Broken pelvis update

[Simkie]

@CHT

Surgery could still be an option if needed I suppose, but it’s three months in the rehab hospital…yikes.

Wow, who is telling you that? Fusing the symphysis should not require 12 weeks of in patient rehab. Geez, they took apart my hip and put it back together and I was in the hospital for 3 days.

I took a quick look at the literature and saw several options like this:

“Postoperatively, the patient is full weight bearing with limitation in activities for approximately 2 weeks, with then slow progression to activities as tolerated. Activities beyond those of daily living should be avoided that include exercise, weightlifting, and impact activities for the first 2 weeks. After 2 weeks, patients should advance these above activities slowly over the next 4 weeks with impact activities being the last to be incorporated. At 6 weeks postoperatively, symptoms should be improved and patients typically are able to return to their usual activities.”

From https://www.arthroscopytechniques.org/article/S2212-6287(17)30313-4/fulltext

(Note: some intra op pictures)

I do agree that you’re expecting a lot, but I worry that you’ve not had the greatest assessment from an orthopedic perspective In your shoes, I’d push hard to see at least a couple surgeons who specialize in this field and understand–really understand–what your day to day looks like, and the level of activity you expect. You don’t have to suffer

[CHT]

I appreciate your input. Hips are MUCH easier than pelvises. you can’t compare the two. I was HOPING it was my hip as I would have been home within days. If they were going to fix my pelvis surgically now, they would have to rebreak the sacrum to straighten out the pubic bones (that are still twisted). I would have pins in back and a plate in front. it’s a pretty serious surgery and nothing like a hip. It is 3-6 months in rehab (6 is if you need an external fixator).

The link you linked to is more for people whose pubic area was stretched due to child birth. Mine was completely twisted, and compressed, like I was run over…it would have to be pulled apart and held apart by a plate to keep it straight. So instead of things being stretched out (like after childbirth) all my muscles/tendons/bones/whatever, contracted, and the cartilage would have completely torn, but apparently it will recreate itself and be stronger than ever…I don’t fully understand that part.

[CHT]

This is kind of like what it looked like, but the bones more overlapped if viewed from the top:
https://www.emrap.org/episode/pelvicfractures/pelvicfractures

[Simkie]

@CHT

Hips are MUCH easier than pelvises. you can’t compare the two

For sure, a total hip replacement is a pretty straightforward surgery. I had a periacetabular osteotomy, where the pelvis is fractured in three places surgically to free the acetabulum from the rest of the pelvis. The acetabular fragment is rotated to better cover the femoral head, and then pinned in piece with several screws. The bulk of surgery is getting through the many muscle layers. It is an open hip procedure.

Here’s a link, if you’re curious:

https://www.hss.edu/conditions_periacetabular-osteotomy-pao.asp

I can’t see the pic at your link, it’s behind a paywall. But based on what you’ve written, I think you tore apart the soft tissue at the symphysis, and disrupted the SI joint. It was a lateral compression, and the force caused the two halves of the pelvis to overlap. But before they were able to get you into surgery, you’d reduced yourself, and the displaced portion of the pelvis was back in place, so you were able to skip surgery. They sent you home, with nwb instructions and no PT. Is that all about right?

So the pelvis is in alignment now, right? A radiograph looks pretty normal? But you’re still struggling and in pain, especially with activity. It sounds like you’re an active person, doing a lot. It doesn’t sound like your pelvic ring is stable. Which is not surprising, you tore and disrupted all the stuff holding the bones together. In a lot of ways, that’s worse that an actual bone fracture. Bone usually heals great. Soft tissue doesn’t.

This paper talks about exam under anesthesia to fully assess pelvic fractures, and how that can truly show what’s going on, because static films don’t tell the whole story. Perhaps that should have happened in your case?

Assessment of instability in type B pelvic ring fractures

Is the info you’ve gotten about surgery and what type of recovery you’d be facing the current recommendation based on your films now, or is it what they told you when things were displaced? The answer now, if your films are “normal” but you’re unstable is different than when your films were very abnormal.

I read about your accident and recovery and just worry for you, because it seems like you should have had more care throughout. It seems like they ruled out acute, life threatening trauma and sent you on your way, but that’s not where the problems, or treatment, should end. If your pelvis is overall in position now, fusing the symphysis and SI should not require a 12 week inpatient rehab. And it would give you a stable ring, which could make you much more comfortable.

These are just the questions and direction I would be asking in this situation, or how I’d help a friend through it.

[LCDR]

I am post pelvic fracture resulting from my horse falling in the hunt field, with the fracture reducing itself before the orthopods could get me on the table, and also went through the anticoagulant requiring ordeal due to thrombi. That was 25 years ago, and it still hurts, a lot at times. I believe I had excellent care and advice from all my colleagues in my university hospital. The only advice I chose to ignore was “quit riding.”

I have no advice to offer, because I don’t know the specifics of your situation, and I am not an orthopedic surgeon. But I do understand your frustration with having limited activity, stamina, and pain.

And I still sleep like a rotisserie chicken. The cats have learned the hard way to sleep only on the foot of my.bed. I love that description. I am stealing it from you.

[CHT]

I am in physio, just not government funded as I didn’t get surgery. I next go Tuesday.

My pelvis is no longer overlapping, but the right pubic bone sits higher still than the left, so there is a slight twist remaining. I don’t actually think anything is unstable (unless I misunderstand what you mean by that) I was re-x-rayed twice since being released from hospital (once while feather weight bearing, and once after I was walking mostly normally), and no change from when I left the hospital… I think it is soft tissue that is causing the issue.

@LCDR did you do physio? If so, for how long>

[Simkie]

@CHT

I think it is soft tissue that is causing the issue.

Yes, when the bony structure is unstable, pain presents in the soft tissue.

Here’s an article about anterior pelvic instability:

Instability of the Pelvic Ring: A Special Clinical Entity?

“The induced painful stimuli are usually localised in the suprapubic region and inner thigh areas, but they can also affect the sacroiliac joints and the buttocks. Such activities as walking on abnormal surfaces, going up and down stairs, side lying, sexual intercourse, running and standing on one limb can aggravate the symptoms.”

And

“Acquisition of supine pelvic views may demonstrate bone pathology such as the non-union of previous sustained pubic rami fractures, chronic osteomyelitis and the presence of metastatic disease. However, being static, instability will be missed.”

This paper is just an excellent overview discussing how the pelvis needs to function as a stable platform and the level of movement that is considered normal. Also how trauma can destabilize, leading to dysfunction, degeneration and pain. There are some great photos showing all the layers soft tissue that would have been very disrupted in your fall.

The sacroiliac joint: an overview of its anatomy, function and potential...

I hope that’s helpful, at the very least to show why it’s going to take a long time to feel “normal.” I also hope you’re able to get a few more opinions on how you might be able to feel better.

[LCDR]

Physical therapy- yes. Physiotherapy - no. Riding is a sport so I went to a sports medicine facility. It was amazing how many horse people I met there. I expected all football players. My goal was to get back in the saddle and back to hunting as soon as possible.

[CHT]

So you avoided the pelvic floor physio, which I am told is very important. I had never even really thought about my pelvic floor muscles before this! I feel I will do both at some point, but currently just doing the pelvic floor physio.

[CHT]

Admittedly the SI article was beyond my current ability to comprehend, but the other was more interesting. What I found most interesting was that they type of pain they describe, and the activities they list are what cause me issues, but at the same time I don’t have pain upon pressure as they describe. I wonder if I have nerve damage though, as I never really had much pain over my pubic area (although the cats managed to find the one spot that did hurt). Good information to bring up with my physio.

I had a very busy last two days, so hopefully not feeling it too much. My gelding shipped out yesterday, and I was super restless waiting for the trailer so rearranged a storage room in the barn and did a lot of walking. Today I was on my feet/walking 7 hours straight looking after horses and teaching.

I thought I would be more sad/emotional seeing my yellow guy leave, but I think I am at the stage where I am ok with not riding, and having him leave takes away the guilt of not being able to keep him worked/entertained (he liked working). He should get to his new home by tomorrow - I hope they love him as I do/did.

[Simkie]

Physiotherapy and physical therapy are the same thing. Regional differences in terminology.

Pelvic floor PT is often out of pocket and not covered by insurance in the US. Understanding the importance of the pelvic floor is also a relatively recent concept.

[CHT]

Yes, but pelvic floor physio is only done by specialists, so a sports physio isn’t (or shouldn’t be) doing pelvic floor physio.

[Simkie]

I’m not saying anything in opposition. PT and physio are the same thing. There are all sorts of specializations in therapy. Pelvic floor PT is usually out of pocket in the US, uncovered by insurance, and therefore often out of reach for many.

Pelvic floor PT beyond “do kegels” is also a relatively new concept. The likelihood it was available at all 25 years ago is pretty slim. Our understanding of pelvic stability has also improved and evolved in the last 25 years, along with the idea that people DO expect to continue athletic pursuits post traumatic pelvic injury and that intervention can allow them to do that.

Doctors vary so widely in approach. It’s worth it to see a few.

[forwardmarch]

Regarding the rotisserie chicken sleep pattern, maybe a long bolster pillow would let you sleep longer before needing to switch positions? I’ve got a hip injury, which is very different than your situation, but I share the sleep problem.

I sleep best on a deep leather couch (think bucket seats), with my back/hips resting against the back part of the couch. That lets me align/stack my hips and pelvis so everything can relax. I don’t seem to need pillows under/between legs in this scenario. If I sleep in a bed, I use a long bolster pillow to mimic the support behind my back so that hips/pelvis are stacked. And add other pillows as needed.

Cograts on all the progress!!

[CHT]

We worked on it in physio today, the muscles on that side are still very tight, and I guess that is causing the issue with not being able to sleep on the right (injured) side. it was a more complicated explanation, but that is how I simplified it. She also suggested planning a time during the day to lay on that side for 5 minutes for a week or two, and slowly work to increase that time. I have new stretches. No more attempts to run for now.

[CHT]

Bursitis. That is why she thinks it is still painful for me to lay on my right side, bursitis in my hip. I need to start taking notes.

[Simkie]

Bursitis isn’t unexpected here, but there’s a lot more to bursitis than inflammation of the bursa, and gradually increasing the time you lie on your side isn’t going to make greater trochanter pain go away. I guess maybe she’s hoping you’ll just get used to it?

Have you had an MRI to assess the damage to the soft tissues? Abductor tendon tears often need surgical repair. And cause greater trochanter pain.

I linked Allison Grimaldi’s site above. She’s really THE expert in this particular thing, and has some great info.

A sports based therapist should also be able to help you with this, since it’s very often an issue with the smaller glute muscles.

[CHT]

She thinks some of it is that my body is expecting to hurt, so by gradually increasing the time I might help my body understand it is getting better/not being further damaged. I did something similar with my chronic pain clinic. There is only a dull pain after 20 minutes or so when I lay on that side - no pain with use. Working on stretches and massage for now.

Having circulatory issues with my legs, so need to see my regular doctor soon. This has been an issue before the injury, but is worse now - could be the change in my exercise levels.

No MRI. I am not good in MRIs. So far she thinks I am doing ok/as expected, but I need to moderate my expectations. I also acknowledge I need to be better about exercising.