A Viewpoint on Pelvic Fracture in Cipto Mangunkusumo Hospital in 2011

Mohammad Fachry Lubis*Ismail HD**Bambang Gunawan**Ihsan Oesman**Djoko Simbardjo**

*Resident of Orthopedic and Trauma, FMUI/CMH

**Staff of Orthopedic and Trauma,FMUI/CMH

Background

Overall incidence of pelvic fractures is

estimated about 3% among all variety of

fractures and individuals. It is counted

approximately 19-37 injuries per 100.000

inhabitants per year. The structure of pelvic

organs include its close proximity of

osteoligamentous, neurovascular, hollow-

viscera, and urogenitalia may lead to wide

range of severe complications and late

sequalae once it is not diagnosed or treated

as early. Recognizing this issue, this study

explores the importance of knowing the

distribution of age, gender, mechanism,

type, treatment, complication, and outcome

of pelvic fractures in Cipto Mangunkusumo

Hospital (CMH).

Methods

Patients with all range of age and gender

included in this study firstly are admitted to

CMH ER. This study is conducted within

the period of 01/10/10 until 01/10/11.

Results

There were 30 patients diagnosed with

pelvic fractures included in this study, which

about 4% of all fractures that were admitted

to CMH ER. 33% of all pelvic fractures

were ranged at 31-50 years old, which are

considered as the peak incidence. The ratio

of male compared to female patient was

2.5:1. According to Tile classification, the

highest incidence occurred in CMH were

type MTA2 (42.86%), followed by MTC2

which were found in 7 cases counted

23.33%. MTC1 and MTC3 were found in

only 3 cases (10%), MTB2 were found in 2

cases (6.67%), and lastly MTB1 was found

in only 1 case (3.37%). This study also

divided the fracture into the stable and the

unstable and there were 14 cases of stable

pelvic fracture counted 46.67% and 16 cases

counted 53.33% of the unstable. Urogenital

injury is the most common complication of

pelvic fractures which occur in 11 cases

counted 36.67% followed by hemorrhage

which occur in 4 cases (13.33%). In

emergency department, 66.67% patients

were treated with pelvic binder, 20% with

skeletal traction, 14.29% with skin traction,

10% with external fixation, and the rest

which counted 13.33% were still under

observation. C- clamp, as one of operative

treatment option, was applied for initial

treatment in 10% among all patient (2

patients) and in 1 patient for both initial and

definitive treatment. In addition, ORIF was

also applied to 12 patients (40%) in CMH

within this 1 year of study period. By using

Majeed Pelvic Score, 8 patients counted

26.67% have an excellent score ranged

calculated >85 and >75. Which, from the 8,

6 patients were treated conservatively and 2

patients were treated operatively. However,

the rest 4 patients showed subordinate score

calculated < 55 and < 45. The 4 consisted of

3 patients that were treated operatively and 1

with conservative treatment. Some of

patients included in this study had just been

treated in below three months.

Conclusion

The age of ranged 31-50 years old is

associated with higher rate of pelvic

fractures. Male have higher incidence of

than female. ORIF, with its high percentage

of usage and success, is now a usual

treatment procedure of pelvic fractures in

CMH. Pelvic fracture cases treated with

ORIF according to Majeed pelvic Score in

CMH shows relatively excellent outcome.

This study aim, however, reported several

option of pelvic fracture treatment in CMH.

Keywords: Pelvic fracture, pelvic trauma.

Introduction

Pelvic fracture cases are rare compared to

fractures in other body regions. Overall

incidence is estimated about 3% among all

fractures, calculated 19–37 injuries per

100,000 inhabitants per year. Amongst

“polytrauma” patients, the incidence has

risen about to 25% and most of cases are

traffic-related fatalities with recorded

percentage of 42%.1

Due to its complicated structure surrounding

the area, peplvic fracture should be

diagnosed and treated as soon. The close

proximity of osteoligamentous to pelvic

organs, neurovascular, hollow-viscera, and

the present of urogenital organs might lead

to severe complications and late sequelae.1,2,3

In addition, detail information of the

mechanism of injury could be very helpful

in treating pelvic fractures.2 Trauma caused

by lateral compression, avulsion, fall from

height, and crush injuries definitely have

different management scenarios.4 In such

cases, accurate anamneses must be followed

by good physical examination detecting

whether there is a complication of injury.

Physical examination should be started from

checking the airway, breathing, and

circulation; followed by the examination

upon pelvic region. It is very important to

notice if there is haematuria and

neurovascular disturbance which might be

the sign of surrounding organ complication.

AP, inlet, and outlet projections are standard

radiological examination to evaluate pelvic

structures.2 CT-scan is necessary to

recognize information including fractures

anatomy, size, and hematoma location. MRI

is considered to gather additional

information such as the condition of pelvic

ligaments.1,4

Initial treatment for pelvic injuries is

resuscitation followed by hemorrhage

control.3 Operative treatment options applied

are external fixation or internal fixation.

External fixation is usually used in the

setting of emergency conditions and internal

fixation is usually for definitive treatment.

Pubic rami fractures, transsymphyseal

instability, sacroiliac instability, or

transsacral instability are examples of injury

treated with internal fixation.5

Materials and Methods

This study was undergone in Orthopedic and

Traumatology department of CMH in range

time of October 2010 – October 2011. All

pelvic fracture patients admitted were

included in this study.

Variables that are evaluated in this study are

age, sex, mechanism of trauma, type of

fracture (according to Marvin Tile, Young

Burgess, and AO), initial treatment,

definitive treatment, complications, and

outcome.

Results

There were 30 patients included in this

study, all with pelvic fractures. 22 patients

(73.33%) of them are male and 8 (26.67%)

of them are female. The ratio of male

compare to female is 2.75:1. The age range

is between 9-77 years old. Age and sex

distribution can be seen in the table below

Table 1. Age and Sex Distribution of Pelvic fractures Patients in Cipto Mangunkusumo Hospital

Age (Years) No.of Patients Sex % Age

men women

<18 9 5 4 30%

18-30 7 5 2 23,33%

31-50 10 10 0 33,33%

51-70 3 2 1 10%

>70 1 0 1 3,33%

Most cases are closed pelvic fracture, with

26 cases counted 86.67%. Anterior-

posterior compression was the highest type

which occur in 73.33% cases (22 patients),

followed by 5 cases (16.67%) of various

type of fracture.

Table II. Trauma Mechanism and Fracture Type Distribution In Cipto Mangunkusumo Hospital

Trauma Mechanism No.of patients

% Type No.of patients

%

Anterior Posterior Compression

22 73,33% Open 4 13,33%

Lateral Compression3 10 % Closed 26 86,67%

Vertical Shear 0 0%

Combination 5 16,67%

By using Marvin Tile Classification, MTA2 is

the highest type occurred with the

percentage 40% (12 patients). Stable

fracture type was found in 14 patients

(46.67%) and unstable in 16 patients

(53.33%). Other classification, Young-

Burgess, APCI has the highest number,

which it is occurs in 13 patients (43.33%).

Thirdly, according to AO classification, the

highest number that occurs is type A (stable

type), as we found it in 16 patients

(53.33%). Open pelvis fracture found in 4

patients (13.33%) and closed pelvic fracture

found in 26 patients (86.67%).

Table III. Pelvic Fracture Classification Distribution in Cipto Mangunkusumo Hospital

Marvin-Tile Young-Burgess AO

Type No.of patients

% Type Jumlah % Tipe No.of patients

%

MTA 1 2 6,67% LC 1 1 3,33% A 16 53,33%

MTA 2 12 40% LC 2 1 3,33% B 6 20%

MTA 3 0 0% LC 3 2 6,67% C 8 26,67%

MTB 1 1 3,33% APC 1 13 43,33%

MTB 2 2 6,67% APC 2 5 16,67%

MTB 3 0 0% APC 3 4 13,33%

MTC 1 3 10% VS 0 0%

MTC 2 7 23,33% CM 4 13,33%

MTC 3 3 10%

1a 1b

1c 1d

Fig 1. (a) clinical picture in AP projection, 34 years old with pelvic fracture MTC type II/LC III+ VS (combined

mechanism).(b) X-ray in AP porjection,(c) outlet projection, and (d) inlet projection.

2a 2b 2c

2d

Fig 2. (a) Clinical picture of 40 years old men in AP projection with closed fracture pelvis MTCIII (b) X-ray of

pelvis in AP projection (c) outlet projection (d) inlet projection

3a 3b

3c 3d

Fig 3. (a) Clinical picture of 11 years old boy with closed fracture pelvis MTCII, Zieg and Torode IV, Morel

Lavallee lesion in lateral projection (b) X ray inlet projection (c) AP projection (d) outlet projection.

4a 4b

4c

Fig 4. (a) Clinical picture of 18 years old woman closed pelvic fracture APC type III (b ) X ray inlet projection (c)

outlet projection

5a 5b

5c 5d

Fig 5. Women with closed pelvic fracture APCIII (a) X ray pelvis in AP projection (b) inlet projection (c) outlet

projection (d) clinical picture in lateral projection.

6a 6b 6c

6d

Fig 6. women, 17 years old with open pelvic fracture MTC2, Bilateral ramus pubis superior et inferior ,right sacrum

fracture (dennis I)(a) X ray pelvis AP projection (b)clinical picture in AP projection (c) X ray inlet projection (d)

outlet projection.

As it is mentioned as the very first treatment,

the usual second action after resuscitation,

which is the initial treatment is the

application of pelvic binder. The above was

applied to 20 patients (66.67%), whereas

followed by skeletal traction application in 6

patients.

The usual procedure for definitive

treatments was ORIF and external fixation

application. ORIF was done in 12 patients

(40%).

Table IV. Initial and Definitive Treatment Distribution in Cipto Mangunkusumo Hospital

Initial Treatment Definitive Treatment

Treatment No.of Patients

% Treatment No.of patients

%

Pelvic Binder 20 66,67% ORIF 12 40%

Skin Traction 4 13,33% External Fixation 4 13,33%

Skeletal Traction 6 20% Observation 14 46,67%

External Fixation 3 10%

Observation 4 13,33%

a 7b 7c

7d 7e

Fig 7. Thirty four years old man, Closed Fracture Pelvis MTC2 / LC III + VS (Combined Mechanism) treated with

ORIF Plate & Screw Reconstruction plate (SI joint) and Curved Reconstruction plate (Ramus Pubis) (a) - (b)

intraoperation picture of applicaton of the plate and screw on symphisis and SI joint (b) post operation X –ray, AP

projection (c) outlet projection (d) inlet projection

8a 8b

8c 8d

Fig 8. Women 18 years old with closed pelvic fracture APCIII, treated with Iliosacral screw Simphyseal Plating (a)

post operation X ray in AP projection (b) application of the symphiseal plate (c)post operation x ray in inlet

projection (d) outlet projection.

9a 9b

9c 9d

Fig 9.eleven years old boy with MTCII, CF Pelvic Torode and Zieg IV Morel Lavalle lesion , treated with closed

reduction and fixated with iliosacral screw and pubic screw (a) post operation pelvic X ray in AP projection (b) inlet

projection (c) outlet projection (d) lumbosacral X ray in AP and lateral projection

10a b

c d

Fig 10.Closed Fracture Pelvis MTC2 (Symphisis Diastasis; Closed fracture Right Rami pubis superior et inferior ;

closed fracture Sacrum transforaminal ) ,Morel-Lavallée lesion on left femur, diterapi dengan Trans Iliac Plate,

anterior plating,Debridement of Morel-Lavallée on left femur (a) post operative x ray in AP projection (b) outlet

projection (c) inlet projection.

Fig 11. Women 17 years old, Open fracture pelvis MTC2

Bilateral ramus pubis superior et inferior ,right sacrum fracture (dennis I) I treated with Anterior Frame of pelvis

(a) clinical picture of application of anterior frame (b) Morel-Lavallee on the left thigh

12a b

c d

e

Fig 12. Man, 34 years old, Closed Fracture Pelvis MTC2 / LC III + VS (Combined Mechanism) treated with ORIF

Plate & Screw Straight Reconstruction plate (SI joint) Curved Reconstruction plate (Acetabulum-ramus superior

pubic ) (a)-(b) intraoperative picture of the application of the plate and screw on SI joint and pubic symphisis (c)

post operative X ray in AP projection (d) outlet projection (e) inlet projection.

Common complications occurred worldwide

including hemorrhage, urogenital injury, and

gastrointestinal injury were also occurred in

CMH. The highest incidence in CMH was

urogenital injury which occurs in 11 cases

(36.67%). The second most commonly

occurred in CMH is hemorrhage, which

present in 4 patients (13.33%).

All patients are being followed up by using

Majeed Pelvic Score. Excellent score was

found in 8 patients (26.67%). Unfortunately,

there are 11 patients that fail to be followed.

14 patients had undergone surgery, 2

(14.29%) of them shows excellent score and

6 (42.86%) patients shows a lower score.

For additional information, some of patients

included in this study had just been

undergone surgery (< 30 days), and 2 of

patients also show a good score.

16 patients undergone conservative

treatment, which 6 of them (37.5 %) shows

excellent score, 2 patients (12.5%) shows a

lower score, and the rest 2 patients (12,5%)

shows a good score. According to Hakim et

al study, evaluation of pelvic fracture with

Oswetry scoring as well took good results

(0%-20%, minimal disability). According to

Hakim et al as well, pelvis fracture patients

that had undergone ORIF have a good

prognosis and can perform a good daily

activities with minimal difficulties.

Discussion

According to this study, we can see that the

incidence of pelvic fractures in CMH is

approximately 4%. In fact, more than a half

number of patient’s fracture is due to traffic

accident. This fact considered could relate

the injury with age factor due to its present

in productive age (31-50 years old).

The outcome evaluation of all patients is by

using Majeed Pelvic score that was studied

by Said Abdul Majeed in 1989. The

evaluation consist of pain, working ability,

sitting ability, sexual activities, and

standing ability.7 However, not all of

patients can be followed up due to reasons

such as the patient dies and the others are

cannot be reached.

Operative treatments for pelvic fractures are

usual procedure in CMH. Although

according to the results, there were still

some patients shows a poor score, but some

patients that operated within 3months have a

better result. Patients with unstable type C

are candidates to undergo surgery. The aims

of orthopedic treatments are anatomical

reduction, shorter time in hospital, and early

rehabilitation.8

The number of patient that dies are 4

patients (13.3%). The unfortunate case is

considered due to serious and complicated

pelvic injuries. Mortality rates of pelvic

fractures patients is still the same with the

study that had been conducted by Ashoke K

Sathy et al. According to above study, the

mortality rate of pelvic trauma at 13.6%.9

According to O’Sullivan the mortality rate

of pelvic fracture is 20% according to his

study in Royal Infirmary of Edinburgh.1

Conclusions

• Productive age ranged 31-50 years

old is associated with higher rates of

pelvic fractures.

• Male have higher incidence of pelvic

fractures compare to female.

• Some patients need more time to be

followed up to get promising results.

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