Minor pelvic fractures in the older adult
- James Fiechtl, MD
James Fiechtl, MD
- Assistant Professor, Departments of Emergency Medicine and Orthopaedics
- Vanderbilt University
- Section Editors
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics
- Professor of Family Medicine
- Oregon Health Sciences University
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
Minor pelvic fractures in the elderly involve either low energy mechanisms or repetitive stresses in osteoporotic bone (insufficiency fractures). These fractures may be either displaced or non-displaced and generally involve both anterior and posterior elements of the pelvis. For the purposes of this review, low energy and pelvic insufficiency fractures will be considered together as some degree of insufficiency is universally present.
The diagnosis and management of minor low-energy and insufficiency pelvic fractures in elder patients is reviewed here. Such fractures consist primarily of fractures of the pubic rami and the sacral ala. Osteoporosis, hip fractures, and major pelvic trauma are discussed separately. (See "Osteoporotic fracture risk assessment" and "Overview of the management of osteoporosis in postmenopausal women" and "Hip fractures in adults" and "Pelvic trauma: Initial evaluation and management" and "Severe pelvic fracture in the adult trauma patient".)
Incidence and mortality — Pelvic fractures represent approximately 3 percent of all skeletal injuries, regardless of age; however, data about minor pelvic fractures specifically in elder patients are limited . A Finnish population study determined the incidence for pelvic insufficiency fractures to be 92 per 100,000. This number represents approximately one-fifth the incidence of femoral neck fractures . The incidence of these fractures is increasing: from 1988 to 2000, the incidence increased 58.4 percent in men and 110.8 percent in women .
A retrospective review of 181 elder patients with pelvic insufficiency fractures reported an associated mortality rate of 23 percent at one year . This rate did not vary significantly with fracture location or the degree of fracture displacement.
Risk factors — Risk factors for these injuries are similar to those for osteoporosis: advanced age, prior pelvic fracture, glucocorticoid therapy, low body weight, smoking, and excess alcohol intake. Additional risk factors include a history of pelvic radiation, Pagets disease, rheumatoid arthritis, and multiple myeloma . (See "Osteoporotic fracture risk assessment", section on 'Clinical risk factor assessment'.)
- Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005; 36:1.
- Kannus P, Palvanen M, Niemi S, et al. Epidemiology of osteoporotic pelvic fractures in elderly people in Finland: sharp increase in 1970-1997 and alarming projections for the new millennium. Osteoporos Int 2000; 11:443.
- Boufous S, Finch C, Lord S, Close J. The increasing burden of pelvic fractures in older people, New South Wales, Australia. Injury 2005; 36:1323.
- Mears SC, Berry DJ. Outcomes of displaced and nondisplaced pelvic and sacral fractures in elderly adults. J Am Geriatr Soc 2011; 59:1309.
- Lyders EM, Whitlow CT, Baker MD, Morris PP. Imaging and treatment of sacral insufficiency fractures. AJNR Am J Neuroradiol 2010; 31:201.
- Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988; 227:67.
- De Smet AA, Neff JR. Pubic and sacral insufficiency fractures: clinical course and radiologic findings. AJR Am J Roentgenol 1985; 145:601.
- Finiels H, Finiels PJ, Jacquot JM, Strubel D. [Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases]. Presse Med 1997; 26:1568.
- Schindler OS, Watura R, Cobby M. Sacral insufficiency fractures. J Orthop Surg (Hong Kong) 2007; 15:339.
- Gotis-Graham I, McGuigan L, Diamond T, et al. Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br 1994; 76:882.
- Bogost GA, Lizerbram EK, Crues JV 3rd. MR imaging in evaluation of suspected hip fracture: frequency of unsuspected bone and soft-tissue injury. Radiology 1995; 197:263.
- Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency department. AJR Am J Roentgenol 2010; 194:1054.
- Dominguez S, Liu P, Roberts C, et al. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs--a study of emergency department patients. Acad Emerg Med 2005; 12:366.
- Henes FO, Nüchtern JV, Groth M, et al. Comparison of diagnostic accuracy of Magnetic Resonance Imaging and Multidetector Computed Tomography in the detection of pelvic fractures. Eur J Radiol 2012; 81:2337.
- Gupta DK, Avram MJ. Rational opioid dosing in the elderly: dose and dosing interval when initiating opioid therapy. Clin Pharmacol Ther 2012; 91:339.
- Beall DP, Datir A, D'Souza SL, et al. Percutaneous treatment of insufficiency fractures : principles, technique and review of literature. Skeletal Radiol 2010; 39:117.
- Incidence and mortality
- Risk factors
- CLINICAL FEATURES
- Physical examination
- DIAGNOSTIC IMAGING
- Approach to imaging
- Plain radiograph
- Computed tomography
- Magnetic resonance imaging
- DIFFERENTIAL DIAGNOSIS
- DEFINITIVE MANAGEMENT
- Specialty consultation
- SUMMARY AND RECOMMENDATIONS