Pelvic fracture is a condition that arises due to breakage of the pelvis bones. It may damage internal organs, nerves, and blood vessels associated with the pelvis region.
The pelvis is a round structure of bones located at the base of the spine, connected to the sacrum of the spine with the help of strong ligaments. The pelvis is composed of three bones, namely ilium, ischium, and pubis that are fused together. The side of the pelvis is composed of a cup shape socket, known as acetabulum.
Various organs related to the digestive and reproductive systems lie within the pelvis ring. Also, several large nerves and blood vessels supplying the lower limbs pass through the pelvis. The pelvis ring also acts as point of attachment for muscles approaching from the upper and lower part of the body.
Based on the damage of the pelvis ring and associated structures, pelvic fractures can be categorized as:
- Stable pelvic fractures: Have single point breakage in the pelvis ring and broken bones remain in position; shows less bleeding
- Unstable pelvic fractures: Have breakage at two or more points, followed by severe bleeding. Unstable pelvic fractures may cause shock, extensive internal bleeding, and damage to the internal organs. It requires immediate medical care followed by long-term physical therapy and rehabilitation.
The common causes responsible for pelvic fractures include:
- Sports injuries or trauma
- Abrupt muscle contraction
- Conditions such as osteoporosis, especially in elderly people
- Accidental injury or fall from a great height
The common symptoms associated with pelvic fractures are:
- Pain and swelling in the groin or hip region that may worsen with ambulation
- Abdominal pain
- Bleeding through the urethra or vagina and the rectum
- Problems in urination
- Unable to stand or walk
The diagnosis of pelvic fracture starts with physical examination including checking the functional activity of the various body organs present in the pelvic region. Imaging techniques such as X-rays, CT (Contrast Tomography) and MRI (Magnetic Resonance Imaging) scan may also be used to confirm the exact condition or breakage of the pelvic bones. In some cases, additional contrasting studies using radioactive dye may be recommended to evaluate the structural and functional activity of organs such as the urethra, bladder, and the pelvic blood vessels.
Treatment of the pelvic fracture depends upon the severity of the injury and condition of the patient. Minor or stable fractures can be treated with conservative methods such as rest, medications, use of crutches, physical therapy, and if required minor surgery. These methods may take 8–12 months for complete healing.
The treatment of unstable fractures includes management of the bleeding and injuries of the internal organs, blood vessels, and nerves. Surgical intervention may be employed for fixation of the fractured pelvic bones using screws and plates. Pelvic bone fixation provides stability to the pelvic bone and promotes natural healing of the fracture.
The femur or thigh bone is the longest and strongest bone in the body, connecting the hip to the knee. A femur fracture is a break in the femur. The distal femur is the lower part of the thigh bone which flares out like an upside-down funnel and its lower end is covered by a smooth, slippery articular cartilage that protects and cushions the bone during movement. Fracture of the distal femur may involve the cartilaginous surface of the knee as well and result in arthritis.
- Distal femur fracture: The distal femur is part of the femur bone that flares out like the mouth of the funnel. A distal femur (top part of knee joint) fracture is a break in thighbone that occurs just above your knee joint.
- Femoral shaft fracture: A femoral shaft fracture is a break that occurs anywhere along the femoral shaft, long, straight part of the femur.
- Proximal femur fracture: A hip fractureor proximal femur fracture is a break in the proximal end of the thigh bone near the hip.
Femur fractures may be caused by high energy injuries such as a fall from height or a motor vehicle accident. Patients with osteoporosis, bone tumor or infections, or a history of knee replacement are more prone to femur fractures. In the elderly, even a simple fall from a standing position may result in a fracture as the bones tend to become weak and fragile with advancing age.
Sudden, severe pain along with swelling and bruising are the predominant symptoms of femur fracture. The site is tender to touch with a visible physical deformity and shortening of the leg.
The diagnosis of femur fracture is based on the patient’s medical history including history of any previous injuries, complete physical examination and imaging studies. The physician will evaluate the soft tissue around the joint to identify any signs of nerve or blood vessel injury. Multiple X-rays and other imaging studies such as CT and MRI scans may be used to identify the location and severity of the fracture.
The management of the fracture is based on the severity of the fracture, medical condition of the patient and the patient’s lifestyle.
Non-surgical treatment comprises of immobilizing the fractured site with the help of casts or braces to prevent weight bearing and to help the healing process. X-rays are taken at regular intervals to assess the healing process. Weight bearing and movement are initiated gradually, depending on the nature of the injury and the condition of the patient.
Surgical treatment is considered to realign the fractured bone. The use of advanced technology and special materials has improved the surgical outcome even in older patients. External or internal fixation or a knee replacement may be required depending on the extent of the fracture. Timing of the surgery is an important factor in improving the surgical outcome.
Timing of anterior hip replacement surgery
In most cases, the surgery is delayed for a few days to develop an effective treatment plan and for preparation of the patient. With most distal femur fractures the surgery can be delayed unless the fracture is open to the environment.
An external fixator is used when the surrounding soft tissue is severely damaged, as the use of plates and screws may be harmful. The external fixator maintains the alignment of the bone till surgery.
Once the patient is prepared for surgery, the surgeon removes the external fixator and places internal fixation devices into the bone during surgery.
The internal fixation may be performed using intramedullary nailing or plates and screws. In intramedullary nailing a metal rod is inserted into the marrow canal of the femur to keep the fractured fragment in position. In the plate and screw method the bone fragments are realigned and held together with screws and plates, attached to the outer surface of the bone. If the fracture is of the comminuted type or the bone has broken into many pieces, plates or rods may be used at the ends of the fracture without disturbing the smaller pieces. The plate or rod will maintain the shape or strength of the bone till it heals. In elderly patients and those with poor bone quality, bone grafting may be used to improve the healing. Knee replacement may also be considered in complicated fractures or those with poor bone quality.
Rehabilitation of the femur fracture depends upon several factors such as age, general health of the patient and the type of fracture. As the femur fracture usually involves the weight bearing joint it may cause long term problems such as loss of knee motion or instability and long term arthritis. Hence a rehabilitation program is initiated along with the treatment comprising of instructions on weight bearing, knee movements, and the use of external devices such as braces.