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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 112-115

The clinical characteristics and conservative management of isolated iliac wing fractures: A single-center experience from North India


Department of Orthopedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission19-May-2020
Date of Decision28-Jun-2020
Date of Acceptance06-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopedics, Government Medical College, Haldwani, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_15_20

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  Abstract 


Background: The fracture of iliac bone or blade is uncommon injury and usually a part of pelvic ring disruption with varied clinical presentation. Isolated iliac bone fractures are rare, with literature limited to few reports or small series. Materials and Methods: Retrospective data of consecutive cases of isolated iliac bone fractures were analyzed during the period of July 2014 to August 2019. Relevant patient demographics, mode of injury, pattern of fracture, associated adjacent regional or remote injuries were noted for each case. Details of previous treatment and that of treatment given by us were also noted for each case. Results: A total of 18 cases with isolated iliac bone fracture of the pelvic bone were noted. The mean age was 31.2 years (range: 22–54 years). All the cases were male, and fall from height was etiology in 12 cases, followed by road traffic accidents in the rest. Left- and right-side involvement was noted in 11 and 7 cases each. The fracture pattern was minimally displaced simple in 13 and comminuted in 5 cases. The conservative management was done in all cases. The radiological union and clinical stability of fractures were assessed as end points. The fracture united in all cases within 8–9 weeks and without any immediate or remote complication. Level of evidence - Level 5, Observational Study. Conclusion: The uncommon isolated iliac wing fractures require better recognition and documentation for its management. Further studies should provide a better understanding of these injuries and treatment guidelines.

Keywords: Iliac blade, iliac bone, iliac crest, iliac wing fracture, pelvic injury


How to cite this article:
Dharmshaktu GS, Adhikari N, Mourya P, Bhandari SS. The clinical characteristics and conservative management of isolated iliac wing fractures: A single-center experience from North India. J Orthop Dis Traumatol 2020;3:112-5

How to cite this URL:
Dharmshaktu GS, Adhikari N, Mourya P, Bhandari SS. The clinical characteristics and conservative management of isolated iliac wing fractures: A single-center experience from North India. J Orthop Dis Traumatol [serial online] 2020 [cited 2021 Apr 16];3:112-5. Available from: https://www.jodt.org/text.asp?2020/3/3/112/305735




  Introduction Top


Pelvic injuries are major traumatic events and may require multidisciplinary approach and dedicated pelvic-acetabular surgery unit for their appropriate management. Early recognition of pelvic ring disruption is important for early management and good outcome.[1] Iliac wing fractures in isolation are rare and have scant description in medical literature. According to the Tile classification, these injuries are stable (type A – not involving pelvic ring).[2] They usually result from direct blow and in most cases are stable injuries. Only ten cases with fractures limited to the iliac wing were noted in a study of 120 major pelvic injuries.[3] Ninety percent of these fractures had associated injuries involving other regions such as head, thorax, spine, abdomen, and orthopedic. Isolated injuries with no significant complication such as unstable pelvic ring, associated life-threatening injuries, or adjacent compression of important structures are treated conservatively. Comminuted iliac wing fractures are reported very infrequently and pose challenges to treatment. In a study involving 695 pelvic ring disruptions, only 13 cases (1.9%) were with comminuted iliac fracture.[4] These fractures were usually part of polytrauma and accompanied degloving around flanks, hemodynamic instability, or neurovascular injuries. These fractures are less reported in medical literature despite huge burden of pelvic injuries and only limited to small series and lesser so from Indian soil. Careful clinical and investigative evaluation of these injuries is a critical element of an uneventful recovery. The current article shall be strengthening the medical literature as these injuries require more studies to comprehend and manage them better.


  Materials and Methods Top


A retrospective collection of consecutive cases of pelvic fractures was noted coming to the outpatient and emergency department of our institution during the period of July 2014 to August 2019. The inclusion criteria were isolated iliac bone fracture without radiological association of pelvic ring disruption and sacroiliac (SI) joint disruption. The isolated iliac bone injuries but with distant unrelated injury such as extremity fracture were included in the study. The cases with life-threatening injuries requiring urgent referral and those with other associated injuries requiring preference in treatment were excluded on a case basis. Pediatric pelvic cases were excluded and so were unstable fractures with any neurovascular injuries. The plain radiographs were used to diagnose the injury routinely with additional special views to check pelvic inlet and outlet if doubtful acetabular involvement was suspected. Computerized tomography (CT) scan was used in cases where required to provide additional benefit such as ruling out doubtful acetabular involvement or avulsion fractures. The relevant patient demographic details were noted along with relevant history such as mode of injury, resuscitation, presence of shock, and distal neurovascular status along with previous and further treatment given. The healing of the fracture was noted on periodic radiographs in the follow-up. The painless and clinically united fracture was confirmed on radiographs as the end point of outcome. Direct compression over fracture site was done clinically to ascertain gradual pain disappearance and bony stability. Periodic review at 3, 6, and 12 months was done for each patient noting down relevant developments such as ambulation, use of support, localized pain, bony stability at fracture site, and any complication of treatment along with radiological evaluation of fracture union. Activities of daily living and other features like ability to squat and sit cross-legged, climb the stairs and ambulation were noted in each follow up visit. Ambulation was recorded initially with and later without assistance of walking aid. The disappearance of fracture gap was easily appreciated in good quality plain radiography till complete union was achieved.


  Results Top


A total of 18 cases of isolated iliac bone fracture were noted during the period of study. All the cases were males, and the mode of injury was fall from tree in 12 cases and the rest were due to road traffic accidents. The mean age was 31.2 years (range: 22–54 years). The radiographs clearly showed the iliac bone fracture with extent to exclude unstable pattern or pelvic ring involvement. Left-side iliac bone was involved in 11 and right side in 7 cases. The fracture was simple and minimally displaced in 13 and comminuted in 5 cases. CT scan was done in five cases only. The cost was also an issue, but in two cases, special radiographic views (external and internal oblique views) were done. The special views were not done routinely as most of the time fracture was seen well limited to iliac blade on plain radiograph. All the cases showed hemodynamic stability as the associated pelvic injuries were limited to adjacent soft tissues in most cases. Three cases of extremity fracture were noted in separate cases. Open ipsilateral femur was noted which was managed by external fixator, followed by nailing in later course of treatment. Both bones of the forearm and ulna fracture in two different cases were also noted and managed by surgery. All the cases were managed conservatively and the average union time in comminuted type fractures was nine week [Figure 1]. The conservative method was chosen as per patient preference and good union was achieved [Figure 2]a, [Figure 2]b, [Figure 2]c in all while surgery for fixation of iliac fracture was refused by one case [Figure 2]d.That case had undergone opposite hip fracture surgery a year back.The fracture united within 8-week period in simple and minimally displaced type fractures uneventfully [Figure 3]. No skin traction was given to patients and a week of bed rest was followed by reclining posture and gradual nonweight-bearing ambulation with walker support in all cases. No immediate or remote complication related to bed rest or immobilization was seen. The fracture union and painless stability at fracture site by palpation and pelvic compression was the end point of outcome. Gradual pain-free ambulation was additional point denoting healing on subsequent follow-ups. As no joint is involved, so no range of motion or scoring was relevant. That statement is for most of cases which were minimally displaced (and without any anterior superior or inferior iliac spine avulsions) and healed well without significantly affecting hip biomechanics. Theoretically, the injuries may affect hip biomechanics, but no significant clinical problem of ambulation, squatting, or stair climbing was seen in our small experiences of most these cases. The cases with severe displacement, though not examined specifically for hip joint biomechanical derangement, also showed little clinical problem. The small case pool is one major limiting factor of our study. Low-resource setting, nonavailability of dedicated pelvic-acetabular unit, minimally displaced nonacetabular fracture, and refusal by some cases with indication for surgery were reasons for conservative treatment.
Figure 1: The radiograph of comminuted fracture of the right iliac bone (a) conservatively treated and united well, though not anatomically, but without clinical problem (b)

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Figure 2: The radiographs of other fractures that were managed conservatively – left-side comminuted fracture (a), right-side simple crack (b), and right-side displaced (c) fracture. Left-side comminuted and displaced fracture in a patient, with previously operated fracture of opposite side hip (d)

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Figure 3: The radiograph of simple fracture pattern in the left iliac bone (a) that was conservatively managed and united well in the follow-up (b)

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  Discussion Top


The cases with iliac fractures require careful exclusion of associated injuries. The presence of open wounds or degloving if present requires irrigation, debridement, and closed suction drainage as per the characteristics of the postdebridement status.[3],[4] The cases with comminuted fractures are reported to have good outcome following operative intervention. Stable internal fixation is the available option as the external fixation is not possible due to broken iliac bone. Extension of fracture lines into greater sciatic notch has to be noted carefully as these might require pelvic angiography to rule out local arterial injury. All our cases had no neurovascular injuries. There has been a rising trend of pelvic injuries in elderly population over the years.[5] All our cases, however, were young adults. The adolescent cases may be seen with avulsion fractures of iliac wing between the range of 11 and 17 years.[6] Our study excluded child or adolescent cases of pelvic injuries.

The association of posterior iliac wing fracture with disruption of SI joint is a result of lateral compression (LC) injuries (Young-Burgess LC type IIB) and is also called “crescent fracture–dislocations.” Day has classified these subsets of fractures on the radiological basis into three distinct types.[7] These subsets of injuries need to be identified in all cases with iliac wing fracture as some of the iliac wing fractures may not have clear radiographic SI joint disruption and may be missed. We did CT scan in cases which consented for it and not in all cases due to financial constraints of patients. Radiographic identification and exclusion of SI joint was done in all cases along with negative posterior SI joint region tenderness to exclude crescent fractures. The crescent fracture–dislocations are managed by open reduction and internal fixations using plates and screws.[8] The percutaneous screw fixations for fractures of iliac wing have been described and may be a good option with less tissue damage and blood loss. The technical expertise is required, but articles describe the easy reduction of these fractures.[9],[10] The inherent anatomy of iliac blade with thin bones and curved outline makes surgeries challenging. A modification of technique using cortical screws was described to benefit the fixation of these fractures.[11] All our cases were managed conservatively as most of the injuries were minimally displaced except one case in which operation was refused by the patient. Very rarely, the iliac wing fracture can result from iatrogenic trauma during autologous iliac crest bone graft harvesting from both anterior and posterior sites.[12] Careful handling during these procedures is warranted despite the fact that most of these injuries heal uneventfully. Further treatment is required in case of pelvic ring disruption following these complications.[13] The stress fractures of iliac crest have also been reported with rare recent report in a female athlete.[14] We attribute the injuries in our cohorts to the reason that the fall from tree or height in hilly areas is a common injury, and people hit the hard ground with direct impact on the iliac region in many cases. The small number of cases and lack of long-term follow-up were shortcomings of the study, but the small pool of cases is attributed to the rarity of these injuries in isolation. The isolated iliac wing fractures are rare injuries, and proper documentation and exclusion of associated injuries is warranted to adequately manage these cases.


  Conclusion Top


The iliac blade fractures, in isolation, are relatively less common injuries. The treatment is individualized and may range from conservative in minimal or undisplaced types or operative in selected cases with displacement or comminution. A good outcome, in general, is expected following appropriate and timely management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khurana B, Sheehan SE, Sodickson AD, Weaver MJ. Pelvic ring fractures: What the orthopedic surgeon wants to know. Radiographics 2014;34:1317-33.  Back to cited text no. 1
    
2.
Tile M. Pelvic ring fractures: Should they be fixed? J Bone Joint Surg Br 1988;70:1-2.  Back to cited text no. 2
    
3.
Abrassart S, Stern R, Peter R. Morbidity associated with isolated iliac wing fractures. J Trauma 2009;66:200-3.  Back to cited text no. 3
    
4.
Switzer JA, Nork SE, Routt ML Jr. Comminuted fractures of the iliac wing. J Orthop Trauma 2000;14:270-6.  Back to cited text no. 4
    
5.
Kannus P, Parkkari J, Niemi S, Sievänen H. Low-trauma pelvic fractures in elderly finns in 1970-2013. Calcif Tissue Int 2015;97:577-80.  Back to cited text no. 5
    
6.
Schuett DJ, Bomar JD, Pennock AT. Pelvic apophyseal avulsion fractures: A retrospective review of 228 cases. J Pediatr Orthop 2015;35:617-23.  Back to cited text no. 6
    
7.
Day AC, Kinmont C, Bircher MD, Kumar S. Crescent fracture-dislocation of the sacroiliac joint: A functional classification. J Bone Joint Surg Br 2007;89:651-8.  Back to cited text no. 7
    
8.
Khaled SA, Abdel Karim MM, Abdel-Azeem AH. Management of cresent fracture-dislocation of the sacroiliac joint: Iliosacral screws versus plate fixation. Egypt Orthop J 2016;51:231-7.  Back to cited text no. 8
  [Full text]  
9.
Starr AJ, Walter JC, Harris RW, Reinert CM, Jones AL. Percutaneous screw fixation of fractures of the iliac wing and fracture-dislocations of the sacro-iliac joint (OTA Types 61-B2.2 and 61-B2.3, or Young-Burgess “lateral compression type II” pelvic fractures). J Orthop Trauma 2002;16:116-23.  Back to cited text no. 9
    
10.
Li M, Huang D, Yan H, Li H, Wang L, Dong J. Cannulated iliac screw fixation combined with reconstruction plate fixation for Day type II crescent pelvic fractures. J Int Med Res 2020;48:300060519896120.  Back to cited text no. 10
    
11.
Cole PA, Jamil M, Jacobson AR, Hill BW. “The Skiver Screw”: A Useful Fixation Technique for Iliac Wing Fractures. J Orthop Trauma 2015;29:e231-4.  Back to cited text no. 11
    
12.
Nocini PF, Bedogni A, Valsecchi S, Trevisiol L, Ferrari F, Fior A, et al. Fractures of the iliac crest following anterior and posterior bone graft harvesting. Review of the literature and case presentation. Minerva Stomatol 2003;52:441-8, 448-52.  Back to cited text no. 12
    
13.
Zermatten P, Wettstein M. Iliac wing fracture following graft harvesting from the anterior iliac crest: Literature review based on a case report. Orthop Traumatol Surg Res 2012;98:114-7.  Back to cited text no. 13
    
14.
Amorosa LF, Serota AC, Berman N, Lorich DG, Helfet DL. An isolated iliac wing stress fracture in a marathon runner. Am J Orthop (Belle Mead NJ) 2014;43:74-7.  Back to cited text no. 14
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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