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Pelvic Fracture

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Other Names

  • Pelvic ring fractures
  • Pelvic fractures
  • "Open Book" injury

Background

  • This page describes fractures of the pelvis or pelvic ring
    • These fracture patterns often co-occur with other injuries which will not be reviewed on this page in detail

History

  • The first case of a pelvis fracture is attributed to Joseph François Malgaigne, who described double vertical fractures of the pelvis in 1857[1]

Epidemiology

  • Pelvic fractures comprise 2% to 8% of all skeletal injuries[2]
  • Overall incidence estimated to be 24-37 per 100,000 person years[3][4]
    • In patients over 55, that incidence increases to 446 per 100,000 person years
  • Bimodal distribution
    • In younger patients age 15-30, there is a male predominence
    • In elderly patients 50-70, there is a female predominence
  • Open pelvic fractures make up only 2-4% of all pelvic fractures[5]

Introduction

Pelvic X-ray showing fractures of the right superior and inferior rami, left superior ramus, and left acetabulum.[6]
Potential fracture sites for pelvic fractures[7]
Classic young and burgess classification

General

  • Pelvic fractures are disruption of the bony pelvis, most commonly due to high energy trauma
  • The range from stable, low energy fractures to complex and unstable injuries with significant morbidity and mortality
  • Often associated with visceral, vascular and genitourinary injuries[8]
  • Diagnosis is made with imaging including XR and CT
  • Management depends on the injury patterns in consultation with trauma and orthopedic surgeons

Classification

  • Lateral Compression
    • Lateral forces compress the pelvis
    • This results in internal rotation of the hemipelvic
    • Produces transverse or oblique fractures of the pubic rami anteriorly, sacrum posteriorly
    • Usually rotationally unstable but vertically stable
  • Anterior-Posterior Compression
    • Sometimes called "open book" pelvic fracture
    • Result from an anterior-posterior force
    • Causes external rotation of the hemipelvis and diastis of either the pubic symphysis or sacroiliac joint
  • Vertical Shear Compression
    • Produced by vertical/ cranial forces (i.e. fall from height)
    • Resulting in vertical displacement of the hemipelvis
    • Involves disruption of both the anterior and posterior pelvic ring structures
    • There is both rotational and vertical instability
    • Highly unstable and high risk of assocaited vascular, GI and GU injuries

Etiology

  • High energy trauma including
    • MVC
    • Fall from height
  • Low energy
    • Fall from height in patients with osteoporosis
  • Force vector helps determine injury pattern
  • Lateral compressive forces
    • Apply internal rotation to the pelvis
    • Lead to fractures of the sacroiliac joint and pubic rami
  • Anterior-posterior forces
    • lead to external rotation of the hemi-pelvis,
    • Injuries include diastasis of the pubic symphysis ("open book" injuries), fractures of the iliac bone
  • Vertical sheer forces
    • Lead to vertical displacement of the hemipelvis

Anatomy of the Pelvis

  • Pelvic Ring
    • Composed of Inonominate, of which there are 2, and the Sacrum
    • Inominate formed by ilium, ischium, and pubis
    • Anterior: pubis bones meet at midline and stabilized by the pubic symphisis
    • Posterior: ilium meets sacrum to form Sacroiliac Joint
  • Functions of pelvis
    • Protect viscera, traversing neurovascular structures
    • Transfer of load from lower extremities and axial skeleton during movement
  • Ligament stability
    • Anterior: Symphaseal ligaments
    • Pelvic foor: sacrospinous ligaments, scarotuberous ligaments
    • Posterior: anterior sacroiliac ligaments, interosseus sacroiliac ligaments, posterior sacroiliac ligaments, iliolumbar ligaments

Associated Injuries

  • 12% to 62% of patients with pelvic fractures had additional injuries[9]
    • Bladder or urethra (63%)
    • Head injuries (35%)
    • Neurologic injuries (24%)
    • Gastrointestinal injuries (20%)
    • Chest injuries (63%)
    • Long bone fractures (50%)
    • Spine fractures (25%)
  • Morel Lavallee Lesion

Risk Factors

Differential Diagnosis

Differential Diagnosis Hip Pain

Clinical Features

Evaluating the stability of the pelvis

History

  • Typically involves acute trauma
  • Describe characteristics of injury including time since injury
  • Patients endorse hip and leg pain
  • They may have assocaited injuries or symptoms if multi organ involvement
  • If EMS involved, obtain history from them including prehospital course

Physical Exam: Physical Exam Hip

  • Inspect for deformity, swelling, ecchymosis, abrasions, open wounds, hematomas, blood at any orifice
    • Emphasis on skin, urogenital, vaginal and rectal examinations
    • May have deformity or abnormal positioning of lower extremity depending on degree of displacement
  • Palpation
    • Test stability by gently placing a rotational force on each iliac crest
    • Palpate for bony tenderness along the pelvis
  • Range of motion is generally deferred
  • Strength examination as tolerated
  • Neuro exam is especially important
    • Sacral nerve function, lower extremity motor and sensory
  • Consider dedicated genitourinary or rectal examination
    • Rectal: evaluate for blood, rectal wall integrity, high riding prostate, loss of sphincter tone
    • GU: blood at meatus, scrotal or perineal hematoma, inability to void
  • Inability to bear weight

Evaluation

Complex pelvic fracture with widening and displacement of the pubis rami and widening of the S1joints bilaterally: arrows shows multiple fractures in the pelvis.[10]
Pelvic X-ray demonstrating a vertical shear pelvic fracture with anteroposterior compression component (AO classification type 61-C2). A pelvic binder is in situ.[11]

Radiology

  • Standard Pelvic Radiographs
  • Anteroposterior (AP) Radiograph
    • Initial trauma evaluation
    • Eseful for major pelvic disruption
    • Look for asymmetry, rotation, displacement
  • Inlet pelvic radiograph
    • useful for anteroposterior and mediolateral translations
    • can diagnosis internal and external rotary deformities
  • Outlet pelvic radiograph
    • useful for superior and inferior translations
    • can diagnosis flexion and/or extension rotational deformities
  • Lateral sacral radiograph
    • may demonstrate transverse sacral fracture
  • Findings suggesting instability
    • > 5 mm displacement of posterior sacroiliac joint
    • presence of posterior sacral fracture gap
    • Avulsion fractures

CT

  • Routine in evaluation of pelvic fractures
    • Gives better characterization of osseous injuries
  • Pelvic angiography
    • Useful for hemorrhage unresponsive to fluids

Contrasted Imaging

  • Retrograde urethrography
    • used to rule out urtheral tear
  • Cystography
    • used to rule out associated bladder injury

Classification

Illustrations of LC-1 pelvic fracture subtypes[12]

Tile Classification

  • A: Stable[13]
    • A1: Fracture not involving the ring (avulsion or iliac wing fracture)
    • A2: Stable or minimally displaced fracture of the ring
    • A3: Transverse sacral fracture (Denis zone III sacral fracture)
  • B: Rotationally unstable, vertically stable
    • B1: Open book injury (external rotation)
    • B2: Lateral compression injury (internal rotation)
      • B2-1: With anterior ring rotation/displacement through ipsilateral rami
      • B2-2: With anterior ring rotation/displacement through contralateral rami (bucket-handle injury)
    • B3: Bilateral
  • C: Rotationally and vertically unstable
    • C1: Unilateral
      • C1-1: Iliac fracture
      • C1-2: Sacroiliac fracture-dislocation
      • C1-3: Sacral fracture
    • C2: Bilateral with one side type B and one side type C
    • C3: Bilateral with both sides type C

Young-Burgess Classification

  • Anterior Posterior Compression (APC)
    • APC I: Symphysis widening < 2.5 cm
    • APC II: Symphysis widening > 2.5 cm.
      • Anterior SI joint diastasis
      • Posterior SI ligaments intact
      • Disruption of sacrospinous and sacrotuberous ligaments.
    • APC III: Disruption of anterior and posterior SI ligaments (SI dislocation).
      • Disruption of sacrospinous and sacrotuberous ligaments.
      • APCIII associated with vascular injury
  • Lateral Compression (LC)
    • LC I: Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture.
    • LC II: Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture).
    • LC III: Ipsilateral lateral compression and contralateral APC (windswept pelvis).
      • Common mechanism is rollover vehicle accident or pedestrian vs auto.
  • Vertical Shear (VS)
    • Posterior and superior directed force.
    • Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%

Management

Demonstrating application of a pelvic binder
A 25-year-old male patient suffered a Tile C pelvic fracture with bilateral transverse acetabular fractures as a result of a motor vehicle accident and received his first surgical treatment on the 10th day after the injury (A, B, C). The sacroiliac joint was first repositioned in the supine position with a left pararectus approach and fixed with double plates (D). Then, the left acetabulum was repositioned and fixed with the K-L approach (E), and the anterior column of the acetabulum was fixed with an antegrade anterior column screw. Considering that the patient had more intraoperative bleeding, the right pararectus approach was performed to fix the contralateral acetabulum 4 days later (F). The X-ray 1 year after surgery showed anatomical reduction in the pelvis and acetabulum with good fracture healing and no screw breakage or entry into the acetabulum (G, H, I)[14]

Acute

  • Prehospital
    • Patient should be transported via EMS
    • Follow pre-hospital protocols such as cervical spine stabilization, airway management, resuscitation, etc
  • ED Management
    • Patients with high energy mechanism, concern for or confirmed pelvic fractures should be prioritized
    • Advanced Trauma Life Support (ATLS) algorithm should be followed
    • Careful evaluation of hemodynamic status and resuscitation as appropriate
    • Evaluation for secondary injuries
    • Management should be directed at confirmed or suspected injuries in addition to pelvic fracture
  • Pelvic Binder
    • Centered over greater trochanters
    • Can be helpful to control hemorrhage in the setting of hemodynamically unstable pelvic fractures
    • Theoretically apply compression and stabilization to fractures
    • Most commonly applied to open book fractures but should be considered for all hemodynamically unstable fractures
    • Have largely replaced external fixation and anti-shock trousers
  • Angiography Embolization
    • Interventional radiology can sometimes embolize the bleeding source
  • External Fixation
    • Pelvic ring injuries with an external rotation component
    • Unstable ring injury with ongoing blood loss
    • Should be placed before emergent laparotomy

Nonoperative

  • Recommend orthopedic surgery and trauma consultation on all pelvic fractures
  • Indications
    • Mechanically stable pelvic ring fractures
    • Lateral Compression 1 (LC1)
    • Anterior-Posterior Compression 1 (APC1)
    • Isolated pubic ramus fractures
    • Parturition (birth) induced pelvic diastasis

Operative

  • Indications
    • Open fractures
    • Unstable pelvis fractures who are requiring operative managment for other reasons
    • Symphysis diastasis > 2.5 cm
    • SI joint displacement > 1 cm
    • sacral fracture with displacement > 1 cm
    • displacement or rotation of hemipelvis
    • chronic pain and diastasis in parturition-induced diastasis or acute setting >4-6cm
  • Technique
    • Open reduction, internal fixation
    • Anterior subcutaneous pelvic fixator (INFIX)
    • Consider diverting colostomy

Rehab and Return to Play

Rehabilitation

  • Stable, non-surgical fractures
    • Early mobilization with protected weight bearing
  • Unstable fractures treated surgically
    • Mobility, weight bearing dependent on location of fracture
    • As radiographic evidence of healing occurs, weight bearing can be advanced

Return to Play

  • Needs to be updated

Complications

Anteroposterior radiographs of the pelvis demonstrating the right superior pubic fracture 5 years after a motor vehicle accident[15]

Prognosis

  • Mortality estimates range from as low as 5-10% to as high as 50-60%[5]
    • Due to hemodynamic instability, multi-organ failure
    • Open fractures have a mortality rate as high as 50% (need citation)
  • Predictors of mortality[16]
    • Injury Severity Score (ISS)
    • Revised Trauma Score (RTS)
    • Age >60
    • Transfusion requirement of more than 6 units in the first 24 hours
    • APC III injury
  • Mortality is bimodal
    • Early death is due to hemorrhage or brain injury
    • Late death is due to sepsis, multi-organ failure
  • Predictors of poor outcome (need citation)
    • SI joint incongruity of > 1 cm
    • high degree initial displacement
    • malunion or residual displacement
    • leg length discrepancy > 2 cm
    • nonunion
    • neurologic injury
    • urethral injury

Complications

  • Early
    • Hemorrhagic shock
    • Death
  • Urogenital injuries
    • Uretheral tear
    • Bladder rupture
  • Neurological injury
    • L5 nerve root can be involved
  • Venous Thromboembolism
    • In up to 60% of pelvic fractures (need citation)
  • Infection
    • Risk factors include DM, obesity, prolonged OR time, ICU stay, etc
  • Long term
    • Mental health issues
    • Chronic pain
    • Pelvic obliquity
    • Leg length or rotational discrepancy
    • Gait abnormalities
    • Urological dysfunction
    • Sexual dysfunction (in up to 50% of patients, need citation)
    • Socioeconomic problems

See Also

Internal

External

References

  1. ↑ Pals, Steven D., Courtney W. Brown, and Thomas G. Friermood. "Open reduction and internal fixation of an acetabular fracture during pregnancy." Journal of orthopaedic trauma 6.3 (1992): 379-381.
  2. ↑ Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury. 2005;36(1):1-13.
  3. ↑ Melton LJ 3rd, Sampson JM, Morrey BF, Ilstrup DM. Epidemiologic features of pelvic fractures. Clin Orthop Relat Res. 1981;155:43-7
  4. ↑ Ragnarsson B, Jacobsson B. Epidemiology of pelvic fractures in a Swedish county. Acta Orthop Scand. 1992;63(3):297-300
  5. ↑ 5.0 5.1 McCormack, Richard, et al. "Diagnosis and management of pelvic fractures." Bulletin of the NYU hospital for joint diseases 68.4 (2010): 281.
  6. ↑ Hanna, Paul, et al. "Intra-Vascular Occlusion of the Aorta for Massive Pelvic Trauma: A New Application." Journal of Current Surgery 8.1-2 (2018): 13-17.
  7. ↑ Image courtesy of merckmanuals.com
  8. ↑ Langford, Joshua R., et al. "Pelvic fractures: part 1. Evaluation, classification, and resuscitation." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 21.8 (2013): 448-457.
  9. ↑ Gänsslen A, Pohlemann T, Paul C, et al. Epidemiology of pelvic ring injuries. Injury. 1996;(27 Suppl 1):S-A13-20.
  10. ↑ Munihire, Jeannot Baanitse, et al. "Complex pelvic fracture with massive hemorrhage in low resource settings: Case report." Radiology Case Reports 18.11 (2023): 4099-4102.
  11. ↑ Govaert, Geertje, et al. "Prevention of pelvic sepsis in major open pelviperineal injury." Injury 43.4 (2012): 533-536.
  12. ↑ Zhang, Bin-Fei, et al. "The morphological mapping of lateral compression type 1 pelvic fracture and pelvic ring stability classification: a finite element analysis." Journal of Orthopaedic Surgery and Research 16.1 (2021): 675.
  13. ↑ https://www.orthobullets.com/trauma/1030/pelvic-ring-fractures
  14. ↑ Li, Renjie, et al. "Combined pelvic and acetabular injuries: clinical features and treatment strategies of a unique injury pattern." Journal of orthopaedic surgery and research 18.1 (2023): 415.
  15. ↑ Davarinos, Nikolaos, et al. "A delayed and rather unusual presentation of a bladder injury after pelvic trauma: 5 years after a road traffic accident." Case reports in orthopedics 2014.1 (2014): 873079.
  16. ↑ Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;21(1):31-7.
Created by:
John Kiel on 5 July 2019 08:28:35
Last edited:
15 September 2025 00:56:07
Categories:
Lower Extremity | Trauma | Hip | Fractures | Pelvis
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