A pelvic fracture is a break in one or more bones of the pelvis.
The pelvis is a butterfly-shaped group of bones located at the base of the spine. It is made up of three bones:
- The sacrum: which is a central triangular shaped bone which forms the base of the spine and at its tip joins on to the coccyx
- Two innominate bones: these are the large bones either side of the sacrum.
- The hip socket (or acetabulum) is a part of the innominate bones. The thigh bone or femur fits into the socket forming the hip joint.
Pelvic fractures range widely in severity. A mild fracture (for example, one that occurs only at the part of the pelvis called the pubic rami) may heal in several weeks without surgery.
However, a serious pelvic fracture, such as ones sustained in car and motorbike accidents, can be a life-threatening event requiring emergency medical care, surgery and long period of recovery. It often also involves damage to nearby internal organs.
Symptoms
The symptoms of a fractured pelvis include:
- Pain: pelvic fractures can be very painful. Depending on where the fracture is, the pain may be felt in different areas. Common areas of pain include groin, buttock and lower back.
- Deformity: Due to the break in the pelvis, one leg may appear shorter than the other or one side of the pelvis may appear larger than the other.
- Swelling and bruising: there will often be a lot of swelling and bruising around the site of the injury. Sometimes bruising or bleeding can occur within the pelvis and not be obvious from the outside.
- Wounds: If the pelvic fracture is severe or was caused by a high impact injury, the broken bone may break through the skin.
- Organ damage: the pelvis is a ring of bone that protects internal organs, especially the bladder, uterus and intestine. A fractured pelvis can cause damage to these organs. This can lead to blood in the urine or stools.
- Nerve damage: nerves that run from the spinal cord to supply the legs can be damaged by pelvic fractures. This may be felt as pain or numbness in the legs. It may also cause weakness in the muscles of the legs.
Pain in other areas of the body: Pelvic fractures are often caused by high impact injuries. These injuries will often affect multiple areas of the body and as such, pain in other areas of the body may indicate additional fractures, strains or bruising.
Causes
Pelvic fractures are often classified into two groups depending on their cause:
- fractures due to high-energy trauma
- fractures due to low-energy trauma
Fractures due to high energy trauma:
High energy trauma means any accident that involves a large amount of force. The most common type of these injuries includes:
- motor-vehicle accidents
- falls from a height
- crushing injuries
There are a variety of different pelvic fractures that can occur depending on the direction of the force and the amount of force. The doctor assessing you will want to know as much information about the accident as possible as this will help to narrow down the possible type of pelvic fracture.
Fractures due to low energy trauma
In these fractures, the force that causes the fracture is not very high and is something that may occur in every day life. There are two main types of pelvic fractures that occur at low energy
- Avulsion fractures: this is where a small piece of bone is pulled off at the site where a muscle attaches. This is most common in teenagers and often occurs during sporting activities. This is a relatively minor form of pelvic fracture.
- Pathological fracture: This means that the fracture occurred due to some kind of disease process (or pathology) affecting the bone. Most commonly this is due to osteoporosis which weakens the bones and makes them more vulnerable to fracture. This type of fracture is seen most commonly in the elderly due to small falls sustained in the home.
Risk Factors
For high energy fractures or those involving a large force the risk factors include:
- car accidents/ motor cycle accidents
- falls from a height
- crush fractures
- high speed sporting accidents such as alpine skiing, down hill mountain-biking, motor cross etc.
For low energy fractures or those involving minimal force, the risk factors include:
- Osteoporosis
- Destructive bone lesion such as cancer
- Age: the elderly are more susceptible to low energy pelvic fractures
Investigations
Clinical assessment
The first step of investigating any medical problem is a clinical assessment with both a thorough history and examination.
The history is particularly important for pelvic fractures as the way the injury happened may guide the doctor to make a diagnosis of the type of pelvic fracture.
The examination will include assessment of any wounds, bruising, deformity or altered leg position, nerves of the leg, as well as an examination of pelvic organs.
Imaging
- X-ray: this is the first step in diagnosis of pelvic fractures and will help to confirm or rule out the presence of a fracture
- CT scan: Will give a more accurate picture of the extent of pelvic fractures and is often used following an X-ray
Diagnosis of instability
The pelvis is a ring of bone which if broken can lead to instability. This means that there is abnormal movement of the pelvic bones during normal activities such as walking. This can be diagnosed by clinical examination if the pelvic fracture is severe but may require imaging to pick up the presence of certain criteria which may indicate.
Complications
The complications of pelvic fractures include:
- Bleeding: This may occur if a broken bone punctures the skin in which case it is easily observable. Bleeding can also occur internally due to a pelvic fracture and lead to large amounts of blood loss without being obvious.
- Organ damage: The bladder and lower bowel may be injured due to a pelvic fracture.
- Infection: An infection may occur at the site of a wound caused by a broken bone, however infections can also occur within the pelvis in the form of an abscess
- Nerve damage: Damage to nerves may occur as a result of broken bones impinging on nerves or as a complication of surgery which may be necessary to stabilise the pelvis. This can lead to numbness or weakness in the legs. It can also lead to sexual dysfunction due to nerve damage affecting the genitals.
- Blood clots (vein thrombosis): Blood clots can develop within the veins of the pelvis which can lead to the further complication of these clots travelling to the lungs.
- Delayed healing of fracture: This may occur if there is incomplete fixation of the broken bones following surgery.
Treatment
Depending on the severity of the fracture, the treatment for pelvic fractures varies from simple rest or medical aids to surgical intervention.
Non-surgical treatment
This approach is appropriate for when the fracture is ‘stable’. This means that with normal activities, the two parts of the broken bone do not move and will heal without surgical intervention. It may be necessary to use crutches or a walking frame and avoid any high impact activities. It will usually take up to 3 months for a full recovery during which time care needs to be taken to avoid aggravating the injury. This approach is often taken with avulsion fractures (where a piece of bone is pulled off by a tendon where it attaches to the bone) or other minor fractures.
Surgical
Surgical intervention is necessary for any fracture that is ‘unstable’. An unstable fracture is present when the two parts of the broken bone will move when performing normal movement. In this case, the bones will not heal unless they are fixed in place by a surgical procedure. The type of surgical technique used depends on the location and the extent of the fracture. Sometimes, as well as fixing the broken bones in place, damage to organs may also need to be repaired.
Seeking Advice
A pelvic fracture is a potentially serious injury. Most people who are suspected of having a pelvic fracture should be taken to the hospital by ambulance, particularly if the injury occurred due to a high impact trauma. When presenting at the hospital, it is important to give as much information about how the accident occurred. It is important not to try to walk after sustaining a pelvic fracture prior to being examined by a medical professional.
Prevention
In a person susceptible to low energy trauma fractures, which means an accident that does not require a lot of force, the following measures may be taken to prevent fractures:
- Prevent falls by using a stool or stepladder to reach high places. Add handrails along stairways and place nonslip mats in your bathroom, shower, and under carpets.
- Maintain your muscle strength which will help to prevent falls.
- Maintain bone density through weight bearing exercise and appropriate medical treatment as guided by your GP
For high energy trauma fractures, the following measures may be taken:
- Lower your chance of injuries due to car and motorcycle accidents by always wearing your seatbelt.
- Always use safety precautions to avoid falls during high-risk sports, such as rock climbing and mountaineering.