Pelvis And Hip Fractures


Fractures of the pelvis and sacrum are usually pathologic due to stress or fatigue. Those fractures due to falls or high-velocity impact are uncommon and are not the focus of this section. Many stress fractures of the pelvis go undiagnosed because the prudent patient may end up self-treating with self-imposed rest until the symptoms ameliorate and activity is once again possible. When they occur, stress injuries occur at the sacrum, sacroiliac joint, pubic rami, and femoral neck. Classically, a pelvis or sacral stress fracture occurs following a recent increase in mileage or intensity. For example, stress fractures of the pubic rami are the most common in the pelvis and usually occur in long-distance runners (Fig. 44-1). Although these fractures are common, in general, the most common stress fracture is in the tibia. Stress fractures may be simplified as (1) primary osseous failure—insufficiency fracture due to inherent weakness such as osteopenia or osteoporosis, and (2) a fatigue fracture from excessive overloading of normal bone. The situation, in most cases, may be a combination of these factors. The stress fracture should also be observed as part of a spectrum of disease. On one end is a stress reaction and on the other end is a frank fracture with a distinct fracture line. Stress fracture cause is also thought to be varied. The current most widely accepted theory is that of repetitive stress causing a periosteal resorption that surpasses the rate of bone remodeling, weakening the cortex and resulting in a stress fracture. The high-intensity female athlete is at risk of stress fractures as a consequence of high-intensity training, catabolic state, poor diet, and low body mass along with menstrual problems. Risk factors for multiple stress fractures include a high longitudinal arch of the foot, leg length inequality, and excessive forefoot varus, female patients with menstrual irregularities, and high weekly training mileage.4

The pain pattern of a stress fracture is typically described as a "crescendo" effect beginning as a tolerable dull ache that quickly transforms into an intense pain, making the lightest exercise activity not possible. The symptoms of a stress injury are worsened with any pounding-type of weight-bearing activities. The key to the diagnosis is in the history and physical examination. The point of maximal tenderness should be identified so






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Figure 44-1 Magnetic resonance imaging of the pelvis depicts a fracture through the right parasymphyseal inferior pubic ramus in a 48-year-old sheriff reservist. The fracture occurred insidiously during endurance training. The patient presented with anterior hip flexor pain and tenderness. The plain radiographs remained negative for 4 weeks. This fracture was successfully treated with activity modification including nonimpact athletic activities and physical therapy. Despite union after 8 weeks, this patient experienced residual symptoms associated with adductor tightness.

that imaging studies may be focused to this area. Plain radiographs are usually negative because of the lack of callus formation in the early stages and sometimes when a fracture line does not form. When a fracture is thought to be occult or difficult to characterize, an MRI is considered more sensitive than a bone scan. The ideal MRI sequence for femoral neck fractures is the "fat saturation T2" (high TR and TE >60) or short tau inversion recovery (STIR) sequences, which are easier and quicker to perform than other sequences.

The treatment for pelvis stress fractures, except femoral neck, is fairly straightforward. Most resolve with 4 to 6 weeks of relative rest and progressive reintroduction of activities. When the patient is pain free, then progressive sporting activities may be initiated.

Due to their potential for major disability, femoral neck stress fractures require special consideration. This includes having increased awareness so that a timely diagnosis is made and specific treatment implemented. In general, these injuries are seen in two distinct populations: (1) young, healthy, active individuals such as runners or military recruits and (2) the elderly who have osteoporosis. In the high performance athlete, a devastating problem may occur when a seemingly simple nondisplaced femoral neck fracture becomes displaced. A delay in the correct diagnosis may be highly problematic and therefore a high index of suspicion is important.5 The early clinical presentation of a femoral stress fracture may mimic other more common conditions. The pain is usually around the anterior groin region similar to a hip flexor strain or pull. To a lesser degree, the pain may also be nonspecific, ill defined, or atypical around the gluteal region. Refraining from the offensive repetitive activity or excessive loading will eventually improve the symptoms and allow union.

The complication rate for femoral neck fractures is partly related to the specific type and the promptness of treatment. In an effort to efficiently guide the treatment, these fractures have been classified based on their plain radiographic and MRI appearance. The tension-type fracture involving the lateral cortex is considered more unstable and should be treated with weight-bearing protection and then expeditious surgical stabilization using a plate and screw device. The reasoning behind surgical treatment of these fractures stems from the potential for malunion and osteonecrosis if they become displaced. The compression-type fracture involving the medial side is biome-chanically more stable and can usually be treated conservatively with serial radiographs, protected weight bearing, and activity modification (Fig. 44-2). In view of the fact that these fractures have potential for major disability, it behooves the clinician to order an MRI study sooner in performance athletes, especially females, to both obtain an expeditious diagnosis and avoid potential litigation. Although extremely uncommon, there have been reports of compression-type fractures also becoming displaced, and, as a consequence, some authors have recommended internal fixation if a compression type of neck fracture involves more than 50% of the cortex.6 All patients with femoral neck fractures should be educated about potential problems with their hip joint. The surgical risks include chondrolysis, nonunion, malunion, osteonecrosis, and subtrochanteric iatrogenic fractures. An appropriate period of toe-touch weight bearing should

Figure 44-2 Magnetic resonance imaging (MRI) of the pelvis depicts a stable compression type of femoral neck fracture. These fractures are typically stable and can be treated with close observation, serial radiographs, protected weight bearing, and physical therapy. In an athlete with groin pain, the consideration for an early MRI should be made in order to avoid potential complications.

Figure 44-2 Magnetic resonance imaging (MRI) of the pelvis depicts a stable compression type of femoral neck fracture. These fractures are typically stable and can be treated with close observation, serial radiographs, protected weight bearing, and physical therapy. In an athlete with groin pain, the consideration for an early MRI should be made in order to avoid potential complications.

follow surgical fixation. Radiographic healing and signs of osteonecrosis are monitored with periodic plain radiographs. Even in cases of appropriate treatment, many patients may have persistent long-term disabling complaints. The results of surgical treatment may be influenced by the amount of fracture displacement and the quality of the fracture reduction. The incidence of osteonecrosis in nondisplaced fractures is approximately 15%.7 Fractures that develop osteonecrosis may require a prosthetic replacement or other secondary procedure. MRI following fixation of a femoral neck fracture is usually of poor quality due to the artifactual signal from the metal screws. Routine removal of the hip fixation device is not recommended unless the hardware has failed or when a future MRI is anticipated. Hip arthroscopy after a healed femoral neck fracture has not been evaluated well in the literature. Young patients who develop symptomatic osteonecrosis may benefit from a referral to a specialist experienced in core decompression, bone grafting, and vascularized fibula transfers. Unfortunately, many patients will continue to experience differing levels of symptoms at long-term follow-up following femoral neck fractures.8

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