Management and treatment outcome of pelvic fractures

     Management and treatment outcome of pelvic fractures

                                           DR KS Dhillon

Pelvic anatomy

The bony pelvis (fig 1) consists of the sacrum and coccyx posteriorly and two innominate bones laterally and anteriorly. The innominate bone (hip bone) consists of the iliac bone, ischial bone and the pubic bone which meet at and house the acetabulum. The two innominate bones articulate with the sacrum posteriorly via the sacroiliac joints and they meet anteriorly at pubic symphysis.

The sacrum is connected to axial skeleton superiorly and to the coccyx inferiorly. The innominate bone is connected to the lower limbs via the hip joint at the acetabulum. Hence the pelvis is able to transmit forces from the axial skeleton to the lower limbs.

Transmission of forces from the axial skeleton to the lower limbs is the primary function of the pelvis and its secondary function is to contain the pelvic organs.The concave iliac fossa, and pelvic floor muscles help support the pelvic organs.

A strong sacrospinous ligament which extends from the sacrum to the  ischial spine converts the sciatic notch into the greater sciatic foramen and lesser sciatic foramen. The lesser sciatic foramen lies between the sacrospinous ligament and the sacrotuberous which runs from the sacrum to the ischial tuberosity. Through the greater sciatic foramen passes the sciatic nerve and the piriformis muscle from the pelvis to the gluteal region. Through the lesser sciatic foramen passes the the tendon of the obturator internus, internal pudendal vessels, pudendal nerve and the nerve to the obturator internus.

The inguinal ligament extends from the anterior superior iliac spine to the pubic tubercle. Below the inguinal ligament the femoral nerve and the femoral vessels exit the pelvis to enter the thigh.
The obturator foramen lies below the acetabulum and is formed by the pubis and the ischial bones. It is covered by a membrane in the upper part of which there is an opening through which the obturator nerves and vessels exit the pelvis and into the thigh.

Classification of pelvic fractures 

To classify pelvic fractures, plain x rays, AP view, inlet and outlet views are required along with 3mm CT scans. There are 3 classification  available which are used in the evaluation of pelvic fractures and these include:

1.Tile Classification
2. Young-Burgess System Classification
3. OTA Classification of Pelvic (Six) Ring (One) Fractures

These classifications helps the surgeon develop the management strategy [1]

1. Tiles classification [2]                               
According to Tiles classification the pelvic fractures are divided into 3 types [1].

Type A        Stable
 A1              Fractures of the pelvis not involving the ring; avulsion 
                   injuries
 A2              Stable, minimal displacement of the ring
A3               Stable, transverse fractures of the sacrum or coccyx.
Type B        Rotationally unstable; vertically stable
 B1              External rotation instability; open-book injury
 B2              LC injury; internal instability; ipsilateral only
 B3              LC injury; bilateral rotational instability
Type C        Rotationally and vertically unstable
 C1              Unilateral injury
 C2              Bilateral injury, one side rotationally unstable, with the
                   contralateral side
 C3              Bilateral injury, both sides rotationally and vertically
                   unstable,  with an associated acetabular fracture
  (LC, lateral compression)


This classification subdivides the fractures into 3 types, type A which are stable injuries, type B which are rotationally unstable but vertically stable and type C which are both vertically and rotationally unstable.

Type A are subdivided into type A1 where the pelvic ring is not involved but there is an avulsion fracture, type A2 where there is minimal displacement of the ring and type A3 where there is a transverse fracture of the sacrum or the coccyx.

Type B injuries are vertical stable but rotationally unstable. The vertical stability is due incomplete disruption of the posterior arch and an intact pelvic floor. Type B1 injuries are open book injuries where there is disruption of the anterior pelvic arch through the symphysis pubis or through the rami, and there is external rotational instability where the rotation hinges on an intact posterior SI complex.
Type B2 fractures are lateral compression injuries where there is a combination of both anterior and posterior arch fractures. B2 fractures can be divided into two, type B2-1 fractures, where the anterior and posterior arch disruption is on the same side and B2-2 where the two arch disruption are on the opposite side.
In B3 pelvic fractures the injuries are bilateral. These are partially stable injuries which includes bilateral open-book fractures (B3-1), bilateral lateral-compression injuries (B3-2), and a combination of both [1].

In type C fractures, the pelvis is unstable vertically as well as rotationally. This results from complete disruption of the anterior arch, posterior arch, and pelvic floor. In C1 fractures the pelvis unilaterally unstable, in C2 fractures the unstable pattern on one side of the pelvis and on the other side the pelvic is partly stable whereas in C3 fractures the pelvic is unstable on both sides.

2. Young-Burgess System Classification
The Young and Burgess classification [3] is based predominantly on the mechanism of injury and severity of pelvic fracture. An anteroposterior (AP) radiograph of the pelvis is the only investigation necessary for this classification but the inlet and outlet views can be useful. According to this classification the fractures are divided into four categories based on the mechanism of injury. Two of the categories are further subdivided according to the severity of injury. According to this classification the fractures are divided into four categories based on the mechanism of injury. Two of the categories are further subdivided according to the severity of injury.

Young-Burgess System Classification [1].
Category        Distinguishing features
 LC                Transverse fracture of pubic rami, ipsilateral or contralateral
                      to posterior injury
 I                    Sacral compression on side of impact
 II                   Crescent (iliac wing) fracture on side of impact
 III                  LC I or LC II injury on side of impact; contralateral open-book
                      (APC) injury
APC              Symphyseal diastasis or longitudinal rami fractures
 I                    Slight widening of pubic symphysis (less than 2.5 cm) or
                      anterior SI joint; stretched but intact SI, sacrotuberous, and
                      sacrospinous ligaments; intact posterior SI ligaments
 II                   Symphyseal diastasis greater than 2.5; widened anterior SI
                      joint; disrupted anterior SI, sacrotuberous, and sacrospinous
                      ligaments; intact posterior SI ligaments
 III                 Complete SI joint disruption with lateral displacement, 
                     disrupted anterior SI, sacrotuberous, and sacrospinous
                     ligaments; disrupted posterior SI ligaments
VS                Symphyseal diastasis or vertical displacement anteriorly and
                     posteriorly, usually through the SI joint, occasionally through
                    the iliac wing or sacrum
CMI             Combination of the injury patterns, LC/VS is most common
(APC, anteroposterior compression; CMI, combined mechanical injury; LC, lateral compression; SI, sacroiliac; VS, vertical shear).


1.Lateral compression fractures (LC) – These fractures result from lateral compression forces, which cause rotation of the pelvis inwards, leading to fractures in the sacroiliac region and pubic rami.
These fractures are subdivided into three grades.
Grade 1:Anterior transverse fracture of rami plus ipsilateral sacral compression fracture.
Grade 2: Anterior transverse fracture of rami plus ipsilateral sacral compression fracture and a fracture of the iliac wing.
Grade 3:Plus -Anterior transverse fracture of rami plus ipsilateral sacral compression fracture and a fracture of the iliac wing with a contralateral anterior posterior compression injury.

2.Anterior posterior compression fractures– These fractures result from a direct or indirect force in an anteroposterior direction leading to a diastasis of the symphysis pubis, with or without obvious diastasis of the sacroiliac joint or fracture of the iliac bone.
These fractures are subdivided into three grades.
Grade 1: Pubic diastasis with no or slight widening of the sacroiliac joint (SIJ). The SIJ ligaments remain intact.
Grade 2: Pubic diastasis with widening of SIJ and disruption of anterior ligaments and intact posterior ligaments.
Grade 3:  Pubic diastasis with complete SIJ disruption and torn anterior and posterior ligament but no vertical displacement of the hemipelvis.
3.Vertical shear fractures (VS) –These fractures result from an axial shear force which disrupts the pubis symphysis and the SIJ and results in a vertical cephalic displacement of the hemipelvis.
4.Combined mechanism injury (CMI)– These fractures results from a combination of two of the above vector. The fracture pattern would be a combination of one or more of the above fracture types.



3.OTA Classification of Pelvic (Six) Ring (One) Fractures [1].

The Orthopaedic Trauma Association (OTA) has developed a more comprehensive classification system for pelvic fractures so as to standardize and improve reporting of pelvic fractures.

OTA Classification of Pelvic (Six) Ring (One) Fractures [1]
Type         Description
A              Lesion sparing (no displacement of posterior arch)
 1              Fracture of innominate bone, avulsion
 2              Fracture of innominate bone, direct blow
 3              Transverse fracture of sacrum and coccyx
B               Incomplete disruption of posterior arch, partially stable
 1               Unilateral, partial disruption of posterior arch, external rotation
                  (open-book)
 2               Unilateral, partial disruption of posterior arch, internal rotation
                  (LC injury)
 3                Bilateral, partial lesion of posterior arch
C                Complete disruption of posterior arch, unstable
 1                Unilateral, complete disruption of posterior arch
 2                Bilateral, ipsilateral complete, contralateral incomplete
 3                Bilateral, complete disruption
(LC, lateral compression)

The OTA type 61A fractures are subdivided into three types and each type is further subdivided into 3 types.. The 61A fractures are stable fractures. 61A1 are avulsion fractures of the innominate bone, 61A2 are fractures of the innominate bone and 61A3 are transverse fractures of the sacrum and coccyx.

OTA type 61B fractures are partially stable. In type 61B1 there is a unilateral disruption of the posterior arch (external rotation, APC, open-book type injury). In type 61B2 fractures there is a unilateral disruption of the posterior arch (internal rotation, LC injury), and in type 61B3 fractures there is bilateral partial lesions of the posterior arch.

The type 61C fractures are unstable injuries where a complete disruption of the posterior arch occurs. The  61C1 injuries are unilateral, 61C2 injuries are complete ipsilaterally and incomplete contralaterally while the 61C3 injuries have complete bilateral disruptions.

Management of pelvic fractures

Historically pelvic fractures have been treated conservative, however in recent years, operative stabilization of unstable pelvic injuries has increased. Operative stabilization of unstable pelvic fractures allows early mobilization of the patient which decreases complications associated with recumbency. Furthermore, operative treatment prevents major pelvic deformities and improves clinical outcomes [4].

Generally stable pelvic fractures are treated conservatively and unstable fractures are treated surgically. The main problem with treatment of pelvic fractures is that the definition of instability is very nebulous and is surrounded with controversies.

Bucholtz and Peters have simplified the issue of instability. They believe that generally “if a posterior ring injury is nondisplaced or impacted, the pelvis is probably stable. If there is a superior or anteroposterior displacement of the hemipelvis of 1 cm or more, the pelvis is clearly unstable. All injuries between these 2 extremes may or may not be stable and must be evaluated and treated individually” [5].

Initial Management

The initial evaluation and management of the patient in the hospital should proceed according to the guidelines of the Advanced Trauma Life Support (ATLS) protocol [6]. The following mnemonic is useful in the initially evaluation of the patient :

• Airway maintenance with cervical spine protection
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability: Neurologic status
• Exposure/Environmental control: Completely undress the patient, but prevent hypothermia

During the primary survey an assessment of the patient’s airway and breathing is immediately carried out and intravenous access is obtained with two large bore IV lines for fluid and blood infusion. During the primary survey, life-threatening conditions  are identified in a prioritized sequence based on the effects of the injuries on the patient’s physiology.

In the initially management of patients with suspected pelvic fractures hemodynamic stabilization is very important. After the airway is adequately secured, sources of bleeding have to be identified. Presences of flank ecchymosis and or scrotal edema indicates injury associated hemorrhage.
Volume resuscitation without hemorrhage control is of no value in the treatment of  the patient and may in fact lead to secondary iatrogenic complications such as hypothermia and coagulopathy [7]. External bleeding can be controlled by direct pressure and a decision has to be made rapidly whether surgery or other interventions are required to control internal bleeding [7].

Plain chest and pelvic x rays should be obtained at this stage. The chest x ray will show if there is haemothorax and pelvic x rays show the type and extent of pelvic fracture. A FAST (Focused Assessment with Sonography for Trauma) examination is carried out in the emergency department to detect intra-abdominal bleeding. A positive scan in an hemodynamically unstable patient would be an indication for a laparotomy. Diagnostic peritoneal lavage (DPL) is now less often used in most centres.

Although a CT scan will be the most useful investigation to detect peritoneal and retroperitoneal injuries, its use however is limited when dealing with unstable polytrauma patients since the patient cannot be taken into a CT suite [7]. Thermal control is essential when dealing with these patients because hypothermia is known to exacerbate traumatic coagulopathies [8].

Treatment of the pelvic injury

A. Hemodynamic status

Relying on systolic blood pressure to evaluate hypovolemia and hemorrhagic shock may be misleading because a 30% blood loss is necessary for hypotension to occur. Tachycardia and cool peripheries are early indicators of blood loss. Narrowed pulse pressure may indicate significant blood loss. Estimations of arterial blood pressure, central venous pressure, hemoglobin and hematocrit have been shown to be unreliable markers of shock in young people [9]. Hence vigilance, constant monitoring and a thorough examination of the patient is of paramount importance.

Base deficit is an accurate indicator of the severity of the shock state and the efficacy of resuscitation [10]. The base deficit can easily be estimated from arterial blood gas analysis. Lactate clearance is an accurate way to quantify both the degree of hemorrhagic shock and the probability of survival [11]. Lactate levels correlate better with total oxygen debt, which reflects the magnitude of hypoperfusion and hemorrhagic shock [12,13]. The measurement of hourly urine output, remains one of the most practical indicators of systemic perfusion.

B. Fracture stability

In patients who are awake and alert there is no need for routine pelvic x rays because a clinical examination will reveal the presence of pelvic injury and than an x ray can be ordered. If radiographs of the pelvic reveal the presences of unstable pelvic fractures than there is no need for aggressive physical examination with compression and distraction since such examination will not provide additional information on injury severity, but may on the other hand cause further injury and increase bleeding [7].

In hemodynamically unstable patients with no obvious bleeding site, a through clinical examination of the pelvis is must even if the pelvic radiographs look normal or a pelvic x rays show a stable pelvic fracture [7].

A physical examination of the pelvic would include, inspection of the groin, perineum, flanks, lower abdomen and buttocks for bruises and wounds. A high riding prostate and blood at the urethral meatus would be indicative of urethral injury where insertion of urinary catheter would be contraindicated and retrograde urethrogram would be indicated. The rectum should be examined for any blood in the rectal vault [7].

Further examination would include looking for any clinical deformity of the pelvis, limb-length discrepancy and or malrotation. Compression and distraction tests of the pelvic would provide evidence of rotational instability of the pelvic. Vertical instability can be assessed with a push-pull test where the examiner palpates both iliac crests while the assistant provides telescoping forces to the ipsilateral lower limb [7].

External stabilization of the pelvis becomes a priority in hemodynamically unstable patients with major bleeding who have pelvic instability. External stabilization reduces bleeding from the presacral venous plexus and from the fractured bone surfaces [7].

C. Pneumatic antishock garments/medical antishock trouser

Pneumatic antishock garment (PASG) or medical antishock trouser (MAST) have been used for immediate mechanical stabilization at the scene of accident [14] and prehospital personnel do apply these garments to  facilitate transfer of patients to the trauma centre [15]. The PASG apparently redistributes blood from the limb to the trunk and restricts the expansion of a pelvic hematoma [16]. Several randomised trials have, however, showed no survival benefit with the use of MAST garment in the treatment of in multiply injured patients with both blunt and penetrating trauma [17,18,19].

A Cochrane review by Roberts et al [20] in 1999 showed that there is no evidence to suggest that MAST/PASG application reduces mortality, length of hospitalisation or length of ICU stay in trauma patients. In fact the use of these devices may increase mortality and length of hospital and ICU stay. The data available does not support the continued use of MAST/PASG in trauma patients. They concluded that the data available is of poor quality, hence, conclusions should be drawn with caution.
Furthermore application of these devices have been found to produce compartment syndrome in the lower limbs [21,22, 23]. Presently the role of PASG and MAST in treatment of trauma patients is limited.

D. Pelvic binders

In recent years the use of pelvic binders to stabilize pelvic fractures and to control hemorrhage has become widely adopted around the world. It has been widely adopted in resuscitation protocols worldwide and is currently a part of the ATLS protocol [24].

Fu CY et al [25]  did a study to evaluated the use of pelvic compression devices in patients with pelvic fractures who required interhospital transfer, and they found a reduction in transfusion requirement, ICU length of stay, and hospital length of stay, both in stable and unstable fractures of the pelvis.

A study by Bottlang et al [26] showed that circumferential pelvic compression with a pelvic sling is an effective, noninvasive, and safe stabilization approach for temporary management of open-book pelvic fractures at the accident site. The use of pelvic binders is noninvasive, and they are easy to apply. They are also inexpensive and can be applied at the site of the accident. Pelvic sheets applied around the greater trochanters and tensioned to 180 N increases pelvic stability by 61% in response to rotational stress and 55% in flexion–extension. This binders can improve hemodynamic status of patients with pelvic fractures and reduce unstable pelvic fractures [27].

Binders bound around the pelvis for too long or if applied too tightly can cause skin necrosis and in patients with lateral compression injuries and in patients with transforaminal sacral fracture they can cause visceral or neural injury [28].

D. External fixation

Anterior external fixation (AEF) to stabilize the pelvis is now considered as part of resuscitation rather than reconstruction of the pelvis in patients with pelvic fractures. Reimer et al [29] reduced mortality rates in pelvic ring injury patients from 26% to 6% by adding acute AEF to their hospital resuscitation protocol and early mobilization of the patients. Reduced transfusion rates and reduced mortality with use of external fixator has been reported by others [30,31,32]. Immediate application of external fixation for hemodynamically unstable patients with pelvic fractures is now considered as a life-saving procedure [33,34,35,36].

Anterior external pelvic fixation is suitable for open book fractures and and  unstable shear type fractures when combined with longitudinal traction. It is not suitable for lateral compression injuries. Posterior unstable fractures are better treated with a pelvic C-clamp which  can exert transverse compression directly across the sacroiliac joint.

E. C-clamps

Ganz et al [37] developed the C-clamps which are now available in most trauma centres. The are usually used for posterior unstable fractures of the pelvis and are easy to apply. These clamps are used both in hemodynamically unstable patients as well as in stable patients with unstable pelvic-ring disruptions. Hemodynamic status improves in patients who have the fractures stabilized with a C-clamp [37].

Though generally these clamps are easy to apply, in patients with comminuted fractures of the sacrum the application can be difficult as well as dangerous and the application should be carried out by an experienced surgeon in such patients [38].

F. Internal fracture fixation

External fixators and C-clamps can be cumbersome when ambulating a patient. However if the patient is too ill to allow for surgical intervention these fixators can be used for definitive treatment. If a laparotomy is contemplated for intra-abdominal visceral injury, internal fixation of the pelvis can be carried out at the same time.

In the hands of appropriately trained surgeons percutaneous pelvic fixation for both anterior and posterior ring injuries can be carried out for stabilization of the pelvis without extensive dissection. The success however relies on correct patient selection, accurate closed reduction with good intraoperative imaging [7].

G. Open fractures of the pelvis

Open fractures of the pelvis are potentially lethal injuries with mortality rates of between 30% to 50% [39]. By definition an open fracture of the pelvis is one where the fracture haematoma communicates with the vagina, rectum and or the exterior though a break in the skin. An open fracture should be suspected if there is clinical evidence of vaginal or rectal bleeding. Patients with open fracture are at risk of exsanguination due to massive hemorrhage which occurs due due to disruption of the natural anatomic compartment and loss of the tamponade effect. Late mortality  usually occurs due to pelvic sepsis and multiple organ failure [40].

There has been a failure to develop a satisfactory classification system for open pelvic fractures and this is in part due to rarity of the injury and in part due to the vast spectrum of soft tissue injury that is involved.

Bircher and Hargrove [41] have proposed a classification for open pelvic fractures . They have divided open pelvic fractures into three major groups, A, B, and C, which are further subdivided into three sections. This classification defines a spectrum of injury from the less serious “A” subgroups to the most potentially lethal “C” type injury.

In type A injuries the bony injury is Tiles A type. Subtype A1 injuries result from penetrating trauma such as from a bullet. In type A2 there is an outside in injury with superficial skin abrasion and in type A3 there is outside in injury with extensive skin loss and soft tissue damage where soft tissue cover is necessary.

Type B injuries represent more soft tissue damage than type A injuries.
In type B injuries the bony injury is Tiles type B. The B1 and B2 injuries are lateral compression injuries while the B3 injury is an open book type. Type B1 injuries are inside-out injuries which are produced by lateral compression forces. There is little external skin damage. Pubic rami fractures can penetrate the bladder, urethra or the vaginal wall. B2
Injuries are also inside-out injuries where there is more soft tissue injury with degloving lesions around the greater trochanter, flanks and on the back.
In B3 injuries there is an open book bony injury with perineal split but there is no skin loss. There is no complete posterior ligament disruption. Partial genitourinary injury may be present.

Type C open pelvic fractures result from high energy trauma where there is extensive soft tissue loss and extensive intrapelvic disruption with opening up of all tissue plains within the pelvis. In type C open fractures the bony injury is of Tiles C category. Type C open injuries are potentially lethal injuries.

In subgroup C1 there is perineal and sacral shear and split with some loss of skin and a complete lesion of bladder/urethra with fecal contamination.
In C2 type of injuries there is destabilization of the hemipelvis with extensive degloving and shearing of tissues with complete genitourinary lesions and bowel laceration with fecal contamination.
In C3 type of injuries there is pelvic crushing with massive internal and external soft tissue injury both internally and externally. There is associated  complex comminution of the pelvis with acetabular fractures.

Treatment of open pelvic fractures

After examination of the patient, macro-debridement of the wounds is done and packing with antiseptic coated swabs is undertaken. Tetanus toxoid cover and broad-spectrum antibiotics are given. Since urine output measurements are important in resuscitation of the patient, an attempt to catheterize the urinary bladder must be made. If urethral catheterization fails, then a suprapubic catheter has to be inserted and contrast studies should be organized. Later definitive urologic treatment can be carried out for genitourinary injuries.

If bowel injury is present or if there is significant wound in the perineum than a diverting colostomy has to be carried out. After diversion of the urine and bowel, wound irrigation, debridement and the necessary soft tissue cover is obtained. Laparotomy and pelvic packing is sometimes necessary to obtain haemostasis.

Internal fixation of pelvic fractures

Symphysis pubis disruptions

Most authors recommend operative stabilization of pubic symphysis when the diastasis is greater than 2.5 cm, based on experimental evidence which showed that pubic bone displacement of greater than 2.5 cm implies that the anterior sacroiliac, sacrospinous, and sacrotuberous ligaments have been torn which renders the pelvis rotationally unstable [42,43]. A 3.5-mm pelvic reconstruction plate with at least 2 screws on either side is usually used for internal fixation.

Pubic rami fractures

The pubic ramus can fracture on either side of the pubic symphysis, through the mid ramus or through the base of the ramus. Displaced rami fractures can lacerate the bladder, vagina, and perineum. Stabilization of the fracture can prevent further injury to these structure. Stabilization is also carried out in association with posterior pelvic ring fixation when there is pelvic instability. Rami fractures involving the obturator neurovascular canal causing neurological injury should be reduced and fixed.
The rami fractures can be stabilized by percutaneous or open, antegrade or retrograde  fixation with a 4.5-mm cortical screw or with a 3.5 mm plate.

Iliac wing fractures

Isolated iliac wing fractures are usually stable ad do not need surgery. Open iliac wing fractures with skin problems and degloving injuries will need surgery. Severely displaced fractures with pelvic instability would need operative stabilization of the fractures. Medullary screws or reconstruction plates can be used for fixation of the fractures.
 

Crescent fractures

Crescent fractures are fractures of the posterior ilium which extend from the iliac crest into the greater sciatic notch and are usually associated with an articular dislocation of the anterior sacroiliac (SI) joint. The posterior iliac fragment is stable because the posterior SI ligaments are intact but the iliac component is rotationally unstable [44]. Surgical stabilization is usually indicated because of inherent instability of the iliac component and the dislocation of the SI joint.
Iliac fractures can be  stabilized with lag screws and 3.5-mm reconstruction plates and percutaneously placed iliosacral screws can be used to supplement fixation.
The SI joint can be stabilized with iliosacral screws and or 3.5-mm reconstruction plates placed perpendicular to one another [45].

Sacroiliac joint disruptions

In complete disruptions or dislocations of the SI joint there is rupture of the  anterior and posterior SI joint ligaments. In such circumstances rotational and/or vertically instability of the pelvis is present, hence, surgical reduction and stabilization is usually recommended.
Open or close reduction of the dislocation can be carried out and percutaneous iliosacral screws can be used to maintain the reduction.
Pelvic reconstruction plates (3.5- or 4.5-mm) placed perpendicular to one another across the SI joint can also be used to stabilize the SI joint.

Sacral fractures

Denis classified sacral fractures into 3 types [46]:

• Type I fractures involve the sacral ala
• Type II fractures involve the sacral foramina
• Type III fractures involve the central portion of the sacrum

Surgical stabilization is usually indicated when the fractures are displaced, when they are part of the pelvic instability injury or when there is foraminal debris causing neurological deficit. Transiliac bars, transiliac screws, transiliac plates, or iliosacral screws can be used to stabilize sacral fractures.

Outcome of treatment

Mortality

In the past hemorrhage was the cause of death in about two third of the patients who presented with pelvic fractures [47]. Now, however the death from hemorrhage has been reduced with about one third of patients with pelvic fractures dying from hemorrhage [48]. When there is major haemodynamic instability the mortality rates can reach as high as 40% to 80% [49,50]. Presently the mortality rate in hemodynamically unstable patients with fractures of the pelvis remains at about 30% [51]. The overall mortality varies between 10% [52](8) to 20% [53].
Besides hemorrhage which causes early mortality, sepsis with multiorgan failure can be the cause of late mortality in some patients with pelvic fractures [54].

Functional outcome

Unfortunately there are no ‘standard disease-specific functional outcome instruments’ that can be used to report functional outcome after pelvic fractures [55]. Lefaivre et al [55] did a systematic review of literature to evaluate the ‘use and interpretation of generic and disease-specific functional outcome instruments in the reporting of outcome after the surgical treatment of disruptions of the pelvic ring’.They found that the ‘existing literature in this area is inadequate to inform surgeons or patients in a meaningful way about the functional outcomes of these fractures after fixation’.
Some of the commonly used scores used to report functional outcome after pelvic fractures include,Majeed score, the Iowa Pelvic Score, and the Medical Outcomes Study Short-Form 36-item Health Survey (SF-36).

The Majeed score [56] is a functional assessment for patients with pelvic fractures which assess five factors which are then scored to provide a clinical grade of excellent, good, fair and poor. The five factors are pain, standing, sitting, sexual intercourse and work performance. More than 85 points is excellent, 70 to 84 is good, 55 to 69 is fair and below 55 is poor outcome.

 The Iowa Pelvic Score assess, activities of daily life, work history, pain, limping,visual pain line and cosmesis. The SF-36 on the other hand is a general health assessment which assess physical functioning,  bodily pain and general health [57].

Suzuki et al [58] used the above scores to report the long term functional outcome after unstable pelvic ring fractures. They studied 57 patients (28 male and 29 female) with an average of 42.4 years who had unstable pelvic ring fractures. The average follow-up was 47.2 months (minimum 2 years). The average Injury Severity Score (ISS) of 24.6 points.Twenty-three of the patients were treated conservatively, 22 had external fixation, and 12 had  internal fixation of the fractures.

The average Majeed score was 79.7 and the average IPS was 80.7. The average ‘physical component summary of the SF-36 was 13.4 points worse than that of the population norm’. Radiological examination showed ‘average residual displacement was 7.3 mm anteriorly and 5.2 mm posteriorly’. They also found that the ‘Majeed score and the physical component summary of the SF-36 correlated with the presence of neurologic injury, and the Iowa Pelvic Score correlated with the presence of a mental disorder, posterior displacement, and neurologic injury’.

The authors concluded that Injury severity Score, fracture location and type of fracture did not influence the long term functional outcome in patients with unstable pelvic ring fractures. They found a close correlation between neurological injury and functional outcome.

Dienstknecht et al [59] reported the functional and socioeconomic long-term outcome in 109 patients with pelvic ring injuries at a minimum of 10 years follow up. The average age of the patients was 28.8 years (5 to 55) and the mean ISS was 22.7. They found that 39% of the patients had a limp, 11% required crutches and 15% of the patients had restrictions in use of car or public transport usage. Overall the outcome was worse in patients with isolated posterior and combined anterior posterior fractures as compared to isolated anterior fractures.

Papakostidis et al [60] did a systematic review of literature to compare the outcome of treatment of pelvic ring fractures by conservative means,  anterior stabilization,and posterior stabilization. They found no difference between the group as far as the incidence of severe pain, return to previous employment, functional scoring systems, or general health and wellbeing outcomes were concerned. A better walking ability was seen among patients who had surgical stabilization of the fractures. Less malunions were seen in patients who had internal fixation of posterior fractures. The relationship between quality of reduction of the fractures and the long-term functional outcomes remains unresolved.

Sexual dysfunction

Sexual dysfunction can present in various forms and includes erectile dysfunction (ED), dyspareunia, loss of sensation, ejaculatory dysfunction, and restricted motion during intercourse [61]. Metze et al [61] in retrospective review studied the incidence of male sexual dysfunction after pelvic fractures. Sixty one percent of the patients reported limitations in sexual function and persistent erectile dysfunction was found in 19% of the patients.Posterior ring disruptions appeared to increase the risk of persistent erectile problems, probably due to nerve injury.
In literature the overall mean reported incidence of sexual dysfunction after pelvic fractures is 35.9% in men and 39.6% in women.There is limited consensus  on the definition of sexual dysfunction,and on the methods and timing of assessment, as well as on its management [62].

Urological injury

Urologic injuries commonly associated with pelvic fractures include injuries of the urethra, corpora cavernosa (penis), bladder, and bladder neck [63]. Injuries to the urinary bladder usually result from shearing force or direct laceration by bone fragments and usually extraperitoneal. Urethral disruption can lead to urethral strictures, incontinence, and impotence. The impotence associated with pelvic fractures is usually of vascular origin and not due to neurologic injury. The management of urethral injury associated with pelvic fractures remain controversial. Some believe in early primary realignment is carried out [63].

There are others who believe that primary suturing of the disrupted urethral ends has the greatest complication rates of incontinence (21%) and impotence (56%), as compared to suprapubic cystostomy and delayed repair [64].

Neurologic injury

Reilly et al [65] did a clinical review of 90 unstable pelvic fractures treated during a 3-year period. Of these 90 patients, 83 were available for follow up examination. They found neurologic injuries in 21 % of the patients. Sensory deficit alone was present in 37% of the patients and the rest (63%) had both sensory and motor deficit. Some neurologic improvement was seen in all patients at one year follow up. Fifty three percent of the patients showed full recovery. Improvement in function took about one year in most instances but they found that L5 function was least likely to recover fully.

Venous thromboembolism

In patients with pelvic fractures the incidence of proximal vein thrombosis is between 25% to 35% with symptomatic pulmonary embolism (PE) occurring in 2% to 10% of the patients, and fatal PE in 0.5% to 2% of the patients [66].

Sharma et al [67] studied the incidence of deep vein, in 507 patients with at least one risk factor for venous thromboembolism, using venous duplex scans. They found that that the highest incidence of deep vein thrombosis (DVT) was seen in patients with pelvic fractures, in patients with previous venous thromboembolism, spinal cord injury and significant head injury (AIS > 2). They also found that deep-vein thrombosis was asymptomatic in 68% of patients and pulmonary embolism (PE)  was silent in 63% of the patients.

Steele et al [68] studied the efficacy low molecular weight heparin (LMWH) in the prevention of thromboembolism in patient with pelvic and acetabular trauma. They reported a 10% overall incidence of proximal DVT and a 5%  incidence of pulmonary embolism. They found that patients who received  LMWH within 24 hours of injury had a 3% incidence of DVT and incidence rose to 22% in patients who had who received LMWH more than 24 hours after the injury. There were ten patients who developed a proximal DVT and five had a symptomatic PE, one of which was fatal. They recommended the use of LMWH within 24 hours in patients with pelvic and acetabular trauma.
Barrera et al [69] did a systematic review of literature for the Cochrane group to evaluate the role of thromboprophylaxis in trauma patients. They found no evidence that thromboprophylaxis reduces mortality or PE. However there was some evidence that thromboprophylaxis prevents DVT.

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