Rehabilitation After Pelvic Ring Injury

Richard D. Wilson, MD, MS

Michelle Kenny, MS, PT

Heather A. Vallier, MD

Dr. Vallier or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the Center for Orthopaedic Trauma Advancement, the Journal of Orthopaedic Trauma, and the Orthopaedic Trauma Association. Dr. Wilson or an immediate family member serves as a paid consultant to SPR Therapeutics; has received research or institutional support from SPR Therapeutics, and serves as a board member, owner, officer, or committee member of the Association of Academic Psychiatrists. Neither Dr. Kenny nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Introduction

Pelvic ring injuries are a common occurrence. Low-energy injuries, frequent after falls from a standing height, are seen in older patients. However, injuries from a high-energy mechanism affect patients of all ages and can result in various fracture patterns, depending on the magnitude and direction of the injury forces. Treatment is based on fracture location and associated displacement and instability. It follows that activity limitations and other aspects of the rehabilitative process would be determined by these features as well.

Classification

The Young-Burgess classification, based on force vectors, is used to describe pelvic ring injuries and to determine associated injuries, transfusion requirements, and type of treatment. Most fractures fall into one of three types: lateral compression, anteroposterior compression, and vertical shear patterns. Lateral compression injuries are most common. These result from force applied to the lateral aspect of the pelvis and greater trochanter. A fall directly onto the lateral aspect of the hip and a motor vehicle collision with side impact are two frequent mechanisms of injury. One or more pubic ramus fracture may occur, and the sacrum is fractured and compressed on the side of the force. Unless the posterior pelvis ring is completely fractured and displaced, these injuries are treated nonoperatively. However, with high-energy injuries, the posterior pelvis on the side of impact can be unstable with sacral and/or iliac fractures. Less commonly, the contralateral hemipelvis can be affected, resulting in anterior sacroiliac disruption. Surgery would be indicated for such injuries in order to reduce the fracture, restoring rotational alignment of the pelvis (Figure 70.1). Fixation also reduces pain and maintains alignment until the fractures are healed.

Anteroposterior compression injuries occur when a force is directed through the anterior and/or posterior aspects of the pelvis. These result in symphyseal disruption, and can cause complete sacroiliac dislocations unilaterally or bilaterally when the force is very large. Injuries with wide displacement of the posterior pelvic ring may be associated with life-threatening hemorrhage from the sacral venous plexus and rarely from adjacent arteries. Initial treatment includes expeditious pelvic reduction with a sheet or binder, which promotes blood clot formation in most cases. Surgical treatment is indicated for wide symphyseal disruptions in association with partial or complete sacroiliac injuries (Figure 70.2). If the posterior ring is not injured, surgery is not indicated.

Vertical shear pelvic ring fractures occur when an axial force is directed through one side of the pelvis, for example, when a patient falls from a height and lands on one leg, or when a motorcycle crash occurs and force is directed through one leg. The anterior ring is disrupted through the pubic rami or symphysis, and the posterior ring is disrupted with sacroiliac dislocation or fracture dislocation, resulting in cephalad displacement of the injured hemipelvis. Surgery is indicated to restore pelvic ring alignment, to provide stability and pain relief, and to promote mobility from bed.

Surgical Treatment

Indications and Contraindications

Most high-energy lateral compression, anteroposterior compression, and vertical shear injuries are treated surgically. Surgery is generally indicated to restore pelvic ring alignment and to provide stability, relieve pain, and promote mobility from
bed. Various procedures may be indicated based on the location and displacement of the fractures; the age, habitus, and functionality of the patient; the quality of the bone; and the presence of open fractures and/or degloving wounds. Pelvic ring injuries may be treated with open reduction and internal fixation (ORIF) anteriorly, laterally, or posteriorly. Percutaneous techniques are also commonly employed for both anterior and posterior ring fractures. Contraindications to surgery would include severe underlying medical illness or life-threatening head injury that precludes general anesthesia.

Figure 70.1 Radiograph of a lateral compression pelvic ring injury. Force directed through the right hemipelvis in a T bone motor vehicle collision generates bilateral ramus fractures and a right sacrum fracture, with internal rotation deformity of the right side and external rotation deformity of the left side. Surgery is indicated to improve alignment and to provide stability.

Open Reduction and Internal Fixation of the Anterior Pelvic Ring

ORIF for the anterior ring is recommended for anteroposterior compression or vertical shear injuries that have displacement of the pubic symphysis (Figure 70.3). A Pfannenstiel exposure is performed. The rectus raphe is divided in the midline, and the rectus tendons are elevated from the rami, but not detached. The pubic symphysis is reduced, and plate fixation is placed. Often, tears in the rectus muscle or insertions are present; care should be taken to repair these after the fracture is reduced and stabilized. Bladder ruptures may also be present, which should be addressed with bladder repair by urologists or general trauma surgeons once the fracture has been reduced and stabilized. Layered repair of the rectus raphe, along with the dermal and epidermal tissues, is then performed. Lifting and abdominal exercises that would strain the injured and healing rectus should be avoided for approximately 8 weeks.

Figure 70.2 Radiograph of an anteroposterior compression pelvic ring injury. Symphysis disruption and left sacroiliac dislocation can be associated with massive bleeding. This injury is treated surgically to control bleeding and to improve pelvic alignment and stability.

Figure 70.3 Radiograph showing plate fixation of a symphysis disruption. Ambulation is limited for 8 to 12 weeks. Lifting or abdominal exercises are avoided for approximately 8 weeks to permit soft-tissue healing and muscle recovery.

Anterior External Fixation

Another way to reduce and stabilize the anterior pelvic ring is with external fixation. Anterior pelvic external fixation may be indicated as a supplement for posterior ring fixation in patients who have lateral compression injuries and multiple pubic rami fractures. External fixation could also be used as an alternative to symphyseal plating in patients with open pelvis fractures in order to minimize the risk of infection. Pins are placed in the ileum using radiographic guidance. Most often, one pin is placed on each side, and reduction maneuvers can be performed by manipulating these pins to improve pelvis alignment. Anterior bars are placed to connect the pins. The external fixator may be left in place for 6 to 12 weeks depending on the severity of the injury and the need for added stability. Pins placed in the anterior inferior ileum prevent upright sitting, while pins placed in the lateral ileum permit sitting upright (Figure 70.4).

Percutaneous Fixation of the Posterior Pelvic Ring

Percutaneous reduction and fixation of the posterior pelvic ring with iliosacral screws is the most common surgical treatment for unstable posterior fractures. This technique is performed in the supine position, as are symphyseal plating and external fixation.
Multiplanar radiography is used to insert a guidewire into the first and or second sacral segment to facilitate cannulated screw placement. Such screws are used to treat the posterior injuries associated with lateral compression, anteroposterior compression, and vertical shear fractures (Figure 70.5). Care must be taken to scrutinize bone and implant position to avoid iatrogenic injury to nerves from the lumbosacral plexus. Displaced posterior ring injuries, especially vertical shear patterns, often are associated with lumbosacral plexus injuries, generating deficits on the side of fracture displacement.

Figure 70.4 Photographs of external fixation for treatment of pelvic ring fracture. A, Pins are placed in the lateral ileum with bars over the abdomen. B, Patient is able to sit upright with lateral ileum pins.

Open Reduction and Internal Fixation of the Posterior Pelvic Ring

Open reduction of the posterior pelvic ring is recommended infrequently. Indications would include unusual anatomic variants that preclude placement of percutaneous iliosacral screws. Some complex pelvis ring fractures may also have adjacent lower lumbar fractures of dislocations. These patients may be best served with lumbopelvic fixation. This technique is generally undertaken by spine surgeons and orthopaedic trauma surgeons working together, with the patient in the prone position. Implants may include lumbar and/or sacral pedicle screws, iliac bolts, and iliosacral screws. A mechanically robust construct is achieved; however, surgical times and associated hemorrhage are increased, and the risk of wound complication or soft-tissue irritation is moderately high (Figure 70.6).

Figure 70.5 Radiograph showing iliosacral screw fixation of bilateral sacral fractures used in conjunction with anterior external fixation to stabilize this pelvic ring injury.

Figure 70.6 Radiograph showing lumbopelvic fixation securing lumbosacral disruption, on the left side of this example. Open reduction and plate fixation of the right ileum was also performed.

Complications

Many complications may occur in the post-acute care phase for those with pelvic ring fractures. The high-energy injury that causes many pelvic ring fractures typically results in comorbid injuries, often in multiple organ systems. The risks for complications and mortality are most associated with the severity of injury and associated injuries rather than the stability of the pelvic ring fracture. Not only is it necessary to be vigilant for typical postoperative complications for those who undergo
surgical repair, there are additional complications associated with pelvic ring fractures, in particular. The complications relevant to the postacute phase of care will be focused on here.

Skin

Many risks to the skin exist after pelvic ring fracture. The immobility associated with recovery increases the possibility of pressure sores at the sacrum and heels due to the time spent supine, at the ischia from time sitting, and for sores related to orthoses, casts, or splints required for treatment or mobility. The ability to avoid pressure sores is dependent on frequently turning the patient, positioning properly, managing bowel and bladder incontinence, optimizing nutrition, and performing suitable inspection. Surgical wounds and pin sites from external fixators also need appropriate care and frequent inspection to reduce occurrence of infection. In spite of these efforts, many surgical wounds may require repeated débridement and vacuum closure devices to achieve healing.

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