Anatomy

What structures are most commonly injured?

The lower part of the spine ends in the sacrum - a group of vertebral bones fused
together at birth. On each side of the sacrum is a sacroiliac joint that joins the ilium of
the pelvis to the sacrum. The ilium is the large blade of bone which arches from the
spine at the back to the hip joint at the side.
There are strong ligaments joining the sacrum to the ilium. In front is the anterior
sacroiliac ligament and behind is the posterior sacroiliac ligament. Together the
sacrum, the sacroiliac joint with its ligaments, and the adjacent ilium can be called the
sacroiliac complex. Because the pelvis is a ring, when the front is broken it is common
for the sacroiliac complex to be disrupted partiall or completel. If the line of injur
goes through the ligament!s" this can be difficult to diagnose.
The ilium is fused to two other bones, the ischium and the pubis. Together these three
structures form the socket of the hip joint called the acetabulum. The pubis is a #-
shaped bone which projects inwards from the hip socket as the superior pubic ramus
in towards the mid line at the front of the abdomen. There it meets up with the pubis of
the other side forming the pubic symphysis. The pubis then passes down and outward
again to form the inferior pubic ramus which meets up with the ischium. Together the
pubis and ischium form a ring at the front of the pelvis. The hole in the ring is called
the obturator foramen.
The ischium is also #-shaped. It projects backwards and downwards from the hip joint
then forwards and inwards to meet up with the pubis. The bone is thickened at its
lowest point, also called the ischial tuberosity. This takes much of the weight of the
upper bod when ou are sitting and also forms the point of attachment of the
hamstring muscles of the thigh.
$ou can feel %uite a number of bon landmarks on the pelvis. &hen our mother
placed her hands on her hips in an authoritarian manner, she was actuall pressing her
hands onto the crest of the ilium on both sides. The hip joint itself is too deep in the
root of the thigh to be felt. If ou feel forward on the crest of the pelvis ou find that it
ends as the anterior superior iliac spine' this is a landmark for measuring the length of
the legs. If ou sit on our fingertips ou will feel the ischial tuberosities. The pubic
smphsis can be felt in men at the root of the penis and just above the labia in
women.
The pelvis itself does not move ver much although the spine and legs are ver
mobile. There is ver little movement at either the sacroiliac joints or the pubic
smphsis. (owever, there is some flexibilit of the ring of the pelvis so it can distort
a certain amount without breaking. )n ring structure is more likel to break in two
places rather than one' this means that if there is a fracture at the front of the pelvis
one must look carefull for another injur at the back or on the other side.
The pelvis is also the site of attachment of important muscles of the thigh and
abdomen. The oblique abdominal muscles take origin from the wing of the ilium and
the rectus abdominis muscle attaches to the pubic bones. The muscles that move the
thigh, swinging it forwards, backwards, outwards or inwards mostl take origin from
the pelvis. *ome of these muscles are strong enough to pull off pieces of their bon
attachment. This is called an avulsion fracture".
+an important blood vessels pass close to the pelvis and ma be injured when the
pelvis is fractured. The internal and external iliac arteries are large vessels that suppl
most of the blood to the legs. ,amage to even a branch of these vessels results in
dangerous bleeding' a major pelvic fracture ma be associated with a dangerous or
even fatal amount of blood loss. The nerves to the legs, rectum, bladder, and genitalia
pass inside the pelvis over the sacrum and sacroiliac joints. The ma be injured when
this part of the pelvic ring is disrupted.
The vagina, the bladder, and the urethra are close to the pelvis and ma be injured in a
pelvic fracture. Other abdominal organs at risk include the colon and rectum. The
pregnant uterus is also ver vulnerable to injur in a major pelvic fracture, placing
both mother and fetus at risk. Because a pelvic fracture is often associated with major
force it is common to see a wide spectrum of other injuries as well - head injuries,
chest and abdominal injuries, and multiple long bone fractures.
Causes
How do fractures of the pelvis commonly happen?
The anatom of the pelvis results in a wide variet of fracture patterns. )vulsion
fractures of the iliac spines or the ischial tuberosit result from over-pull of the
muscles. Impact from the side compresses the ring and ma cause a fracture of the
wing of the ilium or fractures through the pubic rami in front and the sacroiliac
complex at the back. Impact from the front ma cause fractures of the pubic rami on
both sides. Impact driving the leg up into the pelvis ma result in a shear fracture
involving the front and back or ma break the hip socket !acetabulum". ) straddle
injur in which the legs are forced too far apart ma disrupt the pubic smphsis and
the anterior sacroiliac ligament.
Types
What types of fractures can occur?
Avulsion Fractures
These injuries occur in ounger people and are not common. The are often the result
of sports as the patient makes an extra effort in a situation of mechanical disadvantage.
Thus tring to spring up, straightening the knee when the load is suddenl increased
ma result in a pull-off fracture of the site of origin of rectus femoris, one of the
muscles that straightens the knee. This point of attachment is the anterior inferior iliac
spine in the groin. )vulsion fracture of the hamstring origin !the ischial tuberosit" is
less common' a ruptured hamstring muscle occurs more fre%uentl. These injuries
generall heal without the need for surger.
Fragility Fractures of the Pelvis
In osteoporotic elderl patients, a fall compressing the pelvis ma result in a fracture
through the pubic rami. Both rami on one side are usuall broken but this is an
exception to the rule about a ring onl breaking in one place. )lthough it must be
looked for, it is uncommon for there to be significant disruption of the sacro-iliac
complex posteriorl in these cases. These fractures are painful and limit mobilit but
the generall heal without the need for intervention. Their major significance is as an
indication of generali-ed osteoporosis and an increased risk of fracture elsewhere.
These are probabl the most common fractures of the pelvis.
) .atients /uide to Osteoporosis
Bilateral Pubic Rami Fractures
This pattern of fracture involves breaks of both pubic rami on both sides. It is the
result of a direct blow to the pubic region of the pelvis. This ma occur in a variet of
accidents or collisions. Injur to the bladder is common especiall if it was full at the
time of impact. The fractures ma be displaced a few centimeters but do not need
reduction and usuall heal without intervention.
Fractures of the Iliac Wing
)n impact from the side or directl onto the crest of the pelvis ma cause a fracture of
the wing of the ilium. This usuall affects onl one side and does not alwas break the
ring. This fracture has a bad reputation for bleeding and ma need surger on this
account, but it does not usuall re%uire intervention to heal the fracture. 0ven if the
shape of the iliac wing is not restored exactl there is ver little long term effect on
function.
Vertical Shear Fractures
1ertical shear fractures occur with motor vehicle accidents and other forms of high
energ trauma.The force that causes this tpe of fracture is applied to one side of the
pelvis onl. )n example might be falling from a height and landing on one leg. The
pelvis on that side ma be driven upwards and the other side is driven downwards b
the momentum of the upper bod. The fracture line commonl goes through the pubic
rami and posterior sacroiliac complex on the same side. It is most important to
establish the stabilit of this tpe of fracture. If the posterior disruption is complete the
fracture is unstable and one half of the pelvis is likel to migrate upwards relative to
the other side. This injur also ma disrupt the nerves that pass over the wing of the
sacrum and there is a high incidence of injur to the internal organs with this tpe of
fracture.
ateral Compression In!uries
If the ring of the pelvis is compressed forcefull from the side it ma break through
the pubic rami at the front and the sacroiliac complex at the back. The two
components of the break ma be on different sides. If the posterior component is
through bone, the injur is unstable and ma need to be fixed. (owever, if onl the
posterior ilio-sacral ligaments are torn, the fracture ma be stable enough to be treated
non-operativel.
Stra""le In!uries
*ometimes called open book injuries these occur when the legs are forced wide apart
pulling on the pelvic ring in the front. If the pull is too great there is a spectrum of
damage. The lowest grade results in disruption !called diastasis" of the pubic
smphsis. If this is less than 2 cms it is usuall stable and ma not need to be reduced
or stabili-ed. )t the next level of injur the pubic smphsis is pulled apart more
widel and there is also partial damage to the posterior sacroiliac complex. This injur
is potentiall unstable and needs to be treated b some method to 3close the book3 -
meaning to pull and hold the ring of the pelvis back together in the front.
The most severe tpe of injur results in complete disruption of the posterior
structures as well as wide separation of the pubic smphsis. This is definitel
unstable and needs surger to close the pubic smphsis and stabili-e the pelvic ring
posteriorl. *traddle injuries occur in riding accidents as well as motor vehicle
accidents and other high energ trauma. The urethra is %uite commonl injured in
straddle injuries as it is so close to the pubic smphsis.
Acetabular Fractures
4ractures of the pelvis that involve the hip socket !acetabulum" are amongst the most
challenging of all fractures to treat. The are rare, variable, demand meticulous
assessment, re%uire complex surgical treatment and have major conse%uences for long
term disabilit. 4or these reasons patients with acetablular fractures are often
transfered to a tertiar trauma center where the treating team has experience managing
these injuries. These fractures usuall occur as a result of severe forces transmitted
through the legs, motor vehicle accidents, or falls from a height.
,islocations of the hip joint can push off fragments of the rim of the socket or the
head of the femur can be driven up into the pelvis. Because of the importance of the
hip as a weight bearing joint it is recommended to restore the joint surface to
smoothness as exactl as possible. This usuall means surger - often re%uiring a ver
extensive exposure to reduce all the pieces. The force re%uired to cause this injur
means that other injuries are common and ma be life-threatening, so the decision to
undertake surger is a complicated one.
Symptoms
What symptoms do pelvic fractures cause?
*erious pelvic fractures are sometimes not diagnosed at the time of the injur. The
situation is often complicated b multiple injuries, unconsciousness of the patient, or
the effects of drugs, alcohol or pain medication. )n smptoms that refer to the region
of the pelvis should be carefull investigated.
)s with all fractures the most common smptom of a pelvic fracture after an accident
is pain in the pelvic region. In the common situation when an elderl person has fallen
and sustained a pelvic fracture the pain ma easil be mistaken for a hip fracture. If a
hip fracture is not seen on x-ra the pelvis x-ra must be examined carefull to rule
out a fracture of the pubic ramus. In ounger people, pelvic fractures commonl occur
in the setting of multiple trauma. The pain ma not be evident in an unconscious
patient or ma be much less than the pain from other injuries.
The pain is felt in the area of the fracture. 4or example, in a fracture involving the
pubic rami and the posterior sacroiliac complex, the pain is felt in both places. If there
is pain or tenderness at the back, this region must be carefull evaluated b x-ra or
computed tomograph !#T" scan to identif the injur. The muscles that move the leg
take origin from the pelvis so pain is made worse b movement. If the fracture
involves the hip socket !acetabulum", movement of the hip joint will be especiall
painful or impossible. One leg ma appear to be shorter than the other in acetabular
fractures and unstable pelvic fractures.
*hock from blood loss ma be seen when there is a pelvic fracture. If the patient needs
on-going resuscitation and blood transfusion, the pelvis fracture ma be responsible.
Bleeding from a pelvic fracture often tracks down into the groin so swelling and
purple discoloration of the scrotum or the labia are common and ma last a long time.
*welling and bruising ma also extend into the root of the thigh. Bleeding from the
urethra is a sign of a potentiall serious injur to the bladder or the urethra. )nother
smptom of a urogenital injur is the inabilit to pass urine or incontinence.
5umbness or weakness in the leg or groin ma be a sign of a nerve injur associated
with a pelvic fracture.
#valuation
How will my fracture be evaluated?
)t the scene of the accident the focus is often on resuscitating a multipl injured
patient, treating shock, and transporting the patient to hospital as soon as possible.
#linical diagnosis of a fractured pelvis is difficult although it is eas to suspect this
injur. In the case of an elderl person who has sustained a fall the situation can be
confused with a hip fracture - warming the patient, treating shock, splinting, and rapid
transfer to hospital are appropriate in both cases.
In the 0mergenc 6oom the focus of the treating team is on resuscitating the patient,
making sure all the injuries are identified and the appropriate specialists are consulted.
The clothes will need to be removed to allow examination of the pelvic area and this
ma necessitate cutting off some clothing. The site of the injur will be carefull felt
for tenderness and examined for wounds, swelling, bruising, or blood at the urethra.
.ain from movement of the limbs will also be evaluated and related to the sites of
injur. The general medical status will be evaluated, especiall in the case of elderl
patients or patients with multiple injuries.
It is ver common for the bladder to be catheteri-ed to monitor kidne function when
blood loss is suspected. *ometimes it is difficult to pass a catheter and this would
suggest an injur to the urethra or bladder. In shocked or multipl injured patients the
trauma team ma be called in. The focus of this team is diagnosis and management of
life-threatening parts of the injur which might include a pelvic fracture with massive
blood loss.
The x-ras ordered b the 0mergenc 6oom doctors will likel include a plain x-ra
of the pelvis with views of the hip if there seems to be pain on moving it. In the case
of multiple injuries and especiall if there is shock from blood loss, it is common
practice to obtain a computeri-ed tomograph !#T" scan of the chest and abdomen
including the pelvis. If the plain x-ras or #T scans show a fracture of the pelvis an
orthopaedic consultation would be re%uested. The orthopaedic specialist ma be part
of the trauma team or ma be called in b the 06 doctor or the Trauma Team. 7suall
some preliminar evaluation has been done b this time and the pelvic fracture has
been demonstrated b x-ra or #T scan.
The orthopaedic surgeon will ask about the patient8s smptoms and examine the pelvic
area and limbs paing particular attention to sites of tenderness and an areas or
numbness, swelling, or bruising. The x-ras will be evaluated and further views or
computeri-ed tomograph !#T" scans ma be taken to make sure the extent of the
injur is understood and documented. The orthopaedic surgeon will come to a
conclusion about the tpe of injur that has been sustained and discuss the
management options with the patient, the rest of the treating team and the famil. This
discussion will include consideration of the patient8s life-stle, sports and work
activities, general medical status and expectations in addition to the fracture itself. The
management options might include transfer of the patient to a trauma center, non-
operative management or surger. If surger for other injuries !for example a ruptured
bladder" is re%uired this ma also affect the orthopaedic plan.
Treatment
What type of treatment is available for pelvic fractures?
Nonsurgical Treatment
&ith a wide variet of pelvic fractures one finds a similarl wide spectrum of
treatment ranging from smptomatic treatment onl, through bed-rest, traction, slings,
external fixation, and a variet of surgeries. Because the pelvis has a rich blood suppl
and is mostl made up of spong !referred to as cancellous bone" bone which heals
ver well, it is rare for healing to be delaed or insufficient. Treatment is therefore
directed at problems with instabilit and displacement.
Symptomatic Treatment
4or stable pelvic fractures such as minimall displaced avulsion fractures and the
pubic ramus fractures common in the elderl, it is not necessar to reduce or
immobili-e the fracture. (ealing takes place even if the patient moves around.
+anagement is therefore directed at reducing the pain and maintaining mobilit.
.rolonged rest is avoided and a gentle exercise program to retain range of motion can
be used.
.ain, swelling and bruising settles over a period of three to four weeks and the
fracture!s" heal at approximatel six weeks. In the case of avulsion fractures, union of
the fracture should be confirmed before returning to sports activit on a graduated
basis.
Bed Rest
+ore major injuries such as iliac wing fractures, straddle injuries or lateral
compression fractures are patterns which are potentiall unstable. The ma be treated
initiall with bed rest. )fter a few das the x-ras ma be repeated and the patient can
be mobili-ed if there is no shift in position of the fracture. It would be usual to avoid
weight bearing on the affected side for six weeks. These fractures can heal where the
are and do not have to be reduced back to the original shape.
elvic Sling
) pelvic sling is used temporaril in cases where the fracture pattern is unstable or if
there is severe bleeding. In straddle injur patterns s%uee-ing the fracture together b
using a pelvic sling ma prevent further displacement and ma put pressure on the
bleeding points and lessen bleeding. This tpe of treatment is usuall stopped earl
and a more definitive treatment plan used.
Traction
+an acetabular fractures were formerl treated with traction. .ins were placed in the
femur and weights attached to pull the hip down out of the injured socket. In some
cases the joint surface of the socket was restored to a better position. The advantage of
this stle of treatment is that surger is avoided but the joint surface is usuall still
irregular after healing has occurred and the joint is ver likel to be painful and
arthritic.
Traction ma be used in acetabular fractures where there is pre-existing arthritis of the
hip or where the patient is elderl. In the latter case it ma be considered safer to let
the acetabular fracture heal and undertake a total hip replacement once that has
happened. ) hip replacement is a lesser operation than open reduction of an acetabular
fracture and the results are predictabl good in the elderl. Traction ma also be used
in unstable fractures of the pelvic ring to prevent shortening of the affected side.
7suall this would be a temporar measure while a definitive treatment plan is
formed.
!anagement of Bleeding from a elvic "racture
)fter fractures, bleeding from large arteries usuall stops because the blood collects in
the tissues and pressure builds up. )lso it is usuall possible to appl external pressure
to the bleeding point!s". Because the abdomen is such a big cavit this ma not happen
with pelvic fractures.
.ressure suits !+)*T suits" have been used to help with this problem but the results
have not been predictable. In some cases, reducing the fracture with a pelvic sling or a
circular bandage around the pelvis helps. In others, the radiologist can identif the
bleeding point b angiograph and stop the bleeding b blocking the blood vessels
with blood clot !this is referred to as embolization". In some situations it is necessar
to undertake emergenc surger on the bleeding area and either repair the vessels or
pack the region to appl local pressure. &here dangerous bleeding is suspected from a
pelvic fracture it is important to continue to monitor the patient for blood loss in case
it starts again.
#mergency Surgery
Open fractures of the pelvis are uncommon but fractures that are associated with
injuries to the bladder, urethra or rectum are more common. These injuries re%uire
emergenc surger and ma re%uire the expertise of a general surgeon, a urologist and
an orthopaedic surgeon. )n dead or contaminated tissue must be removed and the
fracture should be stabili-ed. *ometimes this can be done provisionall with external
fixation without disturbing the blood suppl of the fracture an further or undertaking
an big surgical exposure in a criticall injured patient.
#$ternal "i$ation
+an unstable pelvic ring fractures can be treated b an external fixation apparatus.
This re%uires an anesthetic. Threaded metal pins are screwed into strong intact areas of
the pelvis, usuall the iliac wings, on both sides. The pins are then attached to a frame
which bridges over the abdomen in the front. The frame can be used to reduce the
fracture, close up a straddle injur or bring down part of the pelvis which has moved
up. (owever, it cannot be used for all pelvic fractures' if there is an extensive unstable
posterior injur a frame ma be insufficient to keep the bones in place.
Because a frame can be applied relativel %uickl without an further damage to the
blood suppl of the area it ma be possible and desirable to combine external fixation
with other forms of treatment such as traction or minimall invasive fixation. 0xternal
fixation ma be complicated b pin track infection and is avoided b some surgeons
for this reason.
!inimally %nvasive Surgery
7sing the fluoroscope and emploing indirect manipulation of the fracture fragments
with fixation through the skin without opening up the fracture site is a techni%ue
which is attracting a lot of attention. The concept is known as minimally invasive
surgery. In the context of pelvic fractures it can be emploed to fix fractures of the
sacrum and the ilium. &here there is an unstable pelvic ring fracture it ma be
possible to stabili-e it b inserting sacral fixation posteriorl and using an external
fixation frame anteriorl, saving the patient a more extensive operation.
&pen Reduction and %nternal "i$ation '&R%"(
There are some situations where surger is performed on a pelvic fracture to move the
fracture fragments back into the correct position !open reduction" and fix them there
with metal implants !internal fixation" until the bones heal. The implants ma be pins,
wires, screws or plates in an combination.
The simplest form of O6I4 of a pelvic fracture is probabl where there has been a
posterior fracture dislocation of the hip. ) fragment of the posterior lip of the hip
socket is broken off with this injur as the head of the femur is driven backwards into
the buttock. The exposure of this fracture is relativel straightforward and usuall the
hip can be put back in the socket without difficult. The fracture fragment can then be
reduced exactl and fixed with a single screw. If it is large then multiple screws or a
small plate can be be used.
,isplaced avulsion fractures ma also be treated b O6I4. In the case of a pull-off
fracture of the anterior inferior iliac spine the bone fragment ma be pulled too far
down into the thigh to heal. The operation re%uires exposing the fracture site,
replacing the fragment with its muscle attachment back where it came from and
holding it, usuall with a single screw from the fragment into the ilium.
)nother use for O6I4 in pelvic fractures is the straddle injur. If the posterior
elements are partiall injured this fracture can be stabili-ed successfull b a plate
across the pubic smphsis. The outer or superior surfaces of the pubic rami are
exposed, the diastasis is reduced bringing the two pubic bones back together and a
plate is fixed across the gap keeping the bones together until the heal.
B far the most complicated situation in which O6I4 is used, is a fracture of the
acetabulum. This injur breaks the hip socket, damaging the joint surface on which the
femoral head moves. )lthough the bone is ver likel to heal, if ridges, steps or gaps
remain in the hip socket the hip will rapidl wear out. The intent of the surger is to
restore the smoothness of the inside of the hip socket. There are several different
fracture patterns which disrupt the hip socket so the surgeon must be ver familiar
with the classification of the injur and the various methods of reducing the fragments
and fixing them in place.
5earl all these methods re%uire extensive exposure of the pelvis from the front or the
back of the hip joint. &hen O6I4 of an acetabular fracture is re%uired, it is best to
have the surger undertaken at a trauma center with experience in the procedure.
%mplant Removal
Once the fracture has healed the pelvis is stable once more. 0xternal fixation devices
!pins and frame" are alwas removed. Internal fixation devices !implants, pins, plates,
screws" ma also be removed if the are causing smptoms. There ma be tenderness
over the metal implants or a vague aching pain. *ometimes the protruding ends of
screws or pins cause catching or grating.
+an patients are ver concerned about hardware removal, fearing the same post
operative pain that occurred after the initial operation. In general, hardware removal is
a more minor operation which can be performed as da surger and which is followed
b rapid recover. The bone does not have to heal and the soft tissue damage that goes
along with a fracture is not repeated when the implants are removed. (owever,
removal of plates and screws from an acetabular reconstruction operation ma re%uire
a big exposure once more, making it a significant undertaking. (ardware removal is
not necessar if there are no smptoms.
Rehabilitation
What should % e$pect as % recover from a pelvic fracture?
Bone healing from a fractured pelvis is %uite rapid. 7suall there are signs of union on
x-ra b six weeks and patients can return to light activities at that stage. 6ecover
from other injuries often dominates the timetable. 6eturn to heavier activities and
sports depends on the individual case.
.hsical therap !.T" is helpful in getting mobile on crutches and recovering range of
motion earl in the process. 9ater ou ma benefit from a .T program for recover of
strength and endurance. If the bone heals in good position, the pelvis is stable and
there are no problems with the hardware, the long term outlook for recover of normal
function following a pelvic fracture is excellent. The main concerns are recover of
an nerve injuries, loss of leg length and irregularit of the hip joint socket. These
issues are considered under complications.
Complications
What are the potential complications of this fracture?
#omplications are events which make the process of healing from a fracture more
length or difficult, or which ma compromise that process. *ome of the activities that
patients are urged to do following a fracture, such as moving the injured part earl
even though it hurts, ma seem meaningless or even cruel. The are intended to
reduce the risk of complications.
This section on complications goes into detail not because the complications
themselves are common, but because avoiding the complication is one of the foci of
treatment. ) full account of the complications of fracture healing is presented in the
.atient8s /uide to 4ractures in /eneral.
)enous Thrombo #mbolism ')T#(
4ollowing an injur, the bod activates the blood-clotting mechanism, circulation in
the blood vessels ma be slowed b swelling and the patient ma be immobili-ed,
reducing circulation even more. This combination ma result in blood clots forming in
the veins of the legs and the pelvic region. These clots themselves reduce the speed of
blood flow in the veins so more clot ma form. If the clot continues to grow and
extends up into the large veins of the thigh and pelvis there is a risk that parts of the
clot ma break off, float up in the veins and lodge in the lungs. This is called
embolism and can be ver dangerous, affecting the blood flow to the lung.
1T0 is a feared complication of pelvic fractures because the severit of the injur
makes clotting of the pelvic veins more likel and there is often a need for bed rest. )s
earl as possible, patients are encouraged to move their legs to improve circulation.
0arl in the recover from a pelvic fracture patients are mobili-ed to sit in a chair or
get up on crutches. )nti-coagulant medication ma also be used if there is evidence of
a blood clot or a ver high risk.
The treatment of established 1T0 generall involves long term anti-coagulation
medication. In selected cases it ma be necessar to insert a filter into the venous
sstem to stop clots from getting as far as the lung.
Nonunion
It is rare for the bone to fail to heal but movement ma persist at the site of injur to
the posterior ligaments in the sacroiliac complex or the pubic smphsis. This
situation ma result in pain on weight-bearing, a feeling of instabilit or upward shift
of the pelvis. Operation or re-operation to fuse the unstable joint ma be re%uired.
!alunion
) situation in which the pelvic ring heals with persistent and smptomatic deformit is
called malunion. The distortion ma result in one leg being shorter than the other or
one half of the pelvis being rotated. This result ma be accepted although it is not
optimal. Operating on the pelvis to restore the normal shape is a difficult, complex
procedure. It ma be preferable to use a shoe lift to even up an leg length discrepanc.
+alunion of the acetabulum is also a serious problem when it results in an uneven
joint surface. 4urther surger is often recommended in this situation. )n attempt ma
be made to take down a healing fracture and make the inside of the hip socket smooth.
)lternativel, after healing, a hip replacement operation or a hip fusion ma be done
to make the leg comfortable and functional.
Nerve %njury
The nerves that pass over the sacrum as the exit from the spine ma be injured when
the pelvic ring is fractured. It is important to establish the existence and extent of this
component of the injur at the beginning. 9oss of sensation in groin or incontinence
ma be %uite difficult to establish in an unconscious patient with a catheter in place.
9ater, these impairments ma be significant long term issues. If the nerves are
stretched there is a good chance of recover' if the are torn the outlook is less
optimistic.
Heterotopic ossification 'H&(
.elvic fractures are often accompanied b massive bleeding and injuries to the
muscles of the region. 5ormall this blood clots and eventuall forms scar tissue. 4or
reasons unknown, bone ma develop in the scar tissue. Because this bone formation
!bone formation is referred to as ossification" is out of place, it is known as
heterotopic ossification. It is common after pelvic fractures and even more common if
the are treated surgicall.
0arl in the recover period the wounded area ma be swollen, tender and feel hard
and 3wood3. &ithin : weeks of injur ;-ras show bone forming in the tissue.
)lthough little is known about the fundamental reasons for this problem, it is clearl
an inflammator process. If one attempts to perform surger at an earl stage and
remove the (O, it creates et more inflammation and bone formation.
The best was to limit (O are to use anti-inflammator medication or radiation.
Because of the potential side effects from these treatments the are not used as
preventative measures !or prophyllaxis" in all cases but ma be used once the
diagnosis is established or suspected.
The bon lumps that form in the tissues ma not cause smptoms. If the do, it is best
to wait <= months for the inflammator process to settle completel before
undertaking surger to remove the heterotopic bone.
%nfection
#ontamination of the fracture, either at the time of the original injur or at surger
ma result in bacterial infection. The wound tends to be swollen, red and more tender
than normal. The patient runs a temperature and pus ma drain from the wound.
#ulture of the pus or blood cultures ma show up the bacteria that causes the problem.
(igh doses of antibiotics are needed for a long time when a surgical site infection
!**I" is present. It fre%uentl re%uires further surger to remove dead and
contaminated tissue and drain the wound so pressure does not build up. It ma be
necessar to remove or revise !change" the implants if the are infected' more often
the are left in place until the bone has healed because a stable fracture is more
resistant to infection than an unstable one. The wound ma re%uire repeated surger to
wash out the infected material. )ntibiotic beads or pellets can be used to maintain a
high local concentration of drug in the wound. This combination of measures is
usuall successful in suppressing or eliminating the infection.
Once the fracture has healed the implants ma be removed to eliminate foreign
material in the wound and allow the bod8s defenses to clear up all the bacteria. **I is
a feared complication which re%uires prolonged treatment and more surger, but the
outcome is usuall satisfactor.
ost Traumatic *rthritis
&hen the hip socket !acetabulum" is involved in the fracture, the joint surface ma be
crushed or fragmented. It ma be impossible to restore the joint surface to smoothness.
The medium and long term result of this ma be premature wearing out of the hip
joint. The remaining joint surface is worn awa and the hip becomes painful and stiff.
)voidance of this outcome is the intent of surger on acetabular fractures but it is not
alwas successful.
The length of time a damaged hip joint will be functional after an acetabular fracture is
unpredictable. The smptoms ma be controlled b anti-inflammator or pain
medication for man ears. The indications for further surger to treat post traumatic
arthritis are unbearable or relentlessl progressive smptoms, particularl of pain and
loss of mobilit. In a oung person with a heav job, consideration ma be given to
fusing the hip joint which gives a painless, strong and durable result. In other
circumstances a hip replacement ma be offered as this gives predictabl good results
as long as it is not over-loaded.