Pelvic fracture

Fractures of the pelvis are mostly a result of motor vehicle accidents (high-energy trauma) in young adults, and therefore often co-exists with other injuries or fractures. It may also occur in elderly due to falls from standing height (low-energy trauma).

Low-energy fractures (elderly) are usually isolated and do not damage the integrity of the pelvic ring. High-energy fractures (young) usually damage the integrity of the pelvic ring, has more than one fracture, and has associated visceral and neurovascular injuries.

These fractures are uncommon, with an incidence of 3 – 4 / 100 000 per year. Males are more often affected. The mortality is quite high in open pelvic fractures and is significant in closed fractures as well due to the possibility of injury of major vessels. Haemorrhage is the leading cause of death due to the proximity of major vessels to the pelvic ring. There is a high prevalence of poor functional outcome and chronic pain. CT is often necessary. They’re classified according to the Tile classification according to the stability of the posterior column. Tile A fractures are treated conservatively while B and C (unstable) are treated surgically. See also acetabular fracture.

Clinical features

Symptoms include pelvic pain, especially with movement or weightbearing and reduced range of motion of the hip joint. Pelvis instability can be detected on physical examination. There may be associated haematomas and injuries of nearby organs, like urethra, bladder, etc.

Diagnosis and evaluation

X-ray may give the diagnosis, but a CT is often used to provide detailed imaging and exclude associated injuries. Ultrasound and angiography may also be used to diagnose associated injuries.

When a pelvic fracture is discovered, other related injuries should be sought, including other fractures of the pelvis or acetabulum, and dislocation of the hip.

Classification

Pelvic fractures are classified according to the Tile classification (or the more modern Young and Burgess classification). The Tile classification considers the location of the fracture and the remaining stability of the pelvic ring. Each type is divided into three subtypes.

Tile type	Description	Detailed description
Type A	Stable fracture	Integrity of posterior arch of pelvis and pelvic diaphragm intact Physiological loading doesn’t cause dislocation
Type B	Partially unstable fracture	The posterior arch of the pelvis is partially injured Instability is visible “only” in the horizontal view
Type C	Unstable fracture	The posterior arch of the pelvis is completely injured Instability in all directions Pelvic diaphragm totally ruptures

Type B1 is the “open book fracture”, where the ligaments of the pubic symphysis are disrupted but the posterior arch is intact, causing the pelvis to open like an open book. Large vessels (internal iliac artery and vein) pass near to these ligaments, and so massive haemorrhage can occur.

Treatment

Patients may require initial resuscitation and stabilisation due to blood loss or visceral injuries. Temporary measures may be used to stop blood loss, like sandbags, straps, bean bags, military antishock trousers, external fixators, or pelvic clamps.

Once stabilised, definitive treatment should be sought. Stable (type A) fractures may be treated conservatively with bed rest and physical therapy. Type B and C fractures should be treated surgically, with ORIF or closed reduction and percutaneous fixation. Disruption of the symphysis requires fixation with a plate.