risk of hip and nonvertebral fractures in older people. Certain types of equipment may help prevent pelvic fractures for the groups which are most at risk.
Complications are likely to result in cases of excess blood loss or punctures to certain organs, possibly leading to shock. Swelling and bruising may result, more so in high-impact injuries. Pain in the affected areas may differ where severity of impact increases its likelihood and may radiate if symptoms are aggravated when one moves around.
Mortality rates in patients with pelvic fractures are between 10 and 16 percent. However, death is typically due to associated trauma affecting other organs, such as the brain. Death rates due to complications directly related to pelvic fractures, such as bleeding, are relatively low.
About 10 percent of patients that seek treatment at a level 1 trauma center after a blunt force injury have a pelvic fracture. Motorcycle injuries are the most common cause of pelvic fractures, followed by injuries to pedestrians caused by motor vehicles, large falls (over 15 feet), and motor vehicle crashes.
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