Pelvic insufficiency fractures in the elderly – what insights has the past year of research brought? A narrative review

Introduction

Pelvic insufficiency fractures (PIFs) are pelvic fractures that occur without trauma or due to low-energy trauma mechanisms like ground-level falls in osteoporotic bone. Within the German population, the incidence of PIFs is recorded as 22.4 per 10,000 individuals over the age of 60 and in the Netherlands, there was an increase in PIFs from 5.19 cases per 10,000 in 1986 to 7.17 cases per 10,000 in 2011 [1], 2]. So as the population ages, the incidence of PIF has increased significantly over the past decades and further increase is predicted [3]. PIFs represent a manifestation of systemic diseases that are commonly associated with impaired bone quality. PIF has been shown to be higher among women, due to hormonal changes after menopause and therefore higher rates of osteoporosis and lower bone mineral density, which increase bone fragility and susceptibility to insufficiency fractures [4]. These fractures have shown to be life-changing experiences for elderly patients as they result in pain, immobility or impaired mobility, and chronic instability. This causes a significant reduction of independence and therefore quality of life [5]. Furthermore, patients with PIF show an increased mortality. A current study has shown that the one-year mortality after osteoporotic pelvic ring fractures is over 20 % [6].

PIF differ greatly from pelvic ring fractures in young patients with respect to the injury mechanisms, clinical presentation and the treatment strategy. The occurrence of pelvic injuries in younger patients (aged between 20 and 30 years) is often associated with traffic accidents or falls from considerable heights, involving high-energy impacts. In polytraumatized patients, the incidence of pelvic injuries is 15 % and in these cases where multiple injuries require treatment, emergency care algorithms are used to guide it [7]. The treatment of PIFs includes both conservative and surgical approaches combined with systemic therapy and depends on the fracture type and stability of the fracture [8]. However, an interdisciplinary approach including orthopaedic surgeons, geriatricians, physiotherapists, and pain specialists is crucial to ensure optimal patient outcomes. Given the complexity of these fractures and the frequent presence of comorbidities in elderly patients, early collaboration is essential to balance surgical stabilization, pain management, and mobilization strategies. A coordinated effort between medical, surgical, and rehabilitation teams helps to reduce complications, improve functional recovery, and enhance overall quality of life [9].

The aim of this narrative review is to critically summarise and present the latest findings published between January 2024 and January 2025 on the diagnosis, treatment, complications, and outcomes of PIFs in older people over the age of 60. By focusing on this defined time frame and patient cohort, the aim is to identify current trends, therapeutic developments, and diagnostic advances. Furthermore, ongoing challenges and heterogeneity in clinical practice will be highlighted. The results will serve as a basis for future research directions, support the development of standardised treatment pathways, and serve as a foundation for possible systematic reviews or the development of guidelines. The clinical implications of this study may include the development of more targeted imaging strategies, the integration of interdisciplinary care models, and the improved implementation of pharmacological osteoporosis treatment in this vulnerable population.

Methods

A selective literature research was carried out of all studies published on pelvic insufficiency fractures between 01/2024 and 01/2025 on PubMed. The search-terms “geriatric pelvic fractures”, “pelvic insufficiency fractures” and (pelvic fractures[Title/Abstract]) AND (elderly[Title/Abstract]) were used. A total of 114 articles were found. The titles of the 114 retrieved articles were then screened by two authors to identify relevant studies. The titles were examined according to the following criteria: the type of publication (case reports, case series, opinion papers, technical notes, scoping and systematic reviews and biomechanical studies were excluded), the language of publication (publications not written in German or English were excluded), and the topics covered (studies that did not address geriatric insufficiency fractures with a population older than 60 years and studies that did not deal with diagnostics, treatment, outcomes, or complications of PFIs were excluded). Articles that have not been published in peer-reviewed journals and duplicate studies were also excluded from the analysis. Subsequently, a comprehensive evaluation of the abstracts of the 31 remaining papers was performed, with relevant information being extracted from each study. This information included authors, publication year, study design, study population, location, main endpoint and main findings. Studies that dealt with other insufficiency fractures, such as acetabular or radius fractures, were excluded from the review. Studies that did not use a clear fracture classification and only referred to sacral fractures were also excluded from the analysis. The findings were organised in an Excel spreadsheet (Microsoft Corporation, USA) and discrepancies were resolved through discussion and consensus of all authors. Following a detailed evaluation, a total of 11 studies were selected for inclusion in this narrative review.

Results

The result of the literature search is depicted in Figure 1. Of the 11 studies that were included in the review, one study focused on the diagnostic process of PFI, with a sample size of 107 patients [10]. Four studies concentrated on treatment, with a total of 1,338 patients included [11], [12], [13], [14]. A total of 1,358 patients were included in three studies that investigated the complications of PFI [15], [16], [17]. Three studies concentrated on the outcome and risk factors of insufficiency fractures of the pelvis and included a total of 24,869 patients [18], [19], [20]. The aggregate number of patients examined in these 11 studies was 27,672.

Figure 1:

Flow chart of the literature search.

Discussion

This study highlights key findings on pelvic insufficiency fractures in the elderly. Conventional radiographs show low sensitivity, underscoring the value of early CT or MRI for diagnosis [10]. Treatment depends on fracture stability, pain, and mobility; while stable fractures are treated conservatively, selected cases benefit from minimally invasive surgery [11], 12]. The OF Pelvis Score shows potential for guiding therapy but requires further validation [13]. Pharmaceutical treatment, especially osteoporosis management, remains underused [14]. Comorbidities such as frailty and sarcopenia significantly impact outcomes and support the need for orthogeriatric co-management. [18], [19], [20]. The findings of this narrative review highlight the significant burden of PIF in an aging population, underscoring the need for optimized diagnostic and treatment strategies. PIF have been rising in incidence in the past years, especially due to aging populations in the western world [1], 3]. PIF are associated with high morbidity and mortality, as well as with high healthcare costs [27], 32], 33]. An interdisciplinary approach is highly recommended in the treatment and follow-up treatment of these patients [9]. Despite the efforts to establish diagnostic and treatment algorithms literature remains heterogenous and big prospective and multicentre studies are warranted. Above all, there is a lack of established models for systemic therapy to treat underlying diseases, especially osteoporosis.

The studies included in this review confirm that PIFs are frequently underdiagnosed due to limitations of conventional radiographs and often require advanced imaging modalities, such as CT or MRI, for accurate detection [10]. The clinical presentation is most often immobilizing pain in the pelvic region and/or lower back after no or low-energy trauma. MRI is of significant value in the early phase of a PFI. It can detect bone edema on the ipsi- or contra-lateral side, a factor that has the potential to influence the therapeutic approach prematurely [34]. It has been shown that PIF are often misclassified or even missed when only using conventional radiographs as a diagnostic tool. Scheyerer et al. [35] found that in 96.8 % of their examined cases, pubic rami fractures were accompanied by posterior pelvic ring fractures that were not initially visible on standard pelvic radiographs but were later detected using CT imaging. Wagner et al. [36] recommended a diagnostic algorithm for detecting fragility fractures of the sacrum. In this algorithm conventional radiographs of the pelvis are recommended if there is a clinically suspected. A CT-scan is then recommended according to the findings in the radiograph or when pain persists. The diagnostic approach was then tested and validated by Beelen et al. [37] The study showed that performing a CT only had a limited direct therapeutic consequence. In addition to that the study found that sacroiliac joint (SIJ) pain has been shown to have a sensitivity of 89 % and a specificity of 61 % in detecting concomitant pelvic ring fractures. While this suggests that SIJ pain is a strong indicator of underlying fractures, the moderate specificity indicates that not all cases of SIJ pain are associated with pelvic ring injuries. Given this diagnostic accuracy, it has been proposed that an additional CT scan should be reserved for patients presenting with SIJ pain, rather than performing CT imaging routinely. Similarly, Abdalmaqsoud et al. [10] conducted a retrospective cohort study on 107 elderly patients with immobilizing pelvic pain, evaluating the diagnostic accuracy of AP pelvic radiographs for detecting pelvic ring fractures. The study found a very low sensitivity (3.4 %) but high specificity (94.4 %), indicating that while true fractures were often missed, most negative cases were correctly classified, emphasizing the need for improved imaging strategies. Given the high rate of initially missed fractures, in conventional radiographs the diagnostic workflow in the clinical setting should emphasize the necessity of early CT imaging in patients with persistent pelvic pain and suspected fractures. In accordance with these findings, Böhme et al. found that since the introduction of standardized CT imaging in patients over 65 years of age with anterior pelvic ring fractures in radiographs or lumbosacral pain, the results of CT scanning had a direct influence on the treatment algorithm [38]. Furthermore, the diagnostic value of sacroiliac joint pain as an indicator of posterior pelvic ring fractures suggests that targeted imaging strategies could improve early diagnosis and management.

The fracture morphology and stability, pain level and mobility are factors that influence treatment recommendation. Conservative treatment is recommended for fractures that are classified as stable [39]. Early mobilization plays a crucial role in preventing complications such as pneumonia, deep vein thrombosis and pressure ulcers [5], 40]. Interventional/surgical treatment is recommended for persistent pain, unstable or displaced fractures or failure of conservative treatment and impeded mobilization [39]. The treatment options for these cases involve interventional methods such as sarcoplasty, as well as various fixation methods such as percutaneous screw osteosynthesis, open procedures such as plate osteosynthesis, and internal or external fixators [41]. Surgical interventions are primarily focused on the management of fractures within the posterior pelvic ring, with the goal of pain relief [42]. The significance of the fixation of the anterior pelvic ring remains unclear, since, in contrast to the results of the clinical studies, biomechanical studies show advantages in terms of stability and fracture progression [43]. Moreover, rigid stabilization constructs such as triangular stabilization may lead to mechanical failure of the osteosynthesis, particularly in the context of poor bone quality, as observed in spine surgery [44]. Furthermore, risk factors such as osteoporosis or sarcopenia should be treated [20].

The OF Pelvis Score has emerged as a promising tool for guiding clinical decision-making and aligning treatment strategies with fracture severity and patient condition. Its high concordance rate with actual treatment decisions suggests that it may be a valuable addition to routine clinical practice. Scores such as the OF Pelvis Score have the capability to inform the decision regarding whether surgical treatment would be beneficial by offering a method of visualising the dynamic clinical presentation of patients with PIF [13]. After validation in a prospective, randomized study this tool could help to avoid longer periods of immobilization, which can lead to significant morbidity [45]. Nevertheless, the score does not provide information about the surgical method to be used.

Concerning pharmaceutical therapy, a discrepancy exists between the literature’s recommendations and clinical treatment of risk factors, such as osteoporosis [46]. The study presented by Novikov et al. found a low rate of PTH treatment initiation for PFIs. The authors attributed this phenomenon to a variety of factors, including the absence of clear data regarding the optimal dosage and duration of treatment, as well as the high cost of the therapy [14]. This highlights that there is still a need for further research regarding the implementation of pharmaceutical therapy to treat underlying diseases such as osteoporosis.

Overall, the treatment of PIF currently still presents a particular challenge, as there is a lack of standardized treatment recommendations that include conservative, surgical and pharmaceutical therapies. There is also a lack of evidence-based recommendations for individualized therapeutic decision-making [32], 47], 48]. The cause is to be found in the heterogeneous data situation, which consists mainly of retrospective studies with small to medium-sized study cohorts, range of outcome parameters and variable study periods [24], 42]. In this context, initiatives such as the SNAPPelvis study of the European Society for Trauma and Emergency Surgery (ESTES) and the S1 guideline of the German Society for Orthopaedics and Trauma Surgery (DGOU) [7] can be considered as approaches to address the existing uncertainty by providing evidence-based recommendations.

Complications associated with PIFs, particularly bleeding risks, remain a topic of debate [15], [16], [17]. While high-energy pelvic fractures are well known to be associated with significant hemorrhage [7], the reviewed studies suggest that low-energy PIFs can also result in considerable blood loss, particularly in patients on anticoagulant therapy. The conflicting findings on bleeding risks necessitate further research to develop clear guidelines for anticoagulation management in patients with PIF.

Finally, the outcomes of patients with PIF highlight the severe impact on mobility, independence, and mortality rates. The reviewed studies confirm a substantial one-year mortality rate of up to more than 20 %, which is comparable to mortality rates seen in hip fractures [49]. It is also demonstrated for hip fractures that the comorbidities are more relevant for the outcome rather than perioperative/surgical factors [50], 51]. It is therefore logical that a special geriatric screening and orthogeriatric co-management is beneficial for patients with PIFs [9]. This also underscores the critical importance of early rehabilitation and secondary fracture prevention strategies. Frailty and pre-injury functional status have emerged as key prognostic factors influencing recovery, further emphasizing the need for individualized treatment plans that address both the fracture and the broader health status of the patient. Here, established scoring systems such as the Charlson Comorbidity Index or ASA-Score can be helpful in assessing the patient’s state of health [52].

The present review is limited in several ways. As a narrative review with a selective search strategy, it does not follow the structured methodology of a systematic or scoping review, including predefined inclusion criteria, quality assessment, or comprehensive reporting according to PRISMA guidelines. The studies included in the review are characterised by heterogeneity in terms of design, sample size, fracture classification used and outcome parameters. This heterogeneity limits the ability to make comparisons and to generalise the findings. Moreover, the majority of studies were retrospective and monocentric, which increases the risk of selection bias and limits the strength of conclusions. Despite these limitations, this review provides a structured overview of current developments and highlights key areas for future research and clinical improvement.

Conclusions

This review provides a comprehensive overview of recent research on PIF, offering valuable insights into diagnosis, treatment, complications, and outcomes. The findings underscore the importance of an interdisciplinary approach, incorporating early and precise diagnostics, tailored therapeutic strategies, and proactive osteoporosis management to improve patient outcomes. Future studies should focus on refining diagnostic algorithms, optimizing treatment protocols, reveal the effect of systemic treatment of osteoporosis, and evaluating long-term interventions aimed at enhancing recovery and quality of life in this vulnerable patient population.