Version May 2024
INTRODUCTION — Minor pelvic fractures in older adults involve either low energy mechanisms or repetitive stresses in osteoporotic bone (insufficiency fractures). These fractures may be either displaced or nondisplaced 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. These injuries are sometimes referred to as "fragility fractures of the pelvis."
The diagnosis and management of minor low-energy and insufficiency pelvic fractures in older adult 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 low bone mass and osteoporosis in postmenopausal women" and "Overview of common hip fractures in adults" and "Pelvic trauma: Initial evaluation and management" and "Severe pelvic fracture in the adult trauma patient".)
EPIDEMIOLOGY
Incidence and mortality — Pelvic fractures represent approximately 3 percent of all skeletal injuries, regardless of age; however, data about minor pelvic fractures specifically in older adult patients are limited [1]. 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 [2]. 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 [3]. The epidemiology of osteoporosis generally is reviewed separately. (See "Screening for osteoporosis in postmenopausal women and men", section on 'Epidemiology'.)
A retrospective review of 181 older adult patients with pelvic insufficiency (fragility) fractures reported an associated mortality rate of 23 percent at one year [4]. 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, Paget disease, rheumatoid arthritis, multiple myeloma, chronic kidney disease, and diabetes [5]. (See "Osteoporotic fracture risk assessment", section on 'Clinical risk factor assessment'.)
ANATOMY — Pelvic insufficiency fractures most commonly involve the pubic rami and, unlike major pelvic trauma, can occur in isolation. Sacral insufficiency fractures most commonly involve the sacral ala (zone 1), either unilateral or bilateral (figure 1 and figure 2) [6]. These injuries rarely occur in isolation; 88 percent of patients have coexisting insufficiency fractures of the pubic rami, parasymphyseal, and/or iliac crest [7]. Pelvic anatomy is discussed in greater detail separately. (See "Pelvic trauma: Initial evaluation and management", section on 'Anatomy'.)
FRACTURE TYPES: CLASSIFICATION — Rommens and Hofmann have proposed a classification scheme for fragility fractures of the pelvis (FFP) that is becoming widely used in studies of management and of the efficacy of particular treatments [8-10]. A simplified version of this scheme is as follows (figure 3):
●FFP type I: Anterior pelvic ring fractures only, either unilateral or bilateral
●FFP type II: Nondisplaced posterior injuries, without or with an anterior pelvic ring injury
●FFP type III: Displaced unilateral posterior injury with an anterior pelvic ring injury
●FFP type IV: Displaced bilateral posterior injuries
Posterior injury can involve the sacrum, ilium, or iliosacral regions. Fracture displacement is the key feature that distinguish between types I and II and types III and IV. This topic deals primarily with the two most common fracture types, I and II.
CLINICAL FEATURES
History — The majority of older adult patients with minor pelvic fractures present atraumatically, with only one-third presenting after minor trauma (eg, fall from standing) [11]. Patients may have persistent symptoms for weeks or months, as the diagnosis is often missed initially or delayed. Patients may complain of lower back pain or groin pain, and are often misdiagnosed as having degenerative disc disease, spinal stenosis, or lumbar spondylosis [12]. Patients may describe increasing difficulty with ambulation, limiting their activities.
Physical examination — Initial inspection should focus on the position of the lower extremities and leg length differences. Next, palpate the major bony landmarks, including the sacrum, sacroiliac joints, iliac crests, pubic rami, and pubic symphysis. The presence of a leg length discrepancy, abnormal positioning of the leg, focal bony tenderness around the pelvis or hip, or reluctance of the patient to move their leg all raises suspicion for a pelvic injury. A careful examination of the groin should be performed to assess for other potential causes of hip pain (eg, inguinal hernia).
Following palpation, ask the patient to perform a straight-leg raise. If the patient is unable to raise their leg, defer range of motion and strength testing until imaging is obtained.
A screening neurovascular examination should be performed, although the minor pelvic fractures discussed here are unlikely to present with neurovascular deficits. Approximately 5 percent of such injuries present with neurologic symptoms, most commonly sacral radiculopathy [13]. Palpate the distal pulses and assess basic motor and sensory function of both lower extremities. (See "The detailed neurologic examination in adults".)
DIAGNOSTIC IMAGING
Approach to imaging — An anterior-posterior (AP) plain radiograph of the pelvis should be obtained for older adult patients at risk for minor pelvic fracture. Plain radiographs can reveal many types of hip, pelvic, and lumbosacral spine fractures and are a useful tool for working through the differential diagnosis of hip, groin, and low back pain in older adults. If plain radiographs reveal an anterior pelvic fracture, computed tomography (CT) is usually obtained to assess for a concomitant posterior ring fracture. According to one observational study, isolated anterior injuries occur only 17.5 percent of the time [14].
If plain radiographs of the pelvis are negative but clinical suspicion is high, magnetic resonance imaging (MRI) should be obtained. If the radiographs are negative and clinical suspicion is low (eg, patient can ambulate and strength is at baseline), the patient may follow up in the out-patient setting. At follow-up, plain radiographs should be repeated if the patient experiences persistent or worsening symptoms. If these radiographs are indeterminate or clinical suspicion is moderate or high, MRI should be obtained.
In resource-limited settings, it is reasonable to treat patients empirically without advanced imaging studies if the initial radiograph is negative but symptoms persist, assuming important alternative diagnoses have been sufficiently ruled out and appropriate follow-up can be ensured.
In general, distinguishing between minor and major pelvic fractures is less important than determining the presence or absence of a fracture. Any fracture type or location seen on plain radiographs of the pelvis may be associated with significant bleeding or additional injuries. However, the insufficiency fractures discussed in this topic, which may be missed on plain radiographs, are unlikely to be associated with such complications.
Plain radiograph — Plain radiographs are the initial study of choice for older adult patients with suspected minor pelvic fractures (image 1 and image 2 and image 3). However, the sensitivity of plain radiographs for pelvic insufficiency fractures is limited. Studies report miss rates ranging from 4.4 to 23 percent [15-17]. Specialized radiographs (inlet and outlet views) can be obtained, but the extent to which these studies improve sensitivity for insufficiency fractures is not known.
Inlet views with the x-ray beam projected 40 degrees caudad better defines the pelvic brim (figure 4); outlet views with the x-ray beam projected 40 degrees cephalad provide better images of the sacrum and sacroiliac joint (figure 5).
Computed tomography — If plain radiographs are indeterminate, computed tomography (CT) scans are sometimes obtained (image 4 and image 5). However, the sensitivity of CT for minor pelvic fractures is also limited. One study comparing CT and MRI reported that CT had a sensitivity for occult pelvic fractures of 77 percent and for occult sacral fractures of 66 percent [18].
Magnetic resonance imaging — Magnetic resonance imaging (MRI) remains the gold standard for evaluating minor pelvic fractures in older adult patients. Reported sensitivities for MRI are 96.3 percent for occult pelvic fractures and 98.6 percent for occult sacral fractures [18]. MRI should be obtained when plain radiographs are negative but clinical suspicion for pelvic fracture remains high (image 6 and image 7 and image 8).
SPECT imaging — Single photon emission computed tomography (SPECT) combines CT scanning with the injection of a radioisotope. According to a small case series, SPECT imaging can be useful for detecting pelvic fractures in older adult patients with inconclusive findings on CT or plain radiographs [19]. SPECT imaging is an acceptable alternative in patients who cannot be imaged with MRI (eg, pacemaker present, non-MRI-compatible coils and stents, claustrophobic).
DIAGNOSIS — Minor low-energy and insufficiency pelvic fractures occur primarily in the pubic rami and the sacral ala. The diagnosis of these minor pelvic fractures in older adult patients is made radiographically using plain radiographs and possibly magnetic resonance imaging (MRI), if suspicion persists in the face of negative radiographs. However, diagnosis is often delayed and appropriate imaging is often only obtained when clinicians carefully consider the presentation and examination findings. Pelvic fracture should be considered in any older adult patient complaining of hip, groin, or low back pain, particularly those with risk factors for fracture (eg, osteoporosis, low body weight, glucocorticoid therapy) and persistent symptoms. A negative MRI rules out the diagnosis in the great majority of cases.
DIFFERENTIAL DIAGNOSIS — The differential diagnosis for sacral and rami insufficiency fractures is broad and determined primarily by the site of pain. The most common conditions in the differential for sacral pain are, not surprisingly, those commonly misdiagnosed for sacral insufficiency fractures. They include lumbar spine pathology such as spondylosis, discitis, disc herniation, and vertebral compression fractures. Unfortunately, these conditions have many overlapping symptoms and signs. Disc herniations and discitis are more likely to present with radicular symptoms than sacral insufficiency fractures. However, these conditions and others included in the differential, such as spondylosis, minimal vertebral compression fractures, and sacroiliitis, generally require advanced imaging studies to differentiate them from insufficiency fractures. (See "Thoracic and lumbar spinal column injury in adults: Evaluation" and "Acute lumbosacral radiculopathy: Etiology, clinical features, and diagnosis" and "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment" and "Clinical manifestations of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults".)
The differential diagnosis for insufficiency fractures of the pubic rami includes conditions that present primarily with groin pain, such as inguinal hernia, lymphadenopathy, retroperitoneal hemorrhage, and genitourinary processes (eg, urinary retention, urinary tract infection, nephrolithiasis). Genitourinary (GU) cancers, including those affecting the bladder, prostate, uterus, and ovaries, may all present with groin pain. Inguinal hernias and lymphadenopathy can usually be identified by physical examination. Most GU conditions can be identified with a careful history and focused diagnostic studies, such as urinalysis. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults" and "Acute simple cystitis in adult and adolescent females" and "Acute urinary retention" and "Kidney stones in adults: Diagnosis and acute management of suspected nephrolithiasis" and "Clinical presentation, diagnosis, and staging of bladder cancer" and "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening" and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis".)
Vascular disorders may present with symptoms suggesting pelvic insufficiency fractures. Arterial insufficiency can present with posterior pelvic pain and should be assessed with a neurovascular examination. Aneurysms, depending upon their location (eg, iliac artery), can present with groin pain, as may venous thromboembolic disease with proximal or deep pelvic vein involvement. (See "Iliac artery aneurysm" and "Clinical features and diagnosis of abdominal aortic aneurysm".)
Particularly in older adult patients, clinicians must beware of intraabdominal conditions presenting with groin pain or in other “atypical” ways. Abdominal pain in older adults is discussed separately. (See "Evaluation of the adult with abdominal pain" and "Evaluation of the adult with nontraumatic abdominal or flank pain in the emergency department".)
In addition to the insufficiency fractures discussed in this topic, plain radiographs of the pelvis and hip may reveal hip fractures or more severe pelvic fractures, but this is unlikely without a history and/or examination findings associated with trauma. Plain radiographs of the lumbar spine may reveal compression fractures, degenerative disc disease, or spondylosis. Otherwise, plain radiographs of the abdomen and pelvis have limited utility, but may show a ureteral calcification, abdominal obstruction, or vascular calcifications. Hip and major pelvic fractures are discussed separately. (See "Overview of common hip fractures in adults" and "Pelvic trauma: Initial evaluation and management" and "Severe pelvic fracture in the adult trauma patient" and "Thoracic and lumbar spinal column injury in adults: Evaluation" and "Acute lumbosacral radiculopathy: Etiology, clinical features, and diagnosis".)
INITIAL MANAGEMENT — The initial management goals for older adult patients with minor pelvic fractures are pain control and early mobilization. Opioids are often required initially for patients with severe fracture pain. However, many older adult patients are more susceptible to the potentially dangerous side effects of opioids (eg, respiratory depression), and therefore, it is best to start with smaller doses than are used for younger adults, and titrate as needed. The frequency of dosing is generally left unchanged [20]. (See "General principles of acute fracture management", section on 'Pain management'.)
Early mobilization is a key component to reducing complications from pelvic fractures. A minority of sacral insufficiency fractures require that patients be non-weightbearing, but in most cases (eg, sacral ala fractures) patients are permitted to bear weight as tolerated. All other pelvic insufficiency fractures occur in locations that allow for weightbearing. Physical therapy is often useful for gait training, including the use of aids such as crutches or a walker. Activity can be advanced as the patient tolerates. Early mobilization and conservative treatment is appropriate for fragility fractures of the pelvis (FFP) types I and II. (See 'Fracture types: Classification' above.)
As long as the patient is mobile, prophylactic medical therapy for deep vein thrombosis is not required. Otherwise, standard prophylaxis should be given. (See "Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults".)
DEFINITIVE MANAGEMENT
Specialty consultation — Invasive treatment for insufficiency fractures of the pelvis (eg, sacroplasty and ramoplasty) has been described but is not well studied [5,21]. Indications remain unspecified, but consultation is reasonable when pain control is difficult and mobilization remains limited. These procedures are performed primarily by interventional radiologists. Most authors agree that surgical treatment is needed for fragility fractures of the pelvis (FFP) types III and IV, and for type II fractures that fail to heal with conservative treatment [8,9]. (See 'Fracture types: Classification' above.)
Disposition — The majority of older adult patients with pelvic fractures require hospital admission for pain control and physical therapy. However, if the patient can ambulate and pain is adequately controlled, they may be discharged to a rehabilitation facility or home, provided they have a good support system at home and close medical follow-up is arranged.
Follow-up — No definitive guidelines exist for follow-up. The author prefers to have patients follow-up within one week for repeat radiographs to ensure no gross fracture displacement has occurred. The one-week follow-up appointment also provides an opportunity to assess mobility and pain control. Thereafter, the patient is seen every few weeks until clinically healed (ie, pain free with ambulation returned to baseline). Clinical healing generally occurs within six to eight weeks, and we usually obtain repeat radiographs at that time to assess healing (image 9). Plain radiographs are also obtained if there is any change in the patient’s symptoms, such as increased pain or new weakness.
During follow-up, appropriate evaluation and treatment of osteoporosis should be performed for patients with insufficiency fractures. Testing should be initiated at the first follow-up appointment (see "Screening for osteoporosis in postmenopausal women and men").
No clear timeframe has been established for initiating anti-osteoporotic treatments acutely following a pelvic fragility fracture [22]. Implementation of such therapy following an acute fracture is reviewed separately (see "Bisphosphonate therapy for the treatment of osteoporosis", section on 'Use immediately after fracture'). In a cohort study of 132 older adults with a pelvic fragility fracture, patients who were already taking anti-osteoporotic medication or were started on such treatment within six weeks of injury showed improved healing [10].
OUTCOMES — A retrospective review of 181 older adult patients with pelvic insufficiency fractures reported an associated mortality rate of 23 percent at one year. In addition, this series reported an increase in the number of patients requiring ambulatory aids and a greater need for higher levels of care (eg, more patients leaving their home for either assisted living or a nursing home). These developments occurred regardless of fracture type. Another series revealed that institutionalization rates were similar for pelvic fragility fractures and traumatic hip fractures [23].
ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:
●(See "General principles of fracture management: Bone healing and fracture description".)
●(See "General principles of fracture management: Fracture patterns and description in children".)
●(See "General principles of definitive fracture management".)
●(See "General principles of acute fracture management".)
●(See "General principles of fracture management: Early and late complications".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pelvic trauma" and "Society guideline links: Hip and groin pain" and "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Lower extremity (excluding hip) fractures in adults".)
SUMMARY AND RECOMMENDATIONS
●Epidemiology and risk factors – Minor pelvic fractures in older adults involve either low-energy mechanisms or repetitive stresses in osteoporotic bone (insufficiency fractures). Pelvic insufficiency fractures most commonly involve the pubic rami and can occur in isolation. Sacral insufficiency fractures most commonly involve the sacral ala, either unilateral or bilateral, and usually coexist with insufficiency fractures of the pubic rami, parasymphysis, and/or iliac crest. (See 'Epidemiology' above.)
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.
●Clinical presentation – Sacral and pelvic insufficiency fractures are often missed. Suspect the fracture in older adult patients with new or persistent pain or focal bony tenderness in the pelvis, hip, or groin region, a leg length discrepancy, or reluctance to move either of their lower extremities.
Most older adult patients with minor pelvic fractures present atraumatically; only one-third present after minor trauma (eg, fall from standing). Patients may have symptoms for weeks or months and may complain of lower back pain or groin pain. (See 'History' above.)
The presence of a leg length discrepancy, abnormal positioning of the leg, focal bony tenderness around the pelvis or hip, or reluctance of the patient to move their leg all raise suspicion for a pelvic injury. (See 'Physical examination' above.)
●Diagnostic imaging – The diagnosis of minor pelvic fractures in older adult patients is made radiographically. We generally obtain a plain radiograph of the pelvis for older adult patients at risk for minor pelvic fracture. However, the sensitivity of plain radiographs is limited. If the radiographs are negative but clinical suspicion is high, we obtain magnetic resonance imaging (MRI). (See 'Diagnostic imaging' above.)
●Management – Adequate pain control and early mobilization are central to preventing complications and successfully managing these fractures in older adult patients. Physical therapy is often helpful for gait training. Consultation and follow-up care are reviewed in the text. (See 'Initial management' above and 'Definitive management' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges James Fiechtl, MD, who contributed to an earlier version of this topic review.
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