Our results of surgical management of unstable pelvic ring injuries

Abstract

Purpose of the study: The authors present a group of patients treated for pelvic fractures in a period of 6 years and they evaluate radiographic findings and clinical outcomes following surgical management of type B and type C fractures. Material and methods: Between July 1998 and June 2004, a total of 271 patients with pelvic fractures, 162 men and 109 women (average age, 42 years; range, 15 to 93 years) were hospitalized at the authors' departments. Of these, 141 patients were operated on (94 men, 47 women; average age, 37 years; range, 15 to 72 years) and 130 were treated conservatively (average age, 47 years; range, 15 to 93 years). The clinical outcome assessment in patients with type B and type C fractures treated surgically was based on the Majeed scoring system, and the radiographs were evaluated as described by Matta and Tornetta. Results: In 85 % of the patients, pelvic fractures were due to a high-energy trauma caused by traffic accidents in 63 % (pedestrian injury, 30 %; injury of the driver or passenger, 28 %; motorcycle injury, 5 %), by falls from heights in 20 % (occupational injury, 10 %; suicidal attempt, 10 %) and by other causes in 2 %. Sports accidents, usually due to a low-energy trauma, accounted for 8 % of the injuries (falls from a bicycle, violent kicks) and ordinary falls of elderly persons for 7 %. Type A injury was in 56 patients (21 %), type B in 103 patients (38 %) and type C in 112 patients (41 %). In 27 % of the patients, pelvic ring injury was part of a multiple trauma, in 58 % it was a combined injury and in 15 % it presented as a single trauma. Primary neurological deficit was found in nine patients (9 %) with type B fracture and in 20 patients (18 %) with type C fracture; this difference was statistically significant (p = 0.005). Urogenital injury was co-existent with type B fracture in 12 patients (12 %) and with type C fracture in 15 patients (13 %); the difference was not significant (p = 0.734). In seven patients (3 %), the injury involved an open fracture. Thirty-three patients (12 %) died during hospitalization. The difference in death rate between the patients with type C and those with type B fractures was significant (p = 0.021). Excellent and good clinical outcomes were achieved in 83 % and 70 % of the patients with type B and type C fractures, respectively. The difference was not significant (p = 0.236). Radiographs showed excellent reduction in 83 % of type B fractures and in 61 % of type C fractures; the difference was not significant (p = 0.271). Intra-operative complications were recorded in 22 %, early post-operative ones in 13 % and late complications in 11 % of the patients. Discussion: The significant difference in primary neurological deficit between the patients with type C fractures and those with type B fractures was attributed to more severe injury and vertical dislocation of the posterior segment in type C fractures. On the other hand, the fact that urogenital involvement was not significantly higher in type C fractures can be explained by an equal presence of anterior segment injury in both type B and type C fractures. The significantly higher number of deaths in patients with type C fractures, as compared with those with type B fractures, was related more to severe injuries of other organ systems in polytraumatized patients than to injuries of the pelvis itself, although severe injury to the posterior segment in type C fractures can result in massive bleeding into the retroperitoneum. Conclusions: An active approach to the treatment of patients with unstable pelvic fractures, which is based on the correct diagnosis, comprehensive multi-disciplinary care, urgent primary stabilization and early definitive fixation by internal osteosynthesis, offers a prospect of survival and a good functional outcome for the patient. However, a high proportion of lasting sequelae due to altered biomechanics of the pelvic ring, and irreversible injuries to neural structures and the urogenital system may lessen good results achieved by a demanding surgical procedure on the skeleton.