Unilateral Sacral Fractures Demonstrate Slow Recovery of Patient-Reported Outcomes Irrespective of Treatment

Nonoperative management of minimally displaced lateral compression type 1 (LC1) injuries with comminuted rami fractures is associated with late displacement

PURPOSE

Rami comminution has been found to be predictive of lateral compression type 1 (LC1) injury instability on examination under anesthesia (EUA) and lateral stress radiographs (LSR). The purpose of this study was to evaluate how rami comminution and subsequent operative vs. nonoperative management impact the late displacement of these injuries.

METHODS

Retrospective review of a prospectively collected LC1 database was performed to identify all patients with minimally displaced LC1 injuries (< 1 cm) and follow-up radiographs over a four-year period (n = 125). Groups were separated based on the presence of rami comminution and subsequent management, including rami comminution/operative (n = 49), rami comminution/nonoperative (n = 54), and no comminution/nonoperative (control group, n = 22). The primary outcome was late fracture displacement, analyzed as both a continuous variable and as late displacement ≥ 5 mm.

RESULTS

As a continuous variable, late fracture displacement was lower in the comminuted rami/operative group as compared to the comminuted rami/nonoperative group (PD: -3.0 mm, CI: -4.8 to -1.6 mm, p = 0.0002) and statistically non-different from control. Late displacement ≥ 5 mm was significantly more prevalent in the comminuted rami/nonoperative group than in the comminuted rami/operative and no comminution/nonoperative groups (control)(PD: -33.9%, CI: -49.0% to -16.1%, p = 0.0002 and PD: -30.0%, CI: -48.2% to -6.5%, p = 0.02, respectively).

CONCLUSION

Late fracture displacement was greatest in the group with rami comminution/nonoperative management. Rami comminution, which has been previously associated with dynamic displacement on EUA and LSR, is also associated with a higher incidence of late displacement when managed nonoperatively.

LEVEL OF EVIDENCE

Level III, prognostic retrospective cohort study.

Pelvic Ring Injuries: Stable or Not?

Pelvic ring injuries occur in varying severity and in vastly different patient demographics. Knowledge regarding which of these injuries require surgical intervention and which can be managed nonsurgically continues to evolve. Previous studies have shown validated criteria for sacral fractures and the posterior ring, explored the role of examination under anesthesia, and other forms of dynamic imaging. Although there is substantial information available, a comprehensive synthesis of this information is lacking. This article provides a comprehensive review of radiographic markers suggestive of stability, discusses treatment strategies, and proposes a treatment algorithm that is easily understood and applicable to not only those with a trauma background but also the general orthopaedic surgeon who will see these injuries frequently while on call.

Postmobilization Plain Radiography After Lateral Compression Type 1 Pelvic Ring Injury Does Not Affect Treatment

INTRODUCTION

The purpose of this study was to describe the practice of postmobilization radiography after lateral compression type 1 pelvis ring injury. We hypothesized that postmobilization radiographs would be more frequent over time and would not influence treatment.

METHODS

Displacement of pelvis ring injury on initial and final plain radiographs was measured. Frequency of postmobilization radiography was determined, and the impact on treatment and final radiographical outcome were assessed.

RESULTS

Of the 156 patients reviewed, 98 (62.8%) were women and mean age was 60.1 years. Thirty-three of 156 patients (21.2%) had a postmobilization radiograph. Over 5 years, radiographs increased to 67% of presenting patients. None of the patients who received postmobilization plain radiographs (n = 33) had any change in clinical plan afterward; all continued with nonsurgical care. Initial fracture characteristics and alignment were no different for patients with postmobilization radiographs. Final alignment was unchanged in nearly 70%. Overall, 74% of all nonsurgical patients experienced no change in alignment, with similar rates among the patients with postmobilization radiographs.

DISCUSSION

Patients with an lateral compression type 1 fracture demonstrated no changes in care after receiving postmobilization radiographs. However, the frequency of postmobilization radiographs increased over time, denoting opportunities to reduce costs and to improve efficiency and safety.

Surgical treatment of sacral nonunions

Sacral fractures are complex injuries that follow a bimodal distribution, typically involving acute high energy trauma in young adults and low energy trauma in older adults (> 65 years old). Nonunion is a rare but debilitating potential complication of undiagnosed or improperly managed sacral fractures. Various surgical techniques, including open reduction and internal fixation, sacroplasty, and percutaneous screw fixation, have been used to manage these fracture nonunions. In addition to reviewing the initial management of sacral fractures and the risk factors for fracture nonunion, this article describes techniques, specific cases and outcomes of these treatment strategies.

Combined Anterior-Posterior versus Posterior-Only Fixation of Stress-Positive Minimally Displaced Lateral Compression Type 1 (LC1) Pelvic Ring Injuries

OBJECTIVES

To compare hospital outcomes and late displacement between stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries treated with combined anterior-posterior versus posterior-only fixation.

DESIGN

Retrospective comparative cohort.

SETTING

Urban level-one trauma center.

PATIENTS/PARTICIPANTS

LC1 injuries managed operatively.

INTERVENTION

Anterior-posterior versus posterior-only fixation.

MAIN OUTCOME MEASUREMENTS

Physical therapy (PT) clearance, discharge location, hospital length of stay (LOS), inpatient morphine equivalent doses (MED), and fracture displacement at follow-up.

RESULTS

Groups were similar in demographic and injury characteristics (age, high energy mechanism, ASA score, stress displacement, and rami/sacral fracture classifications). Anterior-posterior fixation resulted in longer operative times (median difference (MD): 27.0 minutes, 95% confidence interval (CI): 17.0 to 40.0, P < 0.0001) and had a trend of increased estimated blood loss (MD: 10 mL, CI: 0 to 30, P = 0.07). Patients with anterior-posterior fixation required less inpatient MEDs (MD: -180.0, CI: -341.2 to -15.0, P = 0.02), were more likely to clear PT by discharge (100% vs. 70%, proportional difference (PD): 30%, CI: 2.0%-57.2%, P = 0.02), were less likely to discharge to rehabilitation facilities (0% vs. 30%, PD: 30%, CI: 2.0%-57.2%, P = 0.02), and had a trend of less days to clear PT after surgery (MD: -1, CI: -2 to 0, P = 0.09) and decreased LOS (MD: -1, CI: -4 to 1, P = 0.17). Late fracture displacement did not differ between groups.

CONCLUSION

Anterior-posterior fixation of LC1 injuries was associated with an improved early hospital course-specifically, reduced inpatient opioid use and an increased number of patients who could clear PT and discharge home.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.