Stress fractures (fatigue fractures) of the pelvis and femur

Everyone has landed unsuccessfully on their buttocks at least once; the feeling is quite unpleasant, but this is how a person can, although relatively rarely, get sacral fracture. For the most part, everything ends in a bruise, despite the fact that during the injury the bone experiences a colossal load. Due to the anatomical structure of the pelvis, damage to the sacrum is combined with its fractures. Damage of this kind occurs independently only in 20% of cases.

Subtleties of bone anatomy

In ancient Rome, this bone was special, which is why it got its name sacrum, which means “sacred.” The sacrum is an important component of the pelvis and an extension of the spine. The bone has two surfaces, the front or pelvic or the back, which is also called the dorsal. The final section is the coccyx, which in women bends backward during childbirth, ensuring normal passage of the head through the birth canal.

Numerous openings on both surfaces serve for the exit of blood vessels and nerves into the pelvic cavity. The base of the sacrum serves as a guide for obstetricians and allows them to calculate the size of the birth canal; it is called the promontory. The front surface is smooth, the back and sides have irregularities that serve as attachment points for ligaments. The sacrum articulates with the bones of the pelvis using joints that are not very mobile; slight slips are possible in them.

The sacrum consists of five vertebrae, which during the process of human growth and development fuse into a single monolith. This is evidenced by transverse lines; at the back there are longitudinal lines, as a result of fusion of the vertebral processes. The photo gives a clear idea of ​​the structure of the human sacrum.

A set of exercises at the third stage

Gradual walking and physical therapy restores lost skills. The set of exercises includes a wider range of load elements.

It is aimed at further strengthening the muscles of the pelvis and lower extremities, preventing stagnation and preventing the formation of contractures. Classes are conducted in all positions, including vertical positions with support on the legs.

Attention

! Movements should not be performed in the presence of pain. If discomfort and swelling occur, you should consult a doctor.

Experts recommend the following types of exercises.

1. Transition from a standing position with support on the foot to a position on the toes and back.
2. Alternately bending and extending the legs at the knee joints while standing.
3. Flexion and extension of the lower extremities in a sitting position while keeping the leg on the bed for several seconds.
4. While standing, shift the support alternately to each leg.
5. Transition from a sitting position to a standing position.

Gymnastics is complemented by walking with a gradual increase in distance and lengthening of the step. Any movements are performed to the best of the patient’s ability, without any discomfort.

Causes of damage

The reasons that result in a fracture of the sacral bone must have a greater impact force, since the bone is of significant strength. Most often, such damage occurs as a result of a traffic accident. Such an injury is combined with damage to the remaining pelvic bones and requires a special approach to treatment.

Another reason that can result in a fracture of the sacral spine is osteoporosis. The disease leads to a decrease in bone density and loss of calcium. Under such conditions, even the most minor injury can lead to fractures. Manifestations of the disease occur in the later stages and affect elderly and senile people, as well as women in menopause. In people with osteoporosis, any damage can cause disability or death.

Mechanical damage that occurs as a result of a direct blow or fall, especially in winter. Sacral fractures are also diagnosed in people attempting suicide because they fall on the back and buttocks. Along with this, the sacrum is damaged when falling from a ladder or falling from a height onto the buttocks. One of the reasons may be compression of the pelvis in the anteroposterior direction.

Features of rehabilitation in children

Treatment of children with compression fractures is conservative. The first therapeutic measures are aimed at relieving the damaged areas, relieving pain and restoring impaired blood circulation.

A sick child's mobility is limited to prevent complications from developing. It is necessary to remain in an upright position to a minimum, avoid lifting weights and sudden movements.

Functional traction, physiotherapeutic procedures, physical therapy and breathing exercises are prescribed. A little later, back massage and physical exercise are added, the action of which is aimed at strengthening the muscles of the back, abs and shoulder girdle. The child is prescribed to wear a special corset and continue the recovery period of treatment.

Even such a serious diagnosis as a compression fracture is not always a death sentence. The situation can be corrected if you approach the issue of patient rehabilitation competently and responsibly. There are a huge number of techniques and procedures that will help restore damaged areas. It is only important to strictly follow all the doctor’s requirements in order to see the result.

Classification

Like damage to other bones, a sacral fracture has its own classification. It can be without displacement or with displacement of fragments. Along with this, such a fracture may be accompanied by damage to the remaining bones of the pelvis.

A complicated fracture is accompanied by damage to blood vessels, nerves, and internal organs, and the integrity of the pelvic ring is compromised. Another complication is a fracture or dislocation of the coccyx, which is damage to the sacrum.

Uncomplicated damage is stable and does not pose any danger. This is due to the absence of the risk of damage to internal organs, ruptures and damage to the pelvic ring.

The damage can be closed if there is no damage to the skin and open when fragments are visible in the wound. Depending on the direction of the fracture line, injuries are distinguished:

1. Vertical, in which damage affects the right or left sacroiliac joint and pelvic bones.
2. Horizontal are characterized by damage to the lower part of the sacral joint. The damage is characterized by an isolated nature, with no violation of the integrity of the pelvic bones.
3. With a comminuted fracture, a fragment is formed, and the site of damage itself has uneven edges.
4. An oblique injury is characterized by the fracture line passing diagonally. In such a situation, the pelvic bones are damaged along with the sacrum.

Rehabilitation

The next step is rehabilitation after a sacral fracture, which includes various types of exercise therapy, a special course of massage and physiotherapy. How long it will last depends on your diagnosis.

In order to avoid all sorts of complications and consequences, you must take the prescribed treatment and all the recommendations of your doctor seriously. If you are asking the question: “Is it possible not to pay attention to the rehabilitation period?”, then every knowledgeable specialist will answer you that the rehabilitation procedure is as important as the treatment itself.

Symptoms

Any damage to the sacral spine has its own manifestations, which allows the doctor to make a diagnosis. Symptoms after injury are not as pronounced as in other parts of the skeleton. For this reason, the damage may not be diagnosed immediately. The victim may walk with mild discomfort, and the injury may be noticeable by mild swelling.

Symptoms worth noting:

• pain in the lower spine and pelvis;
• pressing on the site of swelling brings a feeling of pain and discomfort;
• with a complex fracture, the victim notes pain in the groin and lumbar spine;
• swelling and hemorrhage at the site of injury;
• pain in the position of the victim on the back;
• the victim constantly tries to find a comfortable position;
• the damage makes it impossible to sit normally;
• violation of the integrity and function of the rectum;
• if there is an old fracture of the sacrum, the function of the pelvic organs is impaired.

Possible problems

A fracture of the sacrum can be accompanied by serious consequences, since this area is connected to the spinal column. The situation is especially complicated when there is a shift.

With this pathology, the following may appear:

• Violation of the integrity of the venous plexus in the lumbosacral area;
• Trauma to the artery in the hypogastric region;
• Trauma to the artery in the middle part of the sacrum;
• Rupture of the abdominal bursa and rectum;
• Pathological changes in the spinal cord.

First aid

If the sacral joint , it is important to provide first aid correctly. This must be done before the doctors arrive; there is no difficulty in providing first aid for a sacral fracture. Immediately after a fall or any other injury, cold must be applied to the injury site. It is better to wrap it in cloth first and apply it to the area of ​​pain for 15-20 minutes, then take a break for 5-10. This will reduce swelling, bleeding and soreness.

Analgesics can be given to the victim only if you are completely sure that there is no damage to internal organs. Otherwise, such actions may distort the clinical picture, complicating further diagnosis.

The victim should only be transported in a horizontal position; sitting is strictly contraindicated, since the displacement may worsen and internal organs and nerves may be damaged. If a fracture of the lateral mass of the sacrum is suspected, the patient should not be transported on his side. You can take a person to the hospital on a hard surface, with your knees bent and your legs spread to the side. You can place a rolled up blanket under your knee joints.

general information

The sacrum is part of the lumbopelvic region of the human skeleton. This area is subject to heavy loads, which can cause damage. The main lobes of the sacrum include:

• Base;
• Channel;
• Top;
• Lateral, anterior and posterior planes.

The bone connects to the coccyx, pelvic bones and lumbovertebral region. Its parameters may differ for people of different genders. In men, the sacrum is curved, wide and elongated.

Fractures of this bone account for 1/3 of all cases of its injuries, and only 20% of them are injuries to only one sacrum. The remaining percentage is due to damage in combination with the pelvic bones.

Diagnosis of sacral injury

Diagnosing sacral injury can be quite difficult. The victim is given an x-ray, and always in two projections (frontal and lateral). Also, before taking the picture, the doctor performs a rather unpleasant, but very important diagnostic procedure - digital examination of the rectum. Such a diagnostic procedure allows not only to establish the fact of damage, but also to determine complications in the form of rectal rupture.

In women, an examination of the vaginal cavity is also performed. If large vessels are ruptured or damage is suspected, puncture of the abdominal cavity through the posterior fornix is ​​indicated. Additionally, representatives of both sexes are indicated for ultrasound diagnostics.

It can be difficult to diagnose a non-displaced sacral fracture using an x-ray. A CT or MRI allows you to get out of this situation; the latter method shows the condition of the soft tissues, which is very important for diagnosing complications. CT, in turn, makes it possible to determine the degree of displacement of fragments and their number. All this information gives the doctor the opportunity to correctly navigate the further treatment process.

Diagnostic methods

A detailed medical examination is required to diagnose a sacral fracture. This disorder can be most accurately identified using x-rays in direct and anterior projection. As additional measures, sagittal and oblique X-ray projections are performed.

To establish an accurate medical conclusion, the following research methods are also used:

1. CT;
2. MRI.

MRI gives the most informational and accurate results. In addition, this procedure is painless and harmless.

Diagnosis if there is concern for a sacral fracture should be comprehensive to exclude the development of other pathologies: neoplasm, thrombophlebitis of the iliac and pelvic veins, gynecological malaise, inflammation in the pelvic area.

Treatment of sacral injuries

After a thorough diagnosis, the treatment process begins, mainly with conservative methods and in very rare situations with the help of surgery, additional medications are prescribed. In case of such damage, plaster is not applied; it is enough to adhere to a certain regime. If the victim is diagnosed with a compression fracture or another without displacement, it is prohibited to sit for approximately 2 months. You need to move around with the help of crutches in a situation where the fracture is displaced.

Operation

When the damage is displaced, there is a risk of damage to internal organs and primarily nerves. Particularly dangerous in this regard is a longitudinal fracture, which requires osteosynthesis surgery. The doctor restores the normal anatomy of the sacrum and fastens the fragments using special screws and plates. After surgery, it is recommended to remain in bed for several weeks and sometimes months.

Use of medications

Additionally, medications are used to accelerate the healing of the injury. First of all, it is worth noting calcium supplements, which are used in courses. The degree of absorption of calcium is largely influenced by vitamin D, which promotes its entry into the bones. Normally, the skin is responsible for its production in the body, which must first be irradiated with ultraviolet rays from the sun. There are preparations that already contain the above vitamin, for example, “Calcium D3 nycomed”. Along with it, the drugs “Structum”, “Osteogenon”, “Kalcemin” are used.

In the fight against pain, the use of non-steroidal anti-inflammatory drugs is indicated. They are indicated in a strictly defined dose, since uncontrolled use can cause the development of stomach ulcers. Medicines can be in the form of injections or droppers:

• Xefocam;
• Revmoxicam;
• Almiral;
• Ketorol;
• Nise;
• Aertal;
• Movalis.

Since there is a high probability of damage to the nerves located in the pelvic cavity, the prescription of B vitamins is indicated. Among the drugs in this group, the following are used: Milgama, Neurobion, Neurorubin.

In other situations, the doctor proceeds depending on the situation and the symptoms that arise. If there is a wound, after suturing the wound, antibacterial drugs are prescribed. with the development of massive blood loss and pelvic fractures, saline solutions are prescribed. These drugs are: “0.9% sodium chloride solution”, “Trisol”, “Ringer’s solution”. And also hemostatic agents: “Etamzilat”, “Ditsinon”, solution of aminocaproic acid.

POLYTRAUMA / POLYTRAUMA

Dulaev A.K., Kazhanov I.V., Presnov R.A., Mikityuk S.I.

State budgetary institution St. Petersburg Research Institute of Emergency Medicine named after. I.I. Dzhanelidze, St. Petersburg, Russia

TRIANGULAR OSTEOSYNTHESIS OF SACUM FRACTURES IN VERTICALLY UNSTABLE PELVIC INJURIES

The choice of method for internal osteosynthesis of longitudinal fractures of the sacrum is one of the difficult issues in the treatment of such victims. Purpose of the study

– to evaluate the results of treatment of victims with vertically unstable pelvic injuries who underwent lumbopelvic stabilization in one of the configurations (unilateral or bilateral) and osteosynthesis with iliosacral screws, depending on the morphological variant of the longitudinal fracture of the sacrum.
Materials and methods.
The results of treatment of 22 patients with polytrauma and longitudinal fractures of the sacrum in a level 1 trauma center from 2013 to 2021 were analyzed. According to the AO/ASIF classification, C1 – 19 (86.4 %), C2 – 1 (4.5 %), C3 – 2 were diagnosed (9.1%) vertically unstable injuries of the pelvic ring.
The average age of the victims was 33.8 ± 9.8 years. The severity of damage on the ISS scale was 24.8 ± 7.9 points. To determine the sequence of treatment and diagnostic measures for the victims upon admission, a detailed assessment of the severity of the condition was made using the HC Pape scheme (2005). During preoperative planning, all patients underwent spiral computed tomography (SCT) of the pelvis. In all cases, for final fixation of longitudinal fractures of the sacrum, lumbopelvic fixation (LPF) was performed using transpedicular systems in one of the configurations and iliosacral screws (triangular osteosynthesis). When choosing the configuration of the PTF and the option for its installation, we took into account the morphology of the longitudinal fracture of the sacrum and its relationship with the articular facet of the L5/S1 vertebrae, the need to perform decompression of the nerve roots of the sacral plexus, and the time period after the injury. Results.
When assessing the results of treatment of 13 victims from 6 months to 3 years after injury, good and excellent results were obtained in 84.6% of cases, which corresponds to literature data.
Conclusions.
The wide variety of morphological variants of sacral fractures requires careful selection of an implant or a combination of implants. Surgical treatment for sacral fractures is preferably performed in the early stages of the traumatic disease, when indirect reduction with complete restoration of the anatomy of the pelvic ring is possible, which helps to obtain good anatomical and functional outcomes.

Keywords:

unstable injuries of the pelvic ring; sacral fractures; iliosacral screws; lumbopelvic fixation; minimally invasive osteosynthesis

The diagnosis and treatment of sacral fractures to this day contains many contradictions and disputes [1, 2]. Longitudinal fractures of the sacrum are observed in high-energy injuries in patients with polytrauma and are a component of injuries to the posterior pelvic ring in 45-90%, and are also combined with spinal trauma in 20-47% of cases [3-5]. Injuries to other areas of the body often dominate in significance over pelvic trauma, which affects the tactics of providing specialized trauma care. The significance of sacral fractures lies not only in their direct relationship to associated neurological complications, but also in the fact that the sacrum plays a critical role in stabilizing the pelvic ring [1, 2, 6]. Methods for external and internal fixation of an unstable pelvic ring are described in the literature [3], but specific clinical recommendations and protocols for the treatment of sacral fractures remain incompletely considered to this day. The variety of morphology of sacral fractures only complicates the choice of optimal surgical treatment, and the frequency of complications and unsatisfactory treatment results for such victims remains at the level of 25-60% [5, 7]. These include post-traumatic deformity, persistent pain during physical activity, as well as neurological disorders due to damage to the roots of the lumbosacral plexus [1, 2, 8]. In recent years, the number of supporters of active surgical tactics in the treatment of victims with injuries to the posterior pelvic ring has increased, and new methods and techniques for fixing sacral fractures are being introduced. However, each method has both advantages and disadvantages, and the indications for choosing one or another option remain not fully formulated. Purpose of the study

– assessment of the results of treatment of victims with vertically unstable pelvic injuries, who underwent lumbopelvic stabilization in one of the configurations (unilateral or bilateral) and osteosynthesis with iliosacral screws, depending on the morphological variant of the longitudinal fracture of the sacrum.

MATERIALS AND METHODS OF RESEARCH

The results of treatment of 22 victims with vertically unstable injuries of the pelvic ring at the St. Petersburg Research Institute of Emergency Medicine named after. I.I. Dzhanelidze (first level trauma center) for the period from 2013 to 2021. Structure of pelvic injuries according to the classification of M.E. Muller-AO/ASIF included: C1 – 19 (86.4%), C2 – 1 (4.5%), C3 – 2 (9.1%) cases. Injuries to the posterior pelvis were represented by various sacral fractures according to the classification of F. Denis (1988) [1]. There were 12 (54.5%) male victims and 10 (45.5%) female victims. Circumstances of injury: fall from a height – 12 (54.5%), road traffic accident – ​​9 (41.0%), compression – 1 (4.5%) cases. The study group included victims who had: working age (from 18 to 65 years), mild traumatic brain injury (AIS ≤4 points), morphology of damage to the pelvic ring, which made it possible to use osteosynthesis technologies with metal structures in the form of transpedicular PTF and iliosacral screws. The average age of the victims was 33.8 ± 9.8 years. The severity of damage on the ISS scale was 24.8 ± 7.9 points. To determine the sequence of surgical procedures on the pelvis and other areas of the body, a more detailed assessment of the severity of the victims’ condition was carried out using the HC Pape chart-table (2005) [9]. According to this scheme, the victims were divided into the following clinical classes: stable - 5 (22.7%), borderline - 13 (59.1%), unstable - 5 (22.7%), critical - 1 (4.5%) observations. If the victim had life-threatening consequences of injuries, emergency operations were performed to eliminate them, of which: ongoing pelvic - in three, intra-abdominal - in six; aspiration asphyxia – in one; tension pneumothorax – in three cases. Two victims had multiple pelvic trauma in the form of: extraperitoneal rupture of the bladder – 1 observation; partial rupture of the urethra in the membranous part – 1 observation. In the preoperative period, the victims underwent CT scanning of the pelvis and other damaged areas of the body. The nature of damage to the anterior and posterior parts of the pelvic ring, acetabulum, the degree of anteroposterior, vertical, external and internal rotational displacements were clarified. In all clinical observations, iliosacral screws were used for primary stabilization of a longitudinal fracture of the sacrum, and a system based on transpedicular screws (so-called triangular osteosynthesis) was used for lumbopelvic fixation. The choice between unilateral or bilateral PTF configurations depended on the location of the sacral fracture line in relation to the articular facet of the L5/S1 vertebrae. For longitudinal fractures of the sacrum extending outward from the articular facet of the L5/S1 vertebrae, a unilateral PTF was used. On the contrary, for longitudinal fractures of the sacrum with the fracture line located medially or through the articular facet of the L5/S1 vertebrae, and bilateral sacral fractures, especially H- and U-shaped ones, bilateral PTF was used in isolation. PTF was used in the second stage as additional stabilization of the sacral fracture. The main morphological types of injuries to the posterior part of the pelvic ring, which made it possible to stabilize it with iliosacral screws, were: H- and U-shaped sacral fractures with residual post-traumatic kyphosis of more than 10 degrees; comminuted bilateral fractures of the sacrum in the areas of the lateral masses or sacral foramina; sacral dysmorphia (lack of anatomical free space for screw installation in the S1 and S2 vertebral bodies, the so-called safe zone or “corridor”); fractures and fracture-dislocations of the sacroiliac joints involving the articular surface of the sacroiliac joint (fractures of the “crescent” or “crescent injury”) type, in which the plane of the main bone fragment of the iliac wing was projected onto the sacroiliac joint in a small area, which did not allow selecting adequate points for safe placement of cannulated screws and creating normal compression. For victims who had the above morphological variants of damage to the posterior part of the pelvic ring, only bilateral lumbopelvic fixation or another method of immersion osteosynthesis was used for final stabilization, therefore these clinical observations were not included in our study. If the general condition of the victim was stable, the longitudinal fracture of the sacrum was additionally stabilized by the PTF during the first 48 hours after the injury. In case of severe condition of the victim, PTF was performed in addition to iliosacral screws only during the period of complete restoration of vital body functions and elimination of complications (within 2 to 3 weeks after injury). Transpedicular systems were installed during the acute period of injury using a minimally invasive technique. The open PTF technique was used when it was necessary to perform open reposition, decompression of the nervous structures in the sacral area, as well as in the late periods of a traumatic illness after relieving complications and improving the general condition of the victim. Intraoperative multi-projection fluoroscopy of the pelvis was performed using a C-arm OEC 9900 Elit (General Electric, USA). Additional projections of the pelvic inlet (Inlet) and outlet (Outlet) were used. The immediate results were assessed before the patient was discharged. The level of pain was taken into account using a visual analogue scale (VAS) and the timing of early verticalization after surgery. Long-term treatment results were observed from 6 months to 3 years. Functional treatment results were determined using the SA Majeed scale [10]. The functional capabilities and quality of life of victims with vertically unstable pelvic injuries were assessed using a specialized modified SF-36 scale [11]. The database of victims was created in Microsoft Office Excel 2010. Statistical analysis of the data was carried out using the BioStat 2009 application package (Analyst SoftInc., USA).

RESULTS AND DISCUSSION

When a victim with a vertically unstable injury to the pelvic ring was admitted to the anti-shock operating room, a pelvic girdle (Medplant, Russia) was used for temporary fixation. For victims classified by the severity of their condition as “stable” (n = 5) and “borderline” (n = 6), subject to stable hemodynamics (SBP > 90 mmHg), in the acute period of injury, final osteosynthesis of the damaged anterior and posterior structures of the pelvic ring. To fix fractures of the anterior semi-ring of the pelvis, cannulated screws were installed in the anterior column of the acetabulum (n = 7), osteosynthesis of the acetabulum fracture (n = 1). The rupture of the symphysis pubis was fixed with a reconstruction plate (n = 2) and a transpedicular system (n = 3). For additional stabilization of the posterior pelvis, PTF was used: unilateral – in 8 cases, bilateral – in 3 cases. In 9 cases, reconstructive operations on damaged parts of the pelvic ring were performed immediately upon admission to the trauma center, and for the remaining victims within 48 hours (a period of relative stabilization of vital body functions). In 8 clinical cases, PTF was performed in a minimally invasive manner through small puncture approaches using special guide systems. Victims classified by the severity of their condition into the classes “unstable” (n = 4) and “borderline” (n = 7) with unstable hemodynamic parameters (with blood pressure < 90 mmHg) underwent temporary fixation of the anterior pelvis in the anti-shock operating room external fixation device (EFD), while in 3 cases the posterior structures were stabilized with a Ganz frame (DePuy Synthes, Switzerland). One patient underwent definitive control of intrapelvic bleeding using diagnostic pelvic angiography and subsequent embolization of the damaged vessel. After eliminating all life-threatening consequences of the injuries, the posterior structures of the pelvis were stabilized with iliosacral screws in 4 victims, and for the rest during a period of relative stabilization (up to 48 hours), of which in 3 after dismantling the Ganz frame. The final osteosynthesis of injuries to the anterior part of the pelvic ring in all victims, as well as PTF (of which, unilateral - in 7 cases, bilateral - in 4 cases), was carried out during the period of complete stabilization of the vital functions of the body (on average after 2 weeks after injury). To stabilize the anterior structures of the pelvis, the following implants were used: cannulated screws installed in the horizontal branch of the pubic bone (n = 7), a plate for rupture of the symphysis pubis (n = 3), AVF was used in 2 cases with concomitant trauma to the pelvic organs. PTF using a minimally invasive technique was performed in 3 clinical cases. In one victim, classified as “critical” by the severity of his condition, in the anti-shock operating room, to temporarily stop intrapelvic bleeding, an obturator balloon was inserted into the aorta through the femoral artery on the side of the injury, the pelvis was stabilized with a Ganz frame and an anterior AVF frame, after which extraperitoneal tamponade was performed pelvis On the second day after admission, the Ganz frame was dismantled and osteosynthesis of the longitudinal fracture of the sacrum was performed with two iliosacral screws. On the 4th day, tampons were removed from the retroperitoneal space of the pelvic cavity. On the 23rd day after the complications were relieved (the period of complete stabilization of the vital functions of the body), external osteosynthesis of injuries to the anterior pelvic ring was performed with a reconstruction plate and unilateral PTF. In most victims, transpedicular systems were dismantled within 6 to 12 months. There were no deaths among the victims studied. In the early postoperative period, complications developed in 12 (54.5%) victims, primarily classified according to the severity of the condition as “borderline” and “unstable”, and were associated with combined trauma to other areas of the body (sepsis, pneumonia, fat embolism, deep thrombosis veins of the lower extremities). In three patients with sacral fractures, a neurological deficit in the form of sciatic nerve neuropathy was observed. In two patients, the results of the control SCT of the pelvis revealed unsatisfactory alignment of the iliosacral screws, which required their removal. These errors were associated with sacral dysmorphia in one case and with a violation of the technology for installing the sacroiliac screw in the S2 vertebral body in another case. The average length of hospital treatment was 34.0 ± 16.0 days. The average pain level on the visual analogue scale (VAS) upon discharge of victims from the trauma center was 3.1 ± 1.7 points. All victims were verticalized within 4 to 2 weeks after the final stabilization of the posterior pelvis. Long-term treatment results were assessed in 13 (59.1%) victims over a period of 6 months to 3 years. The quantitative assessment of the functional state of the pelvis according to the SA Majeed scale was 89.9 ± 14.7 (min – 60, max – 100) points [10]. Excellent and good anatomical and functional results were obtained in 11 (84.6%), satisfactory – in one (7.7%), unsatisfactory – in one (7.7%) observation. Satisfactory treatment results were associated with nonunion of the sacral fracture, which resulted in persistent pain during significant physical exertion. The unsatisfactory result of treatment in one victim was associated with a concomitant complicated injury of the lumbar spine, accompanied by neuropathy of the sciatic nerve (complete disruption of the conductivity of the tibial and partial (up to 80%) of the peroneal portions). It should be noted that when using triangular osteosynthesis, verticalization and expansion of the motor mode of the victims was carried out early after the operation (within the first two weeks). The quality of life of 13 victims with vertically unstable pelvic injuries was assessed using the SF-36 questionnaire [11], and good results were obtained (Table).

Table. SF-36 Quality of Life Scale, n = 13

Basic parameters of quality of life	Average score
Physical functioning, PF	80.9 ± 25.8
Role functioning, RP	70.4 ± 38.8
Pain intensity, BP	84.8 ± 20.4
General health, GH	89.0 ± 3.1
Viability, VT	65.0 ± 15.8
Social Functioning, SF	50.2 ± 16.0
Emotional-role functioning	73.2 ± 39.3
Mental Health, MH	69.8 ± 17.9
PH (general physical health component)	49.2 ± 8.3
MH (general mental health component)	44.7 ± 8.8

The victims were given voluntary informed consent for the publication of clinical observations. We present a clinical observation.

Victim S., 34 years old, was delivered 1.5 hours after catatrauma. On admission, the level of consciousness on the Glasgow coma scale was 15 points, blood pressure was 130 and 80 mmHg. Art., heart rate 100 beats. per minute The examination revealed clinical signs of vertically unstable damage to the pelvic ring, and a pelvic girdle was applied (Medplan, Russia). SCT of the pelvis diagnosed a rupture of the symphysis pubis, fractures of the left pubic and ischial bones, and a comminuted median fracture of the sacrum with anteroposterior and vertical displacement (Fig. 1).

Figure 1. SCT of the pelvis before surgery: a) axial plane; b) frontal plane; c) sagittal plane; d) 3-D reconstruction

The line of the midline fracture of the sacrum in the upper sections was located outward from the articular facet of the L5/S1 vertebrae; the fracture was classified as type 1 according to B. Isler (1990) [6]. The overall severity of damage on the ISS scale was 34 points. The victim was assigned to the clinical class “borderline” with stable hemodynamics. In the anti-shock operating room, osteosynthesis of the fracture of the lateral mass of the sacrum and the left pubic bone was performed with cannulated screws, as well as fixation of the rupture of the symphysis pubis with a transpedicular system using a minimally invasive technique (Fig. 2).

Figure 2. Intraoperative radiographs: a) fractures of the anterior and posterior pelvis are fixed with cannulated screws; b) fixation of the symphysis pubis with a transpedicular system

On the next day after the injury, in order to further stabilize the posterior structures of the pelvic ring, left-sided minimally invasive lumbopelvic fixation was performed based on the transpedicular system (Fig. 3).

Figure 3. Installation
of PTF using a minimally invasive technique: a) guide tubes during insertion of transpedicular screws; b) appearance of the surgical wound

In the postoperative period, SCT of the pelvis was performed, which is presented in Figure 4.

Figure 4. SCT of the pelvis after surgery (3-D reconstruction): a) front view; b) side view

The postoperative period was uneventful. Walking is allowed with additional support on crutches and a 20% load of body weight on the left lower limb. He was discharged in satisfactory condition on the 25th day. Examined after 6 months: no complaints or shortening of the lower extremities, walks without additional support, full painless range of motion in the hip joints, no disturbances in sexual function were noted. When assessing long-term treatment results, the quantitative value of the final index on the SA Majeed scale (1989) [10] was 95 points, which corresponds to excellent functional treatment results. Currently, various methods of fixation of damaged posterior structures of the pelvic ring are used. One of the most common is the use of AVF. This technique is characterized by relative simplicity, speed of installation, and low invasiveness, which is of particular importance in the treatment of victims with severe combined trauma in the acute period of a traumatic illness. That is why rod-based AVFs are used more often than other methods for unstable pelvic injuries [5, 7]. Installation of the device on the anterior pelvic ring does not require a high degree of surgeon training and mandatory intraoperative X-ray monitoring. The disadvantages of this method include: a low degree of stability of fixation (especially the posterior structures of the pelvis), cumbersome structures, a decrease in the quality of life of the victim, as well as a high frequency of local infectious complications. In addition, it is quite a difficult task to achieve the necessary reposition of vertical displacements in the posterior part of the pelvic ring, which requires a more complex design of the devices. This fixation method is often used as the first stage, and can later be replaced with an immersed metal structure. In the literature, there are reports of fixation of the posterior pelvis with a compression transsacral or sacroiliac threaded tie. In the case of transsacral placement, the tie is located transversely in the body of the S1 vertebra; in the sacroiliac location, the tie passes through the posterior iliac spines [12]. The difference in the location of the screed consists in creating different points of support and obtaining different effects from the compression created. This fixation option is in many ways similar to the installation of iliosacral screws. The difference is that a high degree of compression of the fracture zone can be achieved using a screed. This greatly increases stability, and the installation of an iliosacral tie can, in some cases, eliminate pelvic deformities in closed-book fractures. Indications for the use of such a design remain only sacral fractures in zone 1 according to Denis or ruptures of the sacroiliac joint, otherwise the risk of compression of the spinal roots inside the sacral foramina or the sacral canal increases significantly. There is a known method of fixing sacral fractures with plates for small bone fragments in various configurations, in which premodeled reconstructive plates with angular stability or 1/3 tubular plates, as well as short sacroiliac plates are used [2]. With a significantly more traumatic approach, relatively low stability of fixation, as well as a high risk of infectious complications that are associated with physical inactivity, subsequent bed rest and the difficulty of general care for the victim, it nevertheless remains the method of choice in the treatment of sacral fractures associated with neurological deficits and the need for decompression of nerve structures. The higher invasiveness of the approach is compensated by the wide opportunity for reposition when fragments are displaced, which is especially helpful in the case of delayed or late surgical interventions. There is a way to stabilize a damaged posterior pelvis with a transiliac plate placed behind the sacrum and secured with screws to the posterior iliac spines. With this method of immersion osteosynthesis, relatively high stability of fixation is achieved with the possibility of open reposition and decompression of the sacral canal. Negative features are the traumatic nature of the surgical approach and the high risk of developing infectious complications [3]. Sacroplasty (injection of bone cement into the cruciate vertebral bodies and lateral masses of the sacrum) is mainly used for “fatigue”, osteoporotic pathological fractures in the elderly and is technically identical to vertebroplasty. It has the same advantages and disadvantages, and has very limited indications for use [13]. Posterior bridging transiliac transverse fixation involves inserting transpedicular screws into the posterior iliac spines and connecting them with a rod. A minimally invasive method of installing such a system is difficult to apply in cases of pronounced vertical displacement of sacral fractures [14]. Osteosynthesis with iliosacral screws is one of the minimally invasive surgical interventions. In this surgical treatment option, cancellous screws of various diameters are installed through skin punctures in the gluteal region through the ilium and sacroiliac joint into the body of the S1 and/or S2 vertebra. The small massiveness of the structure and the low degree of fixation of the screw threads in the cancellous bone do not provide sufficient stability, and the limited possibilities of closed reduction with vertical displacement make this fixation method inapplicable for vertically unstable pelvic fractures, accompanied by significant displacement of sacral fragments. For lumbopelvic fixation, transpedicular screws are installed using standard techniques in the L4 and L5 lumbar bodies, as well as in the S1 and/or S2 vertebral bodies or in the iliac crests. Fixation can be either unilateral or bilateral depending on the morphology of the sacral fracture. With the help of transpedicular systems, high stability of fixation is achieved. The negative aspects of the technique are the difficulty of installing transpedicular screws in the sacrum and modeling the connecting rod when it is passed subcutaneously. The high profile of the heads of standard pedicle screws causes an increased risk of developing pressure sores in places where the structures are standing. When performing triangular osteosynthesis, lumbopelvic fixation based on transpedicular systems is combined with the installation of iliosacral screws. The axial load of the human upper body (force F1) is transmitted through the spinal column to the body of S1 and the articular processes of the L5-S1 vertebrae, as well as the lateral masses of the sacrum. Through the lower limb, femoral heads and acetabulum, force vector F2 is applied to the posterior parts of the pelvic ring. The location and length of the iliosacral screw should be determined by calculating the shortest distance (L1 and L2) from the line of action of these forces (F1 and F2) under an assumed vertical load with body weight to the axis of rotation passing through the zone of the longitudinal fracture of the sacrum, in order to ultimately balance the moments forces (M1 and M2) or vector physical quantities characterizing the rotational action of these forces (Fig. 5).

Figure 5. Biomechanics of fixation with iliosacral
screws: a) fixation with a short iliosacral screw without vertical load with body weight
( L1
<
L2, F1 = F2, F1xL1 = F2xL2, M1 = M2);
b) fixation with a short iliosacral screw with vertical load with body weight (F1 <
F2; L1
<
L2, F1xL1
<
F2xL2, M1
<
M2);
c) fixation with a long iliosacral screw with vertical load with body weight (F1 <
F2; L1 > L2, F1xL1
≤
F2xL2, M1
≤
M2);
d) combination of iliosacral and iliopsoas osteosynthesis (F1 <
F2; L1 > L2, F2xL2 – F3x(L1 + L
2) ≤
F1xL1, M2 – M3
≤
M1
)

Based on biomechanical schemes, the closer the sacral fracture line is to its midline, the greater the length of the screw should be (L1 + L2), and it should be installed on a larger surface (L1) in the undamaged part of the sacral body. Longer iliosacral screws may provide better fixation because they have greater resistance to rotation and vertical shear stress. Stability of fracture fixation is achieved through a force proportional to the amount of interfragmental compression created. However, in case of Denis II-III sacral fractures, the creation of compression in the fracture zone is contraindicated due to the risk of compression of the sacral roots. Triangular synthesis combines the advantages of both individual methods, which ultimately significantly increases the stability of fixation, without increasing the negative features inherent in them [4]. Lumbopelvic fixation transfers the point of application of the gravity vector F1 to the head of the transpedicular screw installed in the posterior parts of the ilium, which leads to a decrease in the rotational load on the iliosacral screw, equalization of the moments of forces F1 and F2 and provides stability in the area of ​​the longitudinal fracture of the sacrum. Analysis of literature data allows us to identify the following main reasons that determine the unsatisfactory functional results of treatment of longitudinal sacral fractures using triangular fixation: delayed consolidation and pseudarthrosis; fracture of a metal structure; pain syndrome in the projection of standing metal structures; vicious union; iatrogenic damage to the L5 nerve root; pronounced tilt of the L5 vertebral body due to distraction in the L5-S1 vertebral articulation on the side of fixation (with a unilateral PTF configuration) [15]. In our clinical observations, only in one case was nonunion of a sacral fracture noted; there were no other local complications. To prevent the development of tilt of the L5 vertebral body in the frontal plane, the transpedicular system was removed within a period of 6 months to 1 year. The good and excellent functional results obtained in 84.6% of cases indicate the biomechanically sound reliability of this method of fixation of longitudinal fractures of the sacrum.

CONCLUSIONS

1. Longitudinal fractures of the sacrum, which are a component of an unstable injury to the pelvic ring or are accompanied by lumbopelvic dissociation and increasing neurological symptoms, require surgical treatment. 2. A wide variety of morphological options for damage to the posterior structures of the pelvis requires careful selection of an implant or their combination. 3. Stabilization of longitudinal fractures of the sacrum is preferably performed in the early stages of a traumatic disease, when indirect reduction with complete restoration of the anatomy of the pelvic ring is possible, which helps to obtain good anatomical and functional outcomes. 4. Triangular osteosynthesis based on iliosacral screws and transpedicular systems provides reliable fixation strength of the posterior part of the pelvic ring, which allows for early verticalization and rehabilitation of the victim, and can also be actively used in victims in the acute period of injury, with preference should be given to minimally invasive techniques installations.

LITERATURE:

1. Denis F, Davis S, Comfort T. Sacral fractures: an important problem, retrospective analysis of 236 cases. Clin. Orthop. Relat. Res.

1988;
227: 67-81 2. Pohlemann T, Gänsslen A, Tscherne H. The problem of the sacrum fracture. Clinical analysis of 377 cases. Orthopad .
1992;
21(6): 400-412 3. Tile M, Helfet DL, Kellam JF, Vrahas M. Fractures of the pelvis and acetabulum: principles and methods of management. 4 ed. Philadelphia etc.: Stuttgart, Germany: Thieme Publishing Group-Wilkins, 2015. 978 p. 4. Schildhauer TA, Ledoux WR, Chapman JR, Henley MB, Tencer AF, Routt MLJr. Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads. J. Orthop.
Trauma .
2003; 17: 22-31 5. Shlykov IL, Kuznetsova NL. Therapeutic and diagnostic algorithms in patients with unstable pelvic fractures. Kuban Scientific Medical Herald.
2009;
114(9): 156-159. Russian (Shlykov I.L., Kuznetsova N.L. Treatment and diagnostic algorithms for patients with unstable pelvic fractures. Kuban Scientific Medical Bulletin. 2009. T. 114, No. 9. P. 156-159) 6. Isler B. Lumbosacral lesions associated with pelvic ring injuries. J. Orthop.
Trauma. 1990;
4(1): 1-6 7. Milyukov AYu. Objective assessment of the results of treatment of patients with pelvic trauma. In: New Technologies in Medicine: the materials of scientific practical conference
, Kurgan, 2000. 197-198 p.
Russian (Milyukov A.Yu. Objective assessment of the results of treatment of patients who have suffered pelvic trauma // New technologies in medicine: materials of scientific and practical conference, Kurgan, 2000. P. 197-198) 8. Suzuki T, Hak DJ , Ziran BH, Adams SA, Stahel PF, Morgan SJ et al. Outcome and complications of posterior transiliac plating for vertically unstable sacral fractures. Injury.
2009;
40(4): 405-409 9. Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J. Orthop.
Trauma. 2005;
19: 551-562 10. Majeed SA. Grading the outcome of pelvic fracture. J. Bone Joint Surg.
Br. 1989;
71(2): 304-306 11. Ware JE, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Medical Care.
1992;
30: 473-483 12. Mehling I, Hessmann MH, Rommens PM. Stabilization of fatigue fractures of the dorsal pelvis with a trans-sacral bar. Operative technique and outcome. Injury.
2012;
43(4): 446-451 13. Vestermanis V, Kidikas H, Szawlowski J. Sacroplastic under control of computer fluoroscopy. Spine Surgery
.
2013; (3): 8-12. Russian (Vestermanis V., Kidikas H., Shavlovskis J. Sacroplasty under the control of computer fluoroscopy // Spine Surgery. 2013. No. 3. P. 8-12) 14. Dalbayrak S, Yilmaz M, Kaner T, Gokdag M, Yilmaz T , Sasani M et al. Lumbosacral stabilization using ilic wings: a new surgical technique. J. Spine.
2011;
36(10): 673-677 15. Ayoub MA. Displaced spinopelvic dissociation with sacral cauda equina syndrome: outcome of surgical decompression with a preliminary management algorithm. J. Eur Spine.
2012; 21(9): 1815-1825

View statistics

Loading metrics...

Links

• There are currently no links.

Consequences of a sacral fracture

If the treatment for a sacral fracture is carried out adequately and in a timely manner, there is no need to worry about the development of complications. In some rare cases, consequences may occur, the most unpleasant of which is coccydynia. This condition is characterized by pain of significant intensity in the sacral region, which prevents a person not only from sitting normally, but also from moving.

The most common concern after a sacral fracture is severe pain in the lower extremities. Sometimes swelling of the lower extremities, hyperemia, peeling of the skin appears, and the knee reflex weakens.

Doctors divide complications into three main types:

• neurological disorders in the form of pain and weakened reflexes;
• vascular are most often visible on the surface of the skin;
• myofascial ones are characterized by impaired mobility.

Car driving

Is it possible to work as a car driver after such an injury? If it was relatively mild, the bone has healed without consequences, and there is no discomfort, then any physical activity, including driving, can be returned.

But to be more sure that everything has gone completely, you should take a control x-ray. It is possible that discomfort will persist for some time, but it will go away over time. In the first year and a half, you should avoid heavy loads on the injured area.

Recovery

Rehabilitation after a sacral fracture is of particular importance; it allows a person to return to everyday life and work. For this purpose, physiotherapeutic procedures and gymnastics are used. It’s worth starting with physical procedures; they largely help to avoid complications. A patient after a sacral fracture is shown:

1. Magnetotherapy. The body's tissues are exposed to constant electromagnetic waves, which increase blood flow and accelerate bone regeneration processes. The procedure takes from 5 to 10 minutes; the course may require from 15 to 20 sessions.
2. UHF. The procedure involves exposure of tissue to ultra-high frequency waves. Just as the previous procedure promotes tissue restoration, the effect increases the vibration of electrons, which lead to heating of the tissue. A course may require from 10 to 20 procedures.
3. Electrophoresis is an effective remedy, especially with the addition of medications. Due to the influence of alternating current, medicinal substances penetrate into the body's tissues. The procedure is indicated for such complications as coccydynia. The course includes 15 to 20 procedures lasting from 10 to 15 minutes.
4. Bone tissue regeneration is promoted by diodynamics, which is based on alternating current. The course of procedures consists of 10 to 15 sessions.
5. Ultraviolet irradiation in a suberythemal dose is indicated for any fracture. This is due to the skin’s ability to produce vitamin D, which is involved in bone healing. The procedure is carried out under a special lamp after a biodose. The course of procedures ranges from 10 to 20 at the discretion of the doctor.

Prevention

Prevention reduces the risk of injury to a minimum. But it includes not only the need to be careful in different situations, but also a change in lifestyle. Basic measures:

1. Compliance with safety regulations at home and in the workplace.
2. Compliance with traffic rules.
3. Eat properly and balanced.
4. Seek medical help promptly.
5. Playing sports.

How long does it take for a fracture to heal? The body needs both internal and external support. to stay healthy. Nutrition saturates bones with calcium and improves blood circulation. This strengthens bones and muscles from the inside. Safety precautions protect against external negative influences.