1. Brandon Klein DO, MBA – Northwell Health – Huntington Hospital Orthopedic Surgery Residency
2. Kevin Chang MD, MS – Northwell Health – Huntington Hospital Orthopedic Surgery Residency
3. Sarah Rizzo MD – Northwell Health – Huntington Hospital Orthopedic Surgery Residency
4. Joshua Giordano DO – Northwell Health – Huntington Hospital Orthopedic Surgery Residency
5. Salvatore Sclafani DO – Northwell Health – Huntington Hospital Orthopedic Surgery Residency
6. Michael Linn MD – Northwell Health – South Shore University Hospital
7. Randy Cohn MD – Northwell Health – Huntington Orthopedic Surgery Residency, Associate Program Director

Abstract

Introduction
Lateral compression (LC) pelvic ring injuries are common in the geriatric population and carry significant economic burden due to their association with morbidity and mortality.

Methods
A retrospective review of LC pelvic ring injuries was performed. Outcomes included surgical intervention, weight bearing, imaging, length of hospital stay, disposition, outpatient follow-up, subsequent falls, and readmission.

Results
There were 123 patients with an isolated pubic rami fracture or LC-1 injury. The orthopaedic service recommended early mobilization with weight bearing as tolerated (WBAT) in 95.1% of patients (p<0.00001). Inlet and outlet radiographs were more likely to be ordered by orthopaedics (89.7%) compared to the Emergency Department (p<0.00001). Despite an average hospital stay of 5.42 days, patients were seen by orthopedics 1.06 times per admission. Most patients (91.2%) who were able to ambulate independently prior to their injury required assistive devices for ambulation after the fall. Upon discharge, 75.6% of patients required a higher level of care. Within a year, 37.3% of patients returned for subsequent fall, and 7.2% of patients required urgent surgical fixation for an orthopaedic injury sustained in the subsequent injury. Readmission was common among these patients; 90 days (27.3%), 6 months (38.6%), and 1 year (48.2%). There was no correlation between posterior ring involvement and any evaluated outcomes. 

Conclusion
Fragility fractures of the pelvis are associated with a high rate of future fall and subsequent injury. Orthopaedic surgery has a minimal role in active management, however interdisciplinary care and proper rehabilitation may prevent future orthopaedic intervention. 

Keywords: Fragility Fractures of the Pelvis, FFP, Rami Fracture, LC1, Geriatric Trauma

Introduction
Fragility fractures, including pelvic ring injuries, carry significant economic burden, constituting approximately 5% of health care costs associated with osteoporotic fractures.[1] Low energy mechanisms, such as falls from standing height, can result in fragility fractures of the pelvis (FFP) which contribute to 30% of pelvic ring injuries.[2,3] These injuries have been categorized according to their injury pattern; Lateral Compression (LC), Anterior-Posterior Compression (APC) and Vertical Shear (VS).[4] LC injuries occur five times more frequently than APC injuries in geriatric patients. There are three subtypes based on the extent of ligamentous and bony injury.[5] Type 1 (LC-1) injuries are the most stable, involving pubic rami fracture(s) anteriorly with posterior sacral impaction.[6]

LC-1 injuries are often considered benign due to their inherent stability with nonoperative management and early full weight-bearing.[6] However, these injuries carry a significant risk of mortality, reported as high as hip fractures.[7-15] Age, male gender, dementia, and preinjury ambulation independence have been shown to be predictors of mortality, while posterior ring involvement has not been shown to increase mortality risk.[9, 13, 16-18] Patients admitted to the hospital have an elevated risk of complications attributable to pain-limited mobility, including pneumonia, pressure ulcers, and thromboembolic events.[18,19] In addition to morbidity and mortality, many patients lose ambulatory independence and require a higher level of care upon discharge.[11]

Conservative management with immediate weight bearing for LC-1 injuries has been supported by recent literature to allow for more timely mobilization.[19, 20-22] Operative intervention should be reserved only for those who fail to mobilize within 3-5 days of injury despite optimal pain management.[2, 23]. Iliosacral screw placement can stabilize the posterior ring and has been shown to decrease pain after postoperative day two in nondisplaced sacral fractures, but is associated with surgical and hardware-related complications.[24,25]

Orthopaedic consultation is routinely requested for evaluation of isolated LC-1 injuries and pubic rami fractures in geriatric patients. However, given recommendations for early mobilization and appropriate medical management, there may be limited value in orthopaedic consultation. Therefore we explored the following questions: 1) Do orthopaedic consultants recommend weight bearing restrictions?; 2) What role does imaging play in management?; 3) How often are patients evaluated by the orthopaedic service throughout admission?; 4) How does this injury affect patient disposition?; 5) Is this injury predictive of subsequent fall or readmission?

Methods
Institutional Review Board approval was obtained for this retrospective review. Patients were identified by assessing daily orthopaedic surgery censuses of three community hospitals within the same health system from August 2018 to April 2022. Censuses were searched for inclusion of the following keywords to identify patients with LC-1 injuries or pubic rami fractures: LC-1, LC-2, PR, Rami, and Ramus. Electronic medical records (EMR) were reviewed for each patient identified by any of the above keywords. Demographics and injury patterns, as defined by Young and Burgess, were recorded.[4] Injury patterns were determined by the radiologist reading of available imaging (including computed tomography (CT) and/or x-ray (XR)), and was confirmed after review of imaging by author(s). Outcomes of interest during initial hospitalization included surgical intervention, weight bearing restrictions, imaging, length of hospital stay, number of orthopaedic evaluations, and disposition. Future outcomes included return to Emergency Department (ED) for subsequent fall, future operative orthopaedic injury, and readmission. Readmission was defined as admission within the health system at 3, 6 and 12 months from the date of discharge of initial hospitalization.

Patients were excluded due to chronic injury (>2 weeks) at time of initial presentation, young patient age (<55 years), high energy mechanism or injury pattern (LC-2, LC-3, acetabular involvement), poor baseline ambulatory status, and presence of associated injuries. Fractures that involved the anterior pubic root or extra-articular portion of the acetabulum were considered to involve the pubic ramus rather than the acetabulum, and thus were included in the study. Patients discharged from the ED were excluded to focus specifically on patients necessitating admission.

Statistical analysis was performed using Microsoft Excel and Graphpad. Descriptive statistics were described as means with standard deviations, with counts and percentages where appropriate. Numerical variables were evaluated by independent t-tests and z-tests for proportions. Categorical variables were analyzed by chi-square tests. Statistical significance was defined as p-value less than 0.05. 

Results

Patient Population
Search of the inpatient census identified 237 patients. 112 patients were excluded (47.3%) from the cohort due to: associated injury(s) (67.9%), high energy injury pattern (19.6%), chronicity (17.0%), higher energy injury mechanism (13.4%), not requiring hospital admission (11.6%), young age (6.2%), and poor pre-injury ambulation status (2.7%) (Table 1). 

During the 21-month study period, 237 patients presented to the ED with radiographic evidence of LC-1 injury or pubic rami fracture(s). Of the 123 (51.9%) patients who met inclusion criteria, 39.0% had a pubic rami fracture without posterior ring involvement (superior or inferior rami fracture: 13.0%, superior and inferior rami fractures: 26%) while 61.0% had posterior involvement (LC-1). The mean age of patients was 84.4 +/- 8.3 years and the majority were female (84.6%). Most patients presented from home (90.2%) compared to an assisted living facility (9.8%). Prior to the injury, 46.3% of patients ambulated independently, while 53.7% required assistive devices for ambulation.

Hospitalization and Management
Operative intervention was not required for any isolated LC-1 injury or isolated pubic rami fracture. Weight bearing recommendations included protected weight bearing (2.4%), weight bearing as tolerated (WBAT) with assistive devices (4.9%), and WBAT without restrictions (92.7%). The recommendation of WBAT compared to protected weight bearing was significant (p<0.00001). There was no correlation between posterior ring involvement and weight bearing recommendations (p=0.8415).

Imaging
Pelvic radiographs were ordered on all patients. In addition to an Anterior-Posterior film, inlet and outlet views were obtained on 69.9% of patients. Inlet and outlet views were more likely to be ordered by the orthopaedic team (88.4%) than by the emergency department prior to orthopaedic consultation (11.6%) (p<0.00001).

Most patients had CT imaging during hospitalization (95.1%); usually ordered by the emergency department prior to orthopaedic consultation (89.7%). A small subset of patients had CT imaging ordered by the orthopaedic consultant (5.1%), or by the primary service after admission (5.1%). CT imaging was ordered by orthopaedics to evaluate for posterior ring involvement, while CT imaging ordered by the primary team was to evaluate for associated hematoma due to findings of anemia or hypotension. Embolization by interventional radiology was required for active extravasation in 3 cases (2.4%). 

Disposition and Outcomes
The average length of hospital stay for patients with these isolated injuries was 5.42 +/- 3.75 days (range: 1-33 days). Despite this length of admission, patients were only seen by the orthopaedic service an average of 1.06 +/- 0.28 times during admission, with a single orthopaedic encounter in 94.3% of patients. Of the patients with multiple orthopaedic evaluations, repeat evaluation was due to pending imaging to rule out concomitant pathology (2), independent attending evaluation (2), transfer to facility with separate orthopaedic service (1), confirmation of overnight orthopaedic coverage evaluation (1), and general re-evaluation for described injury (1). There was no difference between posterior ring involvement and length of hospital stay (p=0.4748), number of orthopaedic evaluations (p=0.0801), or single orthopaedic encounters (p=0.1738). 

Disposition was largely dependent on the patients’ ability to ambulate with physical therapy. 52 patients (91.2%) who were able to ambulate without assistive devices prior to the fall required assistive devices with inpatient physical therapy. On discharge, only 28 patients (22.8%) returned to their original living arrangement, while 93 patients (75.6%) required a higher level of care (1.6% expired during hospitalization). There was no difference between fracture pattern and ability to WBAT with assistive devices during inpatient physical therapy (p=0.5157) or the need for a higher level of care (p=0.9601).

Readmission within 90 days, 6 months, and 1 year was 27.3%, 38.6%, and 48.2%, respectively. Causes for readmission included medical etiology (63.6%), recurrent fall (27.3%), or related to the primary injury (9.0%). Of those readmitted after a subsequent fall, 44% (3.3% of total patients) required surgery for injuries sustained from the second fall. Future readmission was not associated with posterior ring involvement at 90 days (p=0.9362), 6 months (p=0.8808), or 1 year (p=0.7039).

Subsequent falls within one year of initial injury that required ED evaluation occurred in 36 patients (30.2%), with 12 (10.1%) requiring multiple visits for subsequent falls. In total, there were 50 encounters for subsequent falls, resulting in 22 orthopaedic injuries in 18 (15% of total patients) patients; 8 (6.7% of total patients) of which required urgent operative intervention. When patients with injuries sustained less than a year from study initiation were excluded, 31 (37.3%) presented within a year for subsequent fall and 12.0% required multiple visits due to falls. In this group, there were a total of 43 falls which resulted in 19 orthopaedic injuries in 16 (19.3% of total patients) patients; 6 (7.2% of total patients) of which required operative intervention (Table 2). There was no correlation between posterior ring involvement and subsequent fall (p=0.1285) or future operative fracture (p=0.3628).

Discussion 
LC-1 injuries and pubic rami fractures are common injuries for which orthopaedic consultation is routinely requested. While this patient population is at high risk for future fall, injury, and substantial comorbidities, the orthopaedic service provides minimal role in acute intervention. In this study, orthopaedic recommendations primarily involved conservative management, consistent weight bearing recommendations, and inlet and outlet radiographs. The presence of posterior ring involvement did not influence recommendations in this series. Clearly, the collaboration between hospitalists, social work, physical therapy and physiatrists is paramount in providing adequate rehabilitation and establishing fall prevention strategies. This study offers data that suggests diagnosis-specific protocols could be developed to help optimize the coordination of patient care. Future prospective studies are required to determine if there is a difference in patient outcomes with and without orthopaedic evaluation, as well as with and without physiatry consultation. 

The average length of stay described in previous literature is comparable to that of our cohort (5.42 +/- 3.75 days).[18,26] Loggers et al. found an increased length of stay in patients with posterior ring involvement, but this was not demonstrated in our cohort.[18] In our cohort, only one patient was seen more than once by our orthopaedic team for re-evaluation of the primary injury, which was not related to associated hematoma or active extravasation requiring embolization. CT imaging was routinely performed (95.1%), often providing diagnosis prior to orthopaedic consult (89.7%). Previous literature has suggested that CT imaging is required for accurate diagnosis of sacral fractures that can be missed on plain radiographs.[27,28,29]. A previous review found that when CT imaging is utilized as a standard for diagnosis, approximately 80% of rami fractures were associated with a sacral fracture.[2] Since diagnosis is often made prior to consultation, inlet and outlet radiographs are usually obtained for comparison at outpatient follow-up to evaluate for interval healing and for surgical planning when appropriate.

Many patients in our cohort were recommended WBAT, and none required operative management. In a previous retrospective review, 3.42% of elderly patients with LC-1 injuries required surgical intervention during initial hospitalization, while 2.7% failed nonoperative treatment and required future fixation.18 Multiple studies have supported immediate weight bearing without surgery.[19-21,30,31] Soles et al. found that 99% of these injuries healed with immediate weight bearing with only minimal displacement.[19] No difference in functional outcomes was demonstrated by Gaski et al. between those treated with immediate WBAT versus 6 weeks of flat foot weight bearing.[20] Immobilization of these patients has been shown to be associated with increased complications (20-58%), especially when posterior ring involvement is present, including urinary tract infections (24%), acute renal failure (22%), and pneumonia (9%).[8,13,18,29,32]

Despite recommendation for unrestricted weight bearing, 91.2% of previously independent ambulators required assistive devices after the fall, which limited those who were able to return to their original living arrangement upon discharge (22.0%). The ability of patients to return to their baseline ambulatory status after FFP has been shown to be within 49-62%.[9,13,33] Loggers et al. found that 49% of patients who ambulated independently prior to their injury required the use of assistive devices for ambulation at follow-up.[18] Previous studies have shown that pre-injury community ambulators often required a higher level of care upon discharge, with only 18.0-29.9% returning immediately home.[13,26] Disposition has been shown to be associated with the degree of displacement on lateral stress radiographs, with greater than 10mm correlated with an increased incidence of rehab requirement, time to clear physical therapy, and length of hospitalization.[34] The ability to return to a patient’s baseline living arrangement was not found to be associated with fracture pattern, age, gender, admission requirement, or complications during hospitalization.[18]

Our cohort showed high risk of readmission (90 days: 27.3%, 6 months: 38.6%, 1 year: 48.2%) and fall rates at one year (37.3%), with 7.2% of patients requiring operation for injury(s) from subsequent fall during this time. Readmission has previously been reported at 30 days (4.3-8.1%), 6 weeks (5.9%), and 1 year (32%).[13,18,39] Ting et al. found that 19% of patients with LC-1 injuries had recurrent fall within 1 year of initial injury.[13] No previous studies evaluating risk of future operative orthopaedic injury after isolated LC-1 injuries were identified.

Many patients were excluded from our study due to associated injuries (66.7%). Secondary injuries have been reported to be present in 11%-87% of patients with this injury pattern.[2,26] Burgess et al. found an average of 1.0 additional orthopaedic injury and 1.6 additional non-orthopaedic injuries for each LC-1 injury.[6] Vascular injury should be considered if there are signs of hemodynamic instability, with the internal iliac artery being the most common vessel injury requiring embolization.[35,36]

LC-1 injuries and rami fractures have a significant impact on hospital census and costs. Even when these injuries are treated nonoperatively, the length of stay and hospital resource utilization is similar to that of hip fractures.[37] Under the Medicare/Medicaid “3 Day Rule”, a minimum hospitalization of 72 hours is required prior to discharge to post-acute care facilities.[38] Prolonged hospitalization of FFP is associated with a high complication rate that can impact pay-for-performance outcome measures, directly correlating with reimbursement.[26] As many of these patients are Medicare-insured, health systems should be incentivized to identify patients in the ED requiring rehabilitation and avoid unnecessary admission when possible.

Limitations
The retrospective design limited findings to review of the EMR. This was partially controlled for, as each patient encounter and imaging modality was reviewed by multiple independent reviewers. The study did not include those who were discharged from the ED without hospital admission. Inclusion of these patients would have likely further strengthened our findings, as these patients were able to maintain their independence. Readmission, subsequent fall, and future operative orthopaedic injury rates are likely underestimated as data from outside of our health system is unavailable. 

Conclusion
The standard of conservative management of stable FFP has been widely accepted as early mobilization with immediate weight bearing. After initial diagnosis, there is limited value of additional orthopaedic consultation. Multidisciplinary care with medical, case coordination, physical therapy, and physiatry is essential for expedited rehab placement and improved fall prevention strategies to prevent future injury.

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Table 1 | Table 2

Table Legends

• Table 1: Patients were excluded from the study if they had an additional injury associated with the initial fall. These included both orthopaedic and non-orthopaedic injuries.
• Table 2: Patients often presented within a year of initial injury after a subsequent fall, which may have caused orthopaedic injury. While hip and distal femur fractures required urgent operative intervention, there were a variety of other orthopaedic and non-orthopaedic injuries that may have required operative fixation later.

Required Disclosures and Declaration

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• IRB Approval Information: Yes
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