This document provides an overview of pelvic ring injuries, including: - Epidemiology, with an incidence of 3% of all fractures and 25% among polytrauma patients. Severity depends on mechanism of injury. - Anatomy of the pelvic ring and ligaments that provide stability. - Mechanisms of injury including low vs high energy and direction of forces. - Clinical evaluation focuses on life threats and identifying all injuries, including signs of pelvic instability. Hemodynamic status and hemorrhage control are priorities. - Options for immediate hemorrhage control include pelvic binders, C-clamps, external fixation, and angiographic embolization.

1. Pelvic
Ring
Injuries
Muhammad Abdelghani

2. Epidemiology
• The overall incidence of pelvic ring
injuries is estimated at about 3% of all
fractures (AO).
– Among the polytrauma patients, the
incidence has risen to 25%.

3. Epidemiology
• Severity of fracture depends on mechanism of
injury
– Minor pelvic fractures (fractures of individual bones or
single breaks in the pelvic ring; lower energy) – elderly
patients after simple falls
– Complex pelvic fractures (higher energy) – younger
patients, M:F = 3:1
• Severe pelvic injury usually due to high-velocity
MVA, industrial accidents, falls off a significant
distance

4. Anatomy
• The pelvic ring is
composed of the sacrum
and 2 innominate bones
joined anteriorly at the
symphysis and
posteriorly at the paired
sacroiliac joints.

5. Anatomy
• The innominate bone is formed at
maturity by the fusion of 3
ossification centers: the ilium, the
ischium, and the pubis through the
triradiate cartilage at the dome of
the acetabulum.

6. Anatomy
• The pelvic brim is formed by the arcuate
lines that join the sacral promontory
posteriorly and the superior pubis
anteriorly.
– Below this is the true or lesser pelvis, in
which are contained the pelvic viscera.
– Above this is the false or greater pelvis that
represents the inferior aspect of the
abdominal cavity.

7. Anatomy
Pelvic Ligaments
• Pelvic stability is conferred by ligamentous structures.
• These may be divided into 2 groups according to the
ligamentous attachments:
– Sacrum to ilium: The strongest and most important
- Sacroiliac ligamentous complex: posterior (short and
long) and anterior
- Sacrotuberous ligament
- Sacrospinous ligament
– Pubis to pubis: The symphysis pubis.
• The sacrospinous and sacrotuberous ligaments form
part of the pelvic floor.

9. Anatomy
Pelvic Ligaments
• Sacroiliac ligamentous complex:
- Divided into posterior (short and long) and anterior
ligaments.
- The posterior sacroiliac ligaments, described as the
strongest in the body, provide most of the stability.

10. Anatomy
Pelvic Ligaments
• Sacrotuberous ligament:
– Runs from posterolateral
aspect of sacrum and dorsal
aspect of posterior iliac spine
to the ischial tuberosity.
– Positioned in the vertical plane
– Resists vertical shearing forces
applied to the hemipelvis

11. Anatomy
Pelvic Ligaments
• Sacrospinous ligament:
– It runs vertically from the
lateral margins of sacrum
and coccyx and inserts on
the ischial spine.
– It resists external rotation
of the pelvic ring.
• The entire ligamentous
complex looks and functions
like a suspension bridge.

12. Anatomy
Pelvic Ligaments
• Additional stability is conferred by
ligamentous attachments between the
lumbar spine and the pelvic ring.
1. The iliolumbar ligaments
originate from L4 and L5
transverse processes and insert on
the posterior iliac crest.
2. The lumbosacral ligaments
originate from the transverse
process of L5 to the ala of the
sacrum.

13. Anatomy
Pelvic Ligaments
• The transversely
placed ligaments
– Resist rotational
forces
– Include the short
posterior sacroiliac,
anterior sacroiliac,
iliolumbar, and
sacrospinous
ligaments.
• The vertically placed
ligaments
– Resist vertical shear
(VS)
– Include the long
posterior sacroiliac,
sacrotuberous, and
lateral lumbosacral
ligaments.

14. Anatomy
Ring structure of the pelvis
• The pelvis is a true ring
structure.
• It is self-evident that if the ring
is broken in one area and
displaced, then there must be a
fracture or dislocation in another
portion of the ring.

15. Pelvic Stability
• Definition of pelvic stability:
– The ability of the pelvis to withstand
physiological forces without significant
displacement.
• An unstable injury may be characterized by
the type of displacement as:
– Rotationally unstable (open and externally
rotated, or compressed and internally rotated).
– Vertically unstable

16. Pelvic Stability
• The pelvic bones themselves
have no inherent stability
and therefore the integrity of
the ligamentous structures is
crucial to the preservation or
the loss of stability.
• If the ligamentous structures
are removed, the pelvis falls
into its 3 component parts.

17. Neurovascular structures
• The iliac arterial and venous
trunks pass near the ventral
aspect of the SI joints
bilaterally.
• Disruption of the SI joints and
associated ligaments increases
the risk of vascular injury and
resultant hemorrhage, which
usually arises from the anterior
and posterior divisions of the
internal iliac vessels.

18. Pelvic Viscera
• The bladder and urethra are located
immediately posterior to the pubic
symphysis and the rectum lies immediately
ventral to the sacrum.
• The intimate association of these viscera
with the pelvic skeleton increases the risk
of injury when pelvic fracture occurs.

19. Mechanism of Injury
• Low-energy injuries
– Typically resulting in fractures of individual bones.
– May result from sudden muscular contractions in young
athletes that cause an avulsion injury, a low-energy fall,
or a straddle-type injury.
• High-energy fractures
– May result in pelvic ring disruption.
– Typically due to MVA, pedestrian-struck, motorcycle
accident, fall from heights, or crush mechanism.

20. Mechanism of Injury
• Impact injuries result when a moving
victim strikes a stationary object or vice
versa.
– Direction, magnitude, and nature of the
force all contribute to the type of fracture.
• Crush injuries occur when a victim is trapped
between the injurious force, such as motor
vehicle, and an unyielding environment, such
as the ground or pavement.

21. Mechanism of Injury
Direction of Force
Specific injury patterns vary by the direction of
force application
• Anteroposterior (AP) force
– This results in external rotation of the hemipelvis.
– The pelvis springs open, hinging on the intact posterior ligaments.
• Lateral compression (LC) force:
– Results in impaction of cancellous bone through the sacroiliac joint
and sacrum.
– The injury pattern depends on location of force application.
• Vertical shear force:
– Forces are directed perpendicularly through the sacrum or ilium.
– Severe disruptions of the sacroiliac joint, ilium and sacrum may
occur, leading to significant pelvic instability.

22. Clinical Evaluation
• Primary assessment (ABCDE): airway,
breathing, circulation, disability, and
exposure.
– This should include a full trauma evaluation.
• Initiate resuscitation: Address life-
threatening injuries.

23. Clinical Evaluation
• Evaluate injuries to head, chest,
abdomen, and spine.
– The focused abdominal ultrasound for trauma (FAST) can
detect intraperitoneal fluid.
– Diagnostic peritoneal lavage (DPL) may be helpful where
ongoing bleeding is suspected and the FAST is equivocal.
• If the DPL is grossly positive (>8 mL of blood aspirated
on entry into the peritoneum), operative exploration is
indicated.

24. Clinical Evaluation
• Identify all injuries to extremities and
pelvis, with careful assessment of distal
neurovascular status.

25. Clinical Evaluation
• Pelvic instability may result in a leg-length
discrepancy involving shortening on the
involved side or a markedly internally or
externally rotated lower extremity.
– External rotation and shortening of one of the
lower extremities is a sign of “open-book” or
vertical shear (VS) injury

26. Clinical Evaluation
• AP-LC test for pelvic instability should be performed once only
and involves rotating the pelvis internally and externally.
– This test can document pelvic instability when AP and lateral compression
on the iliac wings produces pain or rotational instability.
– “The first clot is the best clot”.‌
– Once disrupted, subsequent thrombus formation of a retroperitoneal
hemorrhage is difficult because of hemodilution by administered IV fluid
and exhaustion of the body’s coagulation factors by the original thrombus.
– The pelvic rock manoeuvre can demonstrate clinical instability of the
pelvic ring, especially when the instability is gross, but an apparently
normal examination does not exclude severe pelvic injury.
• Therefore, an AP view of the pelvic ring should be included in the
primary survey in all patients with blunt trauma who have signs of
hypovolaemic shock.

27. Clinical Evaluation
• Massive flank or buttock contusions and
swelling with hemorrhage are indicative of
significant bleeding.

28. Clinical Evaluation
• Palpation of the posterior aspect of the
pelvis may reveal a large hematoma, a
defect (representing the fracture), or a
dislocation of the sacroiliac joint.
• Palpation of the symphysis may also reveal
a defect.

29. Clinical Evaluation
• The perineum must be carefully inspected for
the presence of a lesion representing an open
fracture.
• Inspect the patient for bleeding from the
urethral meatus, vagina, or rectum.
– If these latter 2 areas are not carefully inspected,
occult lacerations may be overlooked, with dire
consequences, since these lacerations always
mean an open fracture of the pelvis.

30. Haemodynamic Status
• Attention must be paid to signs of hypovolaemic
shock.
– This can be a silent killer, as 30% of the blood
volume (up to 1500 ml in a 75 kg adult) will be lost
before hypotension is noted.
• Loss of up to this volume from bleeding may
only cause tachycardia.
• If there is hypotension with a systolic blood
pressure of 90 mmHg or less, at least 1500-2000
ml of blood loss has occurred.

31. Haemodynamic Status
• Adequate access to the venous system
for transfusion and fluid replacement
must be achieved in the first hour of
management.

32. Haemodynamic Status
• The primary assessment must focus on
possible sources of bleeding, such as external
blood loss and internal bleeding in the thorax,
abdomen or retroperitoneal space, including
disruption of the pelvic ring and multiple
long-bone fractures, especially of the femoral
shaft.
• Retroperitoneal hemorrhage may be
associated with massive intravascular volume
loss.

33. Haemodynamic Status
Causes of retroperitoneal hemorrhage
secondary to pelvic fracture
• Disruption of the venous plexus in the posterior pelvis (the
usual cause)
• Large-vessel injury (e.g. external or internal iliac
disruption)
– Large-vessel injury causes rapid, massive hemorrhage with
frequent loss of the distal pulse and marked hemodynamic
instability.
– This often necessitates immediate surgical exploration to gain
proximal control of the vessel before repair.

34. Haemodynamic Status
Causes of retroperitoneal hemorrhage
secondary to pelvic fracture
• Pelvic fracture hemorrhage results most frequently from the
venous structures and bleeding bone edges.
– This hemorrhage stops in most patients secondary to tamponade from
increasing tissue pressure in the pelvic retroperitoneal space.
• However, in patients who died of pelvic fracture hemorrhage,
single or multiple arterial lacerations were more likely to be
present.
– Arterial bleeding can overcome the tamponade effect of the
retroperitoneal tissues, leading to shock; this is the most common cause
of death related to the pelvic fracture itself.
• Arterial bleeding usually arises from branches of the internal
iliac system with the superior gluteal and pudendal arteries
being the most commonly identified source.

35. Haemodynamic Status
Resuscitation
• Hemorrhage in pelvic trauma may be life-
threatening.
• The site of bleeding is determined by
peritoneal lavage, portable ultrasound, or CT.
• In the resuscitative phase, control of
hemorrhage must be rapid and may be
lifesaving.

36. Haemodynamic Status
Resuscitation
• After exclusion or control of the intra-abdominal
bleeding, it must be determined whether the
pelvic bleeding is located in the anterior or the
posterior part of the ring, whether it is mainly
from the fracture site and whether it is venous or
arterial.

37. Haemodynamic Status
Resuscitation
• Patients with an unstable pelvic disruption are
at much greater general risk than those with a
stable pelvis.
• Such patients require massive fluid
replacement, as outlined in the ATLS protocol.

38. Haemodynamic Status
Resuscitation
• Pelvic stabilization should be performed early,
in the resuscitative phase of management.
• Provisional stabilization is required only for
those fractures that potentially increase the
volume of the pelvis, i.e., the wide open book
injury (B1, B3.1) or the unstable pelvic fracture
(C).
– It is rarely required for lateral compression injuries
(B2), which make up a large percentage of the total
number of pelvic disruptions.

39. Haemodynamic Status
Options for immediate hemorrhage control
• Military antishock
trousers (MAST):
Typically applied in
the field.
– No impact on survival
rate.
– Severe complications
reported (compartment
syndrome, extremity
loss)

40. Haemodynamic Status
Options for immediate hemorrhage control
• Anterior external fixator:
– In the acute phase many advocate
external fixation as a temporary
device to achieve stabilization of the
fracture and a positive effect on
haemorrhage.
– Placing the pins in the supra-
acetabular bone improves stability
and is safe if insertion is carried out
under fluoroscopic guidance.

41. Haemodynamic Status
Options for immediate hemorrhage control
Pelvic binder (pelvic wrap):
• This is wrapped circumferentially
around the pelvis.
• In an incomplete unstable type of
fracture (e.g. an open book injury),
internal rotation of the legs, if
intact, will reduce the volume of
the pelvic cavity and significantly
improve the clinical condition.

42. Haemodynamic Status
Options for immediate hemorrhage control
• A sheet can be used
if a binder is not
available.

43. Haemodynamic Status
Options for immediate hemorrhage control
• Pelvic C-clamp
– The pelvic C-clamp acts like a simple carpenter’s clamp
and can exert transverse compression directly across the
sacroiliac joint.
– The C-clamp is generally applied in the emergency
department, if possible with the aid of an image intensifier.
– The typical site for pin placement is at the point of
intersection of a line from the posterior to the anterior
superior iliac spine, with the extension of the longitudinal
axis of the dorsal border of femur.
– C-clamp application can not only be difficult but dangerous
in cases of comminuted sacral fractures: neurovascular
injury can occur due to crushing of the sacrum.

44. Pelvic C-clamp

45. Haemodynamic Status
Options for immediate hemorrhage control
• ORIF:
– This may be undertaken if the patient is undergoing
emergency laparotomy for other indications.
– It is frequently contraindicated by itself because loss
of the tamponade effect may encourage further
hemorrhage.

46. Haemodynamic Status
Options for immediate hemorrhage control
• Consider angiography or
embolization if hemorrhage
continues despite closing of
the pelvic volume.
– Arterial lesions only represent
10-20% of cases.

47. Haemodynamic Status
Options for immediate hemorrhage control
• Angiographic embolization may be more time-consuming or
delayed and surgical haemostasis may be available more rapidly.
• In some European trauma centers, pelvic packing has been
advocated as an additional damage control procedure in
posttraumatic pelvic bleeding
• Pelvic packing aims to directly tamponade sources of bleeding
within the pelvis.
• Packs can be placed in the preperitoneal and retroperitoneal
spaces.
• The method is invasive and the packs must be subsequently
removed, usually 48 hours after insertion.
• Packing may be combined with concurrent external fixation.

48. Neurologic Injury
• An accurate neurologic examination is often
difficult to obtain secondary to the patient’s
inability to cooperate with the examination.
• Because the sciatic nerve and the branches of the
sacral plexus are subject to injury with pelvic
fracture, it is important to document neurologic
function if possible.
• Recording the presence of rectal tone and the
bulbocavernosus reflex is important.
• Distal motor and sensory function at the foot and
ankle should be assessed where possible.

49. Genitourinary and Gastrointestinal Injury
• Bladder injury:
– The clinical finding most observed after bladder injury is gross
hematuria, which is present in 95% of patients.
• The remaining 5% of patients will have microscopic hematuria.
– The presence of a pelvic fracture, particularly combined with penile and
scrotal ecchymosis, should raise suspicion for a bladder and/or urethral
injury.
– When bladder injury is suspected, contrast cystography is performed in
stable patients following placement of a Foley catheter.
– Treatment:
• Extraperitoneal bladder injury: treatment is usually with Foley catheter
drainage.
• Intraperitoneal bladder rupture: exploration and suture closure.
Suprapubic catheterization is not usually necessary, but when indicated,
placement of the catheter must take into account the potential for
contamination of anterior internal fixation. The suprapubic catheter may
prevent the use of a suprapubic incision approach for skeletal fixation of
the pelvic fracture. Where this approach to skeletal fixation is
contemplated, another option for bladder drainage such as endoscopic
placement of a transurethral catheter should be considered.

50. Genitourinary and Gastrointestinal Injury
• Urethral injury: 10%
incidence with pelvic
fractures; much more
frequently in male patients.
– Examine for blood at the
urethral meatus or blood on
catheterization.
– Examine for a high-riding or
“floating” prostate on rectal
examination.
– Clinical suspicion should be
followed by a retrograde
urethrogram.

51. Genitourinary and Gastrointestinal Injury
• Clinical examination and pelvic x-rays are obtained and,
based on these, a decision to attempt bladder catheterization
is made.
• When pelvic fracture is present, catheterization should be
attempted by a clinician experienced in passing catheters in
patients with urethral injury.
• Unless there is easy and unobstructed passage of the catheter
into the bladder, efforts at passing the catheter are stopped
and a contrast urethrogram is obtained by inflating the Foley
catheter balloon in the penile urethra with 2-3 mL of saline
and instilling 10-15 mL of water-soluble contrast material
and obtaining an oblique film of the pelvis.

52. Genitourinary and Gastrointestinal Injury
• Bowel Injury:
– Perforations in the rectum or anus owing to
osseous fragments are technically open injuries
and should be treated as such.
– Infrequently, entrapment of bowel in the fracture
site with gastrointestinal obstruction may occur.
– If either is present, the patient should undergo
diverting colostomy.

53. Radiographic Evaluation
• Standard trauma
radiographs:
– AP view of the chest,
– lateral view of the
cervical spine
– AP view of the pelvis
• If possible, the AP pelvis
film is obtained prior to
bladder catheterization
and cystography to avoid
obscuring landmarks.

54. Radiographic Evaluation
• AP of the pelvis:
– Anterior lesions: pubic
rami fractures and
symphysis
displacement
– Sacroiliac joint and
sacral fractures
– Iliac fractures
– L5 transverse process
fractures

55. Radiographic Evaluation
Special views of the pelvis:
• Obturator and iliac oblique views: may be utilized in
suspected acetabular fractures.
• Inlet radiograph
• Outlet radiograph

56. Radiographic Evaluation
Inlet Radiograph
• Taken with the patient supine with
the tube directed 60° caudally,
perpendicular to the pelvic brim.
• Useful for determining anterior or
posterior displacement of the
sacroiliac joint, sacrum, or iliac
wing.
• It may determine internal rotation
deformities of the ilium and sacral
impaction injuries.

57. Radiographic Evaluation
Outlet Radiograph
• Taken with the patient supine with
the tube directed 45° cephalad.
• Useful for determination of vertical
displacement of the hemipelvis.
• It may allow for visualization of
subtle signs of pelvic disruption,
such as a slightly widened sacroiliac
joint, discontinuity of the sacral
borders, nondisplaced sacral
fractures, or disruption of the sacral
foramina.

58. Computed Tomography
• CT is excellent for assessing the posterior
pelvis, including the sacrum and sacroiliac
joints.
• CT is not a method of emergency evaluation
and can in most cases be delayed until the
general condition of the patient stabilizes.
• The presence of a contrast blush seen on CT,
strongly suggests, even in stable patients,
ongoing bleeding and the need for
therapeutic angiography.

59. Magnetic Resonance Imaging
• MRI has limited clinical utility owing to
restricted access to a critically injured
patient, prolonged duration of imaging,
and equipment constraints.
• However, it may provide superior
imaging of genitourinary and pelvic
vascular structures.

60. Stress views
• Push-pull radiographs are performed under general
anesthesia to assess vertical stability.
– Tile defined instability as 0.5 cm of motion.≥
– Bucholz, Kellam, and Browner consider 1 cm of vertical≥
displacement unstable.

61. Radiographic Signs of Instability
• Sacroiliac displacement of 5 mm in any
plane.
• Posterior fracture gap (rather than
impaction).
• Avulsion of the 5th
lumbar transverse
process, the lateral border of the sacrum
(sacrotuberous ligament), or the ischial
spine (sacrospinous ligament).

62. Other Diagnostic Techniques
• Additional diagnostic techniques (e.g.
ultrasonography, cystourethrography,
EMG, etc) must be included in the early
or late phase if a specific lesion is
suspected.

63. Classification of Pelvic Fractures
• Classification of pelvic fractures and
dislocations requires adequate plain
radiography (AP, inlet, and outlet x-rays)
and thin-cut (3-mm) CT scanning.

65. Classification
Young and Burgess
• This system is based on the mechanism
of injury:
– Lateral Compression (LC)
– AP Compression (APC)
– Vertical Shear (VS)
– Combined Mechanism (CM)

66. Classification
Young and Burgess
Lateral Compression (LC)
• Transverse fracture of pubic rami, ipsilateral or
contralateral to posterior injury
– LC-I: Sacral compression on side of impact (Stable because
ligaments remain intact)
– LC-II: Crescent (iliac wing) fracture on side of impact. Lateral
force delivered more anteriorly than the LC-I pattern
– LC-III: LC-I or LC-II injury on side of impact; contralateral
open-book (APC) injury

67. Classification
Young and Burgess
AP Compression (APC)
• Symphyseal diastasis or longitudinal rami fractures
– APC-I: Slight widening of symphysis (<2.5 cm), but the posterior pelvic
ligaments are intact
– APC-II: Widening of the symphysis > 2.5 cm with anterior opening of
the sacroiliac joint. The posterior sacroiliac ligaments are intact, but the
anterior sacroiliac, sacrotuberous, and sacrospinous ligaments are torn
– APC-III: Complete disruption of the ipsilateral ligaments, including the
posterior sacroiliac ligaments, which results in rotational and vertical
instability of the hemipelvis.

68. Classification
Young and Burgess
Vertical Shear (VS)
• Vertically applied forces caused by falls
onto an extended lower extremity, impacts
from above, or MVA with an extended
lower extremity against the floorboard or
dashboard.
• Typically associated with complete
disruption of the symphysis,
sacrotuberous, sacrospinous, and sacroiliac
ligaments and result in extreme instability.
• Highly associated with neurovascular
injury and hemorrhage.

69. Classification
Young and Burgess
Combined Mechanisms (CM)
• Combination of other injury patterns,
LC/VS being the most common.

71. Classification
Tile
• This classification combines a patient’s
mechanism of injury and pelvic stability.
• It classifies pelvic fractures into 3 groups:
– Type A: Stable fractures
– Type B: Rotationally unstable, vertically stable
– Type C: Rotationally and vertically unstable (i.e.
complete disruption of the anterior and posterior
pelvic rings).

73. Classification
Tile
Type A
Stable
• A1: Fractures of the pelvis not
involving the ring; avulsion injuries
• A2: Non-displaced or minimally
displaced pelvic ring fracture (eg,
superior & inferior pubic ramus
fracture)
• A3: Transverse fractures of the inferior sacrum
or coccyx with no disruption of the pelvic ring

74. Classification
Tile
Type B
Rotationally unstable, vertically stable
• B1: External rotation instability; open-book
injury
• B2: LC injury affecting only one side of the
pelvis, ipsilateral anterior and posterior ring
involvement with instability in internal
rotation
• B3: LC injury affecting both sides of the
pelvis; bilateral rotational instability
(‘bucket handle’ fracture)

75. Classification
Tile
Type C
Rotationally and vertically unstable
• C1: Ipsilateral anterior and posterior injury
resulting in rotational and vertical
instability of the hemipelvis
• C2: Bilateral injury resulting in rotational
instability on one side and vertical
instability on the other side
• C3: Bilateral pelvic injury in which both
sides are rotationally and vertically unstable
with an associated acetabular fracture

76. Factors increasing mortality
• Type of pelvic ring injury: Posterior disruption is
associated with higher mortality (APC III, VS, LC III)
• High Injury Severity Score
• Associated injuries: Head and abdominal, 50%
mortality
• Hemorrhagic shock on admission
• Requirement for large quantities of blood
• Perineal lacerations, open fractures
• Increased age

77. Morel-Lavallé lesion
(Skin Degloving Injury)
• A Morel-Lavallée lesion is a closed degloving
injury associated with severe trauma to the
pelvis.
• It presents as a hemolymphatic mass located
over the external aspect of the thigh.
• Since Morel-Lavallée first described the lesion
in the 19th century, the term has been used to
describe similar lesions in other anatomic sites
such as the lumbar area and over the scapula.

78. Morel-Lavallé lesion
(Skin Degloving Injury)
• Infected in one-third of
cases
• Requires thorough
debridement before
definitive surgery

79. Open pelvic fractures
• Open pelvic fractures occur when there is
communication between a fracture fragment and the
skin or a pelvic visceral cavity.
• These injuries are observed in 4-5% of patients with
pelvic fracture.
• The incidences of pelvic infection including soft
tissue infection and osteomyelitis, as well as high
mortality and long-term disability, are raised in
patients with open pelvic fracture.

80. Open pelvic fractures
• During the acute evaluation of genitourinary injury in
the patient with a pelvic fracture, a careful digital rectal
is mandatory and a vaginal examination, if the patient
can be comfortably positioned, is highly desirable.
• Palpable vaginal lacerations indicate open pelvic
fracture.
• Occasionally, rectal lacerations can also be palpated but,
in the majority, the most consistent finding indicating
rectal injury in the patient with pelvic fracture is the
finding of blood in the rectal lumen.

81. Open pelvic fractures
• Vaginal speculum examination and proctoscopic
examination are postponed until it is safe to place the
patient in the lithotomy or lateral decubitus position.
• Evaluation for fecal continence is not an emergency
diagnostic procedure for patients with pelvic fracture.
• Damage to the anal sphincter with a perineal
laceration suggests the need for diverting colostomy.
• When fecal soilage of an open wound is possible,
diversion is performed to reduce the chance of pelvic
wound infection.

82. TREATMENT

83. Decision making
• Decision making can be divided into 2
phases:
– Detection and treatment of life-threatening
situations (Emergency algorithm)
– Diagnosis and detailed classification of the
osteoligamentous injury and operative
planning and surgery, if required.

84. Decision making
• Possible posterior ring injuries are iliac wing fractures,
SI dislocations, and sacral fractures.
• Possible anterior ring injuries are rami fractures and
symphyseal disruptions.
– Pelvic injuries can include any combination of anterior and
posterior injuries, unilateral or bilateral.

85. Non-operative Treatment
• Fractures amenable to nonoperative treatment
include:
– Lateral impaction injuries with minimal (<1.5 cm)
displacement.
– Pubic rami fractures with no posterior
displacement.
– Gapping of pubic symphysis <2.5 cm.

86. Non-operative Treatment
• Rehabilitation:
– Protect weight bearing typically with a walker or
crutches initially.
– Serial radiographs are required after mobilization
has begun to monitor for subsequent displacement.
– If displacement of the posterior ring >1 cm is
noted, weight bearing should be stopped. Operative
treatment should be considered for gross
displacement.

87. Principles of Definitive Fixation of Pelvic
Fractures
1. With complete instability of the posterior ring (i.e.,
the posterior SI ligaments are disrupted), anterior
fixation alone is inadequate.
2. With complete instability of the posterior ring and
vertical instability, any posterior fixation should be
supplemented with some form of anterior
stabilization.
3. With partial instability of the pelvic ring (i.e., the
posterior SI ligaments are intact), anterior fixation
alone is adequate and full weight-bearing may be
permitted.

88. Definitive Fixation of Pelvic Fractures
Disruptions of the Pubic Symphysis
• Options for stabilizing symphyseal
disruptions:
– Anterior external fixators
– Internal fixation with plate and screws

89. Definitive Fixation of Pelvic Fractures
Disruptions of the Pubic Symphysis
• Advantages of external fixations:
– They can be easily applied to pubic rami fractures as well as symphysis
disruption
– They can be applied in the emergency room, ICU, or operating room.
– External fixators can be applied when contamination from abdominal
and genitourinary injuries makes internal fixation approaches hazardous.
– External fixation devices can be removed in the clinic or office setting.
• Disadvantages of external fixation:
– Interference with positioning, sitting, and clothing.
– Pin site care and infection can be problematic, particularly with obese
patients.
– It is more difficult to obtain and maintain an anatomic reduction of the
anterior pelvic ring with external fixation devices.

90. Definitive Fixation of Pelvic Fractures
Disruptions of the Pubic Symphysis
• Advantages of Internal Fixation:
– Absence of interference with positioning, sitting, or with
clothing
– No attendant problems of pin site care.
• Disadvantages of Internal Fixation:
– It cannot be employed when there is contamination of the
operative field
– Formal reoperation is necessary if the fixation hardware
must be removed
– Internal fixation potentially limits pelvic relaxation in
women during childbirth.

91. Definitive Fixation of Pelvic Fractures
Disruptions of the Pubic Symphysis
• Fixation options are
essentially the same for pubic
ramus fractures as for pubic
symphysis diastasis.
– However, internal fixation with
plating does not carry the same
long-term obstetrical or
hardware failure sequelae.

92. Definitive Fixation of Pelvic Fractures
Fixation of Posterior Pelvic Fractures
• Usually, a single pelvic
reconstruction plate or
lag screw along the crest
supplemented with a
second reconstruction
plate or lag screw at the
level of the pelvic brim or
sciatic buttress will
suffice in neutralizing
deforming forces until
healing has occurred.

93. Definitive Fixation of Pelvic Fractures
Fixation of Posterior Pelvic Fractures
• SI joint fixation options
include:
– iliosacral screws
– anterior SI plating
– posterior trans-iliac plating or
compression rods

94. Treatment according to Tile Classification

95. Treatment according to Tile Classification
Type A
Stable
• A1: Fractures of the pelvis
not involving the ring;
avulsion injuries
• A2: Non-displaced or
minimally displaced pelvic
ring fracture (eg, superior &
inferior pubic ramus
fracture)
• A3: Transverse fractures of the
inferior sacrum or coccyx with no
disruption of the pelvic ring
• Stable, minimally
displaced fractures with
minimal disruption of
the bony and
ligamentous stability of
the pelvic ring may
successfully be treated
with protected weight
bearing and
symptomatic treatment.

96. Treatment according to Tile
Classification
Type A
Stable
• Virtually all type A fracture can be managed symptomatically
with the following exceptions.
• Avulsion fractures (A1) of the iliac crest, esp. in young athletes,
can be fixed with lag screws if widely displaced.
• Fractures of the iliac wing with wide displacement (A2) may be
fixed with standard techniques, especially in young women, as this
injury can leave a malalignment of the iliac crest.
• Transverse sacral fractures (A3) should be considered spinal
injuries; therefore, with wide displacement and a sacral plexus
neurological deficit, reduction with or without decompression is
usually required.

97. Treatment according to Tile Classification
Type B
Rotationally unstable, vertically stable
• B1: External rotation
instability; open-book
injury
• B2: LC injury affecting
only one side of the pelvis,
ipsilateral anterior and
posterior ring involvement
with instability in internal
rotation
• B3: LC injury affecting
both sides of the pelvis;
bilateral rotational
instability (‘bucket handle’
fracture)
• B1:
– Symphyseal diastasis <2.5 cm: Protected
weightbearing & symptomatic treatment.
– Symphyseal diastasis >2.5 cm: Ext fixation or
symphyseal plate is performed (ORIF
preferred if laparotomy for associated injuries
and no open injury), with possible fixation for
the posterior injury.
• B2: Elastic recoil may improve pelvic
anatomy. No stabilization is necessary
• B3 (bucket handle): The posterior sacral
complex is commonly compressed.
– Leg-length discrepancy <1.5 cm: No
stabilization is necessary.
– Leg-length discrepancy >1.5 cm: External
fixation? ORIF?

98. Treatment according to Tile Classification
Type C
Rotationally and vertically unstable
• C1: Ipsilateral anterior and
posterior injury resulting in
rotational and vertical instability of
the hemipelvis
• C2: Bilateral injury resulting in
rotational instability on one side
and vertical instability on the other
side
• C3: Bilateral pelvic injury in which
both sides are rotationally and
vertically unstable with an
associated acetabular fracture
• C1, C2, C3:
External fixation ±
skeletal traction and
ORIF are options.

99. Treatment according to Young and Burgess
Classification

100. Treatment according to Young &
Burgess Classification
LC
• LC-I: Sacral compression
on side of impact (Stable)
• LC-II: Crescent (iliac
wing) fracture on side of
impact. Lateral force
delivered more anteriorly
than the LC-I pattern
• LC-III: LC-I or LC-II injury
on side of impact;
contralateral open-book
(APC) injury
• LC-I: Protected weight
bearing on the side of the
posterior ring injury.
Repeat x-rays 2-5 days
after injury
• LC-II: Anterior and
posterior fixation
• LC-III: Anterior and
posterior fixation

101. Treatment according to Young &
Burgess Classification
APC
• Symphyseal diastasis or longitudinal
rami fractures
– APC-I: Slight widening of
symphysis (<2.5 cm), posterior
ligaments intact
– APC-II: Widening of symphysis >
2.5 cm with anterior opening of
sacroiliac joint. The posterior
sacroiliac ligaments are intact, but
the anterior sacroiliac,
sacrotuberous, and sacrospinous
ligaments are torn
– APC-III: Complete disruption of the
ipsilateral ligaments, including the
posterior sacroiliac ligaments, which
results in rotational and vertical
instability of the hemipelvis.
• APC-I: Symptomatic
management only
• APC-II: ORIF
• APC-III: Control
haemorrhage by fracture
reduction and stabilization
with external fixation.
posterior percutaneous
iliosacral screws, either
acutely or on a delayed basis
depending on the patient's
physiologic status

102. Treatment according to Young &
Burgess Classification
VS
• Symphyseal diastasis or
vertical displacement
anteriorly and posteriorly,
usually through the SI
joint, occasionally through
the iliac wing or sacrum.
• Depends on the
posterior fracture
location. Reduction
with traction,
percutaneous iliosacral
screw fixation, and
anterior stabilization
(ORIF or external
fixation).

103. Operative Techniques

104. External Fixation
• This can be applied as:
– a construct mounted on 2-3 5-mm pins spaced 1 cm apart
along the anterior iliac crest, or
– single pins placed in the supraacetabular area in an AP
direction (Hanover frame).
• External fixation is a resuscitative fixation and can
only be used for definitive fixation of anterior pelvis
injuries.
– It cannot be used as definitive fixation of posteriorly
unstable injuries.

105. Internal Fixation
• This significantly increases the forces
resisted by the pelvic ring compared with
external fixation.

106. Internal Fixation
• Iliac wing fractures: Open reduction and stable
internal fixation using lag screws and
neutralization plates.

107. Internal Fixation
• Diastasis of the pubic symphysis: Plate fixation (if no
open injury or cystostomy tube is present).
– If the patient has a visceral injury necessitating a paramedian
midline or Pfannenstiel incision, or if preferred by the
surgeon to external fixation, internal fixation using a 4.5-mm
plate will restore stability.
• A single four-hole plate placed across the superior surface
of the symphysis pubis is used.
• This should be done immediately after the abdominal
procedure prior to closure of the skin.

108. Internal Fixation
• N.B. Plates should not be used in the presence of fecal
contamination or the proposed use of a suprapubic
tube.
– In that situation, external fixation is usually the safer and
preferred option.

109. Internal Fixation
• Sacral fractures: Trans-iliac
bar fixation may be
inadequate or may cause
compressive neurologic
injury; in these cases, plate
fixation or sacroiliac screw
fixation may be indicated.
Transiliac bar
posterior fixation

110. Internal Fixation
• Unilateral sacroiliac
dislocation: Direct
fixation with cancellous
screws or anterior
sacroiliac plate fixation
is used.

111. Internal Fixation
• Bilateral posterior unstable disruptions:
Fixation of the displaced portion of the
pelvis to the sacral body may be
accomplished by posterior screw
fixation.

112. Implants
Plates:
• Because of the difficulty in
contouring the standard plates in
the several directions required,
the 3.5-mm and 4.5-mm
reconstruction plates are
recommended for pelvic fixation.
– In general, the 3.5-mm plates are
used on most women and smaller
men, and the 4.5-mm plates on
larger men.

113. Implants
Screws:
• The 3.5-mm fully threaded cancellous screws and the
6.5-mm fully threaded cancellous screws are essential
components of the fixation system, as well as all the
standard lag screws in the two sizes (4.0 mm and 6.5
mm).
• Screws of exceptional length, up to 120 mm, are
required in the pelvis.

114. Implants
Instruments
• Since reduction of the pelvic fragments is the most
difficult part of the operation, special pelvic clamps
are essential.
• These include the pointed fracture reduction clamps
and the large pelvic reduction clamps held in place
with 2 screws.
• Other specialized pelvic reduction clamps are also
available.

115. Special Considerations

116. Average blood replacement
• LC = 3.6 U
• AP = 14.8 U
• VS = 9.2 U
• CM = 8.5 U

117. Post-operative Management
• Aggressive pulmonary toilet:
– Incentive spirometry
– Early mobilization
– Encouraged deep inspirations and coughing
– Suctioning or chest physical therapy if necessary.

118. Post-operative Management
• Prophylaxis against thromboembolic phenomena:
– Combination of:
• elastic stockings
• sequential compression devices
• chemoprophylaxis (if hemodynamic status allows)
– Duplex ultrasound examinations may be necessary.
– Thrombus formation may necessitate
anticoagulation and/or IVC filter placement.

119. Post-operative Management
• Weight-bearing status may be advanced as follows:
– Full weight bearing on the uninvolved lower extremity within
several days.
– Partial weight bearing on the involved lower extremity is
recommended for at least 6 weeks.
– Full weight bearing on the affected extremity without
crutches is indicated by 12 weeks.
– Patients with bilateral unstable pelvic fractures should be
mobilized from bed to chair with aggressive pulmonary toilet
until radiographic evidence of fracture healing is noted.
Partial weight bearing on the less injured side is generally
tolerated by 12 weeks.

120. Complications
• Infection:
– Incidence is variable (0%-25%)
– Presence of contusion or shear injuries to soft tissues
is a risk factor for infection if a posterior approach is
used.
• This risk is minimized by a percutaneous
posterior ring fixation.

121. Complications
• Thromboembolism: Disruption of the pelvic
venous vasculature and immobilization
constitute major risk factors for the
development of DVT.

122. Complications
• Malunion: Significant disability may result,
with complications including chronic pain, limb
length inequalities, gait disturbances, sitting
difficulties, low back pain, and pelvic outlet
obstruction.

123. Complications
• Nonunion:
– Rare, although it tends to occur more in younger
patients (average age 35 years) with possible
sequelae of pain, gait abnormalities, and nerve root
compression or irritation.
– Stable fixation and bone grafting are usually
necessary for union.

124. Thank You