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Chiropractic Care of a Patient with Low Back Pain Associated with Subluxations and a Malgaigne-Type Pelvic Fracture
CASE REPORTS CHIROPRACTIC CARE OF A PATIENT WITH LOW BACK PAIN ASSOCIATED WITH SUBLUXATIONS AND A MALGAIGNE-TYPE PELVIC FRACTURE Joel Alcantara, DC,a Gregory Plaugher, DC,b Richard Elbert, DC,c and Bryan Gatterman, DC d
ABSTRACT Objective: To describe the chiropractic care of a patient with a pelvic ring fracture and concomitant subluxations of multiple segments of the spinal column. Clinical Features: A 23-year-old male, after falling down a flight of stairs, was initially hospitalized for fractures of the pelvis. Five weeks posthospitalization, the patient initiated chiropractic care with complaints of severe low back pain with lower extremity involvement. He also complained of neck pain and occipital headache. The patient had several positive low back orthopedic tests with bilaterally absent Achilles deep tendon reflexes. The anteroposterior radiographic view revealed ununited fractures at the left superior and inferior pubic ramus, noted as a type I Malgaigne fracture. Subluxations were detected at the left innominate (ie, fracture-subluxation) and at the patient’s lumbar, thoracic, and cervical spine. Intervention and Outcome: The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral and sacroiliac subluxations. The patient’s response to care was positive, receiving great pain relief. Less than 3 months after initiating care, the patient returned to work on regular duty. Conclusion: There are indications that patients suffering from the injuries described above may derive benefits from chiropractic care. The practitioner must pay careful attention to issues of biomechanical and vascular stability and adjustment modifications in these types of patients. (J Manipulative Physiol Ther 2003;26:358-65) Key Indexing Terms: Chiropractic; Malgaigne Fracture; Low Back Pain
a Research Director, International Chiropractic Pediatric Association, Media, Pa, and Private practice of chiropractic, San Jose, Calif. b Director of Research, Life Chiropractic College West, Hayward, Calif, and the Gonstead Clinical Studies Society, Santa Cruz, Calif. c Diplomate of the Gonstead Clinical Studies Society and Private Practice of Chiropractic, Ames, Iowa. d Clinical Radiologist, Health Center, Life Chiropractic College West, Hayward, Calif. This study was funded by Life Chiropractic College West, Hayward, Calif, and the Gonstead Clinical Studies Society, Santa Cruz, Calif. Submit requests for reprints to: Dr Gregory Plaugher, Life Chiropractic College West, 2001 Industrial Blvd, Hayward, CA 94545. Paper submitted April 24, 2001; in revised form May 1, 2001. 0161-4754/$30.00 Copyright n 2004 by National University of Health Sciences. doi:10.1016/S0161-4754(03)00008-3
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raditional research attempts to make inferences to the general population, while doctors continue to see individuals, either singly or in groups.1 Although the group of patients many chiropractors care for have traditionally demonstrated neuromusculoskeletal complaints,2 the range of disorders can vary widely, from soft tissue injuries (ie, sprains and strains) to fractures and dislocations. The literature is replete with chiropractic care of patients with soft tissue injuries, but only a small number of studies, in the form of case reports, have been published describing the care of individuals with fractures or dislocations with concomitant sprain-subluxations. To further contribute to this knowledge base, we describe the chiropractic care of a patient with complaints of low back pain concomitant with a pelvic ring fracture.
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Fig 1. Anteroposterior lumbopelvic radiographs of the patient prior to initiation of chiropractic care.
CASE REPORT A medical physician first saw the patient, a 23-year-old male, after he fell down a flight of stairs and landed on his buttocks on a concrete floor. The patient related that at the hospital, he was informed that his pelvis was fractured and was subsequently hospitalized for 12 days. After being reexamined, he was released from care with no work restrictions. He was given Tylenol with codeine for pain and instructed to soak in a tub of hot water to help alleviate the pain. Not surprisingly, his complaints of pain increased. The patient then sought chiropractic care. The patient sought this care approximately 5 weeks after his accident. He had severe low back pain radiating to the left side, into the left hip, and down the back of the left leg. His left leg was non-weight-bearing, and the patient required the aid of crutches for ambulation. Sitting, standing, lying supine, and coughing exacerbated the pain. Additionally, he complained of left-sided neck pain and occipital headaches. Prior to his fall, the patient had no history of low back, hip, or leg pain. At the time of chiropractic consultation, he admitted to having had consumed approximately 100 Tylenol #3 within the past 3 weeks. The medication had become ineffective in relieving his pain, and the medical physician had refused to renew his prescription.
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Fig 2. Lateral lumbopelvic radiographs of the patient prior to initiation of chiropractic care.
Initial examination revealed swelling and edema over the left sacroiliac and lumbosacral areas. The left innominate appeared markedly higher and narrower than the right. The left thigh and lower leg appeared atrophied compared with the right (no girth measurement was obtained). The L5 vertebral body level and left sacroiliac areas were tender to palpation. The thoracolumbar region was severely restricted in its range of motion due to pain. Orthopedic tests showed a positive Lasegue’s sign, Ely’s sign, and Derifield hip on the left. In addition, the patient had a positive Gonstead test. This test involves percussing over the lower extremity (ie, at the gastrocnemius), which increased pain at the lower lumbar spine. The Achilles deep tendon reflex test was absent in both legs. Radiographic evaluations involved anteroposterior (AP) and lateral full spine views (see Figs 1 and 2) and were obtained prior to initiating chiropractic care. The L5 vertebral body appeared severely posterior ( Z) and inferior ( uX). The cervical curve appeared hypolordotic with a D3-graded intervertebral disk3 at C7-T1, along with retrolisthesis of C7. The AP view revealed healing fractures at the left superior and left inferior pubic rami. The inferior aspect of the sacrum of the left sacroiliac joint appeared 10 mm below the inferior aspect of the left ilium. The L5 vertebra was listed as PR-inf ( Z, uX, +uY), L2 as PR ( Z, +uY),
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Fig 3. Comparative anteroposterior lumbopelvic radiographs of the patient 5 weeks past initiation of chiropractic care.
Fig 4. Lateral lumbopelvic radiographs of the patient 5 weeks past initiation of chiropractic care.
T5 as PRS ( Z, +uY, uZ), C7 as PRS ( Z, +uY, uZ), and the left ilium was listed as an AS13 Ex15 subluxation (+Z, +uX, uY). The millimetric subscripts are derived from an analysis of the AP pelvic portion of the radiograph. The long axis lengths of the innominates are measured. The 13-mm subscript reflects the amount of the discrepancy between the right and left innominate lengths. The Ex portion of the listing refers to external rotation of the posterior superior iliac spine (PSIS) from midline. This listing is derived by comparing the position of the pubic symphysis from a center point line derived from the position of the S2 tubercle of the sacrum. The 15-mm subscript refers to the pubic symphysis being deviated 15 mm to the right of the center sacral line.4 Following the initial examination, the patient was sent home with instructions to use ice on his low back and to return the next day. Patient care consisted of adjustments 2 times per day for the next 7 days at sites of subluxations. Initially, the L5 vertebra was adjusted on a Hi-Lo table, with the patient prone and the thoracic piece locked. Although the side-posture position is generally preferred as a first choice to prone positioning for adjusting lower lumbar vertebrae, the presence of the pelvic fracture on the left complicated using this position due to the patient’s pain. These adjustments helped to relieve his severe low back pain, but the patient’s symptomatic response quickly reached a plateau.
After 3 weeks of care, the left ilium was adjusted as an ASEx using the side-posture ASEx ilium pull move adjustment. In this adjustment, the pelvis is not compressed during the procedure. The pull adjustment was modified to adapt to the patient’s condition. First, the patient was put in the left side-lying position on the side of the fractured innominate, and the patient was queried as to whether this position increased his pain, which it did not. Next, a contact was made over the rim of the left acetabulum with the doctor’s left pisiform. Instead of the doctor’s leg placed on the lateral aspect of the patient’s thigh, the doctor chose to not stabilize the pelvis with any counter pressure. If the pelvis had been stabilized in the normal fashion, this would have produced excessive loading to the left innominate and would have had the potential for increasing the patient’s pain and difficulty in performing the adjustment due to pain. This type of stabilization would also have had greater potential for displacing the fracture site. For these reasons, no leg stabilization was performed. The adjustment was made exclusively with a quick motion of the hand and wrist, which resulted in a substantial movement and audible from the involved articulation. The patient was cared for daily for 2 12 months and was able to return to work with light duty restrictions during this time. Shortly thereafter, the patient was able to return to his regular job duties as a dry cleaner.
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Fracture healing was monitored with 5 comparative AP pelvic radiographs over a 2-year period. The 2-year follow-up comparative radiograph (Figs 3 and 4) demonstrates healed fractures at the left ischium and pubic bones. The superior ramus has not approximated as well as the inferior ramus. Roentgenometric findings from the initial follow-up radiographs at 1 month showed Ferguson’s angle measured at 39j, the L5 disk angle measured at 16j, and the inferior aspect of the sacrum measured 7 mm inferior to the inferior aspect of the ilium at the left sacroiliac joint. Spinographic analysis showed a sacral measurement of 52 mm left and 60 mm right (P-R, uY); the left ilium was listed as ASEx (+Z, +uX, uY); L5 was listed as PRI ( Z, +uY, +uZ); and the radiographic findings showed the gluteal crease to be left of the symphysis pubis. The ASEx ilium listing subscripts were not substantially changed on this radiograph. Reexamination (at 1-month follow-up) of clinical findings showed a positive Derifield hip; positive Ely’s, Braggard’s, and Patrick’s signs on the left; and positive Lasegue’s sign on the right; and the thoracolumbar motion was restricted on extension and right lateral flexion. The right Achilles and left patellar reflex were diminished. Eight months after initiating chiropractic care, the patient was involved in an automobile accident and suffered a hyperflexion cervical sprain and a lumbosacral sprain injury. One month later, he was involved in another automobile accident, receiving a hyperflexion cervical sprain, lumbosacral sprain, and right knee strain injuries. He remained a patient for 6 years thereafter, receiving intermittent chiropractic care. Thirteen years postcare, the patient reports only intermittent ‘‘achiness’’ in his left hip and mild left sacroiliac joint restriction. The patient reports no other complications.
DISCUSSION Clinically significant findings such as fractures and neoplasms are seen in chiropractic patients in addition to the more common findings of degenerative disks and posterior joint changes.5 Winterstein6 stated over 20 years ago that approximately 9% of presenting chiropractic patients might have spinal compression fractures. Today, the prevalence of patients attending chiropractic clinics with a variety of fractures and dislocations may be greater, particularly when one considers the growing popularity of chiropractic. This case brings to the fore several issues in the chiropractic care of patients who have suffered severe trauma and, in particular, in those patients sustaining fracturesubluxations. The chiropractic care of individuals with fractures, dislocations, and fracture-subluxations are not widely performed in the profession but are nonetheless addressed in clinical practice by some chiropractors and
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most notably by Gonstead practitioners.7-10 The decision for a chiropractor to accept a patient with spinal and extraspinal fractures and/or dislocations is dependent on several factors, the foremost of which include the chiropractor’s clinical experience, training, and education, and, ultimately, confidence in their clinical skills to provide care for the individual. The attending chiropractor in this case has been in practice for over 20 years and has cared for a number of patients with spinal fracture-subluxations with good clinical success. He is a Diplomate of the Gonstead technique. Fracture-subluxation management has been taught by the teaching staff of the Gonstead Seminars, Inc. at Mount Horeb, Wisconsin, and throughout the world. In the arena of chiropractic education, fracture-subluxation management has been taught in the past at Palmer College of Chiropractic, Davenport, Iowa (Herbert Wood, DC, oral communication, February 1, 1995), at Palmer College of Chiropractic West, San Jose, California, and at Life Chiropractic College West, Hayward, California by 1 of the authors (GP). Fracture-subluxation management is also addressed in 2 textbooks within the profession.11,12 The Guidelines for Chiropractic Quality Assurance and Practice Parameters, otherwise known as the ‘‘Mercy Document,’’ addresses the issue of fractures and dislocations with the following statement: ‘‘Acute fractures and dislocations, or healed fractures and dislocations with signs of ligamentous rupture or instability, represent an absolute contraindication to high-velocity thrust procedures applied to the anatomical site or region..’’13 Notwithstanding the controversy associated with the Mercy Document,14,15 the patient described in this case report does not befit the above description/criteria. Most notably and discussed in greater detail throughout this section are the nonacute nature of the patient’s injuries at presentation to the chiropractor, the stability of this type of injury, and attention to avoiding further injury by not reproducing the mechanism of injury during the adjustment procedure. The attending chiropractor contemplated reducing the actual fracture fragments because they were severely displaced but decided not to do this, since he reasoned that this could not be done without placing the patient at undue risk. It is obvious that not all chiropractors have the necessary skills from their education and clinical experience to attend to the type of patient presented; however, for some specialist practitioners, the acceptance of such a case would not breach the minimal threshold of acceptable standard of care.11 It is of paramount importance that recognition of loads sufficient to cause a pelvic fracture can also produce a sprain injury (ie, subluxation) nearby. The Malgaigne fracture coexisted with a compression injury to the left sacral ala, as well as a cephalad or superior displacement of the entire innominate on the left side. Ultimately, an adjustment was directed at the fractured innominate (ie, ilium contact) in an attempt to reduce the subluxation of
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the ilium with respect to the sacrum. In this context, the lesion is appropriately described as a fracture-subluxation. Although the adjustment is directed at the subluxation component, the presence of a Malgaigne fracture complicates the adjustment procedure through positioning and stabilization modifications, the potential for aggravation of the fracture site (ie, bleeding) with an unmodified procedure, and the ability of the chiropractor to differentiate symptoms that are arising from the subluxation or joint lesion versus the bony and soft tissue trauma at or near the fracture site. Another issue that arises is the potential for sprain injury more remote from the fracture site and the acute area of interest. Trauma sufficient to produce fracture of the bony pelvis is likely sufficient to produce concomitant sprain injuries, as shown in this patient. Practitioners (eg, medical) may not recognize these more subtle sprain injuries because they are not triaged (ie, prioritized) in a case such as this, given the potential for vascular injuries with a fracture of this type. Chiropractors have a unique perspective they bring to health care and dramatically different emphases on the importance of sprain injury or subluxation, as well as its amelioration. Interdisciplinary discussion of these issues may help the patient to obtain integrated care, which heretofore has been unusual in patients with severe trauma. These secondary lesions can be more responsible for the patient’s clinical complaints, be they pain or functional limitations, as the patient’s clinical response appears to demonstrate. Addressing the L5 subluxation necessitates recognition that positioning issues for the adjustment of this segment is complicated by the presence of the Malgaigne fracture that would be affected by side-posture positioning for the lower lumbar adjustment. Most chiropractic textbooks give scant details on the management of patients who have sustained a spinal fracture. Details regarding pelvic fractures, including the Malgaigne type, and their management implications are even more absent. This is somewhat troubling, given the significant number of patients that chiropractors care for who have experienced significant trauma. In the case described herein, the issue of bleeding at the fracture site, as well as the potential for direct vascular or pelvic organ injury, are important management issues. Inherent in the application of the adjustment is ‘‘primum non nocere,’’ and therefore, in situations wherein further vascular or pelvic organ injury may occur, then the risks to the patient’s well being obviously outweigh the benefit for an adjustment procedure. The stability of the segment to be adjusted is another important consideration. Stability generally falls along a continuum and there are several types applicable to this case: neurological, vascular, biomechanical, concomitant pelvic organ injuries, etc., and allowing some time to lapse (eg, several weeks), which in this case was perhaps prudent, given the potential risks for concom-
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itant vascular injuries, as well as the potential for the fracture site to hemorrhage. In patients with fractures and dislocations, successful management, chiropractic or otherwise, is dependent on proper pretreatment evaluation and a biomechanically sound regimen of care. However, in some states, the chiropractic care of such conditions is outside the scope of practice of chiropractors and in other states, it is undefined.16 As a result, the number of published reports is few. It is therefore important that further investigations and comprehensive documentation on the chiropractic care of such patients continue so that a scientific literature base can be established. Stern et al17 presented the case of a 58-year-old woman who went to a chiropractor with a pelvic insufficiency fracture simulating metastatic bone disease. She was referred to a rehabilitation clinic for physiotherapy and medication for further care. She was not adjusted. Plaugher et al9 described the case of a patient with a missed zone 2 sacral fracture receiving a specific contact sacroiliac adjustment (side posture). The patient self-referred to a medical orthopedist following 2 adjustments and no abatement of her complaint. Medical care thereafter consisted of bed rest, where at 6 weeks her symptoms resolved and she returned to work. Plaugher et al8 reported the care of a patient sustaining a Chance fracture at L3 from a motor vehicle accident. Chiropractic care consisted of specific contact, short-lever-arm spinal adjustments at L3 and L5, as well as bracing. This was the first description in the scientific literature of a patient receiving adjustments to sites of subluxation, including the fracture site, and cared for successfully. Alcantara et al7 followed with a description of the care of a patient with a lamina fracture of C6 following a hyperextension injury as a result of a motor vehicle accident. The patient refused emergency surgical treatment, opting instead for chiropractic care. The case raised several legal, ethical, and clinical issues in the care of individuals with this type of traumatic injury and fractures in general.18-20 Brynin and Yomtob21 described the diagnosis (anterior compression fracture) of a patient reporting to a chiropractic clinic 1 month postemergency care after a diving accident. Following fracture detection based on radiographs, the patient was referred to his medical doctor for further care. Recently, Lapp22 described the chiropractic care of a patient with a pelvic stress fracture in a 42-year-old woman with hip pain after running. Care consisted of high-velocity low-amplitude adjustments, ultrasound, and stretching of the psoas and piriformis muscles. As one can surmise from a review of the above literature, a number of the cases reported were of patients presenting for chiropractic care with complaints of spinal pain posttrauma. These patients were misdiagnosed and released from emergency care. After correct detection of the spinal fracture(s) by the attending chiropractor, referral
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for medical care was the sequelae of care. In only a few of the cases were the patients cared for in a specifically chiropractic manner. The patient described in this case report sustained a group I Malgaigne fracture.23 According to Yochum and Rowe,24 this fracture represents approximately one third of all pelvic fractures. Complications may arise affecting the diaphragm or bowel, sacroiliac instability may also arise, and a high morbidity and mortality rate is reported. The appearance on radiograph involves a fracture of the superior and inferior pubic rami (ipsilaterally) with possible separation of the sacroiliac joint without dislocation. This is consistent with findings by Burgess and Jones.25 They found that fractures of the non-weight-bearing anterior pelvic ring along with some involvement of the posterior ring, such as slight tearing of the anterior sacroiliac ligaments and/or vertical fracture of the sacrum, occurred in Malgaigne injuries. Apparently, these types of injuries are stable and require no reduction. Initial treatment of immobilization in a pelvic sling body bandage with leg traction was proposed by Malgaigne, and this treatment is continued until consolidation is accomplished in approximately 45 to 50 days (6 to 7 weeks). 25 Although considered a stable injury by several authors, the clinical findings in this case do relate to a more ‘‘unstable situation if one considers the definition proposed by White and Panjabi,26 ‘‘clinical instability is the loss of the ability of the spine under physiologic loads to maintain its pattern of displacement so that there is not initial or additional neurological deficit, no major deformity, and no incapacitating pain. As the reader recalls from the history, this patient could not bear weight on the left side, or sit, or lie supine (normal physiological loads) without exacerbation of the pain. These clinical features combined with the well-known late sacroiliac instability that often is the sequelae of these injuries supports the assessment that this patient was experiencing an unstable injury to his pelvis. As a point of interest, 70% of pelvic fractures are relatively uncomplicated, whereas in the other 20% to 30% of patients, they are considered as having major pelvic fractures with a 10% mortality rate.23 As such, in patients with these types of injuries (ie, uncomplicated fractures of the anterior pelvic ring), the approach to care is palliative. According to Connoly, 23 medical protocol typically involves bed rest for 2 to 3 days, followed by crutch walking for 4 to 6 weeks. Within 6 to 8 weeks postinjury, these patients are expected to have ‘‘complete recovery.’’ However, pain and disability may be present, depending on the residual deformity. Chiropractic care of individuals sustaining uncomplicated fractures of the pelvis shares the same objectives of treatment with orthopedic surgeons. Through adjustments at sites of subluxations, the chiropractor attempts to restore bony anatomy, minimize pain and discomfort, and facili-
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tate return of function, as well as prevent further deformity. The chiropractor providing care for the individual described in this case report followed the Gonstead protocol.27,28 Chiropractic adjustments were applied to sites of vertebral subluxation, as well as the fracture subluxation of the left innominate. This type of care resulted in the patient receiving great symptomatic relief, to the point of being able to return to work on regular duty within 1 month from initiation of chiropractic care. One of us (BG) is of the opinion that it is contraindicated to adjust an acute pelvic fracture. But in minimally displaced fractures as in this case, with appropriate hospital immobilization, a 6- to 7-week period allows for a substantial healing response to occur. Since sacroiliac instability is a common occurrence in healed Malgaigne injuries, early initiation of chiropractic care at or about 7 weeks postinjury may address this complication. This patient was adjusted at spinal regions above the pelvis at 5 weeks postinjury. The left ilium was first adjusted approximately 8 weeks posttrauma. For patients with a history of trauma presenting for chiropractic care, a thorough history and physical examination (including the use of imaging studies) are of paramount importance for successful management. For patients with pelvic ring injuries, the history and physical examination should differentiate major versus minor pelvic fractures/injuries. One should monitor the patient’s vital signs and be cognizant of certain conditions such as patient shock. This and other signs and symptoms may require the patient to receive immediate hospital-based emergency care. Concomitant with pelvic fracture injuries, in addition to infection (ie, retroperitoneal infection), the patient’s trauma may also result in hemorrhage and genitourinary and gastrointestinal injury.29 Retroperitoneal infections involve pain in the abdomen or flank and referred pain to the groin or thigh region. The patient reported here was ruled out for these types of concomitant injuries. Several studies have confirmed that hemorrhage is the most perilous complication associated with pelvic fractures.29,30 This may be due to bleeding from the fracture site and the associated damage to bony, soft tissue and vascular elements, including major blood vessels. The chiropractor should be aware of the intimate relationship of the internal iliac artery and its tributaries, including veins to the anterior aspect of the sacroiliac joint and ligaments, prior to adjusting the pelvis, to prevent iatrogenic injuries. These structures are responsible for the high incidence of vascular injury and its associated hemorrhage in patients with pelvic fractures. Fractures of the pelvis have long been associated with injuries to the lower urinary tract.29,31 The patient sustaining a rupture of the bladder following blunt trauma presents with gross hematuria. Urethral injuries in males present with blood at the distal meatus, a high-riding prostate, a
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perineal hematoma, or the inability to void. Injuries to the genitals and gonads must also be recognized. Gastrointestinal injuries may be associated with a pelvic fracture or as a result of trauma alone. In patients with closed fractures of the pelvis, diagnosis may be difficult, since the initial abdominal examination may be normal.30 The pain experienced by the patient may be associated with sprain of the sacrotuberous and sacrospinous ligament and sacroiliac (SI) ligament injuries (particularly from the ASEx displacement). Additionally, there may be strain injuries of the piriformis, obturator internus, the gemellus, and the gluteal muscles. The radiating pain symptomatology may involve irritation/impingement of the sciatic nerve, as well as sclerotogenous pain referral.
CONCLUSION We described the successful chiropractic care of a patient with radiating low back pain after sustaining an anterior pelvic ring fracture(s) (Malgaigne fracture) and spinal subluxations following a fall. This case report provides support that patients with fractures and subluxations may derive benefit from chiropractic care. The potential risks in accepting cases such as this are more substantial. The chiropractor needs to pay particular attention to imaging decisions and follow-up and differentiating potential complicating factors, such as vascular injury or hemorrhage at the fracture site. In addition, special focus should be made to modifying certain examination procedures, patient positioning, and adjustment procedures so that the fracture site is not aggravated during the performance of the side-posture adjustment of the involved innominate. We encourage further prospective research into this topic area.
REFERENCES 1. Barlow DH, Hayes SC, Nelson RO. The scientist practitioner: research and accountability in clinical and educational settings. New York: Pergamon Press; 1984. p. 52. 2. Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG. Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998;88: 771-6. 3. Plaugher G, Lopes MA. Clinical anatomy and biomechanics of the spine. In: Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Baltimore: Williams & Wilkins; 1993. p. 287. 4. Plaugher G, Hendricks AH, Doble RW Jr, Bachman TR, Araghi HJ, Hoffart VM. The reliability of patient positioning for evaluating static radiologic parameters of the human pelvis. J Manipulative Physiol Ther 1993;16:517-22. 5. Marchiori DM. A survey of radiographic impression on a selected chiropractic patient population. J Manipulative Physiol Ther 1996;19:109-12.
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6. Winterstein JF. Diagnosis and management of stable thoracolumbar compression fractures. J Clin Chiropr 1979;3:43-54. 7. Alcantara J, Plaugher G, Abblett DE. Management of a patient with a lamina fracture of the sixth cervical vertebra and concomitant subluxation. J Manipulative Physiol Ther 1997;20: 113-23. 8. Plaugher G, Alcantara J, Hart CR. Management of the patient with a Chance fracture of the lumbar spine and concomitant subluxation. J Manipulative Physiol Ther 1996;19:539-51. 9. Plaugher G, Alcantara J, Doble RW Jr. Missed sacral fracture before chiropractic adjustment. J Manipulative Physiol Ther 1996;19:480-3. 10. Plaugher G, Alcantara J, Cichy DL. Management of the patient with a superior end-plate burst fracture of C7 and concomitant subluxation: a case report. J Clin Chiropr Pediatr 1996;1:79-88. 11. Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Baltimore: Williams & Wilkins; 1993. p. 325-55. 12. Anrig C, Plaugher G, editors. Pediatric chiropractic. Baltimore: Williams & Wilkins; 1998. p. 730-76. 13. Haldeman S, Chapman-Smith D, Petersen DM. Guidelines for chiropractic quality assurance and practice parameters: proceedings of the Mercy Center Consensus Conference. Gaithersburg (MD): Aspen Publishers; 1993. p. 167-77. 14. Cates JR, Young DN, Guerriero DJ, Jahn WT, Armine JP, Korbett AB, et al. Evaluating the quality of clinical practice guidelines. J Manipulative Physiol Ther 2001;24:170-6. 15. Kent C. Evaluating the quality of clinical practice guidelines. J Manipulative Physiol Ther 2001;24:612-8. 16. Lamm LC, Wegner E, Collord D. Chiropractic scope of practice: what the law allows-update 1993. J Manipulative Physiol Ther 1995;18:16-20. 17. Stern PJ, Cote P, Dust W. Pelvic insufficiency fracture simulating metastatic bone disease. J Manipulative Physiol Ther 1994;17:485-8. 18. Ventura JM. Management of a patient with lamina fracture of the sixth cervical vertebrae and concomitant subluxation. J Manipulative Physiol Ther 1997;20:488-9. 19. Miller JS. Management of a patient with lamina fracture of the sixth cervical vertebrae and concomitant subluxation. J Manipulative Physiol Ther 1997;20:494-5. 20. Corenman DS. Management of a patient with lamina fracture of the sixth cervical vertebrae and concomitant subluxation. J Manipulative Physiol Ther 1997;20:489-94. 21. Brynin R, Yomtob C. Missed cervical spine fracture: chiropractic implications. J Manipulative Physiol Ther 1999;22: 610-4. 22. Lapp JM. Pelvic stress fracture: assessment and risk factors. J Manipulative Physiol Ther 2000;23:52-7. 23. Connoly JF. Fractures and dislocations of the pelvis. In: Connoly JF, editor. Fractures and dislocations: closed management. Philadelphia: WB Saunders; 1995. p. 453-96. 24. Yochum TR, Rowe LJ. Essentials of skeletal rad. 2nd ed. Baltimore: Williams & Wilkins; 1995. p. 707. 25. Burgess AR, Jones AL. Fractures of the pelvic ring. In: Rockwood CA Jr, Bucholz RW, Green DP, Heckman JD, editors. Fractures in adults. Philadelphia: Lippincott-Raven; 1996. p. 1575-616. 26. White AA, Panjabi MM. Clinical biomechanics of the spine. 2nd ed. Philadelphia: JB Lippincott Co; 1990. p. 278. 27. Rowe DJ. Chiropractic management of spinal fractures and dislocations. In: Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Baltimore: Williams & Wilkins; 1993. p. 325-55.
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28. Plaugher G, Rowe DJ, Cichy DL, Goble CE, Elbert RA, Hart CR, et al. Adolescent patients with acute spinal fractures. In: Anrig CA, Plaugher G, editors. Pediatric chiropractic. Baltimore: Williams & Wilkins; 1998. p. 730-76. 29. Mucha P Jr, Welch TJ. Hemorrhage in major pelvic fractures. Surg Clin North Am 1988;68:757-73.
30. Fallon B, Wendt JC, Hawtrey CE. Urological injury and assessment in patients with fractured pelvis. J Urol 1984;131: 712-4. 31. Cotler HB, Meadowcroft JA, Smink RD. Enteric fistula as a complication of a pelvic fracture. Case report. J Bone Joint Surg 1983;65A:854-6.
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ABSTRACT Objective: To describe the chiropractic care of a patient with a pelvic ring fracture and concomitant subluxations of multiple segments of the spinal column. Clinical Features: A 23-year-old male, after falling down a flight of stairs, was initially hospitalized for fractures of the pelvis. Five weeks posthospitalization, the patient initiated chiropractic care with complaints of severe low back pain with lower extremity involvement. He also complained of neck pain and occipital headache. The patient had several positive low back orthopedic tests with bilaterally absent Achilles deep tendon reflexes. The anteroposterior radiographic view revealed ununited fractures at the left superior and inferior pubic ramus, noted as a type I Malgaigne fracture. Subluxations were detected at the left innominate (ie, fracture-subluxation) and at the patient’s lumbar, thoracic, and cervical spine. Intervention and Outcome: The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral and sacroiliac subluxations. The patient’s response to care was positive, receiving great pain relief. Less than 3 months after initiating care, the patient returned to work on regular duty. Conclusion: There are indications that patients suffering from the injuries described above may derive benefits from chiropractic care. The practitioner must pay careful attention to issues of biomechanical and vascular stability and adjustment modifications in these types of patients. (J Manipulative Physiol Ther 2003;26:358-65) Key Indexing Terms: Chiropractic; Malgaigne Fracture; Low Back Pain
a Research Director, International Chiropractic Pediatric Association, Media, Pa, and Private practice of chiropractic, San Jose, Calif. b Director of Research, Life Chiropractic College West, Hayward, Calif, and the Gonstead Clinical Studies Society, Santa Cruz, Calif. c Diplomate of the Gonstead Clinical Studies Society and Private Practice of Chiropractic, Ames, Iowa. d Clinical Radiologist, Health Center, Life Chiropractic College West, Hayward, Calif. This study was funded by Life Chiropractic College West, Hayward, Calif, and the Gonstead Clinical Studies Society, Santa Cruz, Calif. Submit requests for reprints to: Dr Gregory Plaugher, Life Chiropractic College West, 2001 Industrial Blvd, Hayward, CA 94545. Paper submitted April 24, 2001; in revised form May 1, 2001. 0161-4754/$30.00 Copyright n 2004 by National University of Health Sciences. doi:10.1016/S0161-4754(03)00008-3
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raditional research attempts to make inferences to the general population, while doctors continue to see individuals, either singly or in groups.1 Although the group of patients many chiropractors care for have traditionally demonstrated neuromusculoskeletal complaints,2 the range of disorders can vary widely, from soft tissue injuries (ie, sprains and strains) to fractures and dislocations. The literature is replete with chiropractic care of patients with soft tissue injuries, but only a small number of studies, in the form of case reports, have been published describing the care of individuals with fractures or dislocations with concomitant sprain-subluxations. To further contribute to this knowledge base, we describe the chiropractic care of a patient with complaints of low back pain concomitant with a pelvic ring fracture.
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Fig 1. Anteroposterior lumbopelvic radiographs of the patient prior to initiation of chiropractic care.
CASE REPORT A medical physician first saw the patient, a 23-year-old male, after he fell down a flight of stairs and landed on his buttocks on a concrete floor. The patient related that at the hospital, he was informed that his pelvis was fractured and was subsequently hospitalized for 12 days. After being reexamined, he was released from care with no work restrictions. He was given Tylenol with codeine for pain and instructed to soak in a tub of hot water to help alleviate the pain. Not surprisingly, his complaints of pain increased. The patient then sought chiropractic care. The patient sought this care approximately 5 weeks after his accident. He had severe low back pain radiating to the left side, into the left hip, and down the back of the left leg. His left leg was non-weight-bearing, and the patient required the aid of crutches for ambulation. Sitting, standing, lying supine, and coughing exacerbated the pain. Additionally, he complained of left-sided neck pain and occipital headaches. Prior to his fall, the patient had no history of low back, hip, or leg pain. At the time of chiropractic consultation, he admitted to having had consumed approximately 100 Tylenol #3 within the past 3 weeks. The medication had become ineffective in relieving his pain, and the medical physician had refused to renew his prescription.
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Fig 2. Lateral lumbopelvic radiographs of the patient prior to initiation of chiropractic care.
Initial examination revealed swelling and edema over the left sacroiliac and lumbosacral areas. The left innominate appeared markedly higher and narrower than the right. The left thigh and lower leg appeared atrophied compared with the right (no girth measurement was obtained). The L5 vertebral body level and left sacroiliac areas were tender to palpation. The thoracolumbar region was severely restricted in its range of motion due to pain. Orthopedic tests showed a positive Lasegue’s sign, Ely’s sign, and Derifield hip on the left. In addition, the patient had a positive Gonstead test. This test involves percussing over the lower extremity (ie, at the gastrocnemius), which increased pain at the lower lumbar spine. The Achilles deep tendon reflex test was absent in both legs. Radiographic evaluations involved anteroposterior (AP) and lateral full spine views (see Figs 1 and 2) and were obtained prior to initiating chiropractic care. The L5 vertebral body appeared severely posterior ( Z) and inferior ( uX). The cervical curve appeared hypolordotic with a D3-graded intervertebral disk3 at C7-T1, along with retrolisthesis of C7. The AP view revealed healing fractures at the left superior and left inferior pubic rami. The inferior aspect of the sacrum of the left sacroiliac joint appeared 10 mm below the inferior aspect of the left ilium. The L5 vertebra was listed as PR-inf ( Z, uX, +uY), L2 as PR ( Z, +uY),
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Fig 3. Comparative anteroposterior lumbopelvic radiographs of the patient 5 weeks past initiation of chiropractic care.
Fig 4. Lateral lumbopelvic radiographs of the patient 5 weeks past initiation of chiropractic care.
T5 as PRS ( Z, +uY, uZ), C7 as PRS ( Z, +uY, uZ), and the left ilium was listed as an AS13 Ex15 subluxation (+Z, +uX, uY). The millimetric subscripts are derived from an analysis of the AP pelvic portion of the radiograph. The long axis lengths of the innominates are measured. The 13-mm subscript reflects the amount of the discrepancy between the right and left innominate lengths. The Ex portion of the listing refers to external rotation of the posterior superior iliac spine (PSIS) from midline. This listing is derived by comparing the position of the pubic symphysis from a center point line derived from the position of the S2 tubercle of the sacrum. The 15-mm subscript refers to the pubic symphysis being deviated 15 mm to the right of the center sacral line.4 Following the initial examination, the patient was sent home with instructions to use ice on his low back and to return the next day. Patient care consisted of adjustments 2 times per day for the next 7 days at sites of subluxations. Initially, the L5 vertebra was adjusted on a Hi-Lo table, with the patient prone and the thoracic piece locked. Although the side-posture position is generally preferred as a first choice to prone positioning for adjusting lower lumbar vertebrae, the presence of the pelvic fracture on the left complicated using this position due to the patient’s pain. These adjustments helped to relieve his severe low back pain, but the patient’s symptomatic response quickly reached a plateau.
After 3 weeks of care, the left ilium was adjusted as an ASEx using the side-posture ASEx ilium pull move adjustment. In this adjustment, the pelvis is not compressed during the procedure. The pull adjustment was modified to adapt to the patient’s condition. First, the patient was put in the left side-lying position on the side of the fractured innominate, and the patient was queried as to whether this position increased his pain, which it did not. Next, a contact was made over the rim of the left acetabulum with the doctor’s left pisiform. Instead of the doctor’s leg placed on the lateral aspect of the patient’s thigh, the doctor chose to not stabilize the pelvis with any counter pressure. If the pelvis had been stabilized in the normal fashion, this would have produced excessive loading to the left innominate and would have had the potential for increasing the patient’s pain and difficulty in performing the adjustment due to pain. This type of stabilization would also have had greater potential for displacing the fracture site. For these reasons, no leg stabilization was performed. The adjustment was made exclusively with a quick motion of the hand and wrist, which resulted in a substantial movement and audible from the involved articulation. The patient was cared for daily for 2 12 months and was able to return to work with light duty restrictions during this time. Shortly thereafter, the patient was able to return to his regular job duties as a dry cleaner.
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Fracture healing was monitored with 5 comparative AP pelvic radiographs over a 2-year period. The 2-year follow-up comparative radiograph (Figs 3 and 4) demonstrates healed fractures at the left ischium and pubic bones. The superior ramus has not approximated as well as the inferior ramus. Roentgenometric findings from the initial follow-up radiographs at 1 month showed Ferguson’s angle measured at 39j, the L5 disk angle measured at 16j, and the inferior aspect of the sacrum measured 7 mm inferior to the inferior aspect of the ilium at the left sacroiliac joint. Spinographic analysis showed a sacral measurement of 52 mm left and 60 mm right (P-R, uY); the left ilium was listed as ASEx (+Z, +uX, uY); L5 was listed as PRI ( Z, +uY, +uZ); and the radiographic findings showed the gluteal crease to be left of the symphysis pubis. The ASEx ilium listing subscripts were not substantially changed on this radiograph. Reexamination (at 1-month follow-up) of clinical findings showed a positive Derifield hip; positive Ely’s, Braggard’s, and Patrick’s signs on the left; and positive Lasegue’s sign on the right; and the thoracolumbar motion was restricted on extension and right lateral flexion. The right Achilles and left patellar reflex were diminished. Eight months after initiating chiropractic care, the patient was involved in an automobile accident and suffered a hyperflexion cervical sprain and a lumbosacral sprain injury. One month later, he was involved in another automobile accident, receiving a hyperflexion cervical sprain, lumbosacral sprain, and right knee strain injuries. He remained a patient for 6 years thereafter, receiving intermittent chiropractic care. Thirteen years postcare, the patient reports only intermittent ‘‘achiness’’ in his left hip and mild left sacroiliac joint restriction. The patient reports no other complications.
DISCUSSION Clinically significant findings such as fractures and neoplasms are seen in chiropractic patients in addition to the more common findings of degenerative disks and posterior joint changes.5 Winterstein6 stated over 20 years ago that approximately 9% of presenting chiropractic patients might have spinal compression fractures. Today, the prevalence of patients attending chiropractic clinics with a variety of fractures and dislocations may be greater, particularly when one considers the growing popularity of chiropractic. This case brings to the fore several issues in the chiropractic care of patients who have suffered severe trauma and, in particular, in those patients sustaining fracturesubluxations. The chiropractic care of individuals with fractures, dislocations, and fracture-subluxations are not widely performed in the profession but are nonetheless addressed in clinical practice by some chiropractors and
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most notably by Gonstead practitioners.7-10 The decision for a chiropractor to accept a patient with spinal and extraspinal fractures and/or dislocations is dependent on several factors, the foremost of which include the chiropractor’s clinical experience, training, and education, and, ultimately, confidence in their clinical skills to provide care for the individual. The attending chiropractor in this case has been in practice for over 20 years and has cared for a number of patients with spinal fracture-subluxations with good clinical success. He is a Diplomate of the Gonstead technique. Fracture-subluxation management has been taught by the teaching staff of the Gonstead Seminars, Inc. at Mount Horeb, Wisconsin, and throughout the world. In the arena of chiropractic education, fracture-subluxation management has been taught in the past at Palmer College of Chiropractic, Davenport, Iowa (Herbert Wood, DC, oral communication, February 1, 1995), at Palmer College of Chiropractic West, San Jose, California, and at Life Chiropractic College West, Hayward, California by 1 of the authors (GP). Fracture-subluxation management is also addressed in 2 textbooks within the profession.11,12 The Guidelines for Chiropractic Quality Assurance and Practice Parameters, otherwise known as the ‘‘Mercy Document,’’ addresses the issue of fractures and dislocations with the following statement: ‘‘Acute fractures and dislocations, or healed fractures and dislocations with signs of ligamentous rupture or instability, represent an absolute contraindication to high-velocity thrust procedures applied to the anatomical site or region..’’13 Notwithstanding the controversy associated with the Mercy Document,14,15 the patient described in this case report does not befit the above description/criteria. Most notably and discussed in greater detail throughout this section are the nonacute nature of the patient’s injuries at presentation to the chiropractor, the stability of this type of injury, and attention to avoiding further injury by not reproducing the mechanism of injury during the adjustment procedure. The attending chiropractor contemplated reducing the actual fracture fragments because they were severely displaced but decided not to do this, since he reasoned that this could not be done without placing the patient at undue risk. It is obvious that not all chiropractors have the necessary skills from their education and clinical experience to attend to the type of patient presented; however, for some specialist practitioners, the acceptance of such a case would not breach the minimal threshold of acceptable standard of care.11 It is of paramount importance that recognition of loads sufficient to cause a pelvic fracture can also produce a sprain injury (ie, subluxation) nearby. The Malgaigne fracture coexisted with a compression injury to the left sacral ala, as well as a cephalad or superior displacement of the entire innominate on the left side. Ultimately, an adjustment was directed at the fractured innominate (ie, ilium contact) in an attempt to reduce the subluxation of
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the ilium with respect to the sacrum. In this context, the lesion is appropriately described as a fracture-subluxation. Although the adjustment is directed at the subluxation component, the presence of a Malgaigne fracture complicates the adjustment procedure through positioning and stabilization modifications, the potential for aggravation of the fracture site (ie, bleeding) with an unmodified procedure, and the ability of the chiropractor to differentiate symptoms that are arising from the subluxation or joint lesion versus the bony and soft tissue trauma at or near the fracture site. Another issue that arises is the potential for sprain injury more remote from the fracture site and the acute area of interest. Trauma sufficient to produce fracture of the bony pelvis is likely sufficient to produce concomitant sprain injuries, as shown in this patient. Practitioners (eg, medical) may not recognize these more subtle sprain injuries because they are not triaged (ie, prioritized) in a case such as this, given the potential for vascular injuries with a fracture of this type. Chiropractors have a unique perspective they bring to health care and dramatically different emphases on the importance of sprain injury or subluxation, as well as its amelioration. Interdisciplinary discussion of these issues may help the patient to obtain integrated care, which heretofore has been unusual in patients with severe trauma. These secondary lesions can be more responsible for the patient’s clinical complaints, be they pain or functional limitations, as the patient’s clinical response appears to demonstrate. Addressing the L5 subluxation necessitates recognition that positioning issues for the adjustment of this segment is complicated by the presence of the Malgaigne fracture that would be affected by side-posture positioning for the lower lumbar adjustment. Most chiropractic textbooks give scant details on the management of patients who have sustained a spinal fracture. Details regarding pelvic fractures, including the Malgaigne type, and their management implications are even more absent. This is somewhat troubling, given the significant number of patients that chiropractors care for who have experienced significant trauma. In the case described herein, the issue of bleeding at the fracture site, as well as the potential for direct vascular or pelvic organ injury, are important management issues. Inherent in the application of the adjustment is ‘‘primum non nocere,’’ and therefore, in situations wherein further vascular or pelvic organ injury may occur, then the risks to the patient’s well being obviously outweigh the benefit for an adjustment procedure. The stability of the segment to be adjusted is another important consideration. Stability generally falls along a continuum and there are several types applicable to this case: neurological, vascular, biomechanical, concomitant pelvic organ injuries, etc., and allowing some time to lapse (eg, several weeks), which in this case was perhaps prudent, given the potential risks for concom-
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itant vascular injuries, as well as the potential for the fracture site to hemorrhage. In patients with fractures and dislocations, successful management, chiropractic or otherwise, is dependent on proper pretreatment evaluation and a biomechanically sound regimen of care. However, in some states, the chiropractic care of such conditions is outside the scope of practice of chiropractors and in other states, it is undefined.16 As a result, the number of published reports is few. It is therefore important that further investigations and comprehensive documentation on the chiropractic care of such patients continue so that a scientific literature base can be established. Stern et al17 presented the case of a 58-year-old woman who went to a chiropractor with a pelvic insufficiency fracture simulating metastatic bone disease. She was referred to a rehabilitation clinic for physiotherapy and medication for further care. She was not adjusted. Plaugher et al9 described the case of a patient with a missed zone 2 sacral fracture receiving a specific contact sacroiliac adjustment (side posture). The patient self-referred to a medical orthopedist following 2 adjustments and no abatement of her complaint. Medical care thereafter consisted of bed rest, where at 6 weeks her symptoms resolved and she returned to work. Plaugher et al8 reported the care of a patient sustaining a Chance fracture at L3 from a motor vehicle accident. Chiropractic care consisted of specific contact, short-lever-arm spinal adjustments at L3 and L5, as well as bracing. This was the first description in the scientific literature of a patient receiving adjustments to sites of subluxation, including the fracture site, and cared for successfully. Alcantara et al7 followed with a description of the care of a patient with a lamina fracture of C6 following a hyperextension injury as a result of a motor vehicle accident. The patient refused emergency surgical treatment, opting instead for chiropractic care. The case raised several legal, ethical, and clinical issues in the care of individuals with this type of traumatic injury and fractures in general.18-20 Brynin and Yomtob21 described the diagnosis (anterior compression fracture) of a patient reporting to a chiropractic clinic 1 month postemergency care after a diving accident. Following fracture detection based on radiographs, the patient was referred to his medical doctor for further care. Recently, Lapp22 described the chiropractic care of a patient with a pelvic stress fracture in a 42-year-old woman with hip pain after running. Care consisted of high-velocity low-amplitude adjustments, ultrasound, and stretching of the psoas and piriformis muscles. As one can surmise from a review of the above literature, a number of the cases reported were of patients presenting for chiropractic care with complaints of spinal pain posttrauma. These patients were misdiagnosed and released from emergency care. After correct detection of the spinal fracture(s) by the attending chiropractor, referral
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for medical care was the sequelae of care. In only a few of the cases were the patients cared for in a specifically chiropractic manner. The patient described in this case report sustained a group I Malgaigne fracture.23 According to Yochum and Rowe,24 this fracture represents approximately one third of all pelvic fractures. Complications may arise affecting the diaphragm or bowel, sacroiliac instability may also arise, and a high morbidity and mortality rate is reported. The appearance on radiograph involves a fracture of the superior and inferior pubic rami (ipsilaterally) with possible separation of the sacroiliac joint without dislocation. This is consistent with findings by Burgess and Jones.25 They found that fractures of the non-weight-bearing anterior pelvic ring along with some involvement of the posterior ring, such as slight tearing of the anterior sacroiliac ligaments and/or vertical fracture of the sacrum, occurred in Malgaigne injuries. Apparently, these types of injuries are stable and require no reduction. Initial treatment of immobilization in a pelvic sling body bandage with leg traction was proposed by Malgaigne, and this treatment is continued until consolidation is accomplished in approximately 45 to 50 days (6 to 7 weeks). 25 Although considered a stable injury by several authors, the clinical findings in this case do relate to a more ‘‘unstable situation if one considers the definition proposed by White and Panjabi,26 ‘‘clinical instability is the loss of the ability of the spine under physiologic loads to maintain its pattern of displacement so that there is not initial or additional neurological deficit, no major deformity, and no incapacitating pain. As the reader recalls from the history, this patient could not bear weight on the left side, or sit, or lie supine (normal physiological loads) without exacerbation of the pain. These clinical features combined with the well-known late sacroiliac instability that often is the sequelae of these injuries supports the assessment that this patient was experiencing an unstable injury to his pelvis. As a point of interest, 70% of pelvic fractures are relatively uncomplicated, whereas in the other 20% to 30% of patients, they are considered as having major pelvic fractures with a 10% mortality rate.23 As such, in patients with these types of injuries (ie, uncomplicated fractures of the anterior pelvic ring), the approach to care is palliative. According to Connoly, 23 medical protocol typically involves bed rest for 2 to 3 days, followed by crutch walking for 4 to 6 weeks. Within 6 to 8 weeks postinjury, these patients are expected to have ‘‘complete recovery.’’ However, pain and disability may be present, depending on the residual deformity. Chiropractic care of individuals sustaining uncomplicated fractures of the pelvis shares the same objectives of treatment with orthopedic surgeons. Through adjustments at sites of subluxations, the chiropractor attempts to restore bony anatomy, minimize pain and discomfort, and facili-
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tate return of function, as well as prevent further deformity. The chiropractor providing care for the individual described in this case report followed the Gonstead protocol.27,28 Chiropractic adjustments were applied to sites of vertebral subluxation, as well as the fracture subluxation of the left innominate. This type of care resulted in the patient receiving great symptomatic relief, to the point of being able to return to work on regular duty within 1 month from initiation of chiropractic care. One of us (BG) is of the opinion that it is contraindicated to adjust an acute pelvic fracture. But in minimally displaced fractures as in this case, with appropriate hospital immobilization, a 6- to 7-week period allows for a substantial healing response to occur. Since sacroiliac instability is a common occurrence in healed Malgaigne injuries, early initiation of chiropractic care at or about 7 weeks postinjury may address this complication. This patient was adjusted at spinal regions above the pelvis at 5 weeks postinjury. The left ilium was first adjusted approximately 8 weeks posttrauma. For patients with a history of trauma presenting for chiropractic care, a thorough history and physical examination (including the use of imaging studies) are of paramount importance for successful management. For patients with pelvic ring injuries, the history and physical examination should differentiate major versus minor pelvic fractures/injuries. One should monitor the patient’s vital signs and be cognizant of certain conditions such as patient shock. This and other signs and symptoms may require the patient to receive immediate hospital-based emergency care. Concomitant with pelvic fracture injuries, in addition to infection (ie, retroperitoneal infection), the patient’s trauma may also result in hemorrhage and genitourinary and gastrointestinal injury.29 Retroperitoneal infections involve pain in the abdomen or flank and referred pain to the groin or thigh region. The patient reported here was ruled out for these types of concomitant injuries. Several studies have confirmed that hemorrhage is the most perilous complication associated with pelvic fractures.29,30 This may be due to bleeding from the fracture site and the associated damage to bony, soft tissue and vascular elements, including major blood vessels. The chiropractor should be aware of the intimate relationship of the internal iliac artery and its tributaries, including veins to the anterior aspect of the sacroiliac joint and ligaments, prior to adjusting the pelvis, to prevent iatrogenic injuries. These structures are responsible for the high incidence of vascular injury and its associated hemorrhage in patients with pelvic fractures. Fractures of the pelvis have long been associated with injuries to the lower urinary tract.29,31 The patient sustaining a rupture of the bladder following blunt trauma presents with gross hematuria. Urethral injuries in males present with blood at the distal meatus, a high-riding prostate, a
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perineal hematoma, or the inability to void. Injuries to the genitals and gonads must also be recognized. Gastrointestinal injuries may be associated with a pelvic fracture or as a result of trauma alone. In patients with closed fractures of the pelvis, diagnosis may be difficult, since the initial abdominal examination may be normal.30 The pain experienced by the patient may be associated with sprain of the sacrotuberous and sacrospinous ligament and sacroiliac (SI) ligament injuries (particularly from the ASEx displacement). Additionally, there may be strain injuries of the piriformis, obturator internus, the gemellus, and the gluteal muscles. The radiating pain symptomatology may involve irritation/impingement of the sciatic nerve, as well as sclerotogenous pain referral.
CONCLUSION We described the successful chiropractic care of a patient with radiating low back pain after sustaining an anterior pelvic ring fracture(s) (Malgaigne fracture) and spinal subluxations following a fall. This case report provides support that patients with fractures and subluxations may derive benefit from chiropractic care. The potential risks in accepting cases such as this are more substantial. The chiropractor needs to pay particular attention to imaging decisions and follow-up and differentiating potential complicating factors, such as vascular injury or hemorrhage at the fracture site. In addition, special focus should be made to modifying certain examination procedures, patient positioning, and adjustment procedures so that the fracture site is not aggravated during the performance of the side-posture adjustment of the involved innominate. We encourage further prospective research into this topic area.
REFERENCES 1. Barlow DH, Hayes SC, Nelson RO. The scientist practitioner: research and accountability in clinical and educational settings. New York: Pergamon Press; 1984. p. 52. 2. Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG. Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998;88: 771-6. 3. Plaugher G, Lopes MA. Clinical anatomy and biomechanics of the spine. In: Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Baltimore: Williams & Wilkins; 1993. p. 287. 4. Plaugher G, Hendricks AH, Doble RW Jr, Bachman TR, Araghi HJ, Hoffart VM. The reliability of patient positioning for evaluating static radiologic parameters of the human pelvis. J Manipulative Physiol Ther 1993;16:517-22. 5. Marchiori DM. A survey of radiographic impression on a selected chiropractic patient population. J Manipulative Physiol Ther 1996;19:109-12.
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6. Winterstein JF. Diagnosis and management of stable thoracolumbar compression fractures. J Clin Chiropr 1979;3:43-54. 7. Alcantara J, Plaugher G, Abblett DE. Management of a patient with a lamina fracture of the sixth cervical vertebra and concomitant subluxation. J Manipulative Physiol Ther 1997;20: 113-23. 8. Plaugher G, Alcantara J, Hart CR. Management of the patient with a Chance fracture of the lumbar spine and concomitant subluxation. J Manipulative Physiol Ther 1996;19:539-51. 9. Plaugher G, Alcantara J, Doble RW Jr. Missed sacral fracture before chiropractic adjustment. J Manipulative Physiol Ther 1996;19:480-3. 10. Plaugher G, Alcantara J, Cichy DL. Management of the patient with a superior end-plate burst fracture of C7 and concomitant subluxation: a case report. J Clin Chiropr Pediatr 1996;1:79-88. 11. Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Baltimore: Williams & Wilkins; 1993. p. 325-55. 12. Anrig C, Plaugher G, editors. Pediatric chiropractic. Baltimore: Williams & Wilkins; 1998. p. 730-76. 13. Haldeman S, Chapman-Smith D, Petersen DM. Guidelines for chiropractic quality assurance and practice parameters: proceedings of the Mercy Center Consensus Conference. Gaithersburg (MD): Aspen Publishers; 1993. p. 167-77. 14. Cates JR, Young DN, Guerriero DJ, Jahn WT, Armine JP, Korbett AB, et al. Evaluating the quality of clinical practice guidelines. J Manipulative Physiol Ther 2001;24:170-6. 15. Kent C. Evaluating the quality of clinical practice guidelines. J Manipulative Physiol Ther 2001;24:612-8. 16. Lamm LC, Wegner E, Collord D. Chiropractic scope of practice: what the law allows-update 1993. J Manipulative Physiol Ther 1995;18:16-20. 17. Stern PJ, Cote P, Dust W. Pelvic insufficiency fracture simulating metastatic bone disease. J Manipulative Physiol Ther 1994;17:485-8. 18. Ventura JM. Management of a patient with lamina fracture of the sixth cervical vertebrae and concomitant subluxation. J Manipulative Physiol Ther 1997;20:488-9. 19. Miller JS. Management of a patient with lamina fracture of the sixth cervical vertebrae and concomitant subluxation. J Manipulative Physiol Ther 1997;20:494-5. 20. Corenman DS. Management of a patient with lamina fracture of the sixth cervical vertebrae and concomitant subluxation. J Manipulative Physiol Ther 1997;20:489-94. 21. Brynin R, Yomtob C. Missed cervical spine fracture: chiropractic implications. J Manipulative Physiol Ther 1999;22: 610-4. 22. Lapp JM. Pelvic stress fracture: assessment and risk factors. J Manipulative Physiol Ther 2000;23:52-7. 23. Connoly JF. Fractures and dislocations of the pelvis. In: Connoly JF, editor. Fractures and dislocations: closed management. Philadelphia: WB Saunders; 1995. p. 453-96. 24. Yochum TR, Rowe LJ. Essentials of skeletal rad. 2nd ed. Baltimore: Williams & Wilkins; 1995. p. 707. 25. Burgess AR, Jones AL. Fractures of the pelvic ring. In: Rockwood CA Jr, Bucholz RW, Green DP, Heckman JD, editors. Fractures in adults. Philadelphia: Lippincott-Raven; 1996. p. 1575-616. 26. White AA, Panjabi MM. Clinical biomechanics of the spine. 2nd ed. Philadelphia: JB Lippincott Co; 1990. p. 278. 27. Rowe DJ. Chiropractic management of spinal fractures and dislocations. In: Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Baltimore: Williams & Wilkins; 1993. p. 325-55.
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28. Plaugher G, Rowe DJ, Cichy DL, Goble CE, Elbert RA, Hart CR, et al. Adolescent patients with acute spinal fractures. In: Anrig CA, Plaugher G, editors. Pediatric chiropractic. Baltimore: Williams & Wilkins; 1998. p. 730-76. 29. Mucha P Jr, Welch TJ. Hemorrhage in major pelvic fractures. Surg Clin North Am 1988;68:757-73.
30. Fallon B, Wendt JC, Hawtrey CE. Urological injury and assessment in patients with fractured pelvis. J Urol 1984;131: 712-4. 31. Cotler HB, Meadowcroft JA, Smink RD. Enteric fistula as a complication of a pelvic fracture. Case report. J Bone Joint Surg 1983;65A:854-6.
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