Authors: Lance Rane, Sanja Thompson
Pelvic insufficiency fractures most commonly affect the pubic rami and the sacrum and are traditionally regarded as "benign", despite causing significant mortality and morbidity in elderly patients, with only 50% reaching their previous level of self-sufficiency by the time of discharge2 and many are left with debilitating chronic back pain.3 Pelvic insufficiency fractures may be challenging to diagnose; they can occur spontaneously without a history of falls,2 may present non-specifically,4 for example with gradually increasing pain, and may not be visible on plain radiographs.5
The mainstay of treatment has been conservative, centred around analgesia, early mobilisation at home and osteoporosis management. However, inadequate pain control and difficulties with mobilising often necessitate hospital admission. As the incidence of these fractures increases in parallel with the growth of the elderly population, the resulting morbidity and healthcare burden may be expected to expand.
As with all osteoporotic fractures the frequency of insufficiency fractures increases exponentially with age and is skewed towards the female gender, with 90% of cases affecting women.2 Incidence for all pelvic fractures reaches a peak of 446.3 per 100,000 person-years in women aged 85 or older.6 By the age of 85 years, lifetime risk in the USA has been estimated at 2% for white women, 0.7% for black women and 0.5% for white men.7 A 4.6-fold increase in all osteoporotic fractures was observed between 1970 and 1997.8
Aetiology and fracture patterns
The main risk factors for all pelvic fractures in elderly people include low bone density, low body weight, previous fractures since the age of 45 years, a maternal history of hip fracture, older age, white race, smoking, previous hysterectomy, needing help with activities of daily living, falling to any direction relative to forward, using walking aids, and epilepsy. Other possible risk factors include Parkinson's disease, hearing loss and left-handedness.9
For pelvic insufficiency fractures the most common risk factors are: osteoporosis (present in almost all cases), previous history of fracture, long-term steroid therapy, pelvic radiotherapy, history of lower-extremity surgery leading to increased activity (eg. total hip and knee replacement), rheumatoid arthritis, hyperparathyroidism, Paget's disease and multiple myeloma.2, 10, 11
In most cases (over 86%)2 pelvic insufficiency fractures result from minor trauma (eg. a fall from a chair or from a standing position); the increasing incidence of simple falls with age goes some way to explaining the parallel increase in fracture incidence. The occurrence of such fractures following a fall in an elderly person has been estimated at 6%.12 "Spontaneous" fractures without a history of trauma are particularly common among patients who underwent lower extremity surgery (for example, hip or knee replacement) and have risk factors for osteoporosis.10
Common sites of pelvic fracture include the pubic rami, sacrum, iliac alae and supraacetabular ilium. Fractures of the pubic rami account for roughly two thirds of all pelvic insufficiency fractures, most frequently resulting from direct impact on the affected side as lateral compression fractures. Bilateral fractures are common, as are concomitant fractures at other sites of the pelvic ring and sacrum. Cosker,3 using MRI, found as many as 90% of patients with a pubic ramus fracture to have concurrent fractures of the posterior ring; Schadel Hopfner,13 using computed tomography, found such associated fractures in 50% of a separate population. There is evidence that prognosis is poorer as fractures move closer to the acetabulum, with those of the high superior pubic ramus doing worst.14
In the sacrum, fractures often take a vertical course, passing parallel and medial to the sacroiliac joint. Bilateral vertical fractures may be joined by a horizontal component, giving rise to the characteristic H-sign with adionuclide uptake scans.15
Patients typically present after a simple fall with pain and tenderness, but may present with spontaneous onset of pain and no history of trauma. In fractures of the pubic rami, pain is mostly felt in the hip or groin region at the site of the fracture, or may be felt on manual pressure at the symphysis pubis. In some cases there is inability to weight-bear but features such as limb shortening are generally absent. Rarely, patients with such fractures present with features of haemodynamic instability, due to bleeding usually caused by the bone fragment. This has been reported mainly in those already taking antithrombotic therapy.16 The particular clinical features to look for in such patients are bruising of the abdomen, groin and perineum, swelling and pain, as well as signs and symptoms of hypovolaemic shock.
With sacral fractures pain is usually felt in the lower back radiating to the groin, buttock or hip region, and is often exacerbated by movement; pain upon palpation of the sacrum or lower back11 is a characteristic feature. Abdominal pain is an unusual finding that sometimes complicates diagnosis. Neurological features may be present; sacral radiculopathy, myelopathy and cauda equina syndrome have all been reported.17,18 Such patients most commonly have lower limb paresthesia and sphincter dysfunction, but these symptoms are often misattributed in elderly patients with many comorbidities, delaying diagnosis.
In patients presenting with chronic back pain of unknown aetiology and in whom risk factors are present, the possibility of prior pubic ramus fracture should be considered. One study found that chronic back pain remains in the majority of patients with fractures of the pubic rami,3 a finding which has also been reported in patients with sacral insufficiency fractures.19 In pubic ramus fractures, the extent to which covert sacral fracture accounts for this finding is unclear.
Assessment and diagnosis
Initial assessment of every patient is performed to confirm haemodynamic stability. Next, a succinct history should focus on the nature of any pain and the circumstances of its onset, with particular heed to any precipitating trauma. Underlying cognitive impairment may necessitate taking a thorough collateral history from relatives and/or carers; cognitive testing and assessment for delirium forms a crucial part of the assessment and should be done early. Risk factors for insufficiency fractures, osteoporosis and falls should be considered and documented.
Examination should be guided by the mechanism of injury if known, and is used to further demonstrate the site and nature of pain. Sacral tenderness in particular should be actively sought out. Full exposure of the patient is important so that concomitant injuries are not missed and so any areas of bruising or bleeding are seen. Thorough neurological screening is essential and should include testing of sphincter function. In cases of suspected urethral injury, genital examination may yield blood at the meatus and rectal examination a high-riding prostate in males. Initial blood tests should include, as a minimum, FBC, INR (where relevant), renal function, calcium and vitamin D levels.
Diagnosis is often challenging as plain film findings may initially be absent. The importance of whole-pelvis visualisation in all cases of suspected pelvic insufficiency fracture has been stressed by multiple authors, given the relative frequency of fractures at multiple sites. Stress fractures through osteoporotic bone are often difficult to detect; this is particularly true of sacral fractures and is made all the more so by obscuration from overlying structures, such as bowel or calcified vessels. As healing progresses radiological changes become more apparent, but may be misleading. Healing sacral fractures appear as vertical bands of sclerosis-any associated horizontal component can be easily missed. Moreover, these can feasibly be interpreted as the changes of sacroiliitis. Later, frank interruptions of bone become apparent. With healing of the pubic rami and pubis, areas of bone with an alarming lytic appearance may develop, mimicking tumour. This and subsequent exuberant callus formation may provoke unnecessary investigation, and even treatment with radiotherapy.15
Technetium bone scanning is highly sensitive and can be a useful adjunct to plain films. Patterns of uptake vary with fracture configuration. However, a diagnosis should not be made on the basis of scintigraphy alone. Because of the proximity of the sacrum to the gamma detector activity is often raised here, masking underlying abnormalities. Specificity is low and findings are easily misinterpreted as sacroiliitis.20
The relative merits of computed tomography and magnetic resonance imaging remain debated. MRI is more sensitive for the detection of pelvic fractures at all sites (98% versus only 53% for CT)5 and also for associated soft tissue abnormalities. Both modalities compare very favourably with plain radiography, which was shown to have a detection rate of only 14.8% for those fractures detected by MRI, and 20.6% for those seen on CT. Some authors still favour CT on the basis of its supposed higher specificity and greater ability to distinguish fracture lines from inflammatory or neoplastic processes20 such as malignant bone marrow infiltration; one study found diagnostic rates of 88% and 83% for CT and MRI respectively.21 Ultimately, the greater availability of CT probably remains the most significant factor in its more widespread usage.
In practice, a combination of radiological modalities is likely to yield the best diagnostic results. Serial plain films can be supplemented by scintigraphy, computed tomography and magnetic resonance imaging as necessitated by clinical circumstance. In particular, a high index of suspicion for sacral fractures warrants especially thorough radiological investigation, and in such cases plain films alone will not suffice.
Traditional management of insufficiency fractures is conservative. According to some authors, initial therapy should focus on bed rest and analgesia, although there is a growing body of literature supporting early mobilisation.22,23 The prevention of thromboembolic complications in all these fractures is important; deep vein thrombosis has been reported in 29-61% and pulmonary embolus in 2-12% of patients with sacral insufficiency fracture.11 The analgesic ladder is employed, with paracetamol as the treatment of choice for mild-moderate pain. Caution must be shown with opioids and non-steroidal anti-inflammatory drugs, given their propensity to cause constipation, confusion, and bleeding among other side effects in older patients.
It is recommended that treatment for underlying osteoporosis should begin early. Bisphosphonates are first line drugs and may also have an analgesic effect.24 Other agents include raloxifene, a selective oestrogen receptor modulator, strontium ranelate and teriparatide, which may be considered in cases of contraindication or intolerance for bisphosphonates. Calcitonin has been shown to have a significant positive effect on bone mineral density,25 albeit of lower magnitude than that of bisphosphonates, but has no place in current UK guidelines by NICE. A role in the treatment of acute pain associated with osteoporotic fracture has been proposed.26 The ideal length of time for which treatment with these drugs should be continued remains controversial.20 Calcium and vitamin D supplementation are given concurrently and vitamin D deficiency should be treated with high dose supplements.
The old view that fractures of the pubic rami are relatively trivial injuries requiring minimal intervention is unsubstantiated. One small study estimated average blood loss around the fracture at one litre;27 some recommend hospital admission and close observation for every patient on anticoagulants presenting with pubic ramus fracture,16 given the risk of life-threatening haemorrhage. Patients who are haemodynamically unstable need urgent intervention, with treatment of hypovolaemic shock and anticoagulant reversal. In some cases embolisation of a bleeding vessel may be necessary,28 or even surgical intervention.
Fracture type and location may dictate the need for further intervention. Significant diastasis at the pubic symphysis correlates with sacroiliac ligamentous damage and is an indication for surgery, with 2.5cm usually taken as a (seemingly arbitrary) cut-off point.29 As many as 37% of males with diastasis suffer impotence as a result of neurovascular interruption.30 Patients with bilateral pubic ramus fractures and sacroiliac joint disruption are at risk of urethral injury; consideration should be given to retrograde urethrography as part of the initial workup. Bladder injury may be covert. In females, inferior pubic ramus fracture can give rise to vaginal impingement. Fractures with concomitant genitourinary injury are particularly serious and in such cases surgery is often inevitable.
The combination of osteoporotic bone and high axial loading in the pelvis causes specific challenges for surgeons.31 Surgical options include anterior plating, ideally within a 24-48 hour window; after 48 hours, the risk of infection is generally considered to be too high. For highly unstable fractures such as those associated with vertical shear forces (caused, for example, by a fall into a seated position) external fixation may be employed, although several authors have argued against the use of such techniques in the elderly, given high complication rates.32,33 Most recently, anterior internal subcutaneous techniques have been developed, to good effect,34 with internal fixation showing promise in establishing stabilisation of complex fractures.31
With sacral fractures percutaneous iliosacral screw fixation may be used.33,35 Sacroplasty-the percutaneous injection of polymethylmethacrylate (PMMA) under radiological guidance-is another, relatively new option. One recent study reported comparable efficacy in the management of fracture-related pain to vertebroplasty,36 although the utility of that technique remains open to debate. A biomechanical comparison yielded no significant difference between sacroplasty and screw fixation, and described good results using a combination of the two.37 Thus far, however, there have been too few studies on the safety and efficacy of the technique, and it remains a last resort for those whose pain fails to respond to conventional methods, with a possible further role in promoting early mobilisation.38,39 The most common reported side effects of the procedure were caused by the uncontrolled injection of hot cement, causing neurological or vascular injuries at the sacral foramina. At present, most authors still favour surgical intervention.
The significance of pelvic insufficiency fractures seems generally under-acknowledged, as evidenced by the available data on prognosis. One year mortality has been cited as 14.3% for all types of pelvic insufficiency fractures2 but this figure does not illustrate the substantial loss of function associated with these injuries. The same study found that 50% of patients failed to re-attain their prior level of mobility, with 25% requiring institutionalisation. These findings have been corroborated by other studies.40 Inpatient stays were complicated, for example by infection, in over 50% of cases. Sacral fractures do even worse, with rates of return to prior mobility as low as 38%.18 Poor prognostic factors include: increased age, social dependency and immobilisation after the injury, risk of falls, and poor mental and physical health prior to the injury (particularly dementia).27 As many as 24% of pubic ramus fracture patients eventually suffer re-fracture,27 a figure that compares unfavourably with the six to 12% one-year risk of re-fracture reported in patients with hip fractures.41,42 Patients requiring hospital admission have poor outcomes, raising the question of whether more aggressive management would be beneficial.
Taken together, the data indicate comparably poor outcomes to hip fracture patients. Hill et al,43 in a 286 patient series, compared mortality rates in those with fractures of the pubic rami with those for a cohort of hip fracture patients. Early mortality rates were greater in the hip fracture group, but subsequently there was greater mortality in the pubic ramus group-such that at five years the two were indistinguishable, despite the average age of the pubic ramus group being five years lower. The only independent risk factors for mortality in the pubic ramus group were dementia and increased age. Excess early mortality in the hip fracture group was mainly in the first three months and can be accounted for by surgical intervention and its complications. The authors explain the subsequent higher mortality in the pubic ramus group on the basis of higher frailty and increased susceptibility to falls. Indeed, the figures are probably indicative of the poor pre-morbid physiological status of these patients, with the insufficiency fracture in many cases signalling a terminal decline. Clinicians should be aware of the importance of the recognition of such fractures so that patients are properly assessed and managed.
While there is currently no consensus on who is best placed to manage patients with pelvic insufficiency fractures, geriatric co-management seems to improve outcomes in patients with hip fractures.44,45 It seems likely that this would also apply to patients with pelvic insufficiency fractures, as has been suggested.27 As the acute phase of injury passes, it is important that the focus of clinical attention moves towards the prevention of further events. Part of this objective is fulfilled by treatment of osteoporosis. A thorough assessment of falls risk is also important, and should encompass a multi-faceted approach that covers drugs optimisation, physiotherapy and occupational therapy.
There is evidence that strict practice of such regimes reduces the risk of new fracture by 43% in patients with osteoporotic fractures.46 The geriatric setting seems ideal to achieve these aims and, through utilisation of the skills of all members of the multidisciplinary team, optimise the functional status of the patient with a view to safe and appropriate discharge.
Conflict of interest: none declared
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