Table Of ContentPol Maria Rommens
Alexander Hofmann
Editors
Fragility Fractures
of the Pelvis
123
Fragility Fractures of the Pelvis
Pol Maria Rommens • Alexander Hofmann
Editors
Fragility Fractures
of the Pelvis
Editors
Pol Maria Rommens Alexander Hofmann
Department of Orthopaedics and Department of Orthopaedics and
Traumatology Traumatology
University Medical Centre University Medical Centre
Johannes Gutenberg-University Johannes Gutenberg-University
Mainz Mainz
Germany Germany
Department of Traumatology and
Orthopaedics
Westpfalz-Clinics Kaiserslautern
Kaiserslautern
Germany
ISBN 978-3-319-66570-2 ISBN 978-3-319-66572-6 (eBook)
DOI 10.1007/978-3-319-66572-6
Library of Congress Control Number: 2017959148
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Movement is life
Life is movement
This book is dedicated to our families
From Pol Maria Rommens
To my wife Kristin
To my children
Pieter, Mimi and Helene and Paul
Karlien, Jeroen and Samuel and Felix
Margot, Tom and Elias and Wout
Mattias and Gloria
From Alexander Hofmann
To my wife Isabelle
To my children Klara and Kathleen Charlotte
Foreword
Our understanding of pelvic ring trauma has been greatly advanced in the
past three decades. Much of the original work to understanding this complex
injury was done by my mentor, George F. Pennal. My original one-volume
book, Fractures of the Pelvis and Acetabulum (Williams and Wilkins, 1984),
was devoted to that work, describing in detail the radiographic views needed
for diagnosis, the classification based on force direction, and the early and
definitive treatment. At that time we recognized two distinct demographics,
injuries caused by high energy trauma, usually younger patients, and those
with minor low energy injuries, usually a fall and often in the old age group.
Our subsequent editions (Fractures of the Pelvis and Acetabulum, 4th Edition,
AO Trauma, Thieme, 2015) have concentrated on the high energy types in
order to save lives, prevent high complications, and improve patient
outcomes.
As in all fracture demographics (wrist, shoulder, ankle, etc.), as pointed
out by the authors, low energy fracture patterns through osteopenic bone are
much more common. This is also true in pelvic ring trauma. However, pedes-
trian injuries are becoming more common in the older age group; those
patients often have life-threatening concomitant injuries and a significantly
higher mortality rate.
This book addresses this injury, the fragility fracture of the pelvic ring, and
greatly adds to our knowledge on this subject.
The authors describe the usual fragility injury as an implosion or lateral
compression mechanism, in most cases through inadequate bone. This has
been our experience, and in most of those stable fracture patterns, nonopera-
tive symptomatic care usually leads to good outcomes.
However, there are patterns that may displace early, leading to difficult
follow-up care and late surgery. The authors have proposed a comprehensive
classification and have indicated those injuries that might benefit from early
operative stabilization. Several chapters are devoted to details of operative
fixation, stressing the importance of minimally invasive techniques, espe-
cially in these older patients to minimize complications.
The final chapter on outcome will require more updating as more studies
are published, but older studies on stable lateral compression patterns reveal
generally good outcomes with symptomatic care, in patients with few
comorbidities.
vii
viii Foreword
I congratulate Pol Rommens, who has contributed much to our under-
standing of pelvic ring trauma, and his co-editor, Alexander Hofmann, for
their contribution to a subject of growing importance in our ever-increasing
elderly population.
Marvin Tile
University of Toronto
Toronto, ON, Canada
Orthopaedic Surgeon
Sunnybrook HSC
Toronto, ON, Canada
Preface
Pelvic injuries have mainly been associated with high-energy pelvic trauma
due to traffic accidents, crush traumas or falls from great height. There is vast
evidence about origin, clinical picture, treatment algorithms and outcome of
these severe injuries. Damage control techniques to stop bleeding in pelvic
trauma are differentiated from definitive surgical procedures, classically open
reduction and internal fixation with plates and screws.
Osteoporotic or insufficiency fractures of the pelvic ring have previously
been described in case reports and review articles, but they remained mar-
ginal reports within the large body of the literature on pelvic trauma. Thanks
to better prevention of infections and diseases, higher life quality and
improvements of medical care, the mean age of most populations of the globe
has increased and remains to do so. With longer lives, the number of age-
related diseases, disabilities and injuries also increases. Osteoporosis is a
typical age-related disease and widespread in industrialized and emerging
countries. It is characterized by a systematic decrease of bone mineral density
and ultimately results in “a fracture that is caused by an injury that would be
insufficient to fracture normal bone; the result of reduced compressive and/or
torsional strength of bone”. The last sentence is the definition given by the
World Health Organization (WHO) for fragility fractures.
Intra- and extracapsular hip fractures, proximal humerus, distal radius and
vertebral compression fractures are well-known fragility fractures with abun-
dant literature, guidelines and recommendations for treatment. Fragility frac-
tures of the pelvis (FFP) are an emerging yet already existing entity, but with
a paucity of literature and evidence on diagnostic algorithms and protocols
for treatment.
With this book, the editors aim at collecting the current knowledge and
experience on diagnostic work-up of and treatment alternatives for these
lesions. The characteristics of FFP are very different from pelvic disruptions
in adolescents and adults. There rather is a collapse of the pelvic ring than an
explosion; fracture morphologies are different, consistent and specific.
Instability may increase over time. With a new, comprehensive classification
system of FFP, the editors provide a framework, in which the multiple frac-
ture configurations can be differentiated from each other according to their
loss of stability. In consecutive chapters, the pathomechanism and clinical
picture of FFP are described.
Multiple contributions on treatment modalities represent the creativity of
the orthopedic trauma surgeon on the one hand. They are also an indication
ix
x Preface
for the lack of golden standard in surgical therapy. As a common rule, less
invasive stabilization techniques are preferred above more aggressive open
reduction and internal fixation procedures. The patient with a fragility frac-
ture of the pelvis does not have the same physiological reserves as adoles-
cents and younger adults. The goal of therapy is more focused on recovery of
motion and independency than on anatomical reduction.
In less invasive surgery, we primarily rely on preoperative imaging, thor-
ough preoperative planning and high-quality intra-operative imaging. Due to
the frequency of fragility fractures of the sacrum and the concept of percuta-
neous fixation, special attention is paid in diverse contributions to the mor-
phology and bone mass distribution of the sacrum. New findings give a direct
insight in the specific fragility fracture patterns of the sacrum and the dimen-
sion and shape of transsacral corridors.
Fragility fractures are the result of a systematic disease in a fragile patient.
Treatment cannot be focused on stabilization of fractures only. A multidisci-
plinary approach with input of the geriatrician, physiotherapist and the ortho-
pedic trauma team must improve the general condition of the elderly patient
on the short term. An analysis of bone metabolism and correction of deficien-
cies will prevent consecutive fragility fractures on the long term.
Diagnostic imaging is an indispensable part of daily practice in orthopedic
trauma surgery. The editors, together with the authors, paid specific attention
to an abundant number of images and commented case presentations. They
hopefully will be an important addition and support to the texts that explain
background knowledge and surgical methods of treatment. A series of cases
at the end of the book is meant for active study and personal discussion.
The editors wish that this book will substantially contribute to the knowl-
edge of the reader on fragility fractures of the pelvis. The book primarily
focuses on orthopedic trauma surgeons, but also should be of specific interest
for practicing orthopedic surgeons, spine surgeons, geriatricians, family doc-
tors and physiotherapists. Much more biomechanical and clinical studies are
needed to shed light on the optimal care for patients with FFP. Consequently,
this book cannot be a standard reference, but rather is a compilation of per-
sonal experiences. The book is intended to be an incentive for the elaboration
of clinical pathways and future guidelines for treatment for this emerging
entity of fragility fractures.
Pol Maria Rommens Alexander Hofmann
Mainz, Germany Mainz, Germany
Kaiserslautern, Germany
