Elsevier

Injury

Volume 38, Issue 4, April 2007, Pages 497-508
Injury

Treatment options of pelvic and acetabular fractures in patients with osteoporotic bone

https://doi.org/10.1016/j.injury.2007.01.021Get rights and content

Summary

The incidence of pelvic ring and acetabular fractures in the elderly is climbing relentlessly. This increase is attributed to a greater longevity and a decrease in the incidence of alcohol-related trauma in younger adults. Often, the elderly trauma patient has compromised physiological reserve and healing capacity due to concomitant morbidities, resulting in a less favourable clinical outcome. The presence of osteopenic or osteoporotic bone and other treatments for existing comorbidities hamper some treatment alternatives, especially those designed for younger patients.

Diverse clinical presentations include minor trauma, major polytrauma and insufficiency fractures. An assessment of the general health and functional status of the patient is of utmost importance to determine the optimal treatment. The different treatment options of pelvic and acetabular fractures in the presence of osteoporosis vary mainly according to the clinical presentation and include: conservative methods, percutaneous or minimally invasive procedures, open reduction and fixation, and primary total hip arthroplasty.

Whichever treatment is chosen, even for elderly people, the aim is a rapid mobilisation of the patient in order to reduce complications to some extent inherent to this age group.

Introduction

Pelvic ring or acetabular fractures in the elderly represent the most rapidly growing segment of the spectrum of pelvic trauma. This is partially the result of the relative decrease in motor vehicle-related pelvic and acetabular fractures during the past decade.28

The incidence of fractures of the pelvis in the elderly is climbing relentlessly,10 with a marked predominance in women.40 In Finland from 1970 to 1997, the age-adjusted incidence of pelvic fractures increased from 31/10,000 to 103/100,000 in women and from 13/100,000 to 38/100,000 in men, i.e., by 23% per year. The mean age at the time of injury increased from 74 to 80 years. In addition, the proportion of pelvic fractures related to osteoporosis increased from 18% to 64% overall and from 65% to 94% among individuals older than 60 years off age.23 A fall, mainly due to an “age-associated multifactorial gait disorder” described by Runge55 was by far the most common trauma in 83% of cases. In 47% no other fractures were diagnosed. A mortality rate of 7.6% was noted during the immediate post-fracture period, 27% after 1 year and 10% per year subsequently; after 3 years the survival rate was 50%. Among survivors, 70.9% were able to return home (with home help in 84.3%) and 29.1% required institutionalisation. Dependency was consistently greater after than before the fracture.41

Some fracture patterns are the result of excessive force exerted on relatively normal bone. These are the fracture types we are most familiar with and described by Tile,65 Letournel and Judet.21, 27 However, most pelvic or acetabular fractures in the elderly are pathological fractures through osteoporotic bone and are the result of minimal trauma.

Reconstructive surgery by means of open reduction and internal fixation becomes less important in severe osteoporosis. Salvage procedures on the other hand, which enable elderly people to continue their normal daily life within acceptable time limits are preferable. The purpose of this paper is to review the different treatment options of pelvic ring and acetabular injuries in osteoporotic bone, taking into account the different types of injuries as well as the prior health and functional status of the patient.

Section snippets

Low-energy pelvic ring fractures

Low-energy pelvic ring fractures in the elderly frequently result from a fall while walking, and especially involve stable fractures of the pelvic ring. Insufficiency fractures also occur in elderly patients, typically of the sacrum and anterior pelvic ring.

Acetabular injuries

Elderly patients who sustained a displaced fracture of the acetabulum are frequently treated non-operatively by means of traction.35, 47, 62 The rationale for this approach is that they are candidates for total hip arthroplasty if and when these patients have decreased function, increased pain, or increased deformity from post-traumatic arthritis. The reluctance to operate on fractures of the acetabulum, especially in the elderly patients, is due to several factors, including problems with the

Discussion

The majority of pelvic ring fractures in the presence of osteoporosis are the result of low energy trauma and are typically stable fractures. These can be managed conservatively by means of bed rest and analgesics.41 However, the clinical expression of insufficiency fractures of the sacrum can be variable. Some patients experience low back pain, other truncated sciatica and sciatica of S1 topography requiring moderate analgesics. The time to resolution for these patients can be quite long,

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