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Post Traumatic Double Pelvic Fracture

Short summary

73-year-old female with history of backache and diagnosis of Adult Scoliosis, fell down getting a back trauma at the level of the left hip and inferior limb. After severe symptomatic worsening X-ray examination was performed. The findings were: asymmetric pelvis, bilateral coxarthrosis, coarse arthrosic and osteophytosic manifestations, discopathies and disc arthrosis. The prescribed therapy included Piroxicam, Tioside, Depalgos, and low-molecular-weight-heparin therapy that was later replaced by NSAIDs by injection

Patient's questions

In the light of the two fractures highlighted with the pelvis CAT scan in the framework of the patient’s general clinical picture the following questions are asked:

1) What therapy do you suggest? In the event you suggest bed confinement or, even, complete immobilization, which pharmacologic therapy you think has to be connected? (heparin, anti-platelet therapy, pain medications, etc.)?

2) Is a surgical intervention to take into consideration?

3) Considering that recovery will take a long time, do you think that physiotherapy is useful to avoid a hypomobility syndrome connected to the muscle atrophy and possible articular failure? If yes, can you indicate ways and times?

4) How long will the recovery last? Will the recovery be complete?

5) What therapeutic indications can you suggest in connection with the lumbosacral spine pathology highlighted by the lumbar NMR?

Medical Background

Patient's History
Female , 73 years old
Diagnosis: Post Traumatic Double Pelvic Fracture

Right Annessiectomy due to extrauterine pregnancy.
Gastroduodenal Ulcer under pharmacological therapy.
Hepatitis C.
Past Right Carpal Tunnel intervention.
Arterial Hypertension.
Hip and Lumbar Spine Arthrosis.

Orthopaedic History:
73-year-old female patient suffering from backache since March 2008 for which she has carried out:

- Dorsal and lumbosacral spine X-ray with oblique projections performed on 08/2008 (enclosed): “Lumbar scoliosis convex to the right with torsion of metamers and trace of superior compensation. Marked dorsal and lumbar spondiloarthrosis, with coarse calcifications above all at the front dorsal level on the right lateral side. Osteophytic Bridges also in the lumbar area. Intervertebral spaces reduction in the upper dorsal segment, diffuse at lumbar level with disc calcifications. Marked Interapophyseal Arthrosis with sclerotic aspect of the right interapophyseal region of the lower lumbar segment.”

- Orthopedic visit carried out on 08/2008: at the clinical examination “mobile lumbosacral spine, painful when stressed beyond its passive range of motion, no current peripheral neurological dysfunction, negative Laségue’s sign bilaterally.” The diagnosis has been, therefore, of “Adult Scoliosis” with indication, from the orthopedist, to carry out a Lumbosacral Spine NMR.

- Lumbar Spine NMR carried out on 10/2008 (enclosed): “Right Convex Deviation with moderate anterior sliding of L3 on L4 and L4 on L5. Metameric rotation. Spondiloarthrosis with hypertrophy of articular processes and vertebral osteophytosis. The spine channel at the lower lumbar segment shows reduced size. The hollow at the lower limit of L3 is clear with intact posterior wall with no results of signal alterations. Results of hollow of the upper limit of L4. The intervertebral disc D11-D12 is dehydrated and shows a median posterior focal protrusion with impression on the dural sac. The Intervertebral Disc L1-L2 is totally protruding in particular in left paramedian and median area. The Intervertebral Disc L2-L3 is totally protruding with left foraminal involvement of the disc. Total protrusion of the Intervertebral Disc L3-L4 too, also in connection with the moderate listesis previously described. It also shows a Left Intraforaminal Disc Herniation. The Intervertebral Disc L4-L5 is totally protruding and herniated in the right intraforaminal area. Total protrusion of the Intervertebral Disc L5-S1. Medullary cone normal from the point of view of signals.”

- The following orthopedic visit, on the basis of the above-described NMR, was consistent with indications for the continuative use of a rigid corset and courses of dedicated physiotherapy.

On 12/2008 also a femoral and lumbar CBM was carried out: at lumbar level the sensitometric values still appear to be proportionate to the age of the patient (T-SCORE <L2-L4>: --0,5; Z-SCORE <L2-L4>: + 1.3); at the femoral level, on the contrary, the bone mineral content is reduced if compared to normal limits, at the lower limits of the standard deviation (T-SCORE <femoral neck>: - 2.7; Z-SCORE <femoral neck>: - 1.1).

Case history:
On the morning of March 2009 the patient fell down getting a back trauma at the level of the left hip and inferior limb. Soon after the trauma and during the following 2 days, the symptomatology appeared to be moderate, only restricted to a modest pain to the hip and the left groin that did not involve severe ambulation limitations. From the 3rd day following the fall, a clear worsening of the painful symptomatology took place with ingravescent course until the impossibility of an independent ambulation. Therefore, on April 2009 the patient was taken to the Emergency Room of the Gaetano Pini Orthopaedic Institute in Milan where she underwent orthopedic visit and left hip and pelvis x-ray, without evidence of fracture. The discharge diagnosis reported, therefore, “left hip bruise” with a 14 days prognosis and indication to repeat the X-ray after 14 days of rest in the event of persisting pain. At home the patient did not observe complete rest keeping up, although in reduced measure, the housework walking on a single crutch. The pain remained stable for about two weeks slightly improving during the third week. It is reported, moreover, that this pain, in the meantime, had moved from the groin-thigh and the left hip region to the homolateral gluteal area. From the 4th week, following the Emergency Room assessment, (therefore from May 2009 on) further severe symptomatic worsening located at the left gluteal level near the sacral region of the spine. At this point the GP has invited the patient to observe a complete rest period with possibility to move (when necessary) only by means of two crutches in order to avoid overloading the left inferior limb. The patient underwent therapy with Clexane 2000 UI to prevent her from possible thromboembolism.

New left coxofemoral and pelvis X-ray was carried out on May 2009 (enclosed) with the medical report indicative of: “Asymmetric Pelvis probably due to a wrong position. Bilateral coxarthrosis. Coarse arthrosic and osteophytosic manifestations at the caudal lumbar spine segments highlighted at the lumbosacral passage with reduction of the spaces and probable discopathies and disc arthrosis. Small round calcified image that projects to the right iliac wing probably due to a structural overlap. Reduction in calcium content.” For the intense algic symptomatology the patient is, at this moment, under therapy with 1 daily injection of 1 vial of Piroxicam 20 mg+1 vial of Tioside associated to osteoporosis therapy with Depalgos 10 mg at a dosage of 1 tablet every 8 hours. The low-molecular-weight-heparin therapy has been discontinued for the insertion of NSAIDs by injection. Finding inconsistency between the result of instrumental examination and the clinical picture, the GP deemed it necessary to require further instrumental examinations with the following medical reports:

1) Pelvis CAT scan carried out on 05/2009 (enclosed): “.. the examination highlights a simple complete fracture with little healing callus of the left superior ileo-pubic branch, directly to its connection to the anterior pillar of the acetabulum and a simple fracture with presence of little healing callus at the medial third of the left inferior ileo-pubic branch. No current focal bone lesions. The remaining pelvis skeleton findings are within normal limits as for the age.”

2) Ultrasound scan of soft tissues of the left gluteal and thigh region following the reported injury of 05/2009: “at present, a moderate signal alteration on hyperechoic basis of the piriform and gluteus minimus muscle, probably as a result of trauma with bleeding and bruising but with no evidence of muscular damage, is appreciated. Neither effusions nor extra-muscle masses. The remaining findings are within normal limits as for the age.”

On completion of the patient’s clinical picture the current home pharmacological therapy is reported:
- Protelos 2 g at a dosage of 1 sachet daily;
- Combisartan 160/12.5 mg at a dosage of 1 tablet daily;
- Lucen 20 mg at a dosage of 1 tablet daily; A therapy for the pain management, due to fractures, has been added to this chronic therapy, consisting of:
- Depalgos 10 mg at a dosage of 1 tablet every 8 hours;
- Piroxicam 20 mg + Tioside 2 ml in a single syringe at a dosage of 1 daily injection.


Medical opinion

On the basis of the information available I conclude that the patient suffer form a lateral compression type I pelvic fractures, on top of sever degenerative spondilo-arthrosis.

Lateral compression fracture in this age group might be a result of falling on the lateral aspect of the pelvis, causing fractures of the superior and inferior ramus-pubis and some time a compression fracture of the sacrum as well. Sometimes those fractures are almost invisible on plain radiographs and might be missing while ridding.

The prognosis of these fractures is fairly good. Most of the time fully recover might be anticipate in 3-6 months. Treatment is usually conservative and ambulation is allowed as tolerate with aid of physiotherapy and a walker.

Physiotherapy is recommended to keep up joints motion and muscle strength, in the limit of pain.

If the patient is yet very painful to day, I would recommend for a clinical orthopedic consult to evaluate the origin of the pain: mostly - spine or pelvic. On the basis of this clinical evaluation, if pain is seem to be of pelvic origin I think that new plain radiographs of the entire pelvic (AP+inlet+outlet) as well as new CAT scan are needed in order to rule out non-union of the fractures. I think that evaluation of the SIJ is essential. On the other hand, if the fractures healed and SIJ are in good condition, I would recommend consulting with spine surgeon specialist.