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DOI: 10.1055/s-0038-1673536
Die Fragilitätsfraktur des Beckens ist eine Indikatorfraktur der Osteoporose
The Fragility Fracture of the Pelvis is a Fracture indicating OsteoporosisPublication History
eingereicht:
29 May 2018
angenommen:
04 June 2018
Publication Date:
21 September 2018 (online)
Zusammenfassung
Die Inzidenz der Fragilitätsfraktur des Beckens nimmt erheblich zu. Die Fraktur ist Folge eines niedrigenergetischen Traumas. Risikofaktoren sind das Alter, das weibliche Geschlecht und die Osteoporose. Die Patienten leiden an immobilisierenden Schmerzen im Bereich der Schamregion, der Leiste oder des tiefen Rückens. Die Diagnostik beruht auf der konventionellen Bildgebung und der Computertomographie. Die Morphologie dieser Frakturen unterscheidet sich von denen eines hochenergetischen Traumas. Die neue FFPKlassifikation differenziert vier Kategorien des Stabilitätsverlusts unterschiedlichen Ausmaßes. Die Subtypen unterscheiden verschiedene Lokalisationen der Frakturen im posterioren Beckenring. Die Behandlung beinhaltet Schmerztherapie, Physiotherapie, aktivierende Pflege und eine spezifische Osteoporose-Therapie. Bei Fragilitätsfrakturen mit Beteiligung des posterioren Beckenrings sollte eine operative Stabilisierung in Betracht gezogen werden. Die chirurgische Behandlung sollte möglichst wenig invasiv sein. Die Wiederherstellung der Stabilität ist entscheidender als die Wiederherstellung der Anatomie. Verschiedene minimalinvasive Verfahren für den posterioren und anterioren Beckenring werden vorgestellt.
Summary
The incidence of fragility fractures of the pelvis (FFP) is increasing. Risk factors are age, female sex and osteoporosis. Patients present with immobilizing pain in the pubic region, the groin and/or the lower back. Diagnosis is made with conventional radiographs and computed tomography. The morphology of the fractures is different from those in highenergy trauma. In more than 80% of cases, the posterior and anterior pelvic ring are involved in the fracture pattern. The sacral ala is very frequently fractured, because of the important decrease of bone density in this region. Over time, new fractures may add to the original ones, which make the pelvic ring even more unstable. The new FFP-classification distinguishes between four different categories of increasing instability. FFP Type I has an anterior pelvic ring fracture only, FFP Type II an undisplaced posterior pelvic ring fracture. FFP Type III is characterized by a displaced but unilateral posterior pelvic ring injury, FFP Type IV by a displaced bilateral posterior pelvic ring injury. The subtypes differentiate between the localisation of the posterior pelvic ring lesion: through the ilium, through the iliosacral joint or through the sacrum. Management is multidisciplinary and contains pain therapy, physiotherapy, activating care and therapy of osteoporosis. FFP Type I are treated conservatively. The most important goals are regaining mobility and independency for activities of daily life. Out-of-bed mobilization is started as early as possible when tolerated by the patient. The patient is discharged when distinct prerequisites of mobility and pain control are fulfilled. FFP Type II are also treated conservatively. We may expect a more cumbersome mobilization because of the involvement of the posterior pelvic ring. If mobilization has not been successful after one week, a surgical stabilization must be taken into account. FFP Type III and FFP Type IV should be treated operatively. It is recommended to stabilize both the posterior and the anterior pelvic ring. The principles of surgery for fragility fractures are different than for high-energy pelvic trauma. The surgical procedure must be as less invasive as possible, restoration of stability is more important than restoration of anatomy. Several minimal invasive procedures for the stabilization of posterior and anterior pelvic ring fractures have been developed. Sacroplasty, iliosacral screw osteosynthesis with or without cement augmentation, sacral bar fixation, transiliac internal fixation and iliolumbar fixation are alternative procedures for the posterior pelvic ring. Several techniques can be combined enhancing stability of the bone-implants-construction. Retrograde transpubic screw fixation, anterior internal fixation and plate osteosynthesis are alternative procedures for the anterior pelvic ring. Prospective studies are needed evaluating the benefits of the different procedures and outcome of fragility fractures of the pelvis.