Pelvic Fractures

Pelvic fractures in adult are either stable fractures resulting from low-energy trauma, such as falls in elderly patients, or fractures caused by high-energy trauma mostly results from car accidents that result in significant morbidity and mortality.

Mortality rate is 15% for closed fractures, and 50% for open pelvic fractures. Early mortality most commonly results from hemorrhage or closed-head injury, while late mortality occurs from sepsis or multiple system organ failure.

Risk factors for increased mortality in pelvic fractures include:

1. Patient’s age
2. injury severity score
3. Associated head or visceral injury
4. Blood loss
5. Hypotension
6. Coagulopathy
7. Unstable or open pelvic fractures.

Potential complications of high-energy pelvis injury:

1. Injuries to the major vessels and nerves of the pelvis.
2. Injuries to the major viscera, such as the intestines, the bladder, and the urethra.
3. Avulsion injuries to the surrounding soft tissues.

Anatomy of the pelvis

The pelvis is composed anteriorly of the ring of the pubic and ischial rami connected with the symphysis pubis. A fibrocartilaginous disc separates the two pubic bodies. Posteriorly, the sacrum and the ilium bones are joined at the sacroiliac joint on each side.

The symphyseal ligaments include:

• Pelvic floor: consists of the sacrospinous ligaments and sacro-tuberous ligaments.
• Posterior sacroiliac complex.

See Also: Pelvic Anatomy

Classification

Tile Classification of Pelvic fractures

In tile classification, there are 3 types of pelvic fractures:

Type A: This type is stable because the posterior arch is intact. The sub-type include:

• A1: Avulsion injury.
• A2: Iliac-wing or anterior-arch fracture due to a direct blow.
• A3: Transverse sacrococcygeal fracture.

Type B: This type is partially stable (incomplete disruption of posterior arch). The sub-type include:

• B1: Open-book injury (external rotation).
• B2: Lateral-compression injury (internal rotation):
  • B2-1: Ipsilateral anterior and posterior injuries.
  • B2-2: Contralateral (bucket handle) injuries.
• B3: Bilateral.

Type C: This type is unstable (complete disruption of posterior arch). The sub-type include:

• C1: Unilateral
  • C1-1: Iliac fracture.
  • C1-2: Sacroiliac fracture dislocation.
  • C1-3: Sacral fracture.
• C2: Bilateral, with one side type B, one side type C.
• C3: Bilateral.

Type	Stability	Sub-type
Type A	Stable (posterior arch intact).	– A1: Avulsion injury. – A2: Iliac-wing or anterior-arch fracture due to a direct blow. – A3: Transverse sacrococcygeal fracture.
Type B	Partially stable (incomplete disruption of posterior arch).	– B1: Open-book injury (external rotation). – B2: Lateral-compression injury (internal rotation): – B2-1: Ipsilateral anterior and posterior injuries. – B2-2: Contralateral (bucket handle) injuries. – B3: Bilateral.
Type C	Unstable (complete disruption of posterior arch).	– C1: Unilateral: – C1-1: Iliac fracture. – C1-2: Sacroiliac fracture dislocation. – C1-3: Sacral fracture. – C2: Bilateral, with one side type B, one side type C. – C3: Bilateral.

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 sacro-tuberous ligaments.
• APC-III:
  • Disruption of anterior and posterior SI ligaments (SI dislocation).
  • Disruption of sacrospinous and sacro-tuberous 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:

• Posterior and superior directed force.
• Associated with the highest risk of hypovolemic shock (63%).
• Mortality rate up to 25%.

Pelvic Fracture Symptoms

Hemodynamic status should be evaluated in pelvic injuries because hemorrhage is a leading cause of death. There are three main sources for hemorrhage resulting from pelvic fractures: vascular, osseous, and visceral.

Neurologic examination: the lumbosacral trunk and sciatic nerve are at risk with fractures and dislocations of the sacrum and sacroiliac joint. The femoral nerve is less commonly injured. Pelvic fractures can also injure the pudendal nerve.

Gastrointestinal injury: Required abdominal and rectal examination.

Genitourinary injury: If blood is present at the urethral meatus, a retrograde urethrogram should be performed. Bladder injuries are common with pelvic fractures and should be looked for on CT scan or cytogram.

Radiographic evaluation:

Radiographic views used to diagnosis the pelvic fractures include:

1. Anteroposterior pelvis.
2. Inlet view: evaluate anteroposterior displacement of sacroiliac joint and internal/external rotational deformity.
3. Outlet view: evaluate vertical displacement of sacroiliac joint and flexion of hemipelvis.

CT: it’s particularly useful to evaluate posterior pelvic injury patterns.

Pelvic Fracture Treatment

In patient with pelvic fracture, the initial treatment should include:

1. Control hemorrhage and provisionally stabilize pelvic ring, 85% of bleeding due to venous injury, only 15% arterial source.
2. Volume resuscitation and early blood transfusion.
3. Pelvic binder, wrapped sheet or external fixation.
4. Angiographic embolization.

Nonoperative Treatment is indicated for stable pelvic fractures:

• Weight bearing as tolerated for isolated anterior injuries.
• Protected weight bearing for ipsilateral anterior and posterior ring injuries.

Operative treatment is indicated in case of:

• Symphysis diastasis greater than 2.5 cm.
• Anterior and posterior sacroiliac ligament disruption.
• Vertical instability of posterior hemipelvis.
• Sacral fracture with displacement greater than 1 cm.
• Open fractures.

Anterior injuries are treated as following:

• ORIF with plate fixation.
• External fixation.

Posterior injuries are treated as following:

• Percutaneous iliosacral screw fixation.
• Anterior plate fixation across the sacroiliac joint.
• Posterior transiliac sacral bars or sacral plating.
• Spinal-pelvic fixation considered for bilateral sacral fractures.

Vertically unstable patterns with anterior and posterior dislocations are treated as following:

• Anterior ring internal fixation and percutaneous sacroiliac screw has been shown to be most stable fixation construct.
• Spinal-pelvic fixation may also be considered.

References & More

1. Campbel’s Operative Orthopaedics 12th edition Book.
2. Millers Review of Orthopaedics -7th Edition Book.
3. Davis DD, Foris LA, Kane SM, et al. Pelvic Fracture. [Updated 2022 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430734/
4. Milenkovic, Sasa & Mitkovic, Milan. (2020). Pelvic ring injuries. Acta Facultatis Medicae Naissensis. 37. 23-33. 10.5937/afmnai2001023M. ResearchGate
5. Radiographic Evaluation of the Hip – Musculoskeletal Key