Although the majority of pelvic fractures requiring surgical treatment result from motor-vehicle collisions, a frequent cause of pelvic trauma in certain regions of the United States is horseback riding. The so-called saddle-horn injury occurs as the bucked rider is thrown from the saddle into the air, accelerates back downward, and collides with the large bucking animal below. The collision of the saddle, or the saddle horn, with the rider's perineum causes direct injury to the pelvic area. To our knowledge, Flynn1 was the first to describe this injury mechanism, in a report of two patients. Both patients were treated successfully without surgery. Nine additional cases of saddle-horn injury to the pelvis, with a similar injury mechanism and injury pattern, have been reported2-4. The authors of these reports noted good results following a variety of surgical treatments, although the injury remains incompletely described and no standardized evaluations or measures were used to assess the outcomes. The purpose of this study was to evaluate the clinical, radiographic, and functional outcomes in a consecutive series of patients treated for a saddle-horn injury.
Materials and Methods
Following institutional review board approval, the study cohort was selected from the 147 patients in whom a pelvic ring injury had been treated surgically at our trauma center by a single fellowship-trained orthopaedic trauma surgeon (C.A.C.) from 1999 through 2005. Inclusion criteria were operative treatment of a pelvic ring injury that had been caused by blunt force trauma to the perineum when the individual was bucked from a horse and landed back on the animal and the availability of the patient for follow-up at a minimum of eighteen months5.
All qualified patients were initially evaluated at the time of injury with physical and radiographic examination that included anteroposterior, inlet, and outlet plain radiographs and computed tomography. Operative treatment, standardized for patients with a type-B1 injury according to Tile's classification system6, consisted of open reduction and plate fixation of the symphysis pubis. Indications for surgery were pubic diastasis of ≥25 mm on either the anteroposterior pelvic radiograph or the computed tomography scan made at admission. All injuries were approached through a Pfannenstiel incision. Reduction was achieved by application of a large pointed reduction (Weber) clamp to the pubic tubercles. Surgical dissection on the anterior aspect of the pubis was avoided. A six-hole symphyseal plate and 3.5-mm screws were applied. Percutaneous iliosacral screw fixation was added at the discretion of the operating surgeon; patients receiving iliosacral screws tended to be larger and have greater amounts of symphyseal diastasis.
The patients were mobilized and received physical therapy for gait training on the first postoperative day. Protected toe-touch weight-bearing on the side of the partial sacroiliac joint injury or sacral fracture was encouraged for a period of ten to twelve weeks. The patients were allowed to return to full activity (including horseback riding) once they were able to walk without assistive devices.
Demographic, injury, and treatment data were obtained from our trauma registry as well as from the medical records. The body mass index7 was calculated from the admission data, and definitions provided by the U.S. Centers for Disease Control and Prevention (CDC) were used to determine if a patient was overweight (body mass index of 25 to 29.9 kg/m2 for adults) or obese (body mass index of ≥30 kg/m2). A fellowship-trained orthopaedic trauma surgeon who had not been involved in the treatment of the patients (M.T.A.) acted as an independent reviewer for the radiographic evaluation. Injury radiographs were classified according to the system described by Tile6 and the AO/OTA classification8, and pubic diastasis was measured on both the anteroposterior radiograph and the computed tomography scan made at the time of injury. Postoperative radiographs were graded for the quality of the reduction9 and any changes in fixation or alignment. Patients were reevaluated with a physical examination, radiographic assessment, and clinical outcome measures at a minimum of eighteen months after the index operation.
Twenty patients met our inclusion criteria, and no patients were lost to follow-up. Only one patient had nonoperative treatment of a saddle-horn injury (with pubic diastasis of 10 mm) during this period, and he was excluded from the analysis. All twenty patients in our operative cohort were men, and their mean age was forty-eight years (range, nineteen to sixty-eight years). The mean body mass index was 30 kg/m2 (range, 20 to 39 kg/m2). All patients reported no previous symptoms or preinjury diagnosis of sexual dysfunction, and only one had an illness (diabetes) that we thought might be related to sexual dysfunction. The mean Injury Severity Score (ISS)10 in the series was 12 points (range, 6 to 27 points ). One urethral disruption and one bladder rupture were treated surgically; no other structural genitourinary injuries were identified. One patient had an injury to another region of the body: a thoracic injury that included multiple rib fractures and a pneumothorax that required a tube thoracostomy. No patient was diagnosed with shock or had a systolic blood pressure of <90 mm Hg, and none underwent angiography or embolization. Six patients were provisionally stabilized with a pelvic “sheet-wrap” or binder applied in the emergency department. No patient was treated with external fixation. All twenty pelvic injuries were open-book injuries with disruption through the pubic symphysis; there were eighteen AO/OTA type-B1.1 (sacroiliac joint) and two type-B1.2 (sacral fracture) injuries. The mean amount of pubic diastasis was 43 mm (range, 27 to 79 mm) as measured on the injury radiographs. Figs. 1-A, 1-B, and 1-C are a typical series of injury, postoperative, and final follow-up radiographs.
Surgical treatment of the pelvis was performed at an average of 2.3 days (range, one to five days) after the injury. Operative fixation of the symphysis pubis was performed with a six-hole plate and 3.5-mm screws in all patients. Iliosacral screws were placed percutaneously in thirteen patients. Complications of surgery included one culture-negative wound dehiscence that was successfully treated with incision and drainage and secondary wound closure. In another patient, a perisymphyseal 70-mm screw backed out >30 mm and caused soft-tissue irritation. The symptomatic screw was removed at five months after the index procedure. There were no other perioperative complications, and no other hardware was removed.
Clinical outcome measures included a visual analog pain scale ranging from 0 (no pain) to 10 (worst possible pain)11 and a nonvalidated questionnaire addressing occupational and recreational function that we had created. The International Index of Erectile Function (IIEF)12-15, a self-administered questionnaire, was used to collect information regarding problems with sexual function and satisfaction (see Appendix). The pelvic injury was assessed with the injury-specific Iowa pelvic score16-18. Finally, the Short Form-36 (SF-36)16,17,19-25, a self-administered health status instrument, was employed to assess patient self-perception of physical, psychological, and social well-being.
Data analyses were performed with use of the Fisher exact test and Student t test. Significance was defined as p < 0.05.
Source of Funding
No outside financial support was received for this study.
Twenty patients met our inclusion criteria. The average duration of follow-up was thirty-three months (range, eighteen to fifty-six months), and no patients were lost to follow-up.
The quality of the reduction of the symphysis pubis on postoperative radiographs was graded as excellent (a diastasis of <4 mm) in eighteen of the twenty patients and good (a diastasis of 4 to 10 mm) in two patients9. Neither vertical displacement nor migration of the hemipelvis was noted in any patient. By the time of the final follow-up, a partial loss of reduction, as compared with the reduction measured on the immediate postoperative radiographs, was observed in eighteen of the twenty patients. This loss was accompanied by a loss of screw fixation in sixteen patients and plate failure in two. The average distance between the pubic bones at the symphysis (the pubic space) had increased from 4.8 mm to 8.0 mm (range, 3.0 to 20 mm) at the time of final follow-up; however, only one patient had a loss of reduction of >10 mm. That patient ultimately had a symphyseal diastasis of 20 mm but was doing well clinically (an Iowa pelvic score of 81 points) and did not want further treatment.
At the time of follow-up, the visual analog scores were 1.0 (range, 0 to 3) for “pain-right now,” 2.1 (range, 1 to 6) for “pain-average,” 0.6 (range, 0 to 2) for “pain-at best,” and 4.1 (range, 0 to 8) for “pain-at worst.” The most substantial pain was reported in the area of the posterior pelvic ring injury in ten of the twenty patients, the pubic symphysis in six, and the groin in four.
Eighteen of the twenty patients had returned to their previous employment, although eight had modified their work duties. One patient was not working and was applying for disability compensation. Ten of the twenty patients had returned to their preinjury level of recreation. Notably, all but one patient reported his preinjury level of recreation as “heavy,” and one patient reported it as “moderate.” Seventeen of the twenty patients had returned to riding horses, but fourteen of them reported that their level of riding was limited compared with their preinjury level.
The IIEF scores are presented in Table I. The average total IIEF score for the patients treated in this series was 40.7 ± 21.9 points compared with 57.4 points in a series of patients with a Tile-type-A, B, or C pelvic fracture treated operatively or nonoperatively and 60.8 points for uninjured norms12. Eighteen of the twenty patients in our series were found to have erectile dysfunction (a score of ≤25 points in the erectile function domain14,15). The two patients with normal sexual function after the injury were the youngest patients (nineteen and thirty-four years of age) in this cohort. The average scores in all of the IIEF domains, including erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall sexual satisfaction, were decreased compared with normative data (p < 0.05)26. All patients reported no previous symptoms of sexual dysfunction, and none had sought medical assistance for impaired sexual function prior to the pelvic injury. Sildenafil (Viagra) was prescribed for all patients with erectile dysfunction, and seventeen of the eighteen reported that they had tried the medication three times or more but only one reported satisfactory improvement. Only six of the eighteen patients with sexual dysfunction followed up with a urologist, and none underwent advanced treatments for erectile dysfunction. Eight of the twenty patients described persistent urinary symptoms, with six reporting minor incontinence (dribbling) and three reporting symptoms of urgency.
The mean Iowa pelvic score was 84 points (range, 56 to 99 points). The scores for the eight subsections of the SF-36 at the final evaluation are presented in Table II and are compared, in that table, with previously reported values for patients with non-saddle-horn-type pelvic injuries and with a U.S. age and sex-matched normal population19,20,23. It was only in the role-physical and role-emotional categories that the mean values for the patients treated for a saddle-horn pelvic injury were significantly lower than the normative values.
We evaluated twenty patients with a saddle-horn injury of the pelvis, an injury that has been described as rare and one that remains inadequately defined in terms of injury characteristics and outcomes1-4. While the occurrence of this injury may be geographically regional, it does not appear to be as uncommon as previously reported1-4.
All of our patients were men with an open-book pelvic injury, and 85% were middle-aged (forty to sixty-five years of age) and overweight or obese. The findings in the previous four case reports of saddle-horn injury were similar to those in this series in that they demonstrated a 10:1 male preponderance and an age range of thirty-nine to sixty-five years. U.S. national figures show that 63% of horse-riding injuries requiring emergency medical treatment are sustained by women and in a younger age group than reported in this study27. Previous authors have suggested that differences in men's pelves as compared with those of women make them more vulnerable to injury2 or that physiologic changes in the pubic symphysis that occur with aging make it more susceptible to injury3. Several of our patients suggested that other demographic groups may ride differently and therefore be less susceptible to the saddle-horn injury. For example, many patients treated in this study were injured trying to “break” relatively untamed horses or were otherwise riding aggressively.
Historically, open-book pelvic fractures have been associated with relatively high rates of other injuries and mortality28-31, and deaths from pelvic ring injuries are often related to the associated injury or massive hemorrhage. Only one of our twenty patients had a substantial associated injury, and the average ISS for the entire cohort was relatively low (12 points). Importantly, none of our patients had shock or required massive transfusions or embolization. Similarly, ten of the eleven previously detailed cases of saddle-horn injury did not manifest other risk factors for early mortality1-4.
After the use of standard open reduction and internal fixation techniques for pubic diastasis, nineteen of the twenty injuries healed with acceptable alignment, findings corresponding to previously published accounts32,33. Sixty percent of the patients in this series experienced mild widening (2 to 5 mm) of the pubic symphysis over time, but this mild widening did not appear to have a negative effect in terms of pain or functional outcome scores. At the time of writing, none of these patients had required additional surgical treatment. This mild widening has been reported in other patients after plate fixation of the symphysis pubis. Sagi and Papp34 found that, of sixteen rotationally unstable pelvic ring injuries treated with anterior fixation with a multihole symphyseal plate, four had a failure of fixation and a loss of reduction of ≥5 mm. Tornetta and Templeman33 found that three of twenty-nine patients with similar injuries and treatment had widening of the symphyseal space to 7, 9, and 10 mm.
The clinical outcomes for the patients treated in this series were generally satisfactory, with the striking exception of sexual function. At the time of the latest follow-up, the patients reported relatively mild current and average daily pain levels of 1 and 2 (of 10), respectively, although only two patients were completely pain-free. Pain was mostly characterized as activity-related, with equal rates of involvement of the anterior and posterior portions of the pelvic ring. Recently, Meyhoff et al.35 found a 48% prevalence of chronic pain attributable to pelvic fracture in 161 patients at a mean of 5.6 years postinjury. Prior studies16,18,32,35 addressing pain in patients with an unstable pelvic fracture have been limited by how the pain was defined, measured, and reported. As few as 3%32 and as many as 36%35 of patients with a rotationally unstable Tile-type-B pelvic injury have been reported to have chronic pain.
Eighteen (90%) of the twenty patients had returned to their previous employment, although eight of the eighteen noted that they had modified some of their duties. While return-to-work rates after trauma to the pelvic ring have varied widely24,32,36,37, in two series that included operatively treated Tile-type-B1 injuries19,32 75% to 83% of the patients had returned to work in less than one year. Half of our patients had returned to their preinjury levels of heavy recreation, and seventeen of the twenty had returned to some level of horseback riding. The mean Iowa pelvic score was 84 points. This score is comparable with Iowa pelvic scores reported in previous studies, which have ranged from 79 to 93 points depending on the injury pattern, associated injuries, and treatment modality16-18. Miranda et al.16 found an average Iowa pelvic score of 93 points for thirty-one patients in whom a Tile-type-B pelvic injury had been treated nonoperatively or with external fixation. The bodily pain scores of the SF-36 in our study were higher (better) than those reported in other studies that involved complete lesions of the posterior aspect of the pelvis5,23. However, it is difficult to compare these pain scores as our patients typically had isolated pelvic trauma and the ISS for the patients in the prior studies was significantly higher.
A very high prevalence of erectile dysfunction (90%) was noted in this series of men with saddle-horn injuries to the pelvis. A spectrum of severity for erectile dysfunction was seen, with scores in the erectile function domain indicating dysfunction ranging from mild to severe15 and the mean score having a large standard deviation. Historically, the rate of sexual dysfunction after pelvic fracture has been estimated to be between 5% and 44%12,13,26,38. Like us, the authors of three recent studies analyzed sexual function in men after pelvic injury using validated sexual function outcome instruments. Malavaud et al.12 and Metze et al.13 used the IIEF to evaluate men after pelvic ring injury and identified overall sexual dysfunction in 30% and 61% of their patients, respectively. Pubic diastasis was most clearly correlated with sexual dysfunction in those reports. For example, Metze et al. found that ten of twelve patients with an open-book (type-B1) injury had sexual dysfunction compared with four of ten with a lateral compression (type-B2) injury. Using the Brief Sexual Function Inventory questionnaire, Ozumba et al.39 similarly found impaired sexual function parameters and lower overall sexual satisfaction in men after pelvic fracture when compared with controls.
Erectile dysfunction after injury to the pelvis is reportedly due to vascular injury, neurogenic injury, psychological causes, or structural damage to the corpora cavernosa and pelvic floor, or a combination thereof40-43. Ozumba et al.39 found that the only significant risk factor for worse sexual function in men with pelvic trauma was increasing age. Aging and comorbidities are well-recognized risk factors for erectile dysfunction40,41,43. Our results corroborate those findings, as the two patients with normal sexual dysfunction after the injury were the youngest men in this cohort. Seventeen of the eighteen patients with erectile dysfunction underwent a trial of pharmacologic therapy with sildenafil (Viagra). Only one felt that he had experienced noteworthy improvement despite reports that 35% to 63% of patients with sexual dysfunction after a pelvic fracture have improvement after similar therapy13,42. We found that only a third of our patients with sexual dysfunction followed up with a urologist and none went on to receive advanced treatments for erectile dysfunction. Other authors have suggested that younger patients with impotence have a greater motivation to restore sexual function than do older patients39.
This study demonstrated that the early-to-midterm scores after operative treatment of a saddle-horn injury were similar to the scores for persons without an injury in six of the eight subsections of the SF-36. Only the scores in the role-physical and role-emotional subcategories were lower. These two subcategories measure the degree to which the respondent feels that work or other regular activities are limited as a result of physical or emotional problems. Inferior SF-36 scores, mostly in the physical domains, have been seen in other analyses of patients with pelvic fractures16,19,20,25.
In summary, saddle-horn pelvic injuries occur in a characteristic pattern and demographic group. The patient cohort is typically male, middle-aged, and overweight and the injury is an isolated rotationally unstable pelvic ring injury. Open reduction and internal fixation of the pubic symphysis can be expected to have few complications. Except for a very high prevalence of sexual dysfunction, which does not respond well to pharmacologic treatment, outcomes in this population are generally favorable with good rates of return to work and moderate horseback riding. We believe that it is imperative to educate patients regarding the potential for sexual dysfunction after saddle-horn injury to the pelvis.
The International Index of Erectile Function questionnaire is available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on “Supplementary Material”) and on our quarterly CD/DVD (call our subscription department, at 781-449-9780, to order the CD or DVD).
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Stryker Orthopaedics). Also, a commercial entity (Stryker Orthopaedics) paid or directed in any one year, or agreed to pay or direct, benefits of less than $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
Investigation performed at Harris Methodist Fort Worth Hospital, Fort Worth, Texas
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