Fractures of the Pelvis

Ovid: Manual of Orthopaedics

Editors: Swiontkowski, Marc F.; Stovitz, Steven D.
Title: Manual of Orthopaedics, 6th Edition
> Table of Contents > 21 – Fractures of the Pelvis

Fractures of the Pelvis
I. Incidence and Mechanism of Injury
Pelvic fractures are a common cause of death associated with trauma; head injuries are the most common cause (1,2,3).
Approximately two thirds of pelvic fractures are complicated by other
fractures and injuries to soft tissues. The fatality rate from pelvic
hemorrhage with current management techniques ranges from 5% to 20% (4,5).
Pelvic fractures generally are the result of direct trauma or of
transmission of forces through the lower extremity. The importance of
these fractures lies more in the associated soft-tissue injury and
hemorrhage than in the fracture per se (1,5,6).
II. Classification of Pelvic Fractures
Numerous systems have been proposed, but the Tile system, which expands on Pennel’s work, is the most widely used (7). Burgess has expanded on this work by adding a combined mechanism notion (1).
  • Types
    • Type A: stable
    • Type B: rotationally unstable, but vertically and posteriorly stable
    • Type C: rotationally and vertically unstable
  • Subtypes, which have important influences on treatment, are presented in Table 21-1 and illustrated in Figs. 21-1, 21-2, and 21-3.
  • Fractures of the acetabulum are discussed in Chap. 22.
  • Note for historical purposes that a Malgaigne fracture is a vertical fracture or dislocation of the posterior sacroiliac joint complex involving one side of the pelvis.
III. Examination
  • Pelvic fractures are suspected because of pain, crepitus, or tenderness over the symphysis pubis, anterior iliac spines, iliac crest, or sacrum,
    but a good roentgenographic examination is essential for diagnosis.
    Patients with these injuries are often unconscious or intubated, so the
    examination for stability is helpful. The iliac wings are grasped and
    force-directed to the midline; instability can be detected with this
    maneuver. Gentle handling of the patient minimizes further bleeding and
  • Specific studies.
    Patients with all but minimal trauma should have an indwelling urinary
    catheter for the dual purposes of measuring urine output while the
    associated shock is being treated and investigating possible bladder
    trauma. If there is blood at the penile meatus, then a retrograde
    urethrogram should be performed before passage of the catheter (1,2,6).
    This prevents completion of a partial urethral tear. Intravenous
    pyelography (IVP) and cystography document renal function, bladder
    anatomy, and help delineate the size of any pelvic or retroperitoneal
    hematoma. When the initial urinalysis reveals less than 20 red blood
    cells per high powered field rbc/hpf, an IVP is generally not necessary
    (8). Despite the difficulties involved, a
    pelvic (in women) and rectal examination should be done to check for
    fresh blood and open wounds, perineal sensation in a conscious patient,
    a displaced unstable prostate, and sphincter tone. These fractures
    frequently are associated with neurologic damage, so a careful
    neurologic evaluation should be done in all patients.
IV. Pelvic Hemorrhage (1, 5)
  • Symptoms and signs.
    At presentation, approximately 20% of patients are in shock. Severe
    backache can help differentiate the pain of retroperitoneal bleeding
    from the pain of intraabdominal bleeding.
  • Treatment.
    Pneumatic antishock garments (MAST trousers) help reduce the pelvic
    volume by compression of the iliac wings. MAST trousers are not useful


    a routine transfer aid for patients with blunt trauma (9).
    These garments are useful in transport of patients where there is a
    high degree of suspicion of a pelvic fracture, but should be removed as
    soon as resuscitation is underway because they are associated with
    compartment syndrome in the legs (10). Most
    causes of hemorrhage are adequately handled by rapid replacement and
    maintenance of blood volume, followed by reduction (when appropriate)
    and stabilization of the fractures as described in VI.
    Adequate blood replacement is the first priority, and its effectiveness
    is monitored by the patient’s pulse, blood pressure, central venous
    pressure, urine output, and so on, as described in Chap. 1.
    Blood loss of 2500 mL is common, and blood replacement is usually
    necessary even without evidence of an open hemorrhage. Diagnostic
    peritoneal lavage is a useful test to rule out intraabdominal injury at
    the site of hemorrhage (6). Abdominal computed tomography (CT) scan and abdominal ultrasound are effective (first) screening tests for this condition (2,5).
    The surgeon must follow the patient’s platelet count and coagulation
    studies after 4 units of blood have been given because disseminated
    intravascular coagulation can result from dilution of these components.
    The use of angiography and embolization of distal arterial bleeding
    points with blood clot, Gelfoam, or coils has been proven to be useful (1,2).
    Because only 10% of patients have identifiable arterial bleeding, the
    authors prefer to stabilize the pelvis first with internal or external
    fixation (1,2,5,11,1213). Anterior external fixation with one or two pins in each iliac wing is an effective means of stabilizing the pelvis



    when the traumatic pattern allows its use (11,14,15).
    Alternatively, wrapping the patient in a hospital sheet at the level of
    the iliac rings or in a commercially available pelvic binder have been
    proven to be effective simple methods of decreasing the pelvic volume (4).
    If the pelvic injury involves the posterior wing with a sacral fracture
    or unstable sacroiliac joint injury, the antishock clamp can be
    lifesaving. It requires skill, familiarity with the device, and
    fluoroscopic control (16). Spica casting can also be used if the necessary expertise or equipment is not available (17).
    Distal femoral pins must be incorporated into the cast. If this does
    not control the bleeding, then arteriography and embolization are
    indicated (2).

    TABLE 21-1 Substances of Pelvic Fractures
    Type A: Stable
    A1 Fractures not involving ring; avulsion injuries
       A1.1 Anterior superior spine
       A1.2 Anterior inferior spine
       A1.3 Ischial tuberosity
    A2 Stable, minimal displacement
       A2.1 Iliac wing fractures
       A2.2 Isolated anterior ring injuries (four-pillar)
       A2.3 Stable, undisplaced, or minimally displaced fractures of the pelvic ring
    A3 Transverse fractures of sacrum and coccyx
       A3.1 Undisplaced transverse sacral fractures
       A3.2 Displaced transverse sacral fractures
       A3.3 Coccygeal fracture
    Type B: Rotationally unstable; vertically and posteriorly stable
    B1 External rotation instability; open-book injury
       B1.1 Unilateral injury
       B1.2 Less than 2.5-cm displacement
    B2 Internal rotation instability; lateral compression injury
       B2.1 Ipsilateral anterior and posterior injury
       B2.2 Contralateral anterior and posterior injury; bucket-handle fracture
    B3 Bilateral rotationally unstable injury
    Type C: Rotationally, posteriorly, and vertically unstable
    C1 Unilateral injury
       C1.1 Fracture through ilium
       C1.2 Sacroiliac dislocation or fracture-dislocation
       C1.3 Sacral fracture
    C2 Bilateral injury, with one side rotationally unstable and one side vertically unstable
    C3 Bilateral injury, with both sides completely unstable
    From Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg 1988;70B:I.
    Figure 21-1. A: Type B1, stage 1 symphysis pubis disruption. B: Type B1, stage 2 symphysis pubis disruption. C: Type B1, stage 3 symphysis pubis disruption. (From Hansen ST, Swiontkowski MF. Orthopaedic trauma protocols. New York: Raven, 1993:228.)
    Figure 21-2. A: Type B2 lateral compression injury (ipsilateral). B: Type B3 lateral compression injury (contralateral). (From Hansen ST, Swiontkowski MF. Orthopaedic trauma protocols. New York: Raven, 1993:228.)
V. Roentgenograms
  • An anteroposterior view of the pelvis
    is made routinely in all patients who have suffered severe trauma or
    who complain of pain in and around the pelvic region. After the
    patient’s general condition has stabilized following a pelvic fracture,
    special films are indicated, including a 60-degree caudad-directed
    inlet view and a 40-degree cephalad-oriented tangential (or outlet)
    view (7,12). The former helps visualize the posterior pelvic ring, and the latter is for the anterior ring.
  • CT scans can be most useful in defining posterior ring fractures (1,2,13). Fifty percent of sacral fractures are missed on plain roentgenograms, but they are well visualized on CT scans.
VI. Treatment
  • Stable A type fractures
    are treated symptomatically. Turn the patient by logrolling or begin
    treatment on a Foster frame until the severe pain subsides. As soon as
    the patient can move comfortably in bed, he or she can ambulate in a
    walker and progress to walking with crutches. The fractures are through
    cancellous bone that has good blood supply, and stability of the



    usually is present in 3 to 6 weeks, with excellent healing expected
    within 2 months. Because of the dense plexus of nerves about the sacrum
    and coccyx, injuries to this area may produce chronic pain, especially
    if the patient is not encouraged to accept some discomfort and start an
    early active exercise program.

    Figure 21-3. A: Type C1 pelvic injury. B: Type C2 pelvic injury. C: Type C3 pelvic injury. (From Hansen ST, Swiontkowski MF. Orthopaedic trauma protocols. New York: Raven, 1993:229.)
  • Type B fractures
    (rotationally unstable, but vertically and posteriorly stable) must be
    treated on an individual basis. Fracture displacements, associated
    injuries, age of the patient, and functional demands should be taken
    into account (1,5,13).
    In open-book fractures, disruption of the anterior sacroiliac joints
    and sacrospinous ligaments occurs if the displacement is more than 2.5
    cm. These may be reduced and stabilized by external fixation or plate
    fixation across the symphysis (11,12).
    The authors generally prefer plate fixation because of the problems
    with patient comfort, pin tract infection, and loosening and loss of
    reduction with external fixation (5,14,18).
    Minimally displaced B1, B2, and B3 injuries may be treated
    conservatively with bed to wheelchair mobilization for 6 to 8 weeks,
    followed by crutch ambulation with weight bearing to tolerance on the
    side of the pelvis where the posterior ring is uninjured or more
    stable. Internal fixation is used for more widely displaced and
    unstable injuries (2,12,13). Traction is not recommended because of patient morbidity and the inability to improve fracture displacements.
  • Type C minimally displaced isolated injuries, especially those involving the ilium, may be treated conservatively as in B.
    However, patients need to be followed up closely roentgenographically
    and, if fracture displacement is increasing, reduction and fixation is
    indicated. Some centers utilize simulated weight-bearing radiographs as
    a method for detecting fracture instability. Improved results with
    internal fixation over traction treatment have been documented (12).
    If seen early on, then fractures of the sacrum and sacroiliac joints
    can be managed with closed reduction and percutaneous lag screw
    fixation (2,13).
    Because of the complexity of reduction and fixation techniques as well
    as the potential for high morbidity resulting from adjacent
    neurovascular structures, patients with type C injuries should be
    referred to an experienced pelvic and acetabular surgeon.
VI. Complications
  • Complications from associated injuries (e.g., of the bladder, cranium, chest)
  • Persistent symptoms from sacroiliac joint instability, including pain and leg length inequality
  • Chronic pain patterns from injuries around the coccyx and sacrum and sacroiliac joint (19,15), including dyspareunia
  • Persistent neurologic deficit from nerve root injury with L5, S1, and distal sacral root injuries most common; erectile dysfunction is common in males
  • Pulmonary and fat emboli
  • Infection from bacterial seeding of the large hematomas or from open pelvic fractures (20). Injuries to the large bowel are not uncommon.


1. Burgess AR, Eastridge BJ, Young JWR, et al. Pelvic ring disruptions: effective classification system and treatment protocol. J Trauma 1990;30:848–856.
2. Gruen
GS, Leit ME, Gruen RJ, et al. The acute management of neurodynamically
unstable multiple trauma patients with pelvic ring fractures. J Trauma 1994;36:706–713.
3. Poole GV, Ward EF, Muakkassa FF, et al. Pelvic fractures from major blunt trauma; outcome is determined by associated injuries. Ann Surg 1991;213:532–539.
4. Bottlang M, Krieg JC, Mohr M, et al. Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg (Am) 2002;84:43–47.
5. Failinger MS, McGanity PL. Unstable fractures of the pelvic ring. J Bone Joint Surg (Am) 1992;74:781–791.
6. Mendez C, Grubler KD, Maier RV. Diagnostic accuracy of peritoneal lavage in patients with pelvic fractures. Arch Surg 1994;129:477–481.
7. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg (Br) 1988;70:1.
8. Lieu
TA, Fleisher GR, Mahboubi S, et al. Hematuria and clinical findings as
indications for intravenous pyelography in pediatric blunt renal
trauma. Pediatrics 1988;82:216–222.
9. Mattox KL, Bickell W, Pepe PE, et al. Prospective MAST study in 911 patients. J Trauma 1989;29:1104–1112.
10. Apprahamian C, Gessert G, Bandyk D, et al. MAST–associated compartment syndrome (MACS): a review. J Trauma 1989;29:549–555.
11. Kellam JF. The role of external fixation in pelvic disruptions. Clin Orthop 1989;241:66.
12. Matta JM, Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop 1989;242:83–97.
13. Routt
ML Jr, Kreger PI, Simonian PT, et al. Early results of percutaneous
iliosacral screws placed with the patient in the supine position. J Orthop Trauma 1995;9:207–214.
14. Hupel TM, McKee MD, Waddell JP, et al. Primary external fixation of rotationally unstable pelvic fractures in obese patients. J Trauma 1998;45:111–115.
15. Nepola
JV, Trenhaile SW, Miranda M, et al. Vertical shear injuries: is there a
relationship between residual displacement and functional outcome? J Trauma 1999;46:1024–1030.
16. Ganz R, Krushell RJ, Jakob RP, et al. The antishock pelvic clamp. Clin Orthop 1991;267:71–78.
17. Cotler HB, LaMont JB, Hansen ST. Immediate spica cast for pelvic fractures. J Orthop Trauma 1988;2:222–228.
18. Lindahl
J, Hirvensalo E, Bostman O, et al. Failure of reduction with an
external fixator in the management of injuries of the pelvic ring
long-term evaluation of 110 patients. J Bone Joint Surg (Br) 1999;81:955–962.
19. Copeland
CE, Bosse MJ, McCarthy ML, et al. Effect of trauma and pelvis fracture
on female genitourinary, sexual and reproductive function. J Orthop Trauma 1997;11:73–81.
20. Hak
DJ, Olson SA, Matta JM. Diagnosis and management of closed internal
degloving injuries associated with pelvic and acetabular fractures: the
morel-lavallee lesion. J Trauma 1997;42:1048–1051.
Selected Historical Readings
Bucholz RW. The pathological anatomy of the Malgaigne fracture-dislocation of the pelvis. J Bone Joint Surg 1981;63A:400–404.
Peltier LF. Complications associated with fractures of the pelvis. J Bone Joint Surg (Am) 1965;47:1060–1069.
Rafii M, Firooznia H, Golimbu C, et al. The impact of CT in clinical management of pelvic and acetabular fractures. Clin Orthop 1983;178:228–235.
Saibil EA, Maggisano R, Witchell SJ. Angiography in the diagnosis and treatment of trauma. J Can Assoc Radiol 1983;34:218–227.

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