Chronic pelvic insufficiency fractures and their treatment

Abstract

Fragility and insufficiency fractures of the pelvis (FFP) and sacrum (SIF) are increasingly prevalent, particularly among the elderly, due to weakened bone structure and low-energy trauma. Chronic instability from these fractures causes persistent pain, limited mobility, and significant reductions in quality of life. Hospitalization is often required, with substantial risks of loss of independence (64–89%) and high mortality rates (13–27%). While conservative treatment is possible, surgical intervention is preferred for unstable or progressive fractures. FFP and SIF are primarily associated with osteoporosis, with 71% of patients not receiving adequate secondary fracture prevention. Imaging modalities play a crucial role in diagnosis. Conventional radiography often misses sacral fractures, while computed tomography (CT) is the gold standard for evaluating fracture morphology. Magnetic resonance imaging (MRI) offers the highest sensitivity (99%), essential for detecting complex fractures and assessing bone edema. Advanced techniques like dual-energy CT and SPECT/CT provide further diagnostic value. Rommens and Hofmann’s classification system categorizes FFP based on anterior and posterior pelvic ring involvement, guiding treatment strategies. Progression from stable fractures (FFP I–II) to highly unstable patterns (FFP IV) is common and influenced by factors like pelvic morphology, bone density, and sarcopenia. Treatment varies based on fracture type and stability. Non-displaced posterior fractures can be managed with sacroplasty or screw fixation, while displaced or unstable patterns often require more invasive methods, such as triangular lumbopelvic fixation or transsacral bar osteosynthesis. Sacroplasty provides significant pain relief but has limited stabilizing capacity, while screw augmentation with polymethylmethacrylate improves fixation in osteoporotic bones. Anterior ring fractures may be treated with retrograde transpubic screws or symphyseal plating, with biomechanical stability and long-term outcomes depending on fixation techniques. FFP and SIF management requires a multidisciplinary approach to ensure stability, pain relief, and functional recovery, emphasizing early diagnosis, tailored surgical strategies, and secondary prevention of osteoporotic fractures.