Pelvic fracture

Pelvic fractures most often occur in patients with multiple trauma caused by impact injuries such as car accidents or falls. Patients present with pelvic pain, reduced range of motion, and hematomas. Concomitant injuries such as urethral injury are common. The pelvic stability of every patient with multiple trauma must be checked, as shifted pelvic injuries can lead to extensive intraperitoneal and/or retroperitoneal bleeding, which can lead to hemorrhagic shock or death. The treatment for stable fractures is often conservative, with short-term bed rest and subsequent pain‑adapted mobilization. Unstable pelvic ring fractures with significant bleeding require surgery (e.g., external fixation) and/or angioembolization for hemorrhage control. This is followed by definitive fixation with plates or screws after the patient becomes hemodynamically stable. High-energy trauma may also lead to acetabular fractures. Patients present with hip pain and limited mobility. Management includes careful assessment, with nonoperative measures for stable fractures and surgical intervention for unstable cases. Alongside other possible complications, there is a significantly increased risk of thrombosis, and prophylaxis should be administered accordingly.

• Peak incidence: 15–28 years
• 20% of multiple trauma patients have a pelvic injury.
• 60% of patients with pelvic injury have multiple trauma.

References:^[1][2]

Epidemiological data refers to the US, unless otherwise specified.

• High-speed motor vehicle crashes (MVCs)
• Falls, especially in older adults

Tile classification of pelvic fractures ^[3]

The Tile classification is based on fracture location and remaining stability of the pelvic ring.

• Type A: stable or minimally displaced
  • Type A1: fracture of the pelvic edge
  • Type A2: fracture of the anterior pelvic ring
  • Type A3: transverse fracture of the sacrum and/or coccyx
• Type B: rotationally unstable and vertically stable
  • Type B1: symphysis diastasis (external rotation, open book pelvic fracture)
  • Type B3: bilateral fractures
• Type C: rotationally and vertically unstable
  • Type C1: unilateral fracture
  • Type C2: bilateral fracture (one side type B, one side type C)
  • Type C3: bilateral type C fractures

Young-Burgess classification ^[3][4]

The Young-Burgess classification is based on the mechanism of injury.

• Lateral compression (internal rotation)
  • Typical mechanism: side-impact MVC
  • Impact on stability: varying degrees of rotational instability
  • Associated injuries: bladder and urethral injuries caused by impingement of the lower genitourinary system ^[5]
• Anteroposterior compression (external rotation, open book pelvic fracture)
  • Typical mechanism: frontal-impact MVC (e.g., motorcycle crash)
  • Impact on stability: symphysis diastasis, varying degrees of rotational and vertical instability
  • Associated injuries: tears in the posterior venous plexus and branches of internal iliac arteries; hemorrhagic shock ^[5]
• Vertical shear (vertical displacement of the hemipelvis)
  • Typical mechanism: fall from height
  • Impact on stability: complete rotational and vertical instability
  • Associated injuries: disruption of sacrospinous and sacrotuberous ligaments; hemorrhagic shock ^[5][6]
• Combined fracture mechanism
  • More than one compression force (e.g., both lateral compression and vertical shear) applied
  • Results in complex pelvic fractures

• Pelvic pain caused by movement, weight-bearing, and compression of the iliac crests
• Tilted pelvis and unequal leg length with reduced range of motion in the hip joint
• Pelvic instability ^[4]
  • Movement in any direction during pelvic stability assessment
  • Rotational instability: Laxity of internal rotation or external rotation may be present.
  • Vertical instability: Limb length discrepancy or asymmetry of the anterior superior iliac spines (ASIS) may be present.
• Labial, scrotal, flank, and inguinal hematomas
• Concomitant injuries may occur, e.g.:
  • Urethral injury: blood at urethral meatus, high-riding or nonpalpable prostate, perineal swelling
  • Bladder injury: frank hematuria
  • Rectal, vaginal, perineal lacerations suggest an open fracture
  • Acute abdomen in abdominal trauma (bowel perforation, spleen, liver rupture)
  • Neurovascular injury : decreased rectal tone, perianal paresthesia, compromise of lower limbs
  • Axial and long bone injuries

An isolated unilateral anterior fracture of the pelvic ring may exhibit fairly mild symptoms!

Avoid vigorous downward pressure on the ASIS when assessing pelvic stability, as pressure can loosen blood clots at the fracture site and worsen hemorrhage. ^[5]

Approach ^[5][8][9]

See also “Approach to blunt abdominal trauma” for patients with associated abdominopelvic injuries.

• Primary survey: Assess pelvic stability and identify life-threatening complications and associated injuries.
  • Clinical features of shock
  • Blunt abdominal trauma: e.g., abdominal bruising, peritoneal signs, positive FAST examination
  • Features of genitourinary trauma
  • Lower extremity neurovascular injuries
• Patients with pelvic instability
  • Obtain bedside AP pelvic x-ray.
  • Apply a pelvic binder to reduce the risk of hemorrhage and displacement.
    • Slide the binder under the supine patient, centering it over the greater trochanters.
    • Secure the bind and reassess pelvic stability. ^[8]
• Hemodynamically unstable patients
  • Signs of intraabdominal hemorrhage: Expedite emergency laparotomy and interventions for pelvic hemorrhage control simultaneously or in rapid sequence.
  • No signs of intraabdominal hemorrhage: Initiate interventions for pelvic hemorrhage control.
• Hemodynamically stable patients: Obtain CT abdomen and pelvis with contrast.
  • Evidence of arterial bleeding on CT: Consult interventional radiology for angioembolization.
  • Consult; orthopedic or trauma surgery for fracture stabilization.
• Suspected genitourinary injury
  • Obtain a retrograde urethrogram; and consult urology (see “Approach to genitourinary trauma”).
  • Avoid transurethral catheterization; consider suprapubic catheterization instead.

Pelvic fractures with hemodynamic instability and intraabdominal hemorrhage require coordination among trauma surgery, orthopedic surgery, and/or interventional radiology, with priorities based on patient needs and available resources.

Perform DRE and vaginal examination carefully in trauma patients to avoid causing iatrogenic open pelvic fractures.

Interventions for pelvic hemorrhage control ^[8][9][10]

Temporizing methods

• External pelvic stabilization: e.g., pelvic binder, external fixation, pelvic C-clamp
• Preperitoneal packing: can be performed as part of damage control surgery or combined with surgeries for concomitant injuries
• Resuscitative endovascular balloon occlusion of the aorta (REBOA)
  • A minimally invasive, temporary endovascular occlusion of the aorta to prevent exsanguination ^[11]
  • Typically reserved as a bridge to definitive treatment for patients with severe hemorrhage and/or multisystem trauma ^{[8][12][13][14]}
  • Adverse effects include ischemic injury and venous thromboembolism. ^[8][14]

Angioembolization ^[9][10]

• Goal: definitive hemostatic control
• Indications
  • Hemodynamic instability despite mechanical pelvic stabilization
  • Evidence of active bleeding on CT
• Timing: varies depending on patient requirements and available resources; requires multispecialty coordination ^[10]
  • Usually performed after initial external pelvic stabilization
  • May need to be performed before or after exploratory laparotomy for intraabdominal hemorrhage control

Pelvic injuries can cause heavy and potentially fatal blood loss!

Imaging ^[8][15][16]

For patients with polytrauma, see “Urgent diagnostics for trauma patients.”

• Pelvic x-ray: useful for bedside screening, especially in hemodynamically unstable patients ; ^[8][17][18]
  • AP view: commonly obtained in patients with pelvic pain or tenderness after trauma
  • Inlet and outlet views: can improve diagnostic sensitivity and specificity
  • Findings: radiographic fracture signs
• CT abdomen and pelvis with IV contrast
  • Gold standard for hemodynamically stable patients ^[8]
  • Potential findings
    • Radiographic fracture signs
    • Signs of arterial injury
    • Hemoperitoneum or pneumoperitoneum
• MRI pelvis and affected hip without IV contrast: useful for detecting occult fractures ^[19][20]

Additional diagnostics ^[5][8]

• Urinalysis to screen for hematuria
• Retrograde urethrogram for suspected genitourinary trauma (see “Approach to genitourinary trauma”)
• Hemodynamic monitoring parameters and serial hemoglobin and hematocrit
• Other urgent diagnostics for trauma patients, e.g., coagulation panel, type and screen

See “Initial management of pelvic fractures” for the initial approach for patients with major trauma.

Nonoperative management ^[9]

• Indication: stable fracture patterns (e.g., Tile classification type A) ^[8]
• Treatment
  • Non-weight-bearing status
  • Analgesia for fractures
  • Physical therapy
  • VTE prophylaxis ^[9][21][22]
    • Begin as soon as possible after hemostatic control is achieved
    • Agent of choice: LMWH (See “Approach to VTE prophylaxis” for dosages.)

Surgical management ^[5][8]

• Definitive surgical repair
  • Indications: open, unstable, or complex fractures (e.g., open book pelvic fracture or vertical shear injury)
  • Technique: depends on fracture pattern, e.g., ORIF of pelvic ring disruptions or iliac wing fractures
• Additional surgical interventions
  • Exploratory laparotomy for abdominopelvic organ injury, e.g., bowel injuries
  • Repair of genitourinary injuries, e.g., bladder rupture, urethral injuries

Disposition ^[9]

• Admit patients with hemodynamic instability to the ICU.
• Hospital admission is typically necessary for patients with:
  • Fractures requiring surgical repair
  • Associated acetabular fracture
  • Concomitant injuries (e.g., genitourinary, intraabdominal)
• Consider discharging patients with stable fractures and no evidence of other injuries.

• Use ABCDE approach and assess hemodynamic stability.
• Perform FAST to assess for hemoperitoneum.
• Assess for pelvic instability, tenderness, or deformity.
• Check for features of genitourinary trauma.
• Apply a pelvic binder to patients with pelvic instability.
• Obtain bedside AP pelvic x-ray.
• Identify and treat hemorrhagic shock and concomitant injuries.
• Obtain urgent diagnostics for trauma patients and begin hemodynamic monitoring.
• Hemodynamically unstable without intraabdominal hemorrhage: Prioritize interventions for pelvic hemorrhage control, e.g., consult interventional radiology (IR) for angioembolization.
• Hemodynamically unstable with intraabdominal hemorrhage: Consult surgery and IR for emergency laparotomy alongside interventions for pelvic hemorrhage control.
• Hemodynamically stable: Obtain CT abdomen and pelvis with IV contrast.
• Manage genitourinary trauma, if present, e.g., retrograde urethrogram and/or urology consult.
• Consult orthopedics for fracture management.
• Unstable fractures: Consider definitive surgical repair.
• Stable fractures: Consider nonoperative management.
• Obtain emergency preoperative diagnostics if needed.
• Provide adequate analgesia.
• Administer prophylactic antibiotics for open fractures.
• Consider DVT prophylaxis.

Etiology ^[9][23]

• High-impact trauma, e.g., MVC
• Direct blow to the hip
• Falls

Older individuals, especially those with osteoporosis, may sustain acetabular fractures from low-energy trauma such as falls from standing. ^[23]

Clinical features ^[9]

• Pain exacerbated by movement
• Bruising and swelling
• Inability to bear weight
• Restricted range of motion

Diagnostics ^[9][20][24]

• Initial imaging: Pelvic x-ray (AP and Judet views)
• Confirmatory imaging: CT pelvis and hip to assess fracture pattern, displacement, and/or involvement of surrounding structures, and for preoperative planning
• Occult fracture imaging: MRI pelvis and hip

Management

• Nonoperative management ^[9][25]
  • Indications: nondisplaced or minimally displaced fractures, not a surgical candidate
  • Treatment includes restricted weight-bearing, analgesia, and physical therapy.
• Surgical management ^[26][27][28]
  • Indications: displaced fractures, comminuted fractures, and unstable fractures
  • Techniques
    • Open reduction and internal fixation
    • Complex fractures may require total hip replacement.

Complications ^[29]

• Posttraumatic arthritis
• Avascular necrosis of the femoral head ^[30]
• Nerve injuries (e.g., sciatic nerve palsy)
• Chronic pain

• Intraperitoneal and retroperitoneal bleeding can cause hemorrhagic shock.
• Abdominal compartment syndrome
• Deep vein thrombosis
• Surgical site infection
• Neurological injury: bowel and bladder incontinence, sexual dysfunction

Pelvic fractures typically require VTE prophylaxis because of the high risk of venous thromboembolism. ^[22]

We list the most important complications. The selection is not exhaustive.