9 Pelvic Fractures

Joshua D. Harris, Robert A. Jack II

9 Pelvic Fractures


Pelvic Ring Fractures

  • I. Mechanism of injury: high-energy blunt trauma 1 , 2 :

    1. Motorcycle collision.

    2. Auto-pedestrian collision.

    3. Fall.

    4. Motor vehicle collision.

    5. Crush injury.

  • II. Associated with other high-energy injuries:

    1. Chest/thoracic injury.

    2. Long bone fracture.

    3. Reproductive organ injury.

    4. Head injury.

    5. Abdominal injury.

    6. Spine fracture.

  • III. Mortality rate:

    1. 10–50%. 3 8

    2. Hemorrhage is leading cause. 9 11

    3. Associated with 12 :

      1. Systolic BP less than 90 on presentation.

      2. Age older than 60 years.

      3. 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.

        1. Head and neck.

        2. Face.

        3. Chest.

        4. Abdomen.

        5. Extremity.

        6. External.

      4. Need for greater than 4 U of pure red blood cells.

Acetabular Fractures

  • I. Mechanism of injury: bimodal:

    1. High energy in young patients.

    2. Low energy in elderly patients. 13

    3. May be seen with concomitant hip dislocation ( Fig. 9.1 ).

  • II. Associated injuries (up to 50% of patients) 14 17 :

    1. Extremity injury: 35%.

    2. Head injury: 19%.

    3. Chest injury: 18%.

    4. Nerve palsy: 13%.

    5. Abdominal injury: 8%.

    6. Genitourinary injury: 6%.

    7. Spine injury: 4%.

  • III. Fracture pattern defined by 18 :

    1. Force vector.

    2. Position of the femoral head (hip position).

    3. Bone mineral density.

Anatomic Considerations

Pelvic Ring (Fig. 9.2)

  • I. Osteology:

    1. Sacrum and two innominate bones.

    2. Stability dependent on strong surrounding ligamentous structures.

    3. Displacement with obligatory disruption of ring in minimum of two places.

      Fig. 9.1 Anteroposterior (AP) pelvis radiograph demonstrating a posterior left hip dislocation with associated posterior wall acetabulum fracture.
      Fig 9.2 The pelvic girdle and pelvic ring. Anterosuperior view. The pelvic girdle consists of the two hip bones (coxal bones). The SI joint and the cartilaginous pubic symphysis unite the bony parts of the pelvic girdle with the sacrum to form a stable ring called the pelvic ring (indicated by color shading). It allows very little mobility, because stability throughout the pelvic ring is an important prerequisite for transmitting the trunk load to the lower limbs. (Source: Schuenke M, Schulte E, Schumacher U. Thieme Atlas of Anatomy. General Anatomy and Musculoskeletal System. 2nd edition, ©2014, Thieme Publishers, New York. Illustrations by Voll M and Wesker K.)

  • II. Ligaments ( Fig. 9.3 ):

    1. Anterior symphyseal (resist external rotation):

    2. Pelvic floor:

      1. Sacrospinous ligaments (resist external rotation).

      2. Sacrotuberous ligaments (resist shear and flexion).

    3. Posterior sacroiliac (SI) complex: most important for stability:

      1. Anterior SI ligaments (resist external rotation).

      2. Interosseous SI (resist anteroposterior [AP] translation).

      3. Posterior SI (resist cephalad–caudad translation).

      4. Iliolumbar (resist external and internal rotation).

  • III. Neurovascular structures ( Fig. 9.4 ):

    1. Lumbosacral plexus.

    2. Internal iliac vessels.

    3. Numerous neurovascular structures intimately associated with posterior pelvic ligaments.


  • I. Osteology:

    1. Based on two-column theory ( Fig. 9.5 ):

      1. Acetabulum supported by two columns of bone.

      2. Inverted Y configuration.

      3. Anterior column:

        1. Anterior ilium.

        2. Anterior wall and dome.

        3. Iliopectineal eminence.

        4. Lateral superior pubic ramus.

          Fig. 9.3 (a, b) Ligaments of the male pelvis. (Source: Schuenke M, Schulte E, Schumacher U. Thieme Atlas of Anatomy. General Anatomy and Musculoskeletal System. 2nd edition, ©2014, Thieme Publishers, New York. Illustration by Karl Wesker/Markus Voll.)
          Fig. 9.4 Neurovascular structures on the anterior side of the posterior trunk wall. (a) Lumbar fossa on the right side after removal of the anterior and lateral trunk wall, the intra- and retroperitoneal organs, the peritoneum, and all the fasciae of the trunk wall. The inferior vena cava has been partially removed. (b) Lumbar fossa with the lumbar plexus of the right side after removal of the superficial layer of the psoas major. (Source: Schuenke M, Schulte E, Schumacher U. Thieme Atlas of Anatomy. General Anatomy and Musculoskeletal System. 2nd edition, ©2014, Thieme Publishers, New York. Illustrations by Voll M and Wesker K.)

      4. Posterior column:

        1. Quadrilateral surface.

        2. Posterior wall and dome.

        3. Ischial tuberosity.

        4. Greater and lesser sciatic notches.

  • II. Vascular structures:

    1. Obturator artery and vein.

    2. Corona mortis:

      1. Anastomosis of the external iliac and internal iliac vessels.

      2. At risk during injury and operative intervention.


Pelvic Ring


History and Examination

Information from Emergency Medical Transport Professionals

  • I. Mechanism of injury.

  • II. Level of consciousness:

    1. Glasgow Coma Scale (score range 3–15; eye opening, verbal, and motor responses).

  • III. Initial physical examination.

    Fig. 9.5 Column principle of the hip bone. (a) Lateral and (b) medial views. (Source: Schuenke M, Schulte E, Schumacher U. Thieme Atlas of Anatomy. General Anatomy and Musculoskeletal System. 2nd edition, ©2014, Thieme Publishers, New York. Illustrations by Voll M and Wesker K.)
    Fig. 9.6 Anteroposterior (AP) pelvis radiograph of an APC (anteroposterior compression) III injury.

    Table 9.1 Young–Burgess classification system of pelvic ring injuries



    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 sacrotuberous ligaments


    Disruption of anterior and posterior SI ligaments. Disruption of sacrospinous and sacrotuberous ligaments

    Lateral compression (LC)

    LC type I

    Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture

    LC type II

    Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture)

    LC type III

    Ipsilateral lateral compression and contralateral APC (windswept pelvis)

    Vertical shear


    Vertical shear

    Posterior and superior displacement of the hemipelvis

    Abbreviation: SI, sacroiliac.

    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




    Iliac fracture


    Sacroiliac fracture-dislocation


    Sacral fracture


    Bilateral with one side type B and one side type C


    Bilateral with both sides type C

    Table 9.3 Letournel classification system for acetabulum fractures






    Posterior wall

    Most common


    Posterior column

    Detachment of ischioacetabular segment from the innominate bone


    Anterior wall



    Anterior column

    Anterior border of the innominate bone displaced from the intact ilium



    Only elementary fracture to involve both columns




    Associated both column

    Acetabulum is completely separate from axial skeleton. “Spur sign” on obturator oblique


    Transverse and posterior wall

    Transverse component may be transtectal, juxtatectal, or infratectal



    T portion is an inferior vertical fracture


    Anterior column/wall and posterior hemitransverse

    75% will involve anterior column and not wall


    Posterior column and posterior wall

    Only associated fracture that does not involve both columns


Only gold members can continue reading. Log In or Register to continue

Dec 29, 2020 | Posted by in ORTHOPEDIC | Comments Off on 9 Pelvic Fractures
Premium Wordpress Themes by UFO Themes