[Our results of surgical management of unstable pelvic ring injuries].

PURPOSE OF THE STUDY

The authors present a group of patients treated for pelvic fractures in a period of 6 years and they evaluate radiographic findings and clinical outcomes following surgical management of type B and type C fractures.

MATERIAL AND METHODS

Between July 1998 and June 2004, a total of 271 patients with pelvic fractures, 162 men and 109 women (average age, 42 years; range, 15 to 93 years) were hospitalized at the authors' departments. Of these, 141 patients were operated on (94 men, 47 women; average age, 37 years; range, 15 to 72 years) and 130 were treated conservatively (average age, 47 years; range, 15 to 93 years). The clinical outcome assessment in patients with type B and type C fractures treated surgically was based on the Majeed scoring system, and the radiographs were evaluated as described by Matta and Tornetta.

RESULTS

In 85 % of the patients, pelvic fractures were due to a high-energy trauma caused by traffic accidents in 63 % (pedestrian injury, 30 %; injury of the driver or passenger, 28 %; motorcycle injury, 5 %), by falls from heights in 20 % (occupational injury, 10 %; suicidal attempt, 10 %) and by other causes in 2 %. Sports accidents, usually due to a low-energy trauma, accounted for 8 % of the injuries (falls from a bicycle, violent kicks) and ordinary falls of elderly persons for 7 %. Type A injury was in 56 patients (21 %), type B in 103 patients (38 %) and type C in 112 patients (41 %). In 27 % of the patients, pelvic ring injury was part of a multiple trauma, in 58 % it was a combined injury and in 15 % it presented as a single trauma. Primary neurological deficit was found in nine patients (9 %) with type B fracture and in 20 patients (18 %) with type C fracture; this difference was statistically significant (p = 0.005). Urogenital injury was co-existent with type B fracture in 12 patients (12 %) and with type C fracture in 15 patients (13 %); the difference was not significant (p = 0.734). In seven patients (3 %), the injury involved an open fracture. Thirty-three patients (12 %) died during hospitalization. The difference in death rate between the patients with type C and those with type B fractures was significant (p = 0.021). Excellent and good clinical outcomes were achieved in 83 % and 70 % of the patients with type B and type C fractures, respectively. The difference was not significant (p = 0.236). Radiographs showed excellent reduction in 83 % of type B fractures and in 61 % of type C fractures; the difference was not significant (p = 0.271). Intra-operative complications were recorded in 22 %, early post-operative ones in 13 % and late complications in 11 % of the patients.

DISCUSSION

The significant difference in primary neurological deficit between the patients with type C fractures and those with type B fractures was attributed to more severe injury and vertical dislocation of the posterior segment in type C fractures. On the other hand, the fact that urogenital involvement was not significantly higher in type C fractures can be explained by an equal presence of anterior segment injury in both type B and type C fractures. The significantly higher number of deaths in patients with type C fractures, as compared with those with type B fractures, was related more to severe injuries of other organ systems in polytraumatized patients than to injuries of the pelvis itself, although severe injury to the posterior segment in type C fractures can result in massive bleeding into the retroperitoneum.

CONCLUSIONS

An active approach to the treatment of patients with unstable pelvic fractures, which is based on the correct diagnosis, comprehensive multi-disciplinary care, urgent primary stabilization and early definitive fixation by internal osteosynthesis, offers a prospect of survival and a good functional outcome for the patient. However, a high proportion of lasting sequelae due to altered biomechanics of the pelvic ring, and irreversible injuries to neural structures and the urogenital system may lessen good results achieved by a demanding surgical procedure on the skeleton.