Pelvic fracture

Hip

The complex nature of these fractures can be better understood by looking at the anatomy that is involved. The pelvis is made up of several bones (ileum, ischium and pubic bones) which create a bony ring, meeting at the pubic symphysis in the front and the sacrum (a bone situated at the lower end of the spine) in the back. Together with a number of ligaments and muscles, the bones of the pelvis support the weight of the upper body and rest on the hip joints. The pelvis protects abdominal organs including the intestines and the bladder, as well as major nerves and blood vessels. Pelvic fractures may occur at any location on the bones depending on the nature of the accident and the areas of impact.

The acetabulum refers to the part of the pelvis that meets the upper end of the thigh bone (the femoral head to form the hip joint. In a healthy hip, these two bones fit together like a ball and cup, in which the ball rotates freely in the cup. Cartilage lines the bones where they meet at the joint and there is little friction between the surfaces during movement.

Most people use the term "broken hip" to refer to a fracture of the ball side of the joint, that is, a break in one of two sections of the femur:

• femoral head (the "ball" at the very tip of the upper femur)
• femoral neck (a broad section of the upper femur just below the femoral head)

In this section, we are speaking specifically of a fracture of the cup or acetabulum. Fractures of the acetabulum are harder to treat because access to this bone is more difficult, and because of the acetabulum's proximity to the major blood vessels to the legs, the sciatic nerve (the major nerve that arises from the lower spine and provides sensation and movement to the leg and foot), the intestines, the ureter and the bladder. Unlike a hip fracture, which can be treated relatively easily, to repair an acetabular fracture, the orthopedic surgeon, must, in essence, fix the broken bones from the inside out.

In fractures of this type, the femoral head is often driven through the acetabulum because of the impact of the fall or accident. If the femoral head ends up outside the acetabulum, this is known as a dislocation of the hip joint. Some patients have both a fracture and a dislocation.

Unfortunately, patients with fractures of the pelvis and/or acetabulum, almost always also experience serious injury to surrounding soft tissue (skin and muscles) and neurovascular structures (nerves, arteries and veins). In addition, especially in the case of pelvic fractures, adjacent organs can be seriously injured. With both types of fracture, there is significant bleeding and risk of nerve damage.

In patients with multiple injuries, treatment begins with the trauma team at the scene, and then subsequently in the emergency room – a team of general surgeons, anesthesiologists and nurses – who work together to control bleeding, address damage to the head and chest, and other organs that may have been affected, such as the bladder and intestines, and to stabilize broken bones. During this early resuscitation phase of treatment, the orthopedic surgeon may need to stabilize the fracture by using an external frame to temporarily hold the bones in proper alignment while other problems are treated. This is called temporary external fixation. Surgeons construct these frames using steel pins that are inserted into the bone and joined together by clamps and rods and can do so very rapidly.

Once the patient is stabilized – bleeding has stopped and other life-threatening injuries have been addressed – the fractures can be treated definitively. Successful treatment for both of these types of fractures requires the skills of an interdisciplinary team, with orthopedic surgeons working closely with the trauma team (general surgeons), the anesthesiologists and nurses. Following surgery, rehabilitation specialists play a key role in recovery.
Because of the complex nature of these fractures and because many orthopedic surgeons do not regularly treat them, patients who initially go to a community hospital for emergency attention are often transferred to an institution that specializes in such injuries.
 

Treatment goals

As with any fracture, the main goal of treatment for fractures of the acetabulum and pelvis is to return the patient to their pre-injury functional level, to the greatest extent possible. This means returning comfortably to daily activities – work and play. Physicians, nurses and rehabilitation specialists design a course of treatment that seeks to get the patient back to full strength and with the range of motion that they had before the injury.

To achieve these goals, proper alignment of the bones during healing is vital. Patients with acetabular and pelvic fractures often have displacement. In other words, the bones are not in proper position and must be realigned, or put back into place. Physicians use the term reduction to describe this process.
If a joint surface malheals (that is, with irregularities), the cartilage that lines the joint will rub together and wear down, setting the stage for severe arthritis of the joint, loss of motion, decreased function and pain.
 

Nonsurgical treatments

Treatment for patients with pelvic fractures is based on a number of factors including the type of fracture, the stability of the pelvis, and the degree of displacement of the bones. The orthopedic surgeon uses information gathered through physical examination, conventional radiographs and CT scans to make this determination. Patients with a stable pelvic fracture – without displacement or dislocation--are the most likely candidates for nonsurgical treatment. Some may require closed reduction (realignment without an open surgical procedure) under anesthesia with or without external fixation.

Some patients with fractures of the acetabulum itself may also be treated nonsurgically. Usually, this treatment is selected for patients who do not have displacement and/or those who may not be able to tolerate surgery, such as individuals with significant medical problems, infections or severe osteoporosis. Closed reduction is done either through manipulation conducted while the patient is under anesthesia or by putting the patient in traction.
 

Surgical treatment

Realignment of the bones may be done either as an open reduction, in which the orthopedic surgeon makes an incision to directly manipulate the bone, or as a closed reduction, in which this incision is not necessary. Once the bones are realigned, the surgeon uses internal or external fixation to hold the bone in proper position during healing. Metallic devices including wires, pins, screws, and plates are used.

Patients with pelvic fractures may require one or more surgical procedures. The surgeon may begin with an External Fixation (Ex-Fix) technique in which an open or closed reduction is performed and the bones are then held in place using an external fixator, or frame. This is done by threading pins into the bone on either side of the fracture. These pins are then connected to rods outside the skin, which form a frame.

While the Ex-Fix technique is sometimes the only procedure needed to repair a fractured pelvis, some patients require additional surgery or surgeries in which plates and screws are used internally to hold the bones in place. Depending on the site and complexity of the fracture, the surgeon may have to fix the front of the pelvis, the back of the pelvis, or both. Separate operations may be needed for each area that needs treatment.

Patients with acetabular fractures often require an Open Reduction with Internal Fixation (ORIF), especially those patients who also have displacement of the joint. The surgeon realigns or reduces the bones as precisely as possible to prevent the development of post-injury related problems, especially arthritis. The bones are rigidly fixed with plates and screws to prevent future displacement and allow for rehabilitation to begin as quickly as possible.

Fractures of the acetabulum are usually not treated for 5 to 10 days following the injury. Because the patient experiences significant bleeding with this fracture, the orthopedic surgeon must wait for the patient's own clotting mechanisms to go into effect – usually within three to five days. During this period the patient may be in traction to prevent additional injury.
 

Preoperative procedures

Patients scheduled for surgery undergo a number of tests. These include:

• Blood tests
• An electrocardiogram (or EKG) that tests the electrical activity of the heart
• A chest X-ray to ensure that the lungs have not been injured and have no fluid in them and that the patient has no infection of the lung (pneumonia)
• Conventional radiographs (X-rays), computerized tomography (CT scan), or magnetic resonance imaging (MRI): Each of these tests helps the surgeon get as much information as possible about the fracture before beginning surgery. CT scans are particularly useful since they allow the physician to see the fracture in several planes and also see a 3D model of the fracture on a computer monitor
• Magnetic resonance venogram (MRV): Assesses the patient's veins. Many patients with fractures of the pelvis and acetabulum develop blood clots in the veins of the pelvis, thighs or lower legs. If the clot travels through the body to the lungs it is called a pulmonary embolism and can interfere with the patient's breathing. If the MRV shows that a clot is present, treatment for the clot is immediately started. This may include placement of an Inferior Vena Cava Filter, that is a "strainer" in the major vein to the heart to prevent any blood clots going to the lungs (pulmonary embolism).

In addition to these tests, doctors and nurses frequently check the patient's pulses, the feeling in the injured limb, and ask about any strange sensations such as tingling or numbness in the limbs.
 

Postoperative care

Following surgery, managing the patient's pain and managing any complications that arise due to the injury are primary concerns.

Initially, pain medication will be given by injection. However, many patients are able to use a pump that controls the amount of pain medication given. This is known as patient-controlled analgesia (PCA) and offers patients the benefits of managing his or her pain. Since there is a maximum dose that can be delivered at any given time, there is no danger that the patient will receive too much medication.

Other medications that may be given include anticoagulants to thin the blood and avoid the development of blood clots, and Indocin, which prevents bone formation in areas around the muscles.

Patients are encouraged to get up and out of bed as soon as possible, since doing so helps to avoid some of the complications associated with these injuries. A regimen of physical therapy is followed to maintain muscle strength and range of motion during recovery.

After surgery to repair a pelvic fracture or fracture of the acetabulum, many patients continue to feel the effects of damage to nerves that might have occurred during the traumatic event or the surgery. Important branches of the lumbar and sacral nerves may be either stretched or torn, especially in the case of unstable pelvic fractures. Injuries to the nerves result in decreased feeling in a limb and/or difficulty or inability in moving part of the limb. It is difficult to predict whether these nerves will fully recover. However, the majority of patients do regain some sensation and function of the limb within six to eighteen months after their injury.
 

What are the complications of surgery for a broken pelvis?

Throughout treatment and recovery, doctors and nurses are watchful for the following potential complications:

• Deep vein thrombosis and pulmonary embolism: Blood clots that may form in the veins of the pelvis, thighs, and/or lower legs and may travel to the lungs.
• Pneumonia: An infection of the lungs that may affect any patient who is confined to bed and cannot expand his or her lungs as fully as they normally do.
• Skin Problems resulting from being in one position for a long period of time
• Muscle Complications due to inactivity.
• Heterotopic Ossification, a condition in which the body mistakenly forms bone in an area where there is normally muscle; prompt treatment is required to prevent this new bone from interfering with joint movement.
• Damage to the Head of the Femur: if the articular cartilage lining of the joint is affected in an injury to the pelvis, and particularly in fractures of the acetabulum, it's important to keep the surfaces of the joint from rubbing together-and to avoid the risk of future development of arthritis. Preoperatively, traction or a system of ropes, pulleys and weights are used to relieve pressure in the joint. Obviously, surgery with open reduction and internal fixation is performed to realign the joint with enough stability to allow immediate mobilization and hence preserve the smooth lining of cartilage and avoid subsequent arthritis.
• Avascular Necrosis of the Head of the Femur: Patients with a dislocated hip and/or fracture of the acetabulum may have disrupted blood flow to the head of the femur (the ball in the hip joint). This can result in death and collapse of bone tissue and hip joint arthritis.
• Nutritional Problems: The body requires more protein and calories during healing.
• Constipation resulting from inactivity.
• Infection at the site of the injury

Patients who have suffered a traumatic accident or injury may experience psychological distress over changes in their appearance and physical functioning. The shock of becoming an accident victim may also linger. As with a serious illness, the patient may wonder "why me" and be searching for reasons the accident occurred. Difficulty sleeping and coping with the pain associated with recovery are not uncommon. Patients with pre-traumatic depression or who are experiencing other stressful life events are more prone to experience psychological difficulty connected with their fracture.
In many cases, the passage of time eases these symptoms.
 

Outcomes

The outcome of surgery for a pelvic or acetabular fracture is dependent on a variety of factors including: the extent of injury including injuries to the head and other organs, the health of the patient prior to the injury, and whether this is the patient's first surgery for the condition.

Pelvic fractures and the multiple injuries that often go along with them are potentially life-threatening. In addition, unfortunately, even those patients who survive these injuries and whose bones are successfully realigned and healed, may have a significant degree of long-term disability, and chronic pain is not uncommon. Many have injury to the genitourinary system that can result in incontinence and impotence. The best chance for a good recovery lies in receiving excellent care from specialists who are experienced in rapid decision-making following a traumatic accident.

By itself, a fracture of the acetabulum is generally not a life-threatening injury. (Of course, some patients with these fractures will also have other serious injures.) And, thanks to advances in treatment over the years, especially surgical reduction and stabilization techniques, 80% to 85% of patients, can expect a good to excellent recovery following surgery, provided that the hip can be properly aligned and fixed.

On the second day following surgery for an acetabular fracture, patients are usually able to get out of bed. Crutches must be used for eight weeks following surgery, but by 12 weeks most people are able to walk unassisted. If they are otherwise in good condition, most people recover fully within four to six months and are able to resume recreational activities at that time.

For individuals who have received initial treatment for their pelvic and acetabular fractures elsewhere, who have not healed properly, and are now seeking corrective surgery, a complete recovery can be more difficult to achieve. But previous surgery is not necessarily an obstacle to a good outcome following a second surgery, but this requires an experienced team, as this is the most complicated and difficult surgery of all.

While many of us have become accustomed to the amazing strides achieved by medical science, it's worth noting that these good results following acetabular fractures are remarkable. This progress is due in large part to long-term studies conducted by two French researchers, Judet and Letournel, who identified the common fracture problems and provided key information on the best way to gain access to the fracture with the least amount of injury to the patient. Based on their findings, better instruments and surgical techniques have evolved. Physicians also have a better understanding of how to avoid complications and of the healing process. More recently, additional information about the fracture is achieved through visualizing techniques such as CT and MRI scans. Before any of these developments occurred, patients with acetabular fractures had a far less promising outlook. Most ended with painful arthritic hips, and in young patients a hip bone fusion, which resulted in drastically limited mobility.