Introduction
Background
Pelvic ring fractures occur as the result of high-energy blunt trauma, as may result from motor vehicle collisions and falls. These injuries are associated with significant morbidity and mortality, both from the complications of pelvic ring fractures and from commonly associated injuries. Recognition of the pattern of injury to the bony pelvis directs the search for associated soft tissue injuries and allows implementation of the appropriate therapy.1,2,3,4,5
Anteroposterior compression injury as seen on an anteroposterior radiograph of the pelvis. The symphysis pubis is wider than 2.5 cm (double arrow). The right sacroiliac joint is diastatic (single arrow). This is a type II or type III injury, depending on the status of the posterior sacroiliac ligaments.
Anteroposterior (AP) compression injury as seen on a pelvic CT scan. The location and degree of sacroiliac disruption is better seen on CT scans than on radiographs. The external rotation of the right hemipelvis is a characteristic finding in AP compression. A slight posterior displacement of the right, iliac side of the sacroiliac joint suggests ligamentous disruption (arrow). This represents a type III AP compression injury.
Related eMedicine topics:
Fracture, Hip
Unstable Pelvic Fractures
Pelvis, Insufficiency Fractures
Pathophysiology
Three primary loading vectors result in pelvic ring fractures: anteroposterior (AP) compression, lateral compression, and vertical shear. Each of the forces leaves its mark in a characteristic pattern. The identification of 1 element of the pattern prompts a search for the remaining elements, allowing identification of all osseous and soft tissue injuries.6,7
AP compression injuries most often result from head-on motor vehicle collisions in which the patient is a passenger. The injuries also result when a motorcycle accident occurs or when a pedestrian is struck by a vehicle. The force may be directed either from anterior to posterior or from posterior to anterior (see Image 1).
Anteroposterior (AP) compression injury as seen on an AP radiograph of the pelvis. Characteristic features of an AP compression injury include symphyseal and sacroiliac joint diastasis. In this patient, the pubic symphysis and right sacroiliac joint are widened.
Lateral compression injuries usually result from side-impact motor vehicle collisions. Pedestrians struck by motor vehicles from the side have this pattern of injury (see Image 2).
Windswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The patient sustained a left lateral compression injury with internal rotation of the left hemipelvis and a characteristic sacral buckle fracture. Note the concomitant left sacroiliac joint diastasis. The lateral force vector continued across the pelvis to produce external rotation of the right hemipelvis and diastasis of the right sacroiliac joint. The combination of injuries resulted in a windswept pelvis.
Vertical shear injuries typically occur as a result of a fall from a height, but they can also occur in motor vehicle collisions. The vector of force is caudocranial, usually involving 1 hemipelvis (see Image 3).
Vertical shear injury as seen on an anteroposterior radiograph of the pelvis. The left hemipelvis is displaced in a cranial direction, with associated sacroiliac joint diastasis. The vertically oriented fractures of the pubic rami usually are ipsilateral; however, in this patient, the rami fractures are contralateral.
On occasion, the vector of force is not solely aligned with 1 of the primary vectors, and elements of more than 1 pattern of injury may be evident. These injuries are the result of a complex force.
Frequency
United States
Table 1. Incidences of Pelvic Ring Fractures
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Table
| Study | Lateral Compression, % | AP Compression, % | Vertical Shear, % | Complex Forces, % |
|---|---|---|---|---|
| Young et al 5 | 57 | 15 | 6 | 22 |
| McCort and Mindelzun 8 | 70 | 16 | 7 | 7 |
| Tile 9 | 71 | 13 | 16 | 0 |
| Study | Lateral Compression, % | AP Compression, % | Vertical Shear, % | Complex Forces, % |
|---|---|---|---|---|
| Young et al 5 | 57 | 15 | 6 | 22 |
| McCort and Mindelzun 8 | 70 | 16 | 7 | 7 |
| Tile 9 | 71 | 13 | 16 | 0 |
Mortality/Morbidity
With improvement in emergency management techniques, the morbidity and mortality rates of pelvic fracture have decreased in recent decades.
- The overall mortality rate in pelvic ring fractures is approximately 6%. Uncontrolled pelvic hemorrhage accounts for 39% of related deaths; head injury, 31%; and multiple organ failure, 30%. AP compression and vertical shear injuries are associated with a higher incidence of pelvic vascular injury and hemorrhage.
- Associated injuries are commonly found as a result of the powerful forces necessary to fracture the pelvic ring. Injuries to the peripheral nerve, urethra, and bladder are directly attributable to pelvic ring fractures. The frequencies of associated injuries are as follows:
- Closed head injury — 51%
- Long bone fracture — 48%
- Peripheral nerve injury — 26%
- Thoracic injury — 20%
- Urethra (male) — 15%
- Bladder — 10%
- Spleen — 10%
- Liver — 7%
- GI tract — 7%
- Kidney — 7%
- Urethra (female) — 6%
- Mesentery — 4%
- Diaphragm — 2%
- Immediate complications may be observed.
- Pelvic hemorrhage is the most serious immediate complication of a pelvic ring fracture. Disruption of the osseous pelvic ring leads to disruption of pelvic veins and/or arteries in as many as 75% of patients.
- Venous bleeding may arise from the posterior pelvic veins (usually in the setting of sacral injury) or from the marrow space of broken pelvic bones.
- Arterial bleeding occurs as the result of direct injury to a vessel close to an osseous injury. The injured vessels are typically branches of the internal iliac artery.
- Posterior fractures, especially those through the greater sciatic notch, may injure the superior gluteal artery.
- Anterior fractures or disruptions may injure the internal pudendal artery.
- Pelvic hemorrhage is immediately treated by means of pelvic stabilization, either with sheets wrapped around the pelvis or with external fixator devices. In either case, the goal is to restore the normal anatomic relationships in the pelvis; this restoration serves to reduce the pelvic volume. The larger the pelvic volume, the greater the amount of bleeding that may occur. Uncontrollable hemorrhage requires angiographic evaluation and embolization of the bleeding vessels.
- Bladder injury occurs as either an associated injury or a complication of a pelvic ring fracture.10
- Extraperitoneal bladder rupture occurs more commonly (in approximately 80% of patients) than intraperitoneal rupture (20%). Extraperitoneal rupture results either from direct bladder injury caused by pelvic fracture fragments or from shearing forces near the base of the bladder.
- Intraperitoneal rupture is usually the result of blunt trauma to a distended bladder.
- Pelvic fractures need not be present in either type of bladder rupture; they are more often associated with extraperitoneal injuries. Traditionally, the diagnosis of bladder injury was made by use of conventional cystography; however, with the increased use of computed tomography (CT), CT cystography is now more routinely performed.
- Urethral injury results from the same shearing forces that lead to extraperitoneal bladder rupture. Distraction of the anterior pelvic osseous support structures leads to stretching of the urogenital diaphragm, the most common location for urethral injury. The male urethra is longer and more mobile than the female urethra; therefore, it is more prone to injury.
- In a type I urethral injury, the membranous urethra (above the urogenital diaphragm) is stretched and narrowed.
- In a type II injury, disruption of the membranous urethra occurs near the base of the bladder.
- In a type III injury, the disruption of the membranous urethra extends below the level of the urogenital diaphragm to involve the bulbous urethra.
- Nerve injury occurs as both an immediate and a late complication of pelvic ring fracture. With fractures of the sacrum or sacroiliac (SI) joints, injury to the adjacent sacral plexus or sacral nerve roots may occur. With fractures extending into the region of the greater sciatic notch, injury to the sciatic nerve may occur. Posterior acetabular fractures also are associated with sciatic nerve injury. Nerve dysfunction may persist even after reduction and fixation of the pelvic fracture.
- Pelvic hemorrhage is the most serious immediate complication of a pelvic ring fracture. Disruption of the osseous pelvic ring leads to disruption of pelvic veins and/or arteries in as many as 75% of patients.
- Early complications may occur.
- Blood loss in the preoperative and immediate postoperative period results in morbidity in several ways. Uncontrolled hemorrhage may result in exsanguination. Continued blood loss or inadequate volume repletion may result in shock and its clinical ramifications, such as coagulopathy and renal failure.
- Infection may occur in a number of settings. The pelvic hematoma that accompanies most significant pelvic fractures may transform into an abscess. Open drainage or, if possible, percutaneous drainage is required. Patients undergoing open surgical fixation of a pelvic fracture are at risk for wound infection. Of course, all postsurgical patients are susceptible to a variety of infections, most notably those of the pulmonary system and urinary tract. Fixation devices, either external or internal, may become infected and require removal.
- Thromboembolic disease is frequently encountered in the setting of pelvic fracture. The potential for coagulopathy coupled with inevitable temporary immobility of the patient serves to increase the risk. Deep venous thrombosis (DVT) in the lower extremities is readily visualized by using Doppler ultrasonography (US). However, most clinically significant and potentially deadly thrombi occur in the veins of the pelvis, an area not easily accessible to US. Magnetic resonance venography (MRV) is potentially useful in assessing the pelvic venous system.
- Late complications are possible.
- Pain is the most common long-term complaint of patients with pelvic fractures. Pain most often is associated with abnormalities of the SI joint. Osteoarthrosis, malunion, and nonunion are potential etiologies of the pain.
- Malunion of the fracture most often occurs in the setting of unreduced pelvic fractures. Leg-length discrepancies may result, resulting in gait abnormalities and pain.
- Nonunion of the fracture develops in the setting of vertically unstable pelvic fractures. Treatment for this uncommon complication requires stable fixation of the pelvic disruption and correction of any malpositioning.
Race
Race is not a contributing factor in the incidence or pattern of pelvic ring fractures.
Sex
The incidence of motor vehicle collisions is higher in males, particularly young men, than in females. No difference is noted in the pattern of pelvic ring injuries between males and females. The incidence of urethral injury is higher in males (15%) than in females (6%).
Age
Compared with others, young adults are more likely to be involved in serious motor vehicle collisions. No difference is noted in the pattern of pelvic ring injuries between age groups. Elderly patients are more likely to have isolated pubic rami fractures secondary to osteoporosis.
Anatomy
The osseous pelvis is the bridge between the spine and the lower extremities. The pelvis comprises 3 bones: the sacrum and the 2 innominate bones. The innominate bones are formed by joining 3 ossification centers at the triradiate cartilage of the acetabulum: the ilium, the ischium, and the pubis. The sacrum posteriorly articulates with the 2 innominate bones at the SI joint, with the innominate bones joining anteriorly at the pubic symphysis. The posterior pelvic arch (sacrum, SI joints, and iliac bones) transmits the weight-bearing force from the lower lumbar spine to the acetabula (when a person is standing) or to the ischial tuberosities (when a person is sitting). During weight bearing, the anterior pelvic arch (pubic rami and symphysis) functions as a strut to maintain the shape of the pelvic ring.
Pelvic ligaments as seen on an anterior view of the pelvis. The horizontally oriented anterior sacroiliac and sacrospinous ligaments resist rotation. The vertically oriented sacrotuberous ligaments resist vertical displacement.
Pelvic ligaments as seen on a superior view of the pelvis. The posterior sacroiliac ligaments are the most important structures for pelvic stability.
Pelvic ligaments as seen on a posterior view of the pelvis. The short and long posterior sacroiliac ligaments are the most vital structures for the preservation of pelvic ring stability. Note the iliolumbar ligament attachment to the L5 transverse process. An avulsion fracture at this site may be a sign of posterior ligamentous disruption.
The pelvic ring articulations have no inherent stability; therefore, strong ligamentous structures provide the needed stability. Transversely oriented ligaments resist rotational instability. These include the short posterior SI, the anterior SI, the iliolumbar, and sacrospinous ligaments (see Images 4-5). The ligaments form a tension band and serve to counteract any mechanism (eg, AP compression) that works to open the pelvis by externally rotating the hemipelvis.
Vertically oriented ligaments—that is, the long posterior SI, sacrotuberous, and lateral lumbosacral ligaments—oppose vertical displacement of the pelvis (see Image 6). The strongest of these ligaments, as well as the most important with regard to pelvic stability (especially vertical stability), are the short and long posterior SI ligaments. Interosseous SI ligaments provide an added level of support to the SI joints.
Presentation
The Young-Burgess2,11,12,13 and the Tile9,13 systems are 2 major classification schemes that have been developed for describing pelvic ring fractures. With both systems, injuries are classified on the basis of the direction of the injuring force. The Young-Burgess classification system focuses on the degree of injury (see Table 2).2,11,12 The Tile classification system focuses on pelvic stability (see Table 3).9
Lateral compression injury as seen on an anteroposterior radiograph of the pelvis. Note the characteristic left sacral buckle fracture (long arrow) and the minimally overlapping left pubic rami fractures (short arrow). The sacral fractures may be subtle on radiographs.
Lateral compression injury as seen on a pelvic CT scan. The left sacral buckle (anterior crush) fracture is more readily apparent on the CT scan than on other images.
Windswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The features of each component of the injury are seen to better advantage with CT. Note the internal rotation of the left hemipelvis and external rotation of the right hemipelvis (long arrows). Note also the left sacral buckle fracture (short white arrow) and the right sacroiliac joint diastasis (short black arrow). The left sacroiliac joint also is disrupted.
Anteroposterior compression injury as seen on an anteroposterior radiograph of the pelvis. The symphysis pubis is wider than 2.5 cm (double arrow). The right sacroiliac joint is diastatic (single arrow). This is a type II or type III injury, depending on the status of the posterior sacroiliac ligaments.
Anteroposterior (AP) compression injury as seen on a pelvic CT scan. The location and degree of sacroiliac disruption is better seen on CT scans than on radiographs. The external rotation of the right hemipelvis is a characteristic finding in AP compression. A slight posterior displacement of the right, iliac side of the sacroiliac joint suggests ligamentous disruption (arrow). This represents a type III AP compression injury.
The Young-Burgess system is as follows:
- AP compression injury
- The hallmark of the AP compression injury is pubic diastasis with or without disruption of the SI joints. The location and degree of diastasis is correlated with the magnitude of force imparted to the pelvis and with the amount of resulting instability. The AP compression causes the pelvis to open: one or both hemipelves undergo external rotation. According to the Young-Burgess classification system, 3 degrees of AP compression injury are identified.
- Type I injuries: Less than 2.5 cm of the pubic diastasis is noted, either at the symphysis or through vertically oriented rami fractures. The SI joints and posterior ligaments remain intact, and stability is maintained.
- Type II injuries: The amount of anterior diastasis exceeds 2.5 cm. In addition, diastasis occurs in 1 or both of the SI joints. This incomplete posterior arch disruption results in rotational instability. The posterior ligaments are not injured; therefore, vertical stability is preserved.
- Type III injuries: These injuries extend to the posterior SI ligaments, which are disrupted. Consequently, the pelvis is vertically and rotationally unstable (see Images 7-8).
- External rotation of the hemipelvis results in an increase in the volume of the pelvic cavity. This increased pelvic volume allows more pelvic hemorrhage to occur before the osseous and soft tissue structures cause tamponade. Exsanguination from a pelvic hemorrhage is a primary potential complication. Reduction of the increased pelvic volume is a primary goal in resuscitating a patient with an AP compression injury. Immediate reduction may be achieved by tightly wrapping the pelvis in sheets or a pneumatic antishock garment. The application of an external pelvic fixation device results in more definitive reduction. AP compression injuries are also strongly associated with brain and intra-abdominal injuries.
- The hallmark of the AP compression injury is pubic diastasis with or without disruption of the SI joints. The location and degree of diastasis is correlated with the magnitude of force imparted to the pelvis and with the amount of resulting instability. The AP compression causes the pelvis to open: one or both hemipelves undergo external rotation. According to the Young-Burgess classification system, 3 degrees of AP compression injury are identified.
- Lateral compression injury
- Lateral compression injury results in internal rotation of the affected hemipelvis. This internal rotation decreases rather than increases the pelvic volume. Consequently, pelvic vascular injuries and resulting hemorrhage are less common with this injury than with other injuries. Lateral compression injuries are associated with brain and intra-abdominal injuries.
- The hallmarks of a lateral compression injury include sacral buckle fractures and horizontal pubic rami fractures. The Young-Burgess classification system describes 3 types of injuries.
- Type I injuries: These involve a force directed posteriorly to the lateral aspect of the hemipelvis, which results in an ipsilateral sacral buckle fractures; ipsilateral horizontal pubic rami fractures; or, less commonly, disruption of the pubic symphysis with overlap of the pubic bones (see Images 9-11). The posterior ligaments remain intact; therefore, the pelvis is stable. Lateral forces directed anteriorly to the hemipelvis produce type II and type III injuries.
- Type II injuries: These involve more internal rotation of the hemipelvis. As in type I injuries, ipsilateral sacral buckle fractures and horizontal pubic rami fractures are associated with fracture of the ipsilateral iliac wing or disruption of the ipsilateral posterior SI joint. The pelvis is rotationally unstable, but its vertical stability is maintained.
- Type III injuries: The force continues from the ipsilateral side across the midline to affect the contralateral hemipelvis. The ipsilateral hemipelvis sustains either a type I or type II injury with associated internal rotation. The contralateral pelvis undergoes external rotation. This pattern has been described as a windswept pelvis (see Images 12-13). Contralateral vertical pubic rami fractures or disruption of the sacrotuberous and/or sacrospinous ligaments may occur. As in type II injuries, the pelvis is rotationally unstable but vertically stable.
- Vertical shear injury
- A vertically oriented force applied to a hemipelvis, usually by the femur, results in a vertical shear injury. At the anterior aspect, vertically oriented fractures of the pubic rami occur. Posteriorly, the ipsilateral SI joint (or occasionally the contralateral SI joint) and its associated ligaments are disrupted (see Images 14-18).
- The affected hemipelvis is displaced in a cranial direction. Complete disruption of the posterior ligaments yields a rotationally and vertically unstable pelvis.
- Associated injuries seen in the vertical shear pattern are similar to those encountered in type III AP compression injuries.
- Complex injury
- The forces applied to the pelvis may not conform to the primary vectors described for other types of injuries.
- Complex injuries involve more than 1 pattern of injury. The specific findings of each pattern are still present.
- Pelvic stability may be determined by use of the criteria outlined above.
- Ring-sparing injury
- The Tile classification system includes fractures of the pelvis that do not significantly disrupt the pelvic ring (Tile type A). These injuries include avulsion fractures of the anterior iliac spine, iliac crests, and ischial tuberosities (see Image 19).
- Also included are iliac wing fractures (see Image 20) and sacrococcygeal fractures that do not involve the SI joints. Minimally or nondisplaced pubic rami fractures resulting from a direct blow or straddle injury do not affect pelvic ring stability.
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Table
| Mechanism and Type | Characteristics | Hemipelvis Displacement | Stability |
|---|---|---|---|
| AP compression, type I | Pubic diastasis <2.5 cm | External rotation | Stable |
| AP compression, type II | Pubic diastasis >2.5 cm, anterior SI joint disruption | External rotation | Rotationally unstable, vertically stable |
| AP compression, type III | Type II plus posterior SI joint disruption | External rotation | Rotationally unstable, vertically unstable |
| Lateral compression, type I | Ipsilateral sacral buckle fractures, ipsilateral horizontal pubic rami fractures (or disruption of symphysis with overlapping pubic bones) | Internal rotation | Stable |
| Lateral compression, type II | Type I plus ipsilateral iliac wing fracture or posterior SI joint disruption | Internal rotation | Rotationally unstable, vertically stable |
| Vertical shear | Vertical pubic rami fractures, SI joint disruption +/- adjacent fractures | Vertical (cranial) | Rotationally unstable, vertically unstable |
| Mechanism and Type | Characteristics | Hemipelvis Displacement | Stability |
|---|---|---|---|
| AP compression, type I | Pubic diastasis <2.5 cm | External rotation | Stable |
| AP compression, type II | Pubic diastasis >2.5 cm, anterior SI joint disruption | External rotation | Rotationally unstable, vertically stable |
| AP compression, type III | Type II plus posterior SI joint disruption | External rotation | Rotationally unstable, vertically unstable |
| Lateral compression, type I | Ipsilateral sacral buckle fractures, ipsilateral horizontal pubic rami fractures (or disruption of symphysis with overlapping pubic bones) | Internal rotation | Stable |
| Lateral compression, type II | Type I plus ipsilateral iliac wing fracture or posterior SI joint disruption | Internal rotation | Rotationally unstable, vertically stable |
| Vertical shear | Vertical pubic rami fractures, SI joint disruption +/- adjacent fractures | Vertical (cranial) | Rotationally unstable, vertically unstable |
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Table
| Type | Characteristics | Hemipelvis Displacement | Stability | ||
Type A, posterior arch intact | A1, pelvic ring fracture (avulsion) | A1.1 | Anterior iliac spine avulsion | None | Stable |
A1.2 | Iliac crest avulsion | ||||
A1.3 | Ischial tuberosity avulsion | ||||
A2, pelvic ring fracture (direct blow) | A2.1 | Iliac wing fracture | None | Stable | |
A2.2 | Unilateral pubic rami fracture | ||||
A2.3 | Bilateral pubic rami fracture | ||||
A3, transverse sacral fracture | A3.1 | Sacrococcygeal dislocation | None | Stable | |
A3.2 | Nondisplaced sacral fracture | ||||
A3.3 | Displaced sacral fracture | ||||
Type B, incomplete posterior arch disruption | B1, AP compression | B1.1 | Pubic diastasis, anterior SI joint disruption | External rotation | Rotationally unstable, vertically stable |
B1.2 | Pubic diastasis, sacral fracture | ||||
B2, lateral compression | B2.1 | Anterior sacral buckle fracture | Internal rotation | Rotationally unstable, vertically stable | |
B2.2 | Partial SI joint fracture/subluxation | ||||
B2.3 | Incomplete posterior iliac fracture | ||||
B3.1, AP compression | B3.1 | Bilateral pubic diastasis, bilateral posterior SI joint disruption | External rotation | Rotationally unstable, vertically stable | |
B3.2, AP and lateral compression | B3.2 | Ipsilateral B2 injury, contralateral B1 injury | Ipsilateral internal rotation, contralateral external rotation | Rotationally unstable, vertically stable | |
B3.3, bilateral lateral compression | B3.3 | Bilateral B2 injury | Bilateral internal rotation | Rotationally unstable, vertically stable | |
Type C, complete posterior arch disruption | C1, vertical shear | C1.1 | Displaced iliac fracture | Vertical (cranial) | Rotationally unstable, vertically unstable |
C1.2 | SI joint dislocation or fracture/dislocation | ||||
C1.3 | Displaced sacral fracture | ||||
C2, vertical shear and AP/lateral compression | C2 | Ipsilateral C1 injury, contralateral B1 or B2 injury | Ipsilateral vertical (cranial), contralateral internal | Rotationally unstable, vertically unstable | |
C3, bilateral vertical shear | C3 | Bilateral C1 injury | Bilateral vertical (cranial) | Rotationally unstable, vertically unstable | |
| Type | Characteristics | Hemipelvis Displacement | Stability | ||
Type A, posterior arch intact | A1, pelvic ring fracture (avulsion) | A1.1 | Anterior iliac spine avulsion | None | Stable |
A1.2 | Iliac crest avulsion | ||||
A1.3 | Ischial tuberosity avulsion | ||||
A2, pelvic ring fracture (direct blow) | A2.1 | Iliac wing fracture | None | Stable | |
A2.2 | Unilateral pubic rami fracture | ||||
A2.3 | Bilateral pubic rami fracture | ||||
A3, transverse sacral fracture | A3.1 | Sacrococcygeal dislocation | None | Stable | |
A3.2 | Nondisplaced sacral fracture | ||||
A3.3 | Displaced sacral fracture | ||||
Type B, incomplete posterior arch disruption | B1, AP compression | B1.1 | Pubic diastasis, anterior SI joint disruption | External rotation | Rotationally unstable, vertically stable |
B1.2 | Pubic diastasis, sacral fracture | ||||
B2, lateral compression | B2.1 | Anterior sacral buckle fracture | Internal rotation | Rotationally unstable, vertically stable | |
B2.2 | Partial SI joint fracture/subluxation | ||||
B2.3 | Incomplete posterior iliac fracture | ||||
B3.1, AP compression | B3.1 | Bilateral pubic diastasis, bilateral posterior SI joint disruption | External rotation | Rotationally unstable, vertically stable | |
B3.2, AP and lateral compression | B3.2 | Ipsilateral B2 injury, contralateral B1 injury | Ipsilateral internal rotation, contralateral external rotation | Rotationally unstable, vertically stable | |
B3.3, bilateral lateral compression | B3.3 | Bilateral B2 injury | Bilateral internal rotation | Rotationally unstable, vertically stable | |
Type C, complete posterior arch disruption | C1, vertical shear | C1.1 | Displaced iliac fracture | Vertical (cranial) | Rotationally unstable, vertically unstable |
C1.2 | SI joint dislocation or fracture/dislocation | ||||
C1.3 | Displaced sacral fracture | ||||
C2, vertical shear and AP/lateral compression | C2 | Ipsilateral C1 injury, contralateral B1 or B2 injury | Ipsilateral vertical (cranial), contralateral internal | Rotationally unstable, vertically unstable | |
C3, bilateral vertical shear | C3 | Bilateral C1 injury | Bilateral vertical (cranial) | Rotationally unstable, vertically unstable | |
Preferred Examination
Radiography1,10,12,14,15,16,17
The anteroposterior image of the pelvis is routinely acquired as part of the initial radiographic examination of the pelvis.
Compared with the anteroposterior view, the inlet perspective of the pelvis better demonstrates internal or external rotation and anteroposterior displacement of the hemipelvis.
Cranial displacement of the hemipelvis is demonstrated better on this outlet view of the pelvis than on other images. In addition, the sacral neural foramina are better profiled.
- AP radiography of the pelvis (see Image 21)
- AP radiographs of the pelvis and chest and lateral radiographs of the cervical spine are included in the initial radiographic assessment of a patient with major traumatic injuries.
- Radiographs are obtained with the patient in the supine position, with the x-ray beam passing in an AP direction.
- Abnormalities depicted on the AP pelvis radiograph direct the need for the next set of radiographs, which include oblique (Judet) views of the pelvis in acetabular fractures,18,19 and inlet and outlet radiographs of the pelvis in patients with pelvic ring fractures.
- Inlet and outlet radiography of the pelvis
- Inlet radiographs of the pelvis are obtained with the patient in the supine position, with the x-ray tube positioned at the patient's head and angled 45° toward the feet (see Image 22). The x-ray beam is perpendicular to the pelvic brim (or inlet). This view allows the evaluation of pelvic brim integrity, AP displacement of the hemipelvis, internal/external rotation of the hemipelvis, and sacral impaction.
- Outlet radiographs of the pelvis are obtained with the patient in the supine position, with the x-ray tube positioned at the patient's feet and angled 45° toward the head (see Image 23). The x-ray beam is perpendicular to the sacrum. This view allows confirmation of vertical (cranial) displacement of the hemipelvis and evaluation of the sacral neural foramina.
- Pelvic CT20
- During the initial trauma evaluation, CT images may be obtained of the pelvis in isolation, or CT scans of the pelvis may be obtained at the same time that scans of the abdomen are obtained.
- Axial CT scans may be obtained, but helical CT scans (especially with multidetector CT) yield better 2-dimensional (2D) and 3-dimensional (3D) images.
- CT allows the detection of subtle fractures and displacements not appreciated on radiographs.
Limitations of Techniques
Radiographs of the pelvis may not demonstrate subtle fractures that do not affect classification of the injury. Spatial orientation of fracture fragments and joints is visualized better on pelvic CT scans.
Pelvic CT scans require transport of the patient to the CT scanner; most patients need to undergo abdominal and pelvic CT for an assessment of visceral injury.
Differential Diagnoses
More on Pelvic Ring Fractures |
Overview: Pelvic Ring Fractures |
| Imaging: Pelvic Ring Fractures |
| Follow-up: Pelvic Ring Fractures |
| Multimedia: Pelvic Ring Fractures |
| References |
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Further Reading
Keywords
pelvic ring fracture, pelvis fracture, blunt trauma, bladder rupture, vertical shear injury, anteroposterior compression injury, AP compression injury, lateral compression injury, pelvic hemorrhage, osseous pelvis, Young-Burgess classification, Tile classification, pubic diastasis, sacral buckle fracture, pubic rami fracture, iliac wing fracture




























Overview: Pelvic Ring Fractures