9 Pelvic Fractures
Pelvic Ring Fractures
I. Mechanism of injury: high-energy blunt trauma 1 , 2 :
Motor vehicle collision.
II. Associated with other high-energy injuries:
Long bone fracture.
Reproductive organ injury.
III. Mortality rate:
Hemorrhage is leading cause. 9 – 11
Associated with 12 :
Systolic BP less than 90 on presentation.
Age older than 60 years.
Increased injury severity scale (ISS): an anatomical scoring system providing overall score for patients with multiple injuries, based on assignment of an Abbreviated Injury Scale (AIS) score to each of six body regions—score range 3 to 75.
Head and neck.
Need for greater than 4 U of pure red blood cells.
I. Mechanism of injury: bimodal:
High energy in young patients.
Low energy in elderly patients. 13
May be seen with concomitant hip dislocation ( Fig. 9.1 ).
II. Associated injuries (up to 50% of patients) 14 – 17 :
Extremity injury: 35%.
Head injury: 19%.
Chest injury: 18%.
Nerve palsy: 13%.
Abdominal injury: 8%.
Genitourinary injury: 6%.
Spine injury: 4%.
III. Fracture pattern defined by 18 :
Position of the femoral head (hip position).
Bone mineral density.
Pelvic Ring (Fig. 9.2)
Sacrum and two innominate bones.
Stability dependent on strong surrounding ligamentous structures.
Displacement with obligatory disruption of ring in minimum of two places.
II. Ligaments ( Fig. 9.3 ):
Anterior symphyseal (resist external rotation):
Sacrospinous ligaments (resist external rotation).
Sacrotuberous ligaments (resist shear and flexion).
Posterior sacroiliac (SI) complex: most important for stability:
Anterior SI ligaments (resist external rotation).
Interosseous SI (resist anteroposterior [AP] translation).
Posterior SI (resist cephalad–caudad translation).
Iliolumbar (resist external and internal rotation).
III. Neurovascular structures ( Fig. 9.4 ):
Internal iliac vessels.
Numerous neurovascular structures intimately associated with posterior pelvic ligaments.
Based on two-column theory ( Fig. 9.5 ):
Acetabulum supported by two columns of bone.
Inverted Y configuration.
Posterior wall and dome.
Greater and lesser sciatic notches.
II. Vascular structures:
Obturator artery and vein.
Anastomosis of the external iliac and internal iliac vessels.
At risk during injury and operative intervention.
History and Examination
Information from Emergency Medical Transport Professionals
I. Mechanism of injury.
II. Level of consciousness:
Glasgow Coma Scale (score range 3–15; eye opening, verbal, and motor responses).
III. Initial physical examination.
Table 9.2 Tile classification system of pelvic ring injuries
A: rotationally and vertically stable
Fracture not involving the ring (avulsion or iliac wing)
Stable or minimally displaced fracture of the ring
Transverse sacral fracture
B: rotationally unstable, vertically stable
Open book injury (external rotation)
Lateral compression injury (internal rotation)
Anterior ring displacement through the ipsilateral rami
Anterior ring displacement through the contralateral rami
C: rotationally and vertically unstable
Bilateral with one side type B and one side type C
Bilateral with both sides type C