Fragility Fractures of the Pelvis: An International Survey of Expert Opinion

Purpose: Fragility fractures of the pelvis (FFPs) in elderly patients are an underestimated injury with a significant impact on mobility, independency, and mortality, and represent a growing burden for society/health care. Current clinical challenges are to identify patients who benefit from additional imaging and those patients in which surgical treatment is indicated. The goal of this study was to assess the heterogeneity in the current use of diagnostic modalities, mobilization policies, treatment strategies, and follow-up of patients with FFP. The hypothesis was that there is a lot of (inter)national variation in the management of FFP, as a guideline is currently lacking.

Methods: All International Orthopaedic Trauma Association (IOTA) steering committee members were asked to select 15-20 experts in the field of pelvic surgery to complete a case-driven international survey. The survey addresses the definition of FFP, use of diagnostic modalities, timing of imaging, mobilization protocols, and indications for surgical management. The study is currently ongoing.

Results: To date, 140 experts within 14 IOTA societies responded to the survey. Among the experts, 88% have >10 years of working experience and 81% works in a referral center for pelvic fractures. However, only 45% of experts reported to have a (local) protocol for the management of FFP. Over 90% feel the need for a (inter)national evidence-based guideline. Of all experts, 71% use both radiographs and CT to diagnose FFP, of which 62% gets a routine CT and 38% based on clinical symptoms. Treatment strategies of anterior ring fractures were compared to combined (anterior + posterior ring) fractures; 38% of patients with anterior ring fractures get admitted to the hospital compared to 74% of patients with combined fractures. Experts allow pain-guided mobilization in 72% after anterior ring fracture, but propose restricted weightbearing in case of a combined fracture in 44% of patients. Surgical indications are primarily based on the inability to mobilize during hospital admission (37%) or persistent pain after 2 weeks (24%). Over 91% plans an outpatient follow-up independent of type of fracture or treatment.

Conclusion: This survey shows that there is a great worldwide heterogeneity in the current use of diagnostic modalities and management of fragility fractures of the pelvis. This study stresses the need for an evidence-based guideline or consensus meeting.

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