Fragility Fractures of the Pelvis PDF
Preview Fragility Fractures of the Pelvis
Pol Maria Rommens Alexander Hofmann Editors Fragility Fractures of the Pelvis 123 Fragility Fractures of the Pelvis Pol Maria Rommens • Alexander Hofmann Editors Fragility Fractures of the Pelvis Editors Pol Maria Rommens Alexander Hofmann Department of Orthopaedics and Department of Orthopaedics and Traumatology Traumatology University Medical Centre University Medical Centre Johannes Gutenberg-University Johannes Gutenberg-University Mainz Mainz Germany Germany Department of Traumatology and Orthopaedics Westpfalz-Clinics Kaiserslautern Kaiserslautern Germany ISBN 978-3-319-66570-2 ISBN 978-3-319-66572-6 (eBook) DOI 10.1007/978-3-319-66572-6 Library of Congress Control Number: 2017959148 © Springer International Publishing AG 2017 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Movement is life Life is movement This book is dedicated to our families From Pol Maria Rommens To my wife Kristin To my children Pieter, Mimi and Helene and Paul Karlien, Jeroen and Samuel and Felix Margot, Tom and Elias and Wout Mattias and Gloria From Alexander Hofmann To my wife Isabelle To my children Klara and Kathleen Charlotte Foreword Our understanding of pelvic ring trauma has been greatly advanced in the past three decades. Much of the original work to understanding this complex injury was done by my mentor, George F. Pennal. My original one-volume book, Fractures of the Pelvis and Acetabulum (Williams and Wilkins, 1984), was devoted to that work, describing in detail the radiographic views needed for diagnosis, the classification based on force direction, and the early and definitive treatment. At that time we recognized two distinct demographics, injuries caused by high energy trauma, usually younger patients, and those with minor low energy injuries, usually a fall and often in the old age group. Our subsequent editions (Fractures of the Pelvis and Acetabulum, 4th Edition, AO Trauma, Thieme, 2015) have concentrated on the high energy types in order to save lives, prevent high complications, and improve patient outcomes. As in all fracture demographics (wrist, shoulder, ankle, etc.), as pointed out by the authors, low energy fracture patterns through osteopenic bone are much more common. This is also true in pelvic ring trauma. However, pedes- trian injuries are becoming more common in the older age group; those patients often have life-threatening concomitant injuries and a significantly higher mortality rate. This book addresses this injury, the fragility fracture of the pelvic ring, and greatly adds to our knowledge on this subject. The authors describe the usual fragility injury as an implosion or lateral compression mechanism, in most cases through inadequate bone. This has been our experience, and in most of those stable fracture patterns, nonopera- tive symptomatic care usually leads to good outcomes. However, there are patterns that may displace early, leading to difficult follow-up care and late surgery. The authors have proposed a comprehensive classification and have indicated those injuries that might benefit from early operative stabilization. Several chapters are devoted to details of operative fixation, stressing the importance of minimally invasive techniques, espe- cially in these older patients to minimize complications. The final chapter on outcome will require more updating as more studies are published, but older studies on stable lateral compression patterns reveal generally good outcomes with symptomatic care, in patients with few comorbidities. vii viii Foreword I congratulate Pol Rommens, who has contributed much to our under- standing of pelvic ring trauma, and his co-editor, Alexander Hofmann, for their contribution to a subject of growing importance in our ever-increasing elderly population. Marvin Tile University of Toronto Toronto, ON, Canada Orthopaedic Surgeon Sunnybrook HSC Toronto, ON, Canada Preface Pelvic injuries have mainly been associated with high-energy pelvic trauma due to traffic accidents, crush traumas or falls from great height. There is vast evidence about origin, clinical picture, treatment algorithms and outcome of these severe injuries. Damage control techniques to stop bleeding in pelvic trauma are differentiated from definitive surgical procedures, classically open reduction and internal fixation with plates and screws. Osteoporotic or insufficiency fractures of the pelvic ring have previously been described in case reports and review articles, but they remained mar- ginal reports within the large body of the literature on pelvic trauma. Thanks to better prevention of infections and diseases, higher life quality and improvements of medical care, the mean age of most populations of the globe has increased and remains to do so. With longer lives, the number of age- related diseases, disabilities and injuries also increases. Osteoporosis is a typical age-related disease and widespread in industrialized and emerging countries. It is characterized by a systematic decrease of bone mineral density and ultimately results in “a fracture that is caused by an injury that would be insufficient to fracture normal bone; the result of reduced compressive and/or torsional strength of bone”. The last sentence is the definition given by the World Health Organization (WHO) for fragility fractures. Intra- and extracapsular hip fractures, proximal humerus, distal radius and vertebral compression fractures are well-known fragility fractures with abun- dant literature, guidelines and recommendations for treatment. Fragility frac- tures of the pelvis (FFP) are an emerging yet already existing entity, but with a paucity of literature and evidence on diagnostic algorithms and protocols for treatment. With this book, the editors aim at collecting the current knowledge and experience on diagnostic work-up of and treatment alternatives for these lesions. The characteristics of FFP are very different from pelvic disruptions in adolescents and adults. There rather is a collapse of the pelvic ring than an explosion; fracture morphologies are different, consistent and specific. Instability may increase over time. With a new, comprehensive classification system of FFP, the editors provide a framework, in which the multiple frac- ture configurations can be differentiated from each other according to their loss of stability. In consecutive chapters, the pathomechanism and clinical picture of FFP are described. Multiple contributions on treatment modalities represent the creativity of the orthopedic trauma surgeon on the one hand. They are also an indication ix x Preface for the lack of golden standard in surgical therapy. As a common rule, less invasive stabilization techniques are preferred above more aggressive open reduction and internal fixation procedures. The patient with a fragility frac- ture of the pelvis does not have the same physiological reserves as adoles- cents and younger adults. The goal of therapy is more focused on recovery of motion and independency than on anatomical reduction. In less invasive surgery, we primarily rely on preoperative imaging, thor- ough preoperative planning and high-quality intra-operative imaging. Due to the frequency of fragility fractures of the sacrum and the concept of percuta- neous fixation, special attention is paid in diverse contributions to the mor- phology and bone mass distribution of the sacrum. New findings give a direct insight in the specific fragility fracture patterns of the sacrum and the dimen- sion and shape of transsacral corridors. Fragility fractures are the result of a systematic disease in a fragile patient. Treatment cannot be focused on stabilization of fractures only. A multidisci- plinary approach with input of the geriatrician, physiotherapist and the ortho- pedic trauma team must improve the general condition of the elderly patient on the short term. An analysis of bone metabolism and correction of deficien- cies will prevent consecutive fragility fractures on the long term. Diagnostic imaging is an indispensable part of daily practice in orthopedic trauma surgery. The editors, together with the authors, paid specific attention to an abundant number of images and commented case presentations. They hopefully will be an important addition and support to the texts that explain background knowledge and surgical methods of treatment. A series of cases at the end of the book is meant for active study and personal discussion. The editors wish that this book will substantially contribute to the knowl- edge of the reader on fragility fractures of the pelvis. The book primarily focuses on orthopedic trauma surgeons, but also should be of specific interest for practicing orthopedic surgeons, spine surgeons, geriatricians, family doc- tors and physiotherapists. Much more biomechanical and clinical studies are needed to shed light on the optimal care for patients with FFP. Consequently, this book cannot be a standard reference, but rather is a compilation of per- sonal experiences. The book is intended to be an incentive for the elaboration of clinical pathways and future guidelines for treatment for this emerging entity of fragility fractures. Pol Maria Rommens Alexander Hofmann Mainz, Germany Mainz, Germany Kaiserslautern, Germany
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