1.1 Health outcomes and health measurement

Assessing outcomes after pelvic ring fractures is required to refine and guide treatment decisions, aid in prognostication, and improve management algorithms. For assessment to be meaningful, appropriately valid and reliable instruments are required. Traditionally, evaluation of pelvic ring injuries and treatment results has focused on radiological outcomes and nonvalidated measures of pain and function [1, 2]. These older measurement tools have limitations that are now more widely recognized. With the advent of validated measurement instruments, deficits in physical, social, and emotional function subsequent to injury and disease can now be more consistently quantified and allow comparison between studies more readily [3].

Health measurement instruments that sample broad aspects of mental and physical well-being are known as “generic” instruments. These instruments can be used to compare the health effects of different diseases (ie, renal failure versus arthritis) but they may not address all the concerns that individuals with a specific condition might have. Examples include the SF-36 score, the EQ-5D score [4, 5], and the Musculoskeletal Function Assessment (MFA) instrument [6]. Disease-specific measurement instruments are intended to evaluate specific problems experienced by individuals with a particular health condition. Disease-specific instruments generally exhibit better evaluative properties than generic tools, but they are less useful for comparing disparate health conditions. When assessing patient outcomes in clinical studies, a generic questionnaire can be supplemented with a disease-specific instrument. Examples of disease-specific pelvic ring assessment tools include the Majeed score [7], the Iowa Pelvic Score [7], and the Hannover Pelvic Outcomes score [8]. However, no pelvic-specific outcome instrument scoring system has been validated to date.

Summarizing outcome research on pelvic fracture management is challenging due to several factors. Patients with pelvic fractures usually sustain injuries to multiple body systems, including extremities, thoracoabdominal organs as well as urological, head, and spinal injuries [9, 10]. The associated injuries that occur with pelvic ring trauma make it difficult to ascribe functional limitations solely to the pelvic ring in many follow-up studies. Additionally, assessment of radiographic outcomes is challenging due to the complex 3-D shape of the pelvis. Radiographic attempts to quantify displacement and quality of reduction have been applied but there is no standardized, accepted method to quantify these values [1].

Substantial further research is required to generate reliable radiographic and clinical assessment measurements for patients with pelvic ring fracture. While the current literature on pelvic fracture outcomes has limitations, many important findings have been established that can guide our treatment strategies.

2.1 Survival

Pelvic ring fractures are associated with the highest early mortality rate among patients with orthopedic injuries [11–13]. Hemorrhage is responsible for one-third of deaths in patients with pelvic ring fracture, and bleeding from the pelvis is due mostly to disruption of the presacral and paravesical venous plexuses, while up to 20% of pelvic bleeding has been ascribed to internal artery injury [13, 14]. Angioembolic therapy has shown a benefit in reducing ongoing blood loss and increasing the chances of survival [11, 12, 15–17]. Some centers have instituted a protocol that includes surgical packing of the pelvis to control both venous and arterial bleeding [18, 19]. The role of primary surgical packing of the pelvis in contrast to volume control and angiography is currently unclear [20]. However, each trauma center needs to have an efficient system to manage pelvic arterial bleeding with the available resources.

Several successful emergent management strategies involve minimizing acute blood loss by decreasing pelvic volumes and stabilizing fractured bony surfaces to enhance venous clot formation. External pelvic binders are fast and easy to apply, as well as inexpensive, and have been shown to reduce transfusion requirements, length of hospital stay, and mortality in patients with anterior posterior compression (APC) injuries [12, 21]. A simple pelvic sheet can accomplish initial stabilization of the pelvic ring [22]. Anterior external fixation has been shown to improve survival outcomes; while posterior C-clamp application has been effective at reducing posterior ring disruption, no study has specifically identified a difference in patient survival rates [23, 24]. The greatest improvement in survival has been attributed to the implementation of hospital trauma protocols, which, as various studies have shown (see Chapter 1.4), can decrease pelvic fracture-related deaths by 50–65% [16, 25, 26].

2.2 Overall functional outcomes for pelvic fracture survivors

Reports on functional outcome following pelvic ring fractures reveal that some degree of residual disability is to be expected compared to the noninjured population regardless of the treatment chosen. This observation is consistent for each fracture type, with more severe fracture patterns being more prone to worse outcomes.

Historically, nonoperative treatment was considered the treatment of choice for many pelvic ring injuries. It is now established that patients with unstable pelvic ring injuries benefit from surgical stabilization due to reduced pain, decreased incident of malunion and nonunion, and other outcomes [9, 11, 27, 28]. Severe pelvic instability is often readily diagnosed, and the role of surgical stabilization is clear ( Fig 1.16.1-1 ). However, instability is not always obvious and the role for surgery to prevent displacement and late disability is defined less clearly ( Fig 1.16.1-2 ). Examination of the patient under anesthesia has been shown to be a useful adjunct to imaging in determining instability and the need for fixation [29]. The differentiation between Tile classification type B1 and B2 fractures (the latter having been shown to have a high likelihood of displacement if treated nonoperatively) is another indication that can be used to guide surgical decision making [29, 30].

In 1996, Tornetta et al [28] published one of the first detailed analyses on pelvic fracture outcomes. Instead of using predeveloped scoring instruments, narrative descriptions and an ad-hoc scale were used. The authors noted excellent results following open reduction and plating of the anterior pelvic ring in 29 patients with Tile classification type B fractures at a mean follow-up of 39 months (range, 12–84 months). The results also showed that 76% of patients had no limp, 96% had no pain or pain only with strenuous activity, and 83% returned to work (75% of them to their original jobs). Despite plate breakage in four of 29 patients, this phenomenon was not associated with deterioration in function and did not require reoperation. The same center evaluated operatively treated Tile classification type C (Young-Burgess APC III, VS, combined) fractures [31]. At a mean follow-up of 44 months (range, 12–101 months), 63% of patients ambulated without a limp or aides, 63% reported no pain or pain only with strenuous activity, and 84% returned to work, with 67% able to return to their usual work activity.

In 2005 Lindahl and Hirvensalo [32] published 101 consecutive Tile classification type C (Young-Burgess APC III, VS, combined) pelvic fractures using both a modified Majeed score as well as the Hannover pelvic score to assess functional outcomes. These patients had an average Injury Severity Score (ISS) of 29 and all patients were treated surgically, with 78 patients receiving both anterior and posterior ring fixation. The Majeed functional score results were excellent in 68 patients, good in 16, fair in 16, and poor in one patient. Their Hannover Pelvic Outcome score, which combines radiographic and clinical results into a single score, was excellent in 43 patients, good in 38 patients, fair in 17 patients, and poor in three patients. An earlier report by Cole in 1996 [33] on surgically treated patients with Tile classification type C (Young-Burgess APC III, VS, combined) pelvic fracture used components of the SF-36 to evaluate outcomes. Although follow-up times varied widely (range; 5–74 months; average 36 months), they also noted significant impairment in function with an overall mean physical function score of 61 of 100; mean role physical score of 47 of 100; and a mean bodily pain score of 61 of 100.

Putnis et al [34] followed up 49 patients who required surgical management of traumatic pubic symphysis disruption (30 of whom also required posterior fixation). Their study showed that at a minimum of 1-year follow-up patients self-reported their overall physical function to be 69% of 100%. Furthermore, the physical function SF-12 scores were worse than that of the average population (42.5 versus 50); however, this did not reach statistical significance and the mental health SF-12 scores were nearly identical (49.5 versus 50) to population norms. In 2011, VanLoon [35] reported a cohort of 38 surgically treated open book fractures with a 13-year follow-up. Majeed scores and six of the eight SF-36 subcategory scores were not significantly worse than that of the average population. This suggests that in long-term follow-up, patients’ functional capacity, or at least their perception of their functional capacity, may continue to improve gradually with open book fractures.

Borg et al [9] published a prospective observational report on 54 surgically treated patients with unstable pelvic fracture. At 2 years follow-up, patients with fracture scored significantly lower than the reference population in all eight domains of SF-36. Similarly, patients scored significantly lower than the reference population in all eleven items on the LiSat-11 questionnaire, with the domain “Physical Health” indicating the lowest scores and the largest discrepancy between injured and control populations.

2.3 Pain

Persistent pain is one of the main contributors to long-term disability and poor functional outcome scores in patients with pelvic fracture. Putnis et al [34] reported that among 49 patients with pelvis fractures, 15 patients were pain free (37%); 12 had either mild or very mild pain (29%); 11 moderate (27%); and 3 severe after 1-year follow-up (7%) [34]. In Lindahl and Hirvensalo′s series [32] of Tile classification type C (Young-Burgess APC III, VS, combined) fractures, after an average final follow-up of 23 months (range, 1–84 months), 34 (34%) of 101 reported persistent pain. Of these 34 patients, 33 described the pain location as “posterior.” Similarly in Kabak et al [36] series of 36 type C (Young-Burgess APC III, VS, combined) fractures, 25% experienced pain of pelvic origin beyond 1 year. Although relatively high, these numbers are an improvement over published data [8, 37] where 70% and 85% of patients, respectively, with type C (Young-Burgess APC III, VS, combined) pelvic fractures complained about long-term pelvic pain. This difference may be related to the improved surgical and rehabilitation protocols over the past decades.

2.4 Urological complaints

A 2001 review article from the urology literature reported that the most commonly associated injuries of the genitourinary tract after pelvic fracture include bladder ruptures and urethral injuries [38]. Multiple orthopedic studies corroborate this finding that 9–16% of all unstable pelvic disruptions have a concomitant bladder rupture (most commonly extraperitoneal) (see Chapter 1.13). The posterior urethra is injured in roughly 10–12% of pelvis fractures in males and in up to 6% of pelvic fractures in females [36, 38–40]. Prolonged and painful micturition is one of the most common outcomes of these injuries. Such long-term complaints are correlated to both type B fractures and degree of postsurgical residual displacement [8, 41]. Type C fractures are associated with an increased incidence of incontinence, suspected to be related to sacral nerve damage [8].

Using the US National Trauma Data Bank registry of 31,380 patients with pelvic fractures, Bjurlin et al [42] found that 1,444 patients (4.6%) had suffered genitourinary injuries. This number is lower than those reported in other studies because it takes into account all types of pelvic fractures, whereas most orthopedic studies consider only surgically treated or unstable pelvic fractures. As shown by other studies, men were more vulnerable to genitourinary injuries than women: the incidence of urogenital, bladder, and urethral injuries for men were 5.34%, 3.41%, and 1.54%, respectively; while for women the same injuries had an incidence of 3.62%, 3.37%, and 0.15%.