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Outcome of pubic rami fractures with or without concomitant involvement of the posterior ring in elderly patients

  • Sverre Arvid Ingemar Loggers
  • Pieter Joosse
  • Kees Jan Ponsen
Original Article

Abstract

Introduction

Pubic rami fractures are common fractures in a growing osteoporotic geriatric population. Concomitant posterior ring fractures (cPRF) are often found when properly looked for. The pain and consequent immobilization leaves this vulnerable patient group at risk for complications. Conservative therapy is usually sufficient, but with cPRF’s surgery can be indicated. Although previous studies have pointed out that mortality rates are high, longer term morbidity outcomes are lacking. This study aims to further establish the longer term consequences of these fractures. Risk factors will be identified for complications, also addressing the possible differences between patients with or without a cPRF.

Method

Retrospective analysis of patients aged over 65 years sustaining a pubic rami fracture in the North-West Hospital Group Alkmaar combined with a survey to establish risk factors for morbidity and mortality after 6 months’ post trauma. Multiple logistic regression analysis was used to identify risk factors.

Results

117 patients matched inclusion criteria with a median age of 83 and of which 86% was female. 23 cPRF’s were identified. Significant deterioration in ambulation and independency was found. 34% was institutionalized at discharge. 49% lost their independent mobility status and 40% of the patients did not experience a full recovery. One-year mortality rate was 23%. Patients with a cPRF had a significant higher complication rate (44 vs 18% p = 0.02), but mortality and other morbidity outcomes did not statistically differ. The strongest predictor for 1-year mortality was complications during admission and a dependent ambulatory status (OR 5.2 and 4.1 respectively).

Conclusion

Pubic fractures with or without involvement of the posterior pelvic ring in patients aged over 65 have a significant impact on mobility and independency. Mortality rates are similar to hip fracture patients. Careful evaluation of every patient’s mobility status is necessary to identify patients at risk for complications and determine their future health care needs. Future studies are needed to achieve consensus on diagnostic and treatment protocols and identify ways to decrease the significant impact of this injury.

Keywords

Pubic rami fracture Elderly patients Pelvic fracture Posterior pelvic ring Sacral fracture Geriatric patients 

Notes

Compliance with ethical standards

Conflict of interest

S. A. I. Loggers declares that he has no conflict of interest. P. Joosse declares that he has no conflict of interest. K. J. Ponsen declares that he has no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Epidemiology of osteoporotic pelvic fractures in elderly people in Finland: sharp increase in 1970–1997 and alarming projections for the new millennium. Osteoporos Int. 2000;11:443–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis related fractures in the United States, 2005–2025. J Bone Miner Res. 2007;22:465–75.CrossRefPubMedGoogle Scholar
  3. 3.
    Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: recommendations for surgical treatment. Injury. 2013;44:1733–44.CrossRefPubMedGoogle Scholar
  4. 4.
    Alnaib M, Waters S, Shanshal Y, Caplan N, Jones S, St Clair Gibson A, Kader D. Combined pubic rami and sacral osteoporotic fractures: a prospective study. J Orthop Traumatol. 2012;13(2):97–103.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Lau TW, Leung F. Occult posterior pelvic ring fractures in elderly patients with osteoporotic pubic rami fractures. J Orthop Surg (Hong Kong). 2010;18(2):153–7.CrossRefGoogle Scholar
  6. 6.
    Studer P, Suhm N, Zappe B, Bless N, Jakob M. Pubic rami fractures in the elderly—a neglected injury? Swiss Med Wkly. 2013;143:w13859.PubMedGoogle Scholar
  7. 7.
    Wagner D, Ossendorf C, Gruszka D, Hofmann A, Rommens PM. Fragility fractures of the sacrum: how to identify and when to treat surgically? Eur J Trauma Emerg Surg. 2015;41(4):349–62.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Peh WC, Khong PL, Ho WY, Yeung HW, Luk KD. Sacral insufficiency fractures. Spectrum of radiological features. Clin Imaging. 1995;19(2):92–101.CrossRefPubMedGoogle Scholar
  9. 9.
    Babayev M, Lachmann E, Nagler W. The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate? Am J Phys Med Rehabil. 2000;79:404–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Maier GS, Kolbow K, Lazovic D, Horas K, Roth KE, Seeger JB, Maus U. Risk factors for pelvic insufficiency fractures and outcome after conservative therapy. Arch Gerontol Geriatr. 2016;67:80–5.CrossRefPubMedGoogle Scholar
  11. 11.
    Hill RM1, Robinson CM, Keating JF. Fractures of the pubic rami. Epidemiology and five-year survival. J Bone Jt Surg Br. 2001;83(8):1141–4.CrossRefGoogle Scholar
  12. 12.
    van Dijk WA1, Poeze M, van Helden SH, Brink PR, Verbruggen JP. Ten-year mortality among hospitalised patients with fractures of the pubic rami. Injury. 2010;41(4):411–4.CrossRefPubMedGoogle Scholar
  13. 13.
    Krappinger D, Struve P, Schmid R, Kroesslhuber J, Blauth M. Fractures of the pubic rami: a retrospective review of 534 cases. Arch Orthop Trauma Surg. 2009;129(12):1685–90.CrossRefPubMedGoogle Scholar
  14. 14.
    Leung WY, Ban CM, Lam JJ, Ip FK, Ko PS. Prognosis of acute pelvic fractures in elderly patients: retrospective study. Hong Kong Med J. 2001;7(2):139–45.PubMedGoogle Scholar
  15. 15.
    Breuil V, Roux CH, Testa J, Albert C, Chassang M, Brocq O, Euller-Ziegler L. Outcome of osteoporotic pelvic fractures: an underestimated severity. Survey of 60 cases. Jt Bone Spine. 2008;75(5):585–8.CrossRefGoogle Scholar
  16. 16.
    Koval KJ, Aharonoff GB, Schwartz MC, Alpert S, Cohen G, McShinawy A, Zuckerman JD. Pubic rami fracture: a benign pelvic injury? J Orthop Trauma. 1997;11(1):7–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Scheyerer MJ, Osterhoff G, Wehrle S, Wanner GA, Simmen H-P, Werner CML. Detection of posterior pelvic injuries in fractures of the pubic rami. Injury. 2012;43:1326–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Nüchtern JV, Hartel MJ, Henes FO, Groth M, Jauch SY, Haegele J, Briem D, Hoffmann M, Lehmann W, Rueger JM, Großterlinden LG. Significance of clinical examination, CT and MRI scan in the diagnosis of posterior pelvic ring fractures. Injury. 2015;46(2):315–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Morris RO, Sonibare A, Green DJ, Masud T. Closed pelvic fractures: characteristics and outcomes in older patients admitted to medical and geriatric wards. Postgrad Med J. 2000;76:646–50.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Tile M. Pelvic ring fractures: should they be fixed? J Bone Jt Surg Br. 1988;70(1):1–12.CrossRefGoogle Scholar
  21. 21.
    Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990;30(7):848–56.CrossRefPubMedGoogle Scholar
  22. 22.
    Shortt NL, Robinson CM. Mortality after low-energy fractures in patients aged at least 45 years old. J Orthop Trauma. 2005;19(6):396–400.CrossRefPubMedGoogle Scholar
  23. 23.
    Rapp K, Cameron ID, Kurrle S, Klenk J, Kleiner A, Heinrich S, König HH, Becker C. Excess mortality after pelvic fractures in institutionalized older people. Osteoporos Int. 2010;21(11):1835–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Hu F. Preoperative predictors for mortality following hip fracture surgery: a systematic review and meta-analysis. Injury 2012;43(6);676–85.CrossRefPubMedGoogle Scholar
  25. 25.
    Grigoryan KV, Javedan H, Rudolph JL. Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma. 2014;28(3):e49–55.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Giannoudis P, Tzioupis C, Almalki T, Buckley R. Fracture healing in osteoporotic fractures: is it really different? A basic science perspective. Injury. 2007;38(Suppl 1):S90–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Vanderschot P. Treatment options of pelvic and acetabular fractures in patients with osteoporotic bone. Injury. 2007;38(4):497–508.CrossRefPubMedGoogle Scholar
  28. 28.
    Sheikh HQ. A comprehensive analysis of the causes and predictors of 30-day mortality following hip fracture surgery. Clin Orthop Surg. 2017;9(1):10–8.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Hopf JC, Krieglstein CF, Müller LP, Koslowsky TC. Percutaneous iliosacral screw fixation after osteoporotic posterior ring fractures of the pelvis reduces pain significantly in elderly patients. Injury. 2015;46(8):1631–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Taillandier J, Langue F, Alemanni M, Taillandier-Heriche E. Mortality and functional outcomes of pelvic insufficiency fractures in older patients. Jt Bone Spine. 2003;70(4):287–9.CrossRefGoogle Scholar
  31. 31.
    Höch A, Özkurtul O, Pieroh P, Josten C, Böhme J. Outcome and 2-year survival rate in elderly patients with lateral compression fractures of the pelvis. Geriatr Orthop Surg Rehabil. 2017;8(1):3–9. (PMID:28255503).CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.NorthWest Clinics AlkmaarAlkmaarThe Netherlands

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