1
|
Kastanis G, Pantouvaki A, Siligardou MR, Chaniotakis C, Kroustalakis E, Stavrakakis I, Kapsetakis P. Can Nondisplacement Osteoporotic Pubic Rami Fracture Be Life-Threatening Injuries? A Case Report, Overview, and Algorithm Protocol for Management. J Investig Med High Impact Case Rep 2024; 12:23247096241231648. [PMID: 38491774 PMCID: PMC10943755 DOI: 10.1177/23247096241231648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/13/2024] [Accepted: 01/23/2024] [Indexed: 03/18/2024] Open
Abstract
Pubic rami fractures in the geriatric population are usually osteoporotic fractures resulting from low energy trauma and are characterized as stable injuries. Established treatment of these injuries is conservative, including rest, analgesic medication, and progressive active mobilization. These injuries are life-threatened when pubic rami fractures are accompanied by acute bleeding, either from an injury to a vessel (corona mortis) or from medication (anticoagulant or antiplatelet) for comorbidities, then. In this case study, we present the unusual case of an 82-year-old woman admitted to the emergency department 24 hours after a simple fall, causing nondisplacement osteoporotic pubic rami fracture, who, after 48 hours, developed a hematoma on the contralateral side of the pelvis, with progressive anemia and acute abdominal pain. This study has 2 objectives: to increase awareness of this life-threatening injury in the emergency department and to describe diagnosis and treatment modalities.
Collapse
Affiliation(s)
| | - Anna Pantouvaki
- General Hospital of Heraklion “Venizeleio-Pananeio,” Greece
- Hellenic Mediterranean University, Heraklion, Greece
| | | | | | | | | | | |
Collapse
|
2
|
Putzeys G, Dekeyser T, Garré P, Chesser T, Pottel H. Posterior pelvic ring involvement detected with CT taken within a week of admission in acute fragility fractures of the pelvis (FFP) does not predict failure of conservative treatment: a retrospective cohort study. BMC Musculoskelet Disord 2023; 24:320. [PMID: 37087474 PMCID: PMC10122380 DOI: 10.1186/s12891-023-06439-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/18/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Acute low energy pubic rami fractures in the elderly receive primarily conservative treatment. There is debate to what extent posterior ring involvement, which is detected superiorly by CT compared to X-ray, has an impact on outcome and may require modified treatment. We want to demonstrate if posterior ring involvement has an influence on different types of outcome in primarily conservatively treated acute FFP, questioning the usefulness of early CT. Additionally we analysed the early fracture pattern in cases where conservative treatment failed with need for secondary surgery. METHODS A retrospective cohort study of 155 consecutive patients, recruited between 2009 and 2016, aged over 65 years diagnosed with an acute LE-PFr on X-ray at the emergency department of a single, level-one trauma centre and receiving an early CT. A set of outcome parameters was compared between patients with an isolated pubic rami fracture (CTia) and patients who had a combined posterior pelvic ring fracture (CTcp). RESULTS There were 155 patients of whom 85.2% were female with a mean age of 83 years. 76.8% of patients living at home returned home and 15.5% moved to a nursing home. Mortality rate during hospitalisation was 6.4% and 14.8% at one year post-trauma. Secondary fracture displacement occurred in 22.6%. Secondary surgery was performed in 6 cases (3.9%). Median hospitalisation length of stay was 21 days (range 0 to 112 days). There was no significant association between the subgroups and change in residential status (p = 0.65), complications during hospitalisation (p = 0.75), mortality rate during admission (p = 0.75) and at 1 year (p = 0.88), readmission within 30 days (p = 0.46) and need for secondary surgery (p = 0.2). There was a significant increased median length of stay (p = 0.011) and rate of secondary displacement (p = 0.015) in subgroup CTcp. Secondary displacement had no impact on in-hospital complications (p = 0.7) nor mortality rate during admission (p = 0.79) or at 1 year (0.77). Early CT in patients who underwent secondary surgery showed stable B2.1 lesions in 4 of 6 cases. CONCLUSIONS Our data suggest that early CT in patients with conservatively treated acute LE-PFr in order to detect posterior lesions, has limited value in predicting failure of conservative treatment.
Collapse
Affiliation(s)
- Guy Putzeys
- Orthopedic and Trauma Department, AZ Groeninge hospital, Kortrijk, Belgium.
| | | | - Patrick Garré
- Department of data management, AZ Groeninge hospital, Kortrijk, Belgium
| | | | - Hans Pottel
- Department of Public Health and Primary Care, KULeuven KULAK, Kortrijk, Belgium
| |
Collapse
|
3
|
Schicho A, Schmidt SA, Seeber K, Olivier A, Richter PH, Gebhard F. Pelvic X-ray misses out on detecting sacral fractures in the elderly - Importance of CT imaging in blunt pelvic trauma. Injury 2016; 47:707-10. [PMID: 26861798 DOI: 10.1016/j.injury.2016.01.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 11/29/2015] [Accepted: 01/22/2016] [Indexed: 02/02/2023]
Abstract
Patients aged 75 years and older with blunt pelvic trauma are frequently seen in the ER. The standard diagnostic tool in these patients is the plain a.p.-radiograph of the pelvis. Especially lesions of the posterior pelvic ring are often missed due to e.g. bowel gas projection and enteric overlay. With a retrospective study covering these patients over a 3 year period in our level I trauma centre, we were able to evaluate the rate of missed injuries in the a.p.-radiograph whenever a corresponding CT scan was performed. Age, gender, and accompanying fractures of the pelvic ring were recorded. The intrinsic test characteristics and the performance in the population were calculated according to standard formulas. Thus, 233 consecutive patients with blunt pelvic trauma with both conventional radiographic examination and computed tomography (CT) were included. Thereof, 56 (23%) showed a sacral fracture in the CT scan. Of 233 pelvic X-ray-images taken, 227 showed no sacral fracture. 51 (21.7%) of these were false negative, yielding a sensitivity of just 10.5%. Average age of patients with sacral fractures was 85.1±6.1 years, with 88% being female. Sacral fractures were often accompanied by lesions of the anterior pelvic ring with pubic bone fractures in 75% of sacrum fracture cases. Second most concomitant fractures are found at the acetabulum (23.3%). Plain radiographic imaging is especially likely to miss out fractures of the posterior pelvic ring, which nowadays can be of therapeutic consequence. Besides the physicians experience in the ED, profound knowledge of insensitivity of plain radiographs in finding posterior pelvic ring lesions is crucial for a reliable diagnostic routine. Since the high mortality caused by prolonged immobilisation due to pelvic ring injuries, all fractures should be identified. We therefore provide a diagnostic algorithm for blunt pelvic trauma in the elderly.
Collapse
Affiliation(s)
- Andreas Schicho
- University of Ulm, Department for Orthopaedic Trauma, Albert-Einstein-Allee 23, D-89081 Ulm, Germany.
| | - Stefan A Schmidt
- University of Ulm, Department for Radiology, Albert-Einstein-Allee 23, D-89081 Ulm, Germany
| | - Kevin Seeber
- University of Ulm, Department for Orthopaedic Trauma, Albert-Einstein-Allee 23, D-89081 Ulm, Germany
| | - Alain Olivier
- University of Ulm, Department for Orthopaedic Trauma, Albert-Einstein-Allee 23, D-89081 Ulm, Germany
| | - Peter H Richter
- University of Ulm, Department for Orthopaedic Trauma, Albert-Einstein-Allee 23, D-89081 Ulm, Germany
| | - Florian Gebhard
- University of Ulm, Department for Orthopaedic Trauma, Albert-Einstein-Allee 23, D-89081 Ulm, Germany
| |
Collapse
|
4
|
Nüchtern JV, Hartel MJ, Henes FO, Groth M, Jauch SY, Haegele J, Briem D, Hoffmann M, Lehmann W, Rueger JM, Großterlinden LG. Significance of clinical examination, CT and MRI scan in the diagnosis of posterior pelvic ring fractures. Injury 2015; 46:315-9. [PMID: 25527459 DOI: 10.1016/j.injury.2014.10.050] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 05/29/2014] [Accepted: 10/14/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients with a fracture in the anterior pelvic ring often simultaneously demonstrate pain in the posterior pelvic ring. The aim of the present prospective study was to assess the sensitivity of CT, MRI and clinical examination in the detection of fractures in the posterior pelvic ring in patients with fractures of the anterior pelvic ring diagnosed in conventional radiographs. METHODS Sixty patients with radiographic signs of an anterior pelvic ring injury were included in this prospective analysis. Following a focused clinical examination of the posterior pelvis, all patients underwent both a CT and then a MRI scan of their pelvis. Two board certified radiologists evaluated the CT and MRI scans independently. To estimate the presence of osteoporosis the Hounsfield units of the vertebral body of L5 were measured in each case. RESULTS Fifty-three women and seven men, with a mean age of 74.7+/-15.6 years were included into the study. A fracture of the posterior pelvic ring was found in fourty-eight patients (80%) patients using MRI. Fractures of the posterior pelvic ring would have been missed in eight cases (17%), if only CT had been used. Eighty-five percent of the patients with a posterior fracture had an osteoporosis. The majority of the cases suffered from a low energy trauma. Thirty-eight patients (83%) with positive clinical signs at the posterior pelvic ring actually had a fracture of the posterior pelvic ring in the MRI. The clinical examination proved to be equally effective to CT in detecting posterior pelvic ring fractures. CONCLUSION The significance of both, clinical examination and CT was confirmed in the detection of fractures in the posterior pelvic ring. MRI examination of the pelvis however, was found to be superior in detecting undislocated fractures in a cohort of patients with a high incidence of osteoporosis. Using MRI may be beneficial in select cases, especially when reduced bone density is suspected.
Collapse
Affiliation(s)
- J V Nüchtern
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
| | - M J Hartel
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - F O Henes
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - M Groth
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - S Y Jauch
- Institute of Biomechanics, TUHH Hamburg University of Technology, Denickestrasse 15, 21079 Hamburg, Germany
| | - J Haegele
- Clinic for Radiology and Nuclear Medicine, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - D Briem
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - M Hoffmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - W Lehmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - J M Rueger
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - L G Großterlinden
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| |
Collapse
|
5
|
|
6
|
Scheyerer MJ, Osterhoff G, Wehrle S, Wanner GA, Simmen HP, Werner CML. Detection of posterior pelvic injuries in fractures of the pubic rami. Injury 2012; 43:1326-9. [PMID: 22682148 DOI: 10.1016/j.injury.2012.05.016] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 02/10/2012] [Accepted: 05/14/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fractures of the pubic rami are associated with prolonged pain, bed rest and increased morbidity and mortality. Often no further diagnostic work-up is undertaken and the pubic rami fractures are classified as stable injuries. However, fractured pubic rami seem to be only part of the picture and are often associated with posterior pelvic ring injury. This retrospective study was designed to evaluate the posterior ring for undetected injury in patients diagnosed with pubic rami fractures. METHODS All patients (n=233) with diagnosed fractures of the pubic rami were retrospectively retrieved. All patients with a CT scan available at time of admission (n=177) were included in the study. RESULTS In 28.8% of the cases a fracture of the acetabulum was found additionally to the pubic rami. In cases without obvious other injury of the ap radiograph, an injury of the posterior pelvic ring was found on CT scans in 96.8% of the patients. Most lesions represented transforaminal sacral fractures, avulsion fractures of ligaments or compression fractures of the lateral mass. All patients with dorsal injuries could initially be treated conservatively, nevertheless 30% of them needed operative treatment in the course. CONCLUSION Nearly all cases with fractures of the pubic rami do have a lesion elsewhere within the pelvic ring. In patients with prolonged pain and immobility following 'pubic rami fractures' one should be aware that they probably represent an undiagnosed pelvic ring injury and further diagnostic work-up - sometimes even surgery - is warranted.
Collapse
Affiliation(s)
- Max J Scheyerer
- Department of Surgery, Division of Trauma Surgery, University Hospital Zurich, Switzerland.
| | | | | | | | | | | |
Collapse
|
7
|
Quantitative assessment of bone marrow attenuation values at MDCT: An objective tool for the detection of bone bruise related to occult sacral insufficiency fractures. Eur Radiol 2012; 22:2229-36. [DOI: 10.1007/s00330-012-2472-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 03/09/2012] [Accepted: 03/17/2012] [Indexed: 12/14/2022]
|
8
|
Winkelhagen J, van den Bekerom MPJ, Bolhuis HW, Hogervorst M. Preliminary results of cannulated screw fixation for isolated pubic ramus fractures. Strategies Trauma Limb Reconstr 2012; 7:87-91. [PMID: 22547056 PMCID: PMC3535133 DOI: 10.1007/s11751-012-0134-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 04/09/2012] [Indexed: 11/26/2022] Open
Abstract
Isolated pubic ramus fractures are common fractures in the elderly, and treatment is typically non-operative. Up to 35 % of patients have a prolonged hospital stay due to pain. A small number of these patients do not respond to standard (non-operative) treatment. We retrospectively reviewed six patients with isolated pubic ramus fractures and persistent pain who were treated with percutaneous retrograde pubic ramus screw fixation. The study group consisted of six women with an average age of 81 years (72–86 years). Patients with symptomatic posterior pelvic ring injuries were excluded. All patients showed improvement after surgery, with three patients pain free and three patients with reduced pain. The mean time spent in the hospital was 9 days (range 3–18 days). There were complications post-operatively: two patients had pneumonia, two with confusional states, and one patient had a urinary tract infection. Despite these events, which are associated with surgery in patients with comorbidites from advanced age, retrograde pubic ramus screw fixation is an effective treatment option for patients with persistent pain from isolated pubic fractures.
Collapse
Affiliation(s)
- Jasper Winkelhagen
- Department of General Surgery and Traumatology, Gelre Hospitals, Location Lukas, P.O. Box 9014, 7300 DS Apeldoorn, The Netherlands
| | - Michel P. J. van den Bekerom
- Department of General Surgery and Traumatology, Gelre Hospitals, Location Lukas, P.O. Box 9014, 7300 DS Apeldoorn, The Netherlands
| | - Hugo W. Bolhuis
- Department of General Surgery and Traumatology, Gelre Hospitals, Location Lukas, P.O. Box 9014, 7300 DS Apeldoorn, The Netherlands
| | - Mike Hogervorst
- Department of General Surgery and Traumatology, Gelre Hospitals, Location Lukas, P.O. Box 9014, 7300 DS Apeldoorn, The Netherlands
| |
Collapse
|
9
|
Krappinger D, Kammerlander C, Hak DJ, Blauth M. Low-energy osteoporotic pelvic fractures. Arch Orthop Trauma Surg 2010; 130:1167-75. [PMID: 20521061 DOI: 10.1007/s00402-010-1108-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Indexed: 11/27/2022]
Abstract
The vast majority of pelvic fractures in geriatric patients are classified as stable injuries. The current treatment strategies of these fractures involve pain management and mobilization. Pain-related immobility may pose a serious hazard to patients with severe preexisting comorbidities. There is paucity of literature on the outcome and mortality after osteoporotic pelvic fractures in the elderly. This review aims to provide an overview of epidemiology, injury mechanism, fracture patterns, management and outcome after osteoporotic pelvic fractures.
Collapse
Affiliation(s)
- Dietmar Krappinger
- Department of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Anichstrasse 35, Innsbruck, Austria.
| | | | | | | |
Collapse
|
10
|
Die Diagnosestrategie bei der okkulten Fraktur des Os sacrum. Unfallchirurg 2008; 111:473-4. [DOI: 10.1007/s00113-008-1477-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
11
|
|
12
|
Imaging of Abdominal and Pelvic Injuries. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
13
|
Cosker TDA, Ghandour A, Gupta SK, Tayton KJJ. Pelvic ramus fractures in the elderly: 50 patients studied with MRI. Acta Orthop 2005; 76:513-6. [PMID: 16195067 DOI: 10.1080/17453670510044634] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Whilst it is well known that fractures of the pelvic rami in the elderly are frequently associated with posterior ring injuries, the extent of this second injury is less well known. We evaluated this question by MRI scanning a group of elderly patients presenting at our unit with pelvic rami fractures. PATIENTS AND METHODS We investigated 50 consecutive elderly patients (45 women) with fractures of the pelvic rami using an MRI scan of the pelvis in order to assess the competency of the pelvic ring. RESULTS On MRI, 45 (95% CI 42-48) patients had a sacral fracture. At 5-month follow-up, 39 (of 41 reviewed) still complained of posterior sacral tenderness. INTERPRETATION Pelvic rami fractures in the elderly are nearly always associated with posterior ring injuries. This probably explains why these patients take longer to rehabilitate than might be expected if only the anterior injury is considered, and it also explains why they experience long-term back pain.
Collapse
Affiliation(s)
- Thomas D A Cosker
- Department of Trauma and Orthopaedics, Royal Gwent Hospital, Newport, Gwent, UK.
| | | | | | | |
Collapse
|