Osteologie 2018; 27(03): 144-153
DOI: 10.1055/s-0038-1673536
Orthopädische Osteologie – Orthopedic Osteology
Georg Thieme Verlag KG Stuttgart · New York

Die Fragilitätsfraktur des Beckens ist eine Indikatorfraktur der Osteoporose

The Fragility Fracture of the Pelvis is a Fracture indicating Osteoporosis
P. M. Rommens
1   Zentrum für Orthopädie und Unfallchirurgie, Universitätsmedizin Mainz, Johannes Gutenberg-Universität, Mainz
,
P. Drees
1   Zentrum für Orthopädie und Unfallchirurgie, Universitätsmedizin Mainz, Johannes Gutenberg-Universität, Mainz
,
S. Thomczyk
1   Zentrum für Orthopädie und Unfallchirurgie, Universitätsmedizin Mainz, Johannes Gutenberg-Universität, Mainz
,
U. Betz
2   Institut für Physikalische Therapie, Prävention und Rehabilitation, Universitätsmedizin Mainz, Johannes Gutenberg-Universität, Mainz
,
D. Wagner
1   Zentrum für Orthopädie und Unfallchirurgie, Universitätsmedizin Mainz, Johannes Gutenberg-Universität, Mainz
,
A. Hofmann
3   Klinik für Unfallchirurgie und Orthopädie 1, Westpfalz-Klinikum Kaiserslautern, Kaiserslautern
› Author Affiliations
Further Information

Publication 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.

 
  • Literatur

  • 1 Sullivan MP, Baldwin KD J, Donegan DJ, Mehta S, Ahn J. Geriatric fractures about the hip: Divergent patterns in the proximal femur, acetabulum, and pelvis. Orthopedics 2014; 37 (03) 151-157.
  • 2 Kannus P, Parkkari J, Niemi S, Sievänen H. Lowtrauma pelvic fractures in elderly finns in 1970–2013. Calcif Tissue Int 2015; 97 (06) 577-580.
  • 3 Silke SAndrich, Burkhard BHaastert, Neuhaus E, Neidert K, Arend W, Ohmann C, Grebe J, Vogt A, Jungbluth P, Rösler G, Windolf J, Icks A. Epidemiology of pelvic fractures in Germany: considerably high incidence rates among older people. PLoS ONE 10 (09) e0139078.
  • 4 Maier GS, Kolbow K, Lazovic D, Horas K, Roth KE, Seeger JB, Maus U. Risk factors for pelvic insufficiency fractures and outcome after conservative therapy. Arch Gerontol Geriatr 2016; 67: 80-85.
  • 5 Dachverband Osteologie e.V. Prophylaxe, Diagnostik und Therapie der Osteoporose bei postmenopausalen Frauen und bei Männern. Version 2017. Langfassung. AWMF-Register-Nr. 183/001, 216 Seiten.
  • 6 Rommens PM, Hofmann A, Hessmann MH. Management of acute hemorrhage in pelvic trauma: an overview. Eur J Trauma Emerg Surg 2010; 36 (02) 91-99.
  • 7 Rommens PM, Kuhn S, Hofmann A. Stammverletzung: Becken. Kapitel 16 in: Management des Schwerverletzten. Hrsg. Pape HC, Hildebrand F, Ruchholtz S. 1. Aufl. 2018. Springer Heidelberg; Seiten: 155-178.
  • 8 Rommens PM, Wagner D, Hofmann A. Fragility fractures of the pelvis. JBJS Rev. 2017 21; 05. (3)
  • 9 Wagner D, Kamer L, Sawaguchi T, Richards RG, Noser H, Rommens PM. Sacral bone mass distribution assessed by averaged three-dimensional CT models: implications for pathogenesis and treatment of fragility fractures of the sacrum. J Bone Joint Surg Am 2016; 98 (07) 584-590.
  • 10 Linstrom NJ, Heiserman JE, Kortman KE, Crawford NR, Baek S, Anderson RL, Pitt AM, Karis JP, Ross JS, Lekovic GP, Dean BL. Anatomical and biomechanical analyses of the unique and consistent locations of sacral insufficiency fractures. Spine (Phila Pa 1976) 2009; 34 (04) 309-315.
  • 11 Hammer N, Lingslebe U, Aust G, Milani TL, Hädrich C, Steinke H. Ultimate stress and age-dependent deformation characteristics of the iliotibial tract. J Mech Behav Biomed Mater 2012; 16: 81-86.
  • 12 Dietz SO, Hofmann A, Rommens PM. Haemorrhage in fragility fractures of the pelvis. Eur J Trauma Emerg Surg 2015; 41 (04) 363-367.
  • 13 Nüchtern JV, Hartel MJ, Henes FO, Groth M, Jauch SY, Haegele J, Briem D, Hoffmann M, Lehmann W, Rueger JM, Großterlinden LG. Significance of clinical examination, CT and MRI scan in the diagnosis of posterior pelvic ring fractures. Injury 2015; 46 (02) 315-319.
  • 14 Cabarrus MC, Ambekar A, Lu Y, Link TM. MRI and CT of insufficiency fractures of the pelvis and the proximal femur. AJR Am J Roentgenol 2008; 191: 995-1001.
  • 15 Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: Recommendations for surgical treatment. Injury 2013; 44: 1733-1744.
  • 16 Rommens PM, Wagner D, Hofmann A. Minimal invasive surgical treatment of fragility fractures of the pelvis. Chirurgia (Bucur) 2017; 112: 524-537.
  • 17 Schilling S. Epidemic vitamin D deficiency among patients in an elderly care rehabilitation facility. Dtsch Arztebl Int 2012; 109: 33-38.
  • 18 Peichl P, Holzer LA, Maier R, Holzer G. Parathyroid hormone 1–84 accelerates fracture-healing in pubic bones of elderly osteoporotic women. J Bone Joint Surg Am 2011; 93 (17) 1583-1587.
  • 19 Sato T, Shiota N, Sawaguchi T. Non-Operative Treatment. Chapter 8 in “Fragility fractures of the pelvis”. Rommens P, Hofmann A. eds. Springer; London: 2017: 87-99.
  • 20 Babayev M, Lachmann E, Nagler W. The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate?. Am J Phys Med Rehabil 2000; 79: 404-409.
  • 21 Kates SL, Mears SC. A Guide to Improving the Care of Patients With Fragility Fractures. Geriatric Orthopaedic Surgery & Rehabilitation 02 (01) 5-37.
  • 22 Bastian JD, Ansorge A, Tomagra S, Siebenrock KA, Benneker LM, Büchler L, Keel MJ. Anterior fixation of unstable pelvic ring fractures using the modified Stoppa approach: mid-term results are independent on patients’ age. Eur J Trauma Emerg Surg 2016; 42: 645-650.
  • 23 Garant M. Sacroplasty: a new treatment for sacral insufficiency fracture. J Vasc Interv Radiol 2002; 13: 1265-1267.
  • 24 Bastian JD, Keel MJ, Heini PF, Seidel U, Benneker LM. Complications related to cement leakage in sacroplasty. Acta Orthop Belg 2012; 78: 100-105.
  • 25 Kortman K, Ortiz O, Miller T, Brook A, Tutton S, Mathis J. et al. Multicenter study to assess the efficacy and safety of sacroplasty in patients with osteoporotic sacral insufficiency fractures or pathologic sacral lesions. J Neurointerv Surg 2013; 05: 461-466.
  • 26 Keating JF, Werier J, Blachut P, Broekhuyse H, Meek RN, O’Brien PJ. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma 1999; 13: 107-113.
  • 27 Hopf JC, Krieglstein CF, Müller LP, Koslowsky TC. Percutaneous iliosacral screw fixation after osteoporotic posterior ring fractures of the pelvis reduces pain significantly in elderly patients. Injury 2015; 46: 1631-1636.
  • 28 Wähnert D, Raschke MJ, Fuchs T. Cement augmentation of the navigated iliosacral screw in the treatment of insufficiency fractures of the sacrum: a new method using modified implants. Int Orthop 2013; 37 (06) 1147-1150.
  • 29 Wagner D, Kamer L, Sawaguchi T, Richards RG, Noser H, Hofmann A, Rommens PM. Morphometry of the sacrum and its implication on transsacral corridors using a computed tomography data-based three-dimensional statistical model. Spine J. 2017 Mar 31. pii: S1529–9430(17)30131–6.
  • 30 Vanderschot P, Kuppers M, Sermon A, Lateur L. Trans-iliac-sacral-iliac-bar procedure to treat insufficiency fractures of the sacrum. Indian J Orthop 2009; 43: 245-252.
  • 31 Mehling I, Hessmann MH, Rommens PM. Stabilization of fatigue fractures of the dorsal pelvis with a trans-sacral bar. Operative technique and outcome. Injury 2012; 43: 446-451.
  • 32 Füchtmeier B, Maghsudi M, Neumann C, Hente R, Roll C, Nerlich M. Die minimalinvasive Stabilisierung des dorsalen Beckenrings mit dem transiliakalen internal Fixateur (TIFI): chirurgische Technik und erste klinische Ergebnisse. Unfallchirurg 2004; 107: 1142-1151.
  • 33 Salášek M, Pavelka T, Křen J, Weisová D, Jansová M. [Minimally invasive stabilization of posterior pelvic ring injuries with a transiliac internal fixator and two iliosacral screws: comparison of outcome]. Acta Chir Orthop Traumatol Cech 2015; 82: 41-47.
  • 34 Schildhauer AT, Chapman JR. Triangular Osteosynthesis and Lumbopelvic Fixation. Chapter 16 in “Fragility fractures of the pelvis”. Rommens P, Hofmann A. eds. Springer; London: 2017: 177-192.
  • 35 Gänsslen A, Krettek C. Retrograde transpubic screw fixation of transpubic instabilities. Oper Orthop Traumatol 2006; 18: 330-340.
  • 36 Acklin YP, Zderic I, Buschbaum J, Varga P, Inzana JA, Grechenig S, Richards RG, Gueorguiev B, Schmitz P. Biomechanical comparison of plate and screw fixation in anterior pelvic ring fractures with low bone mineral density. Injury 2016; 47: 1456-1460.
  • 37 Hiesterman TG, Hill BW, Cole PA. Surgical technique: a percutaneous method of subcutaneous fixation for the anterior pelvic ring: the pelvic bridge. Clin Orthop Relat Res 2012; 470: 2116-2123.
  • 38 Vaidya R, Kubiak EN, Bergin PF, Dombroski DG, Critchlow RJ, Sethi A, Starr AJ. Complications of anterior subcutaneous internal fixation for unstable pelvis fractures: a multicenter study. Clin Orthop Relat Res 2012; 470: 2124-2131.
  • 39 Rommens P, Wagner D, Hofmann A. Surgical management of osteoporotic pelvic fractures: a new challenge. Eur J Trauma Emerg Surg 2012; 38: 499-509.
  • 40 Oberkircher L, Ruchholtz S, Rommens PM, Hofmann A, Bücking B, Krüger A. Osteoporotic pelvic fractures. Dtsch Arztebl Int 2018; 115: 70-80.