Surgical management of osteoporotic pelvic fractures: a new challenge

Abstract

The number and variety of osteoporotic fractures of the pelvis are rapidly growing around the world. Such fractures are the result of low-impact trauma. The patients have no signs of hemodynamic instability and do not require urgent stabilization. The clinical picture is dominated by immobilizing pain in the pelvic region. Fractures may be located in both the ventral and the dorsal pelvic ring. The current well-established classification of pelvic ring lesions in younger adults does not fully reflect the criteria for osteoporotic and insufficiency fractures of the pelvic ring. Most osteoporotic fractures are minimally displaced and do not require surgical therapy. However, in some patients, an insidious progress of bone damage leads to complex displacement and instability. Therefore, vertical sacral ala fractures, fracture dislocations of the sacroiliac joint, and spinopelvic dissociations are best treated with operative stabilization. Angular stable bridge plating, the insertion of a transsacral positioning bar, and iliolumbar fixation are operative techniques that have been adapted to the low bone mineral density of the pelvic ring and the high forces acting on it.

Fig. 1

Bilateral fracture of the sacral ala in a 79-year-old patient with previous lumbar spine fusion surgery (arrows). The site of bone harvesting is near to the left sacroiliac joint and to the left sacral fracture (asterisk)

Fig. 2

a Pelvic overview of 91-year-old female with severe osteoporosis. Pubic and ischial rami fractures with slight displacement are visible (arrows). b Transverse CT-cuts through the sacrum showing a vertical fracture in the sacral ala (arrow). The patient was treated conservatively

Fig. 3

a Bilateral fractures of sacral ala with intrusion of the lumbar spine and sacrum into the small pelvis. There also is instability of the symphysis pubis. b Transverse CT-cuts through the sacrum and dorsal ilium, showing bilateral insufficiency of the sacroiliac joints with widening of the right joint and nitrogen bubble in the left joint

Fig. 4

3D-Reconstruction of a suicide jumper’s fracture in an 18-year-old male. There is complete spinopelvic dissociation, separating the body of S1 from the rest of the sacrum

Fig. 5

Bilateral ilium fractures, starting at the inner curves of the iliac wings, in a 67-year-old female patient with severe osteoporosis. A slight intrusion of the lumbar spine and the sacrum in the small pelvic ring is visible. There also are pubic and ischial rami fractures on the left and instability of the symphysis pubis

Fig. 6

a Left ilium fracture and left pubic rami fractures in a 78 year old male with Alzheimer’s disease and after repetitive falls at home. The disruption and gap at the iliac crest is clearly recognizable (arrows). b Pelvic inlet view, showing the slight internal rotation of the left hemipelvis. The exact place of the cortical disruption at the pelvic brim is also visible. c Pelvic outlet view, also showing the fracture and displacement of the iliac wing. d Postoperative pelvic ap overview. The gap at the iliac crest has been closed and fixed with a long lag screw. An angle stable plate has been placed along the sacroiliac joint and over the pelvic brim, bridging the fracture area. In the anterior pelvis, a retrograde pubic screw has been placed. e Postoperative pelvic inlet view. f Postoperative pelvic outlet view. There was an uneventful healing. Patient was again able to ambulate independently

Fig. 7

a Postoperative ap pelvic overview of the same patient as in Fig. 3a–b. A bilateral fusion with debridement of the sacroiliac joints, cancellous bone grafting, double anterior plate osteosynthesis over the sacroiliac joint and transsacral bar osteosynthesis were performed to restore stability in the dorsal pelvis. At the symphysis pubis, a double bridging plate osteosynthesis was also performed. b Postoperative inlet view, nicely showing the intraosseous trajectory of the transsacral bar. c Postoperative outlet view. Two years after surgery, the patient is able to walk smaller distances without walking devices and help of other people