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Updated: Jul 5 2024

Pelvic Ring Fractures

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  • Summary
    • Pelvic ring fractures are high energy fractures of the pelvic ring which typically occur due to blunt trauma.
    • Diagnosis is made radiographically with pelvic radiographs and further characterized with CT scan.
    • Treatment is typically operative fixation depending on degree of pelvis instability, fracture displacement and patient activity demands. 
  • Etiology
    • Associated injuries
      • orthopaedics
        • chest injury in up to 63%
        • long bone fractures in 50%
        • spine fractures in 25%
      • non-orthopaedic
        • urogenital
        • head and abdominal injury in 40%
    • Pediatric pelvic ring fractures
      • children with open triradiate cartilage have different fracture patterns than do children whose triradiate cartilage has closed
        • if triradiate cartilage is open the iliac wing is weaker than the elastic pelvic ligaments, resulting in bone failure before pelvic ring disruption
        • for this reason fractures usually involve the pubic rami and iliac wings and rarely require surgical treatment
  • Anatomy
    • Osteology
      • ring structure made up of the sacrum and two innominate bones
      • stability dependent on strong surrounding ligamentous structures
      • displacement can only occur with disruption of the ring in two places
      • neurovascular structures intimately associated with posterior pelvic ligaments
        • high index of suspicion for injury of internal iliac vessels or lumbosacral plexus
    • Ligaments
      • anterior
        • symphyseal ligaments
          • resist external rotation
      • pelvic floor
        • sacrospinous ligaments
          • resist external rotation
        • sacrotuberous ligaments
          • resist shear and flexion
      • posterior sacroiliac complex (posterior tension band)
        • strongest ligaments in the body
        • more important than anterior structures for pelvic ring stability
        • anterior sacroiliac ligaments
          • resist external rotation after failure of pelvic floor and anterior structures
        • interosseous sacroiliac
          • resist anterior-posterior translation of pelvis
        • posterior sacroiliac
          • resist cephalad-caudad displacement of pelvis
        • iliolumbar
          • resist rotation and augment posterior SI ligaments
    • Vascular
      • common iliac system begins near L4 at bifurcation of abdominal aorta
        • external iliac artery courses anteriorly along pelvic brim and emerges as the common femoral artery distal to the inguinal ligament
        • internal iliac artery dives posteriorly near SI joint and divides in the posterior division (giving of superiior gluteal artery) and anterior division (becoming obturator artery)
      • corona mortis is a connection between the obturator and and external iliac systems
        • mean distance of 6.2cm from the pubic symphysis
      • venous plexus in posterior pelvis accounts for 90% of the hemorrhage associated with pelvic ring injuries
    • Neurologic
      • Lumbosacral trunk crosses anterior sacral ala and SI joint
      • L5 nerve root exits below L5 TP a courses over sacral ala 2cm medial to SI joint
  • Classification
    • Tile classification
      • Tile classification
      • A: Stable
      •  
      • 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
      • Symphysis widening > 2.5 cm. 
        Anterior SI joint diastasis. 
        Posterior SI ligaments are intact. 
        Disruption of sacrospinous and sacrotuberous ligaments.
      • 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.
      • Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture).
      • Ipsilateral lateral compression and contralateral APC (windswept pelvis).
      • Common mechanism is rollover vehicle accident or pedestrian vs auto.
      • Vertical Shear (VS)
      • Vertical shear
      • Posterior and superior directed force.
      • Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%
  • Physical Exam
    • Symptoms
      • pain & inability to bear weight
    • Physical exam
      • inspection
        • test stability by placing gentle rotational force on each iliac crest
          • low sensitivity for detecting instability
          • perform only once
        • look for abnormal lower extremity positioning
          • external rotation of one or both extremities
          • limb-length discrepancy
      • skin
        • scrotal, labial or perineal hematoma, swelling or ecchymosis
        • flank hematoma
        • lacerations of perineum
        • degloving injuries (Morel-Lavallee lesion)
      • neurologic exam
        • rule out lumbosacral plexus injuries (L5 and S1 are most common)
        • rectal exam to evaluate sphincter tone and perirectal sensation
        • up to 10-15% of patients will sustain neurologic injury
      • urogenital exam
        • most common finding is gross hematuria
        • more common in males (21% in males, 8% in females)
      • vaginal and rectal examinations
        • mandatory to rule out occult open fracture
  • Imaging
    • Radiographs
      • recommended views
        • AP
          • part of initial ATLS evaluation
          • look for asymmetry, rotation or displacement of each hemipelvis
          • evidence of anterior ring injury needs further imaging
        • inlet
          • xray beam angled 40° caudad (may be as little as 25 degrees)
            • adequate image when S1 overlaps S2 body (i.e. perpendicular to S1 endplate)
          • ideal for visualizing
            • anterior or posterior translation of the hemipelvis
            • internal or external rotation of the hemipelvis
            • widening of the SI joint
            • sacral ala impaction
        • outlet
          • xray beam angled ~40° cephalad (may be as much as 60 degrees)
            • adequate image when pubic symphysis overlies S2 body
          • ideal for visualizing
            • vertical translation of the hemipelvis
            • flexion/extension of the hemipelvis
            • disruption of sacral foramina and location of sacral fractures
        • Single-leg stance AP pelvis ("flamingo views")
          • Patient alternates with right and left foot up while AP pelvis is obtained
            • Used in evaluation of suspected chronic pelvic ring instability
            • Examiner measures vertical translation of the pubic bones
            • Serves as a means of assessing pathologic motion at the SI joint
      • findings
        • radiographic signs of instability
          • > 5 mm displacement of posterior sacroiliac complex
          • presence of posterior sacral fracture gap
          • avulsion fractures (ischial spine, ischial tuberosity, sacrum, transverse process of 5th lumbar vertebrae)
    • CT
      • routine part of pelvic ring injury evaluation
      • better characterization of posterior ring injuries
      • helps define comminution and fragment rotation
      • visualize position of fracture lines relative to sacral foramina
      • radiographic signs of sacral dysmorphism:
        • anterior up-sloping upper sacral ala
        • irregular, non-circular, sacral nerve root tunnels
        • residual S1 disk
        • tongue-and-groove SI joint
  • Studies
    • Serum labs
      • hgb
      • serum lactate
      • base excess
  • Initial Management & Resusitation
    • Bleeding Source
      • intraabdominal (present in up to 40% of cases)
      • intrathoracic
      • retroperitoneal
      • extremity (thigh compartments)
      • pelvic
        • common sources of hemorrhage
          • venous injury (80%)
            • shearing injury of posterior thin walled venous plexus
            • leads to retroperitoneal hematoma (can hold up to 4L of blood)
          • bleeding cancellous bone
        • uncommon sources of hemorrhage
          • arterial injury (10-20%)
            • superior gluteal most common (posterior ring injury, APC pattern)
            • internal pudendal (anterior ring injury, LC pattern)
            • obturator (LC pattern)
    • Treatment
      • resuscitation
        • PRBC:FFP:Platelets ideally should be transfused 1:1:1
        • this ratio shown to improve mortality in patients requiring massive transfusion
      • pelvic binder/sheet
        • indications
          • initial management of an unstable ring injury
            • should be centered over the greater trochanters
        • contraindications
          • hypothetical risk of over-rotation of hemipelvis and hollow viscus injury (bladder) in pelvic fractures with internal rotation component (LC)
          • no clinical evidence exists of this complication occurring
        • pitfalls
          • binder can mask pelvic ring injuries, creating false negative radiographs and CT images
          • stress examination under anesthesia may be indicated in patients who present to the trauma slot in a pelvic binder, hemodynamic instability, and negative pelvis radiographs/CT scan
      • external fixation
        • indications
          • pelvic ring injuries with an external rotation component (APC, VS, CM)
          • unstable ring injury with ongoing blood loss
          • should be placed before emergent laparotomy
        • contraindications
          • ilium fracture that precludes safe application
          • acetabular fracture
      • angiography / embolization
        • indications
          • controversial and based on multiple variables including:
            • protocol of institution, stability of patient, proximity of angiography suite , availability and experience of IR staff
          • CT angiography useful for determining presence or absence of ongoing arterial hemorrhage (98-100% negative predictive value)
        • contraindications
          • not clearly defined
        • technique
          • selective embolization of identifiable bleeding sources
          • in patients with uncontrolled bleeding after selective embolization, bilateral temporary internal iliac embolization may be effective
            • repeat angiography if patient continues to be hypotensive after embolization
              • recurrent hemorrhage from previously embolized artery is common
          • complications include gluteal necrosis and impotence
  • Definitive Treatment
    • Overview by Classification
      • Definitive treatment of Anterior Posterior Compression (APC) injuries
      • APC I
      • Non-operative. Protected weight bearing
      • APC II
      • Anterior symphyseal plate or external fixator +/- posterior fixation
      • Anterior symphyseal multi-hole plate or external fixator and posterior stabilization with SI screws or plate/screws
      • Definitive treatment of Lateral Compression (LC) injuries
      • Majority non-operative.
        -Protected weight bearing (complete, comminuted sacral component.
        -Weight bearing as tolerated (simple, incomplete sacral fracture)
      • -Posterior stabilization in unstable fractures results in decreased short-term pain
      • LC II
      • Open reduction and internal fixation of ilium
      • LC III
      • Posterior stabilization with plate or SI screws as needed. 
        Percutaneous or open based on injury pattern and surgeon preference.
      • Definitive treatment of Vertical Shear (VS) injuries
      • Vertical Shear
      • Posterior stabilization with plate or SI screws as needed. 
        Percutaneous or open based on injury pattern and surgeon preference.
    • Nonoperative
      • weight bearing as tolerated
        • indications
          • mechanically stable pelvic ring injuries including
            • LC1
              • anterior impaction fracture of sacrum and oblique ramus fractures with < 1cm of posterior ring displacement
            • APC1
              • traumatic widening of symphysis < 2.5 cm with intact posterior pelvic ring
            • isolated pubic ramus fractures
            • parturition-induced pelvic diastasis
              • bedrest and pelvic binder in acute setting with diastasis less than 4cm
    • Operative
      • ORIF
        • indications
          • symphysis diastasis > 2.5 cm
          • SI joint displacement > 1 cm
          • sacral fracture with displacement > 1 cm
          • displacement or rotation of hemipelvis
          • open fracture
          • chronic pain and diastasis in parturition-induced diastasis or acute setting >4-6cm
        • technique
          • for open fractures aggressive debridement according to open fracture principles
      • anterior subcutaneous pelvic fixator (INFIX)
        • indications
          • same indications as anterior external fixation and symphyseal plating
        • complications
          • heterotopic ossification, femoral nerve injury, infection
      • diverting colostomy
        • indications
          • consider in open pelvic fractures
            • especially with extensive perineal injury or rectal involvement
  • Techniques
    • Pelvic Binding
      • technique
        • centered over greater trochanters to effect indirect reduction
        • do not place over iliac crest/abdomen
          • ineffective and precludes assessment of abdomen
        • may augment with internal rotation of lower extremities and taping at ankles
        • transition to alternative fixation as soon as possible
          • prolonged pressure from binder or sheet may cause skin necrosis
        • working portals may be cut in sheet to place percutaneous fixation
      • early pelvic binding and CT have been associated with underestimation of pelvic ring instability
        • fluroscopic exam under anesthesia can be used to assess stability in these circumstances
    • External fixation
      • theoretically works by decreasing pelvic volume
      • stability of bleeding bone surfaces and venous plexus in order to form clot
      • pins inserted into ilium
        • supra-acetabular pin insertion
        • single pin in column of supracetabular bone from AIIS towards PSIS
          • obturator outlet view
            • helps to identify pin entry point
          • iliac oblique view
            • helps to direct pin above greater sciatic notch
          • obturator oblique inlet view
            • helps to ensure pin placement within inner and outer table
          • AIIS pins can place the lateral femoral cutaneous nerve at risk
          • pedicle screws with internal subcutaneous bar may be used
        • superior iliac crest pin insertion
        • multiple half pins in the superior iliac crest
          • place in thickest portion of ilium (gluteal pillar)
          • may be placed with minimal fluoroscopy
    • ORIF
      • anterior ring stabilization
        • single superior plate
          • apply through rectus-splitting Pfannenstiel approach
          • may perform in conjunction with laparotomy or GU procedure
      • posterior ring stabilization
        • anterior SI plating
          • risk of L4 and L5 injury with placement of anterior sacral retractors
        • iliosacral screws (percutaneous)
          • good for sacral fractures and SI dislocations
          • safe zone is in S1 vertebral body
            • outlet radiograph view best guides superior-inferior screw placement
            • inlet radiograph view best guides anterior-posterior screw placement
            • in sacral dysmorphism, the safe zone in S2 is larger
          • L5 nerve root injury complication with errors in screw placement
          • entry point best viewed on lateral sacral view and pelvic outlet views
          • risk of loss of reduction highest in vertical sacral fracture patterns
        • posterior SI "tension" plating
          • can have prominent HW complications
      • anterior and posterior ring stabilization
        • necessary in vertically unstable injuries
      • ipsilateral acetabular and pelvic ring fractures
        • in general, reduction and fixation of the pelvic ring should be performed first
    • Rehabilitation
      • stable fractures treated nonsurgically
        • patients may mobilize immediately with protected weight bearing after stable fracture pattern in confirmed (may require post-mobilization views to confirm stability)
      • unstable fractures treated surgically
        • patient mobility and weight bearing depend on the location of the posterior pelvic ring fracture
        • mobility includes weight-of-limb weight bearing ipsilateral to the posterior pelvic injury with full weight bearing on contralateral side
        • patients with bilateral posterior pelvic ring injuries limited to bed-to-chair transfers only
        • when radiographic healing has occured weight bearing can be gradually advanced
  • Complications
    • Urogenital Injuries
      • present in 12-20% of patients with pelvic fractures
        • higher incidence in males (21%)
      • includes
        • posterior urethral tear
          • most common urogenital injury with pelvic ring fracture
        • bladder rupture
          • may see extravasation around the pubic symphysis
          • associated with mortality of 22-34%
      • diagnosis
        • made with retrograde urethrocystogram
        • indications for retrograde urethrocystogram include
          • blood at meatus
          • high riding or excessively mobile prostate
          • hematuria
      • treatment
        • suprapubic catheter placement
          • suprapubic catheter is a relative contraindication to anterior ring plating
        • surgical repair
          • rupture should be repaired at the same time or prior to definitive fixation in order to minimize infection risk
      • complications
        • long-term complications common (up to 35%)
          • urethral stricture - most common
          • impotence
          • anterior pelvic ring infection
          • incontinence
          • parturition sequelae (i.e. caesarean section)
    • Neurologic injury
      • L5 nerve root runs over sacral ala joint
      • may be injured if SI screw is placed to anterior
      • anterior subcutaneous pelvic fixator may give rise to LFCN injury (most common) or femoral nerve injury
    • DVT and PE
      • DVT in ~ 60%, PE in ~ 27%, fatal PE in 2%
      • prophylaxis essential
        • mechanical compression
        • pharmacologic prevention (LMWH or Lovenox)
        • vena caval filters (closed head injury)
    • Chronic instability
      • rare complication; can be seen in nonoperative cases
      • presents with subjective instability and mechanical symptoms
      • diagnosed with alternating single-leg-stance pelvic radiographs (flamingo views)
    • Infection
      • risk factors include:
        • obesity
        • diabetes
        • prolonged operation time
        • prolonged ICU stay
        • larger amount of packed red blood cell transfusions,
        • associated genitourinary and abdominal trauma
        • open fractures
        • preoperative angioembolization is controversial
  • Prognosis
    • High prevalence of poor functional outcome due to chronic pain and/or sexual dysfunction
    • Poor outcome associated with
      • SI joint incongruity of > 1 cm
      • high degree initial displacement
      • malunion or residual displacement
      • leg length discrepancy > 2 cm
      • nonunion
      • neurologic injury
      • urethral injury
    • Mortality rate 1-15% for closed fractures, as much as 50% for open fractures
      • hemorrhage is leading cause of death overall
        • closed head injury is the most common for lateral compression injuries
      • increased mortality associated with
        • systolic BP <90 on presentation
        • age >60 years
        • increased Injury Severity Score (ISS) or Revised Trauma Score (RTS)
        • need for transfusion > 4 units
        • APC III injury
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