Vol. 20 • Issue 18 • Page 7
Subacute and Long-term Care
Pelvic fractures are just as incapacitating and dangerous as hip fractures, with similar statistics on the number of patients who suffer reduced quality of life and fracture-related deaths. In a French study of 60 people hospitalized with osteoporotic pelvic fractures, 82 percent were women; 80 percent of whom had Vitamin D deficiency. The fractures, 65 percent of which were located at one or both pubic rami, were triggered by a fall in 89 percent of the cases.1During their hospital stay, 52 percent of patients had a complication, mostly urinary tract infections or bedsores. At discharge, only 31 percent went directly home. In follow-up after 29 months, 11 patients had died. Of those living, 75 percent were home but 60 percent required assistance for at least one activity of daily living; 6 percent of patients had a new fracture. In a Hong Kong study of patients over 60 years old, the one-year mortality rate for patients with osteoporotic pelvic fractures was 12 percent and the two-year mortality rate was 20 percent. Eighty-seven percent of patients were women. There was a high incidence of associated cardiovascular disorders and dementia.2
Identifying the Pain Source
When trauma to the pelvis occurs, the rami tend to fracture first. Patients admitted to the nursing home present with groin pain that requires the assistance of a physical therapist or physical therapist assistant for gait training. Because the rami are not needed for structural support for walking, no surgery is indicated and weight bearing is usually not restricted.
Most people can walk short distances with a walker by one week and are fairly comfortable in one to two months. Bone healing can occur in six to 12 weeks, but restoring bone strength may take up to a year. There is tenderness in the groin and pain during leg movement.
Some authors feel that micromotion, or movement of the broken bones, causes the pain. In the presence of osteopenia or osteoporosis, an undisplaced pubic ramus fracture may be hard to see on X-rays until callus formation begins. In addition to gait and transfer training, lower-extremity exercises should be started early in the patient's stay, as most patients will not be able to walk far enough to restore their previous levels of strength and stamina. Wheelchair cushions are a must for all patients, and especially for those sitting on pelvic and hip fractures. When the patient is less painful, higher-level balance and gait activities can be done to lessen the risk of future falls. Back pain is a common complication, especially when the SI joint is damaged either directly or indirectly. Many patients with pubic rami fractures also injure their SI joint or lumbar spine. Other associated problems are anxiety, depression, fear of falling, fear of pain, insomnia, weight loss, dehydration and side-effects of narcotic pain medications.
New Treatment for Fractures
Dr. Susan Bukata and Dr. J. Edward Puzas, at the University of Rochester Medical Center in New York, recently found that Forteo, a genetically engineered fragment of human parathyroid hormone, can be used to speed fracture healing and reduce intense pain from pelvic and other slow-healing or non-healing fractures.3
Forteo (Teriparatide/Eli Lily) has been on the market since 2002 for the treatment of osteoporosis. It is a daily subcutaneous injection given in the thigh or stomach to increase the activation of osteoblasts, the cells that build new bone. Forteo is expensive, but can shorten the length of nursing home stays, especially in patients with slow-healing fractures.
1. Breuil, V. et al. (2008). Outcome of osteoporotic pelvic fractures: An underestimated severity. Joint Bone Spine, 75(5), 585-586.
2. Leung, W. (2001). Prognosis of acute pelvic fractures in elderly patients. Hong Kong Medical Journal, 7(2), 139-145.
3. U.S. National Institutes of Health: Use of Teriparatide to accelerate fracture healing. Accessed via the World Wide Web, August 22, 2009, at ClinicalTrials.gov.
Emi Storey is a floating physical therapist for Consonus Rehab Services, based in Milwaukie, OR. An alumna of Stanford University, she has worked in long-term care for 15 years. Bob Thomas is a geriatric physical therapist and serves as president of Infinity Rehab, based in Wilsonville, OR. He lectures nationally for GREAT Seminars on rehabilitation for the frail elderly, and is an adjunct professor at Pacific University.