Introduction.
Along with the development of medicine and increasing life expectancy, the number of elderly people is steadily increasing. Currently, in developed countries, the elderly make up about 15% of the population. According to the UN report, by 2030 their increase is predicted to be 1.5 times, and by 2050 - a 3-fold increase in the age group over 80 years old. Moreover, these age groups account for 37% of all fractures among adults [1, 2].
Injuries in the elderly and senile age have their own characteristics. Low-energy fractures due to a fall or cyclic stress load on osteopenic or porous bones are defined as pathological fragility fractures [3]. In these cases, the integrity of the ligamentous complex is preserved, which limits the displacement of bone fragments [4]. Osteoporosis is responsible for 9 million fractures per year [5], and the number is increasing in the elderly [6], becoming a serious economic problem. The loss from the consequences of osteoporosis in the European Union alone amounts to 37 billion euros annually [7].
The main attention in the treatment of low-energy fractures is paid to femoral fractures, while the problem of pelvic fractures (PFC) due to osteoporosis remains in the shadows [8]. The Russian clinical guidelines (Clinical guidelines “Pathological fractures complicating osteoporosis” (approved by the Russian Ministry of Health) 2021) also do not propose algorithms for the management of patients with low-energy PCT. While PCTs are among the five most common among patients over 65 years of age, accounting for 73% of all such injuries [9, 10]. The low-energy nature of the injury is reflected in a smaller number of complicated fractures in 2.8% of cases [11], which is 4 times higher than in young people [12]. An uneven distribution by gender is determined - 79% of elderly patients with PCT are women [13], which is also confirmed by the work of J. Kanis et al. [14], in which the authors write that in Russia there is a high 10-year probability of fractures due to osteoporosis in women over 65 years of age. If a pelvic fracture occurs for the first time due to osteoporosis, the risk of fractures at other locations within 5 years exceeds 30% [15]. Unfavorable factors influencing the occurrence of fractures, in addition to a decrease in bone mass, are senile asthenia, the occurrence of which is due to a decrease in the adaptive functions of the body and destabilization of homeostasis. Clinical manifestations include weakness, significant loss of body weight, muscle strength and low level of physical activity [16]. According to a study by M. Rollmann et al. [17], during the period from 1991 to 2013, the number of PCT among patients over 60 years of age increased 5 times and, importantly, the average score on the Injury Severity Score (ISS) increased. Patients over 65 years of age with high-energy trauma are 4 times more likely to die than younger patients, and only 29% of patients of this age did not require additional long-term treatment [18]. Male gender, age, and high-energy trauma are unfavorable prognostic factors for one-year survival after undergoing PCT [6, 17]. Mobile, socially protected patients have a better chance of recovery and achieving a normal quality of life. Taking medications for the treatment of osteoporosis and the presence of a clear algorithm for treatment and rehabilitation reduce the time of consolidation, prevent malunion and create optimal conditions for returning to the previous level of activity [8]. It has been noted that treatment prescribed by an orthopedic traumatologist immediately after a fracture is observed better than the recommendations of other specialists [19]. Promising in the field of screening examination are changes in laboratory blood parameters and their association with PCT. Thus, in every 5th patient with PCT, an increase in the blood level of osteo-associated Ca and Mg is recorded, in 9% - P, in 37% - the hormone osteocalcin, and in 57% - ALP activity [20].
Diagnosis of pelvic ring fractures against the background of low bone mass is difficult due to insufficient awareness of orthopedists regarding the possible causes of their development and clinical manifestations [21]. Pathological sacral fractures are often missed by conventional radiography [22]. It is unacceptable to ignore the presence of a fracture of the pubic bones, and even in the absence of displacement, intrapelvic bleeding must be suspected [23]. Initially, incorrectly chosen treatment tactics in combination with low bone mass and delayed consolidation can lead to further displacement of fragments, the emergence of new fracture lines, nonunions and poor clinical results [24]. In every 7th case, during conservative treatment, the fracture line spreads with its aggravation [25]. Considering the difficulties of treating elderly patients with PCT and the small number of Russian-language publications, it was decided to conduct a study in order to optimize approaches to the treatment and rehabilitation of this group of patients.
Patients and methods
A retrospective analysis of the results of treatment of 64 patients with pelvic ring injuries in the period 2017–2018 was carried out: 48 (75%) women and 16 (25%) men, average age 78±7.4 (66–92) years. 12 (18.7%) patients (8 men and 4 women) had polytrauma. The average ISS score was 22.4±3.2 points. According to the AO/OTA classification, the distribution of fractures was as follows: type A2 in 5 (7.8%) patients, B1 in 18 (28.1%), B2 in 28 (43.7%), B3 in 8 (12.5%) ), C1 in 3 (4.6%), C2 in 2 (3.1%).
Inclusion criteria for the study
: age over 65 years, violation of the integrity of the pelvic ring, including those associated with fractures of the acetabulum.
Exclusion criteria:
fractures of types A1 and A3 according to the AO/OTA classification.
At the first stage, all patients underwent examination and elimination of life-threatening conditions. Screening diagnostics included radiography of the pelvic bones, which is informative for the anterior part of the pelvic ring [26]. However, the accuracy of detecting posterior injuries with this method is limited [27], and therefore all patients with fractures also underwent computed tomography (CT) of the pelvis. Patients in a state of shock were treated with pelvic ring fixation using an external fixation device, which, due to the high risks of rod migration and the development of infectious complications [28], was used only until the condition stabilized. All patients underwent prevention of hypostatic complications, thrombosis and embolism, and symptomatic therapy. For fractures of types A2, B1, B2, activation on crutches with partial load on the injured side was prescribed for 6 weeks. Then, as the pain syndrome subsided, from the 6th to the 12th week the load was gradually increased. For fractures of types B3 and C, in the first 6 weeks, activation within the bed, movement on a sedentary gurney and walking with additional support were recommended from the 6th to the 12th week as the pain syndrome subsided. An aggressive approach to rehabilitation measures is fraught with increased displacement of fragments, extension of the fracture line and increased pain. During inpatient treatment, all patients were prescribed drug therapy for osteoporosis by a traumatologist, followed by a recommendation for observation by an endocrinologist. Nonunion was assessed as no consolidation within 1 year. Long-term results were assessed after 6 and 12 months using the S. Majeed scale (1987).
Emergency help
If you suspect a fracture of the ischium, you should immediately call an ambulance. Self-transportation should be avoided as this may worsen the condition.
Before the doctors arrive, it is recommended to place the patient in the frog position, i.e. on your stomach with your knees slightly apart. If the pain is unbearable, you can give him an anesthetic drug or apply a cold compress to the injured area.
After the ambulance arrives, the victim should be placed on a stretcher, placing a pillow under the knees and firmly fixing the legs. For bleeding of any type (internal or external), a bandage is used to compress the injured vessels.
In the hospital, the patient is placed on a special orthopedic bed, with his legs fixed in a certain position: pillows are placed under the knees, they are slightly bent and spread apart.
The doctor takes measures to prevent bleeding by applying a fixative to the damaged area. Sometimes internal osteosynthesis is used.
results
The average length of hospitalization was 12.3±4.6 bed days. 8 (12.5%) patients were transferred directly from the hospital to the rehabilitation center. In-hospital mortality was 6.2% (4 patients). In the first 6 months, 9 (14%) patients died, within 12 months - 4 (6.2%). The overall annual mortality rate was 26.5%.
Long-term treatment results after 6 months could be assessed in 48 (75%) patients: in 39 they were good, in 6 - satisfactory, in 3 - unsatisfactory. After 12 months, assessment was carried out in 44 (68.7%) patients: 40 had good results, 3 had satisfactory results, 1 had unsatisfactory results. Thus, after 1 year, 30 (68.1%) of 44 patients regained their previous level of activity.
When analyzing control radiographs after 12 months, 5 cases of malunion were identified; in 2 cases, consolidation of the fracture did not take place.
Clinical cases
1. Fixation of the sacrum on the right with a cannulated screw allows for safe early activation of the patient and relief of pain.
Clinical example 1.
Patient
R.
, 68 years old, injured as a result of an accident, passenger. Delivered by emergency medical services (EMS). The diagnosis was made: polytrauma. Fracture of the lateral masses of the sacrum on the right Denis I. Fracture of the ischium on the right with displacement of fragments. AO/OTA - 61-B2.1 Fracture of the transverse processes on the left L3–L5 (Fig. 1).
Rice.
1. Patient R., 68 years old. Computed tomogram, 3D reconstruction, visualized a fracture of the transverse processes on the left L3–L5. Fracture of the lateral masses of the sacrum on the left Denis I. Closed fracture of the distal metaepiphysis of both bones of the right forearm with displacement of fragments. Chest contusion. On the ISS scale 21 points. After stabilizing the patient's condition, an attempt was made to activate her. Due to the presence of an ipsilateral fracture of the upper limb and severe pain in the lumbosacral region, on the 3rd day the right sacrum was simultaneously fixed with a cannulated 7.0 mm screw. Osteosynthesis of the forearm bones was carried out with plates and screws. The patient was mobilized on the 1st day after surgery. The postoperative period was without complications.
Long-term results after 12 months: control radiographs revealed consolidated fractures of the lateral masses of the sacrum on the right and the ischium on the right (Fig. 2).
Rice. 2. Patient R., 68 years old. X-ray of a consolidated fracture of the lateral mass of the sacrum on the right 12 months after surgery. Osteosynthesis with a cannulated screw. Consolidated fracture of the ischium on the right. a - projection: exit from the pelvis; b — projection: entrance to the pelvis. According to the S. Majeed scale - 85 points, according to the “Timed up & go” test [30] 9 s (Fig. 3).
Rice. 3. Patient R., 68 years old. a–c — appearance and function 12 months after surgery.
2. Low-energy fractures of the anterior pelvic ring without significant displacement of fragments are subject to conservative treatment.
Clinical example 2.
Patient
L.
, 70 years old. Injury resulting from a fall from one's own height. He sought medical help the next day after the injury due to increasing pain.
The examination revealed a fracture of the pubic and ischial bones on the left with displacement of the fragments. Against the background of symptomatic therapy and prevention of thromboembolic complications, the patient was activated with additional support, dosed load on the left lower limb. Discharged on the 3rd day.
Long-term results after 12 months: control radiographs revealed a consolidated fracture of the pubic bone and a pseudarthrosis of the ischial ramus (Fig. 4).
Rice. 4. Patient L., 70 years old. Control radiographs after 12 months. Consolidated fracture of the pubic bone, false joint of the ischium. a - projection: exit from the pelvis; b — projection: entrance to the pelvis. According to the S. Majeed scale - 82 points, according to the “Timed up & go” test of the test 11 s.
Uses a cane when walking for more than an hour (Fig. 5).
Rice. 5. Patient L. 70 years old. a–c — appearance and function 12 months after injury.
Anatomy
The pelvic region includes two bones that do not have a name. Before a person reaches adolescence, these bones are divided into 3 parts: pubis, ischium and ilium. After age 18, these parts begin to fuse and eventually become one bone. Cartilage connects them to the femur.
The ischium has a thin structure. It consists of a body and branches that bend at a certain angle. Its upper part contains blood vessels and nerve fibers. In the same zone there is a tubercle (a small thickening with a rough surface).
Discussion
Analysis of clinical data for 2 years suggests that before the advent of CT in the routine practice of examining patients, some pelvic fractures in elderly patients remained undetected and were treated with conservative methods. In all cases, when treating elderly patients, early activation is necessary to prevent hypostatic complications, combat pain and senile dementia. However, today, after establishing the correct diagnosis, the question remains open about the need to fix fractures using known methods of internal or external fixation. One of the main problems is the choice between the risks of surgical treatment and its benefits in the form of stabilization of the pelvic ring and the possibilities of early activation. Obviously, the main obstacle to early activation in elderly patients is pain. In addition, it is quite difficult to assess the intensity of pain in patients after various types of treatment due to the lack of objectivity of such a parameter as pain.
Russian authors report that minimally invasive fixation, activation and early rehabilitation can significantly reduce the number of complications and mortality [30]. According to A. Höch et al. [11], in 18% of cases in the surgical treatment group complications occurred, however, despite this, the 2-year survival rate was 82%, while in the conservative treatment group there were encouraging results (8% complications) and a disappointing survival rate of only 61%. . According to N. Kanakaris et al. [8], in most cases, preference is given to a conservative method of treatment, since the majority of fractures are considered mechanically stable and there are a limited number of fixation techniques in conditions of porous bone and aggravated somatic status of patients. In addition, the situation is aggravated by the insufficient number of qualified surgeons. A. Hoch et al. [13] revealed that the choice of treatment method is based on the patient’s age, regardless of the type of fracture: thus, surgical treatment is mainly carried out in the group of patients under 80 years of age, while older patients are treated with conservative therapy. For type C fractures, surgical interventions were performed in 50% of cases, which exceeds the rates of previous studies [31].
M. Rollmann et al. [17] believe that type B fractures with stable hemodynamics, the possibility of early activation and adequate pain relief must be treated conservatively, and type C fractures have the highest mortality rate and require surgical intervention.
This work shows the need for further study of the problem by conducting ethically and organizationally possible randomized scientific studies using conservative and surgical methods and subsequent comparison of results.
Diagnostics
Diagnosing a fracture is a mandatory procedure before prescribing treatment. During a medical examination, the patient must tell the specialist all his complaints about changes in well-being. Next, the doctor palpates the area in which the patient has pain.
To accurately diagnose a fracture of the ischium, an x-ray is prescribed. It can be used to determine how severe the injury is to the bone and nearby tissues and organs. To evaluate the organs, a targeted x-ray is used, which allows you to take a picture of the pelvis from the side.
To determine the possibility of internal injuries, additional diagnostic procedures are prescribed. The introduction of contrast makes it possible to identify the condition of the genitourinary system. A cystographic examination is prescribed if there is a risk of through holes in the bladder.
Symptoms of an ischium fracture
At the moment of fracture, severe, acute pain occurs. It can cause painful shock and cause the victim to faint. The following symptoms also occur:
- swelling of adjacent tissues;
- hematoma;
- loss of the ability to move the injured leg or lift it.
All this in some cases may be accompanied by rupture of both pelvic vessels and internal organs:
- rectum;
- urethra or bladder;
- vagina or uterus.
The result of all this will be bleeding, the detection of which will require additional research.
Structure of the sacrum
The sacrum itself is a wedge-shaped bone. It is located between the pelvic bones at the very base of the spine. Comprises:
- concave pelvic surface;
- convex rear surface;
- lateral sides, wide in their upper part;
- tops;
- grounds;
- sacral canal.
This part of your musculoskeletal system has connections with both the coccygeal vertebra and the fifth segment of the lumbar spine.
In addition, there are points of contact with the pelvic bones. Due to its location, it is the sacrum that takes the brunt of the blow. And although it does not break so often (cracks and severe bruises are much more common), it is important to conduct a detailed diagnosis. An advanced form of injury can cause a lot of discomfort and is difficult to treat.
Causes of injury
A fracture of the sacrum of the pelvis occurs for many reasons. Among them are often found such as:
- Strong mechanical impact. This could be a blow, an unsuccessful landing on the buttocks. Injuries often plague skydivers, base jumpers and other fans of extreme sports. On the other hand, a person is capable of earning a displaced fracture of the sacrum, even if he simply slips on the stairs in the entrance.
- Osteoporosis. In patients with this type of illness, the likelihood of fractures is much higher. Bone density decreases, so even the smallest impact can cause injury.