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Tintinalli's Emergency Medicine: A
Comprehensive Study Guide >
Pelvis Injuries
Mark T. Steele; Jeffrey G. Norvell
Epidemiology
Pelvic fractures and associated injuries are a cause of significant morbidity and mortality. Most pelvic fractures are
secondary to automobile passenger or pedestrian accidents but are also the result of minor falls in older persons
and from major falls or crush injuries. The mortality rate from all pelvic fractures is approximately 5%. However,
with complex pelvic fractures, the mortality rate is 22%.1
Anatomy and Biomechanics
The major functions of the pelvis are protection, support, and hematopoiesis. The pelvis consists of the two
innominate bones, which are made up of the ilium, ischium, and pubis; the sacrum; and the coccyx. The two
innominate bones and sacrum form a ring structure, which is the basis of pelvic stability. This stability is largely
dependent on the strong posterior sacroiliac (SI), sacrotuberous, and sacrospinous ligaments (Figure 269-1). A
small amount of pelvic stability is also provided by the pubic symphysis. Any single break in the ring will yield a
stable injury without significant risk of displacement. An injury with two breaks in the ring is unstable with
the risk of displacement.
FIGURE 269-1.
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The major posterior stabilizing structures of the pelvic ring—that is, the posterior tension band of the pelvis—
include the iliolumbar ligament and the posterior sacroiliac, sacrospinous, and sacrotuberous ligaments.
The iliopectineal, or arcuate, line divides the pelvis into the upper, or false, pelvis, which is part of the abdomen,
and the lower, true pelvis (Figure 269-2). In addition, this line constitutes the major portion of the femorosacral
arch, which, along with the subsidiary tie arch (bodies of pubic bones and superior rami), supports the body in the
erect position. In the sitting position, the weightbearing forces are transmitted by the ischiosacral arch augmented
by its tie arch, the pubic bones, inferior pubic rami, and ischial rami. The tie arches fracture first, especially at the
symphysis pubis, pubic rami, and just lateral to the SI joints. Incorporated in the pelvic structure are five joints that
allow some movement in the bony ring. The lumbosacral, SI, and sacrococcygeal joints, and the symphysis pubis
allow little movement. The acetabulum is a ball-and-socket joint that is divided into three portions: the iliac portion,
or superior dome, is the chief weightbearing surface; the inner wall consists of the pubis and is thin and easily
fractured; and the posterior acetabulum is derived from the thick ischium.
FIGURE 269-2.
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Roentgenographic anatomy of the pelvis and acetabulum.
The pelvis is extremely vascular. The iliac artery and venous trunks pass near the SI joints bilaterally. The nerve
supply through the pelvis is derived from the lumbar and sacral plexuses. Injury to the pelvis may produce deficits
at any level from the nerve root to small peripheral branches (Figure 269-3). The lower urinary tract is contained in
the pelvis (Figure 269-4). In the adult, the bladder lies behind the symphysis and pubic bones, and the peritoneum
covers the dome and base posteriorly. The location of the bladder and the degree of peritoneal reflection are
determined by urine content. The lower GI tract housed in the pelvis includes a small portion of the descending
colon, the sigmoid colon, the rectum, and the anus. In women, the uterus and vagina are also housed in the bony
pelvis.
FIGURE 269-3.
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Arterial and nerve supply of the pelvis. a = artery; aa = arteries; Ext. = exterior; Inf. = inferior; Int. = interior; Lat. =
lateral; sup. = superior. (Reproduced with permission from Pansky B: Review of Gross Anatomy, 6th ed. © 1995,
McGraw-Hill, New York.)
FIGURE 269-4.
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Sagittal section of the male pelvis showing the relation of the full bladder.
Clinical Features
History
The possibility of pelvic fracture should be considered in every patient with serious blunt trauma. Determine the
mechanism of injury and the prehospital evaluation and treatment. Ask the patient about areas of pain, last
urination or defecation, present bladder sensation, and the last solid and fluid intake. In addition, the time of the
last menses or the presence of pregnancy, brief past medical history, current medications, and allergies should be
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ascertained.
Physical Examination
In trauma patients who are awake and alert, the physical examination is very sensitive for the diagnosis of a pelvic
fracture.2 Symptoms and signs of pelvic injuries vary from local pain and tenderness to pelvic instability and severe
shock. On inspection, examine for perineal and pelvic edema, ecchymoses, lacerations, and deformities. Inspect
for hematomas above the inguinal ligament or over the scrotum (Destot sign). Examine the patient by palpating for
tenderness or movement at the iliac crests, pubic rami, ischial rami, sacrum, and coccyx. Compress the pelvis
lateral to medial through the iliac crests, anterior to posterior through the symphysis pubis, and anterior to
posterior through the iliac crests. Compress the greater trochanters and determine the range of motion of the
hips.2 During the physical examination, avoid excessive movement of unstable fractures as this could
produce further injury and additional blood loss.
Rectal examination may detect superior or posterior displacement of the prostate, rectal injury, or an abnormal
bony prominence or large hematoma or tenderness along the fracture line (Earle sign). Proctoscopic examination
may be required to fully assess for the presence of rectal tears. Decrease in anal sphincter tone may suggest
neurologic injury, and blood at the urethral meatus may suggest urologic injury. Pelvic examination should be
carefully performed in women to detect the presence of blood or lacerations that suggest the possibility of open
fracture. Carefully evaluate neurovascular function. If a pelvic fracture is found, assume intra-abdominal,
retroperitoneal, gynecologic, and urologic injuries until proven otherwise.
Radiologic Evaluation
The initial stabilization of the patient takes priority over obtaining radiographs. In patients with suspected hip
fracture, a standard anteroposterior (AP) pelvis radiograph is often used to evaluate for bony injury. Indications for
a pelvis radiograph include a hemodynamically unstable blunt trauma patient, pelvic tenderness, or other finding
on physical examination concerning for pelvic fracture. Asymptomatic individuals who are alert and oriented do not
require routine radiographs.3,4 If additional radiograph views are needed, lateral views, AP views of either
hemipelvis, internal and external oblique views of the hemipelvis, or inlet and outlet views of the pelvis may be
performed. An inlet view shows anterior-posterior displacement of ring fractures. An outlet view shows superiorinferior displacement. Oblique views of the hemipelvis are true AP and lateral views of the acetabulum.
Many severely injured blunt trauma patients are initially evaluated at hospitals using an ATLS algorithm that
involves a pelvis radiograph as part of the initial evaluation. However, routine pelvic radiographs are probably not
needed in stable patients who will undergo an emergency CT scan of the abdomen and pelvis.5–7CT is more
sensitive than plain radiographs for the detection of pelvic fractures, and plain radiographs rarely change
the management plan in stable patients. With an unstable blunt trauma patient, a pelvic radiograph can be used
to identify a pelvic fracture quickly, allowing early stabilization maneuvers and mobilizing resources for emergent
angiography.
CT is considered the gold standard for evaluating pelvic injuries. Compared with CT, pelvic radiographs have a
sensitivity of only 64% to 78% for identifying pelvic fractures in blunt trauma patients. CT is also superior to
radiography in evaluating pelvic ring instability.5–8 Therefore, CT should be considered in patients with a high
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clinical suspicion and negative pelvic radiographs, or in patients with pelvic fractures on plain films, to evaluate for
additional injuries and instability. Contrast-enhanced CT also provides useful information about soft tissue injury,
contrast extravasation, and the presence of a pelvic hematoma. Contrast extravasation on CT scan is 80% to 90%
sensitive for the identification of arterial bleeding.9,10
Pelvic angiography is performed by an interventional radiologist who uses a catheter to inject contrast into pelvic
arteries to diagnose areas of active bleeding by contrast extravasation. Areas of ongoing bleeding can be
selectively embolized using coils, Gelfoam® (Pfizer, Inc., New York, NY), and other materials. Angiographic
embolization can control hemorrhage in >90% of patients with arterial injury from a pelvic fracture.11 Angiography
should be considered early in a hemodynamically unstable patient with a pelvic fracture after other sources
of bleeding have been excluded. Contrast extravasation on CT is considered by many to be an indication for
angiography to evaluate for arterial source of bleeding that may be amenable to embolization.9,10,12,13 Some
protocols advocate angiography based upon hemodynamic status, the need for ongoing blood transfusion, or in
patients who meet certain blood transfusion amounts.10,11
Pelvic Fractures
Pelvic fractures include those that involve a break in the pelvic ring, fractures of a single bone without a break in
the pelvic ring, and acetabular fractures. Pelvic fractures involving a break in the pelvic ring can be complex and
difficult to classify. These injuries range from low-energy stable fractures to high-energy unstable patterns. The
most clinically useful classification is presented in Table 269-1. This system differentiates fracture patterns based
on mechanism of injury and direction of causative force. Incidence of complications (i.e., urogenital and vascular) is
correlated with the fracture pattern, making identification of the type more clinically significant and useful.
Table 269-1 Young-Burgess Classification System and Incidence of Complications
Severe
Hemorrhage
(%)
Bladder
Rupture
(%)
Urethral
Injury
(%)
Category
Characteristics
Lateral
compression
fractures
Transverse fracture of pubic rami,
ipsilateral or contralateral to posterior
injury.
Type I
I—Sacral compression on side of impact,
transverse fractures of pubic rami.
Treatment is bed rest, pain control,
followed by protected weightbearing.
0.5
4.0
2.0
Type II
II—Crescent (iliac wing) fracture on side
of impact.
36.0
7.0
0.0
Type III
III—LC-I or LC-II injury on side of impact;
contralateral open-book (APC) injury.
60.0
20.0
20.0
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APC
fractures
Symphyseal diastasis and/or longitudinal
rami fractures.
Type I
I—Slight widening of pubic symphysis
and/or anterior SI joint; stretched but
intact anterior SI, sacrotuberous, and
sacrospinous ligaments; intact posterior
SI ligaments. Treatment is bed rest, pain
control, followed by protected
weightbearing.
1.0
8.0
12.0
Type II
II—Widened anterior SI joint; disrupted
anterior SI, sacrotuberous, and
sacrospinous ligaments; intact posterior
SI ligaments. Treatment is open reduction
and internal fixation.
28.0
11.0
23.0
Type III
III—Complete SI joint disruption with
lateral displacement; disrupted anterior
SI, sacrotuberous, and sacrospinous
ligaments; disrupted posterior SI
ligaments. Treatment is open reduction
and internal fixation.
53.0
14.0
36.0
VS fractures
Symphyseal diastasis or vertical
displacement anteriorly and posteriorly,
usually through SI joint, occasionally
through the iliac wing and/or sacrum; may
have a fracture of the ipsilateral
transverse process of L5. Treatment is
open reduction and internal fixation.
75.0
15.0
25.0
Mixed
patterns
Combination of other injury patterns,
LC/VS being the most common.
58.0
16.0
21.0
Abbreviations: APC = anteroposterior compression; LC = lateral
compression; SI = sacroiliac; VS = vertical shear.
There are three main types of pelvic fracture patterns: lateral compression (LC), AP compression, and vertical
shear (VS). LC, the first and most common mechanism (Figures 269-5, 269-6, 269-7, 269-8 and 269-9), accounts
for close to half the injuries. Motor vehicle crashes in which a car is broadsided or a pedestrian struck from the side
are examples. AP compression or open book fracture (Figures 269-10, 269-11, and 269-12) is the second type,
accounting for approximately 25% of injuries. A head-on motor vehicle crash is the classic example. The least
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common mechanism is VS (Figure 269-13), which is typified by a fall or jump from a height, accounting for
approximately 5% of fractures. Combinations of other injury patterns make up the other 20% to 25% of injuries.
FIGURE 269-5.
Type I lateral compression fracture. The lateral force is applied posteriorly (arrow). This causes a crush effect on
the sacroiliac joint, which may be visible radiographically as a sacral fracture (A). The characteristic fracture pattern
of the pubic rami will be seen (B). No ligamentous injury is seen.
FIGURE 269-6.
Type II lateral compression fracture. The force is applied anteriorly (arrow), causing the typical anterior public rami
fractures (B). In this case, however, rotation of the pelvis around the anterior sacral margin may occur, causing
rupture of the posterior sacroiliac ligaments (R). A crush fracture of the sacrum may also be seen (A).
FIGURE 269-7.
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Alternatively (compared with Figure 269-6), a fracture of the iliac wing may occur, which dissipates the rotational
forces and thus leaves the posterior ligaments intact.
FIGURE 269-8.
Type III lateral compression fracture. The force is applied laterally (arrow), causing internal rotation of the anterior
hemipelvis. Continuing through to the contralateral hemipelvis (arrow), the force causes it to rotate externally. The
result is a pattern of lateral compression on the ipsilateral side, with apparent anteroposterior compression on the
contralateral side. (A) This results in rupture of the posterior sacroiliac ligaments on the ipsilateral side (R) and
sacrospinous/sacrotuberous complex (T) and anterior ligaments on the contralateral side. (B) Typical public rami
fractures are to be expected.
FIGURE 269-9.
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Alternatively (compared with Figure 269-8), as in type II B fractures (Figure 269-7), there may be an iliac wing
fracture sparing the posterior sacroiliac joint on the ipsilateral side.
FIGURE 269-10.
Type I anteroposterior compression fracture. The force is delivered in an anteroposterior direction (arrow), tending
to “open” the pelvis. This gives rise to mild splaying of the symphysis, due to rupture of the anterior sacroiliac
ligaments.
FIGURE 269-11.
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Type II anteroposterior compression fracture. The anteroposterior force vector (arrow) has caused further
“opening” of the anterior pelvis, with additional rupture of the anterior sacroiliac, sacrotuberous, and sacrospinous
ligaments.
FIGURE 269-12.
Type III anteroposterior compression fracture. There is total disruption of the sacroiliac joint because of wide
“opening” of the pelvis (arrow). All supporting ligament groups, including the posterior sacroiliac ligaments, may be
disrupted.
FIGURE 269-13.
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Vertical shear vector. The injury force vector is delivered in a vertical plane (arrow), causing disruption along this
line. Fractures of the pubic rami are usually seen anteriorly, whereas fractures of the sacrum, sacroiliac joint, or iliac
wing are usually seen posteriorly. The fractures are vertical and are associated with vertical displacement of
fragments. Ligamentous injury to the posterior (R) and anterior (A) sacroiliac ligaments may be seen, as well to
sacrospinous/sacrotuberous (T), and (possibly) symphysis ligaments.
The different injury types may be suggested by history but can also be differentiated radiographically. The
alignment of pubic rami fractures is a clue to the mechanism and direction of force. Horizontal fractures suggest
LC injury, whereas vertical fractures point to an AP force. If there is SI joint diastasis and an associated crush
fracture of the sacrum, then the injury is from LC. Central hip dislocations suggest an LC mechanism, whereas
posterior dislocation suggests an AP force. With VS patterns, fractures are vertical in alignment, with vertical
displacement of fragments. Based on the recognition of the fracture pattern, one can then predict the likelihood of
severe hemorrhage or urogenital injury (Table 269-1).
Avulsion and Single Bone Pelvic Fractures
For fractures of the anterior superior iliac spine, anterior inferior iliac spine, ischial tuberosity, pubic ramus, body of
the ischium, iliac wing, sacrum, or coccyx, refer to Figures 269-14 and 269-15 and Table 269-2. By themselves,
these fractures do not disrupt the pelvic ring.
FIGURE 269-14.
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Pelvic fractures (type I, II, and III) according to classification by Key JA, Conwell HE: The Management of Fractures,
Dislocations, and Sprains, 4th ed. St. Louis, Mosby, 1946, p 857, as adapted by Kane WJ: Fractures of the pelvis,
in Rockwood CA Jr, Green DP (eds): Fractures in Adults, 4th ed. vol. 2. Philadelphia, Lippincott, 1996, p. 1119.
FIGURE 269-15.
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Avulsion fractures of the pelvis. 1. Iliac wing fracture (Duverney fracture). 2. Superior pubic ramus fracture. 3.
Inferior pubic ramus fracture. 4. Transverse sacral fracture. 5. Coccyx fracture. 6. Anterior superior iliac spine
avulsion. 7. Anterior inferior iliac spine avulsion. 8. Ischial tuberosity avulsion.
Table 269-2 Avulsion and Single Bone Fractures
Fracture
Description/Mechanism
of Injury
Clinical
Findings/Associated
Injuries
Iliac wing
(Duverney)
fracture
Direct trauma, usually
lateral to medial
Swelling, tenderness
over iliac wing;
abdominal pain; ileus;
acetabular fractures;
serious injury
infrequent
Single
ramus of
pubis or
ischium
Fall or direct trauma in
elderly; exercise-induced
stress fracture in young
or in pregnant women
Local pain and
tenderness; may
have inability to
ambulate
Treatment
Disposition
and FollowUp
Analgesics,
nonweightbearing
until hip
abductors
pain-free,
usually
nonoperative
Discharge
with
orthopedic
follow-up in
1–2 wk;
admit for
open fracture
or
concerning
abdominal
examination
Analgesics,
crutches
Discharge
with PCP or
orthopedic
follow-up in
1–2 wk
Analgesics,
Discharge
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Ischium
body
Sacral
fracture
Coccyx
fracture
External trauma or from
fall in sitting position;
least common pelvic
fracture
Transverse fractures
from direct
anteroposterior trauma;
upper transverse
fractures from fall in
flexed position
Fall in sitting position;
more common in women
Anterior
superior
iliac spine
Forceful sartorius muscle
contraction (e.g.,
adolescent sprinters)
Anterior
inferior
iliac spine
Forceful rectus femoris
muscle contraction (e.g.,
adolescent soccer
players)
Ischial
tuberosity
Forceful contraction of
hamstrings
Local pain and
tenderness; pain with
hamstring movement
bed rest,
donut-ring
cushion,
crutches
with
orthopedic
follow-up in
1–2 wk
Analgesics,
bed rest,
surgery may
be needed for
displaced
fractures or
neurologic
injury
Discharge
with
orthopedic
follow-up 1–
2 wk;
orthopedic
consultation
for displaced
fractures or
neurologic
deficits
Pain, tenderness over
sacral region; pain on
compression during
rectal examination
Analgesics,
bed rest,
stool
softeners, sitz
baths, donutring cushion
PCP or
orthopedic
follow-up in
2–3 wk;
surgical
excision of
fracture
fragment if
chronic pain
Pain with hip flexion
and abduction
Analgesics,
bed rest for
3–4 wk with
hip flexed and
abducted,
crutches
Discharge
with
orthopedic
follow-up in
1–2 wk
Pain in groin; pain
with hip flexion
Analgesics,
bed rest for
3–4 wk with
hip flexed,
crutches
Discharge
with
orthopedic
follow-up in
1–2 wk
Pain with sitting or
flexing the thigh
Analgesics,
bed rest for
3–4 wk in
extension,
external
rotation,
crutches
Discharge
with
orthopedic
follow-up in
1–2 wk
Pain on rectal
examination; sacral
root injury with upper
transverse fractures;
vertical fractures may
transect the pelvic
ring
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Abbreviation: PCP = primary care physician.
Acetabular Fractures
Acetabular fractures are usually secondary to motor vehicle crashes. The fracture force is either transmitted
laterally through the hip or through the femur as with a knee-versus-dashboard mechanism. Acetabular fractures
are seen commonly with other injuries, including femur, hip fractures and dislocations, and knee injuries. The
radiographic anatomy of the acetabulum is shown in Figure 269-2. There are five simple types of fractures as
classified by Judet-Letournel, and nearly all are associated with hip dislocations—posterior wall, posterior column,
anterior wall, anterior column, and transverse14 (Figure 269-15.1 and Table 269-2.1). In addition, combinations of
any of these fractures can occur and are classified as complex acetabular fractures. If an acetabular fracture is
suspected, it can be evaluated with an AP film, a 45-degree iliac oblique, and a 45-degree obturator oblique view;
together known as Judet views. CT is more sensitive than radiography in detecting acetabular injury.15 Also,
CT is able to give more detailed information about the displacement of fracture fragments, degree of comminution,
and other information that is useful in preoperative planning.
FIGURE 269-15.1.
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The Judet-Letournel classification of simple acetabular fractures. 1. Posterior wall fracture. 2. Posterior column
fracture. 3. Anterior wall fracture. 4. Anterior column fracture. 5. Transverse fracture.
Table 269-2.1 Acetabular Fractures
Fracture
Type
Mechanism
Description
Associated
Injuries
Treatment/Disposition
Posterior
wall
Direct trauma
to flexed hip
and knee
Acetabulum fracture;
ilioischial line intact
Sciatic nerve
injury; femoral
fractures
Bed rest, analgesics;
orthopedic
consultation, hospital
admission
Posterior
column
Posteriorly
directed force
to abducted,
flexed leg
Fracture acetabulum
through obturator
foramen; obturator
ring and ilioischial
Sciatic nerve
injury (40%),
weightbearing
disrupted
Bed rest, analgesics;
orthopedic
consultation, hospital
admission
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line disrupted
Anterior
wall
Lateral force
to the greater
trochanter
with hip
externally
rotated
Fracture extends
anterior inferior iliac
spine to superior
ramus; iliopectineal
line disrupted
Weightbearing
disrupted
Bed rest, analgesics;
orthopedic
consultation, hospital
admission
Anterior
column
Lateral force
to the greater
trochanter
with hip
externally
rotated
Fracture from pubic
ramus through iliac
crest; obturator ring
and iliopectineal line
disrupted
Weightbearing
disrupted
Bed rest, analgesics;
orthopedic
consultation, hospital
admission
Force lateral
to medial over
greater
trochanter
Fracture extends
anterior to posterior
through acetabulum;
ilioischial and
iliopectineal line
disrupted
Sciatic nerve
injury
Bed rest, analgesics;
orthopedic
consultation, hospital
admission
Transverse
Posterior Wall Fracture
The mechanism of injury in a posterior fracture is direct trauma to a flexed knee and hip. AP and lateral radiologic
views easily demonstrate the posterior acetabular fracture with the posterior hip dislocation. The fracture only
involves the posterior border of the acetabulum.
Posterior Column Fracture
In this fracture, the posterior column of the acetabulum is completely detached. The fracture originates at the
greater sciatic notch, traverses through the weightbearing portion of the acetabulum, and exits through the
obturator foramen. An AP view shows medial displacement of the femoral head and sciatic buttress. The ilioischial
line is also clearly disrupted. The oblique view is the best radiograph to identify this fracture. Complications are
sciatic nerve injury, which may occur in up to 40% of this fracture type, and femoral fractures.
Anterior Wall Fracture
This fracture originates at the anterior inferior iliac spine and passes inferiorly through the junction of the articular
dome and superior ramus. It results from a lateral force applied to the greater trochanter with the hip externally
rotated. On radiograph, the iliopectineal line is disrupted, and involvement of the weightbearing dome can be seen.
The most common complication is sciatic nerve injury.
Anterior Column Fracture
This fracture extends from the middle of the pubic ramus through to any point exiting the anterior segment of the
iliac crest. The iliac oblique view reveals disruption of the iliopectineal line and the weightbearing dome of the
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acetabulum.
Transverse Fracture
This fracture extends transversely from the anterior to the posterior column. It may or may not include the
weightbearing portion of the dome. The ischial ring remains intact in this fracture. The mechanism is force lateral to
medial over the greater trochanter, or force posterior to anterior on the posterior pelvis with the hip flexed. An AP
film clearly demonstrates the fracture with a central hip dislocation.
Early orthopedic consultation and hospital admission is indicated for all patients with acetabular fractures.
Nondisplaced fractures may be treated with bed rest and analgesics. Early reduction and internal fixation is
indicated for displaced fractures. Significant long-term disability is associated with acetabular fractures.
Treatment of Pelvic Fractures
Due to pelvic bleeding and associated injuries, patients with pelvic fractures may need resuscitation with
crystalloid, blood, and blood products. Retroperitoneal bleeding is an inevitable complication of pelvic
fractures, and up to 4 L of blood can be accommodated in this space until vascular pressure is overcome
and tamponade occurs. Most bleeding in pelvic fractures is due to low-pressure venous bleeding and bleeding
from the bone edges. Only about 10% to 15% of patients with pelvic fractures have arterial bleeding. The arteries
involved are typically branches of the internal iliac system, with the superior gluteal artery and the obturator artery
being the most common (Figure 269-3). Shock and death are generally due to arterial rather than venous
bleeding.9,10,16,17 Arterial bleeding can occur in all types of pelvic fractures.11
The pelvis can be stabilized with a bed sheet or other pelvic binding device to reduce pelvic volume and stabilize
fracture ends.18–20
The simplest technique is the application of a folded bed sheet tightly wrapped around the pelvis and upper legs
and secured by towel clips. In hemodynamically unstable trauma patients with pelvic fractures, carefully evaluate
other sources of blood loss, such as the thorax and in the peritoneal cavity. If the focused assessment with
sonography for trauma examination reveals free intraperitoneal fluid in an unstable patient, that is an
indication for a laparotomy. If a patient with a pelvic fracture is hemodynamically unstable and other sources of
bleeding have been excluded, that is an indication for other treatment options such as angiography with
embolization and external fixation of the pelvic fracture. External fixators are devices used to stabilize certain types
of pelvic fractures. Angiographic embolization is effective at controlling arterial bleeding, and external fixation is
thought to be effective at controlling venous bleeding.11,12 Hemorrhage from pelvic fractures refractory to
resuscitation is more likely arterial than venous in origin; angiography with possible embolization should be
pursued.12,16 However, both of these treatments may be needed to control hemorrhage. Another hemorrhage
control method used in the treatment of pelvic fractures is extraperitoneal packing. This technique involves
surgically placing packing in the pelvis to reduce the potential space needed to tamponade bleeding. This
technique has been described for use as a bridge for those patients who have pelvic fractures who are too
unstable to survive angiography.21 Extraperitoneal packing has been used more in Europe but has not yet gained
widespread acceptance in the U.S.21,22
The definitive treatment of pelvic fractures occurs once the patient has been stabilized and after other associated
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injuries have been addressed. The treatment of LC type I and AP compression type I injuries consists of a few days
of bed rest followed by protected weightbearing. All other injury types typically require open reduction and internal
fixation within 5 to 14 days of injury.23 The exact treatment of pelvic fractures is guided by fracture location and
pelvic stability.
Complications of Pelvic Fractures
Acute complications and associated injuries of pelvic fractures include urogynecologic injury, rectal injury, ruptured
diaphragm, and nerve root injury. Pelvic fractures can also have long-term effects, including chronic pain, sexual
dysfunction, and persistent functional disability.
Urogynecologic Injury
If a urethral injury is suspected clinically, retrograde urethrography should be performed before placing a Foley
catheter. Urinary tract injuries are discussed in greater detail in Chapter 262, Genitourinary Trauma. Gynecologic
injuries are uncommonly associated with pelvic trauma. Vaginal laceration can occur with anterior pelvic fractures.
A bimanual pelvic examination should be performed on all women with pelvic fractures. If blood is detected, a
speculum examination is needed. Treatment of vaginal lacerations is irrigation, debridement, wound repair in the
operating room, and antibiotics. In pregnancy, a high fetal death rate is associated with pelvic trauma if the mother
is in shock or if there is placental, uterine, or direct fetal injury (see Chapter 253, Trauma in Pregnancy).
Rectal Injuries
Rectal injuries are uncommon and are usually associated with urinary injuries and ischial fractures. Diagnosis is by
rectal examination or by proctoscopy, during which gross blood is found in the rectum. Treatment includes early
diverting colostomy with washout of the distal colon and presacral space drainage. Antibiotics that cover gramnegative organisms should be administered as soon as the injury is discovered.
Nerve Root Injury
Nerve root or peripheral nerve injuries can occur because of traction, pressure from hemorrhage, callus or fibrous
tissue, and impingement laceration by bone fragments. The onset of symptoms and signs may be delayed, but
deficits usually follow a nerve root pattern. Lumbar nerve root injuries are associated with SI joint dislocation or
fracture. Sacral root injuries are associated with sacral fractures, especially fractures of S1 and S2 (Figure 269-3).
Long-Term Complications
The long-term outcome following unstable pelvic fractures is generally fair, with persistent morbidity involving
chronic pain, sexual dysfunction, and functional disability. One study showed that 25% of patients had complaints
of chronic pelvic pain after an average follow-up period of 45 months. Sexual dysfunction is also one of the
complications of unstable pelvic fractures, with approximately 40% of patients having at least temporary sexual
dysfunction. Approximately 60% to 70% of patients with unstable pelvic fractures will return to their previous
occupations. Of the remaining 30% to 40% of patients, a minority are able to return to work with job
modifications.24,25
Acknowledgment
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The authors wish to thank Stefanie R. Ellison, who contributed to this chapter in the previous edition.
References
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roentgenogram. J Trauma 41: 994, 1996. [PubMed: 8970552]
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Useful Web Resource
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The major posterior stabilizing structures of the pelvic ring—that is, the posterior tension band of the pelvis—
include the iliolumbar ligament and the posterior sacroiliac, sacrospinous, and sacrotuberous ligaments.
Roentgenographic anatomy of the pelvis and acetabulum.
Arterial and nerve supply of the pelvis. a = artery; aa = arteries; Ext. = exterior; Inf. = inferior; Int. = interior; Lat. =
lateral; sup. = superior. (Reproduced with permission from Pansky B: Review of Gross Anatomy, 6th ed. © 1995,
McGraw-Hill, New York.)
Sagittal section of the male pelvis showing the relation of the full bladder.
Type I lateral compression fracture. The lateral force is applied posteriorly (arrow). This causes a crush effect on
the sacroiliac joint, which may be visible radiographically as a sacral fracture (A). The characteristic fracture pattern
of the pubic rami will be seen (B). No ligamentous injury is seen.
Type II lateral compression fracture. The force is applied anteriorly (arrow), causing the typical anterior public rami
fractures (B). In this case, however, rotation of the pelvis around the anterior sacral margin may occur, causing
rupture of the posterior sacroiliac ligaments (R). A crush fracture of the sacrum may also be seen (A).
Alternatively (compared with Figure 269-6), a fracture of the iliac wing may occur, which dissipates the rotational
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forces and thus leaves the posterior ligaments intact.
Type III lateral compression fracture. The force is applied laterally (arrow), causing internal rotation of the anterior
hemipelvis. Continuing through to the contralateral hemipelvis (arrow), the force causes it to rotate externally. The
result is a pattern of lateral compression on the ipsilateral side, with apparent anteroposterior compression on the
contralateral side. (A) This results in rupture of the posterior sacroiliac ligaments on the ipsilateral side (R) and
sacrospinous/sacrotuberous complex (T) and anterior ligaments on the contralateral side. (B) Typical public rami
fractures are to be expected.
Alternatively (compared with Figure 269-8), as in type II B fractures (Figure 269-7), there may be an iliac wing
fracture sparing the posterior sacroiliac joint on the ipsilateral side.
Type I anteroposterior compression fracture. The force is delivered in an anteroposterior direction (arrow), tending
to “open” the pelvis. This gives rise to mild splaying of the symphysis, due to rupture of the anterior sacroiliac
ligaments.
Type II anteroposterior compression fracture. The anteroposterior force vector (arrow) has caused further
“opening” of the anterior pelvis, with additional rupture of the anterior sacroiliac, sacrotuberous, and sacrospinous
ligaments.
Type III anteroposterior compression fracture. There is total disruption of the sacroiliac joint because of wide
“opening” of the pelvis (arrow). All supporting ligament groups, including the posterior sacroiliac ligaments, may be
disrupted.
Vertical shear vector. The injury force vector is delivered in a vertical plane (arrow), causing disruption along this
line. Fractures of the pubic rami are usually seen anteriorly, whereas fractures of the sacrum, sacroiliac joint, or iliac
wing are usually seen posteriorly. The fractures are vertical and are associated with vertical displacement of
fragments. Ligamentous injury to the posterior (R) and anterior (A) sacroiliac ligaments may be seen, as well to
sacrospinous/sacrotuberous (T), and (possibly) symphysis ligaments.
Pelvic fractures (type I, II, and III) according to classification by Key JA, Conwell HE: The Management of Fractures,
Dislocations, and Sprains, 4th ed. St. Louis, Mosby, 1946, p 857, as adapted by Kane WJ: Fractures of the pelvis,
in Rockwood CA Jr, Green DP (eds): Fractures in Adults, 4th ed. vol. 2. Philadelphia, Lippincott, 1996, p. 1119.
Avulsion fractures of the pelvis. 1. Iliac wing fracture (Duverney fracture). 2. Superior pubic ramus fracture. 3.
Inferior pubic ramus fracture. 4. Transverse sacral fracture. 5. Coccyx fracture. 6. Anterior superior iliac spine
avulsion. 7. Anterior inferior iliac spine avulsion. 8. Ischial tuberosity avulsion.
The Judet-Letournel classification of simple acetabular fractures. 1. Posterior wall fracture. 2. Posterior column
fracture. 3. Anterior wall fracture. 4. Anterior column fracture. 5. Transverse fracture.
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