Pelvic Fracture in Emergency Medicine 

Updated: Oct 10, 2017
Author: Nicholas Moore, MD; Chief Editor: Trevor John Mills, MD, MPH 

Overview

Practice Essentials

Pelvic fracture is a disruption of the bony structures of the pelvis, including pelvic ring fractures, acetabular fractures, and avulsion fractures. Generally, pelvic fractures occur due to high-energy trauma; however, elderly patients may suffer pelvic injuries due to lower energy mechanisms.The bony pelvis consists of the ilium, ischium, and pubis, which form an anatomic ring with the sacrum. Disruption of this ring requires significant energy, often leading to multiple fractures. Because of the forces involved, pelvic fractures frequently cause injury to organs contained within the bony pelvis. In addition, trauma to extrapelvic organs is common. Pelvic fractures are often associated with severe hemorrhage due to the extensive blood supply to the region.[1, 2, 3, 4, 5, 6, 7]

Most commonly, pelvic fractures result from motor vehicle crashes, falls, and pedestrians struck by motor vehicles.  There tends to be a bimodal distribution of these injuries with younger males sustaining high-energy pelvic fractures with other associated traumatic injuries, and elderly female suffering low-energy pelvic fractures without associated injuries.[8, 9]

Physical exam should not be used to rule out a pelvic fracture in unconscious patients, but it can nearly definitively rule it in.[10]  The clinical exam is useful in patients who are awake and alert.[11]  Signs that may suggest a pelvic fracture include hematuria; a hematoma over the ipsilateral flank, inguinal ligament, proximal thigh, or in the perineum; neurovascular deficits in the lower extremities; or rectal bleeding. 

​​Anteroposterior pelvic radiography (see image below) is a basic screening test for pelvic fracture and has historically been indicated in all blunt trauma patients according to ATLS protocols. in patients who are hemodynamically stable, it may be reasonable to forego pelvic plain films and rely on CT, as it will likely not change their management or outcome.[12, 13, 14, 15]   

Anterior-posterior (AP) compression pelvic fractur Anterior-posterior (AP) compression pelvic fracture.

CT scanning (see the image below) has largely replaced plain radiographs except for screening, and it has virtually eliminated the use of auxiliary views.

Windswept pelvis (lateral compression injury) as s 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.

The pelvis should be rapidly stabilized with a sheet or commercial pelvic external stabilizer. This is very important prior to neuromuscular blockade because the muscles may be the only thing maintaining pelvic stability. When stabilizing the pelvis, be sure to place the binder around the greater trochanters to provide adequate compression.

The primary treatment of pelvic fracture is administration of  narcotic analgesics for pain.  Avoid nonsteroidal anti-inflammatory drugs until hemorrhage has been excluded. If open pelvic fracture is diagnosed or suspected, empiric antibiotics should be given within 6 hours to prevent osteomyelitis. Initial therapy should target gram-positive organisms with antibiotics such as cefazolin.[16]  If there is concern for associated perforation of the bowel or vagina, broad-spectrum antibiotic coverage against gram-negative and anaerobic pathogens should be considered. Patients with open pelvic fractures should also receive prophylaxis against tetanus. 

For related information, see Medscape's Fracture Resource Center. For excellent patient education resources, see eMedicineHealth's patient education article Total Hip Replacement.

Pathophysiology

Pelvic fractures are most commonly described using one of two classification systems.  The Tile classification system is based on integrity of the posterior sacroiliac complex as well as stability in the rotational and vertical planes. The Young and Burgess Classification System is based on mechanism of injury: lateral compression, anterioposterior compression, vertical shear, or a combination of these forces.

Tile Classification System [17] (Open Table in a new window)

Type A Sacroiliac complex is intact.  Stable fractures of the pelvic ring that can be managed nonoperatively.
Type B Rotationally unstable, vertically stable.  Caused by external or internal rotation forces causing partial disruption of the posterior sacroiliac complex.  
Type C Rotationally and vertically unstable.  Complete disruption of the posterior sacroiliac complex.  

 

Young and Burgess Classification System [18] (Open Table in a new window)

Lateral Compression  
Grade I Sacral compression fracture on side of impact.
Grade II Sacral compression fracture with associated posterior iliac fracture on side of impact.
Grade III Type I or II plus associated contralateral sacroiliac joint injury.
Anterior-Posterior Compression  
Grade I Mild widening of the pubic symphysis with intact posterior pelvic ring ligaments and sacroiliac ligaments.
Grade II Diastasis of pubic symphysis with associated anterior sacroiliac joint widening with intact posterior sacroiliac joint ligaments.
Grade III Diastasis of pubic symphysis with complete disruption of sacroiliac joint and posterior pelvic ring ligaments.
Vertical Shear Displacement of the hemipelvis superiorly or posteriorly involving diastasis of the pubic symphysis, rami fractures, displacement of the sacroiliac joint, and/or fractures of the iliac wing or sacrum.
Combined Mechanism Because of the high-energy nature of these injuries, the mechanisms are often combined and difficult to determine and categorize.

See the images of anterior-posterior compression and vertical-sheer fractures below.

Anterior-posterior (AP) compression pelvic fractur Anterior-posterior (AP) compression pelvic fracture.

 

Vertical shear (VS) fracture pattern. Vertical shear (VS) fracture pattern.

 

A recent comparison of the Tile and Young and Burgess classification systems applied to a group of trauma patients with pelvic ring fractures showed no difference in predictive value for mortality, need for transfusion, or associated injuries.[19]   Intraobserver and interobserver variability among orthopedic surgeons asked to use these systems to classify pelvic fractures may limit their utility.[20]

Acetabular fractures most commonly involve disruption of the acetabular socket when the hip is driven backward in a motor vehicle accident. Occasionally, they occur in a pedestrian struck by a vehicle moving at a significant rate of speed.

Pelvic avulsion fractures (see the image below) occur due to indirect trauma from sudden muscular contraction causing injury to the muscular attachment on the pelvis. These most often occur in skeletally immature athletes because of the inherent weakness of the pelvic apophyses.  The three most common sites are the anterior superior iliac spine (ASIS), the anterior inferior iliac spine (AIIS), and the ischial tuberosity because of contraction of the sartorius, rectus femoris, and hamstring muscles, respectively.[21]

Pelvic apophyseal avulsion fracture of the ischial Pelvic apophyseal avulsion fracture of the ischial tuberosity due to contraction of the hamstring muscles. Courtesy of Wikipedia (https://de.wikipedia.org/wiki/Apophyse).

Epidemiology

Pelvic fractures make up approximately 3% of all skeletal injuries. Open pelvic fractures are rare and represent only 2-4% of all pelvic fractures.[22]  Of all pelvic ring fractures, approximately 55% are stable, whereas 25% have rotational instability, and 20% have rotational and vertical instability.  Approximately 16% of patients have associated acetabular fractures.[23]

A study of a large patient database in the United States found that around 70% of patients sustaining pelvic ring fractures are female.[24] A trauma registry review from New South Wales, Australia, revealed that most patients sustaining high-energy pelvic ring fractures, such as from a motor vehicle crash, were male, whereas females predominated in low-energy injuries.[9]  Males also sustain associated genitourinary injuries more commonly than females.[25]

In the United States, a large patient database review found that the mean age of patients sustaining a pelvic ring fracture is about 65 years. The average age actually increased significantly over the 17-year study period, which may represent an increase in low-energy pelvic fractures. [24]

 

 

 

Prognosis

Mortality/Morbidity

An analysis of a database of more than 63,000 trauma patients showed that pelvic fracture was associated with higher mortality compared to trauma patients without pelvic fractures; however, these studies are difficult to interpret because of confounders.  Because pelvic fractures generally occur via high-energy mechanisms, these patients are more likely to suffer other associated injuries that may contribute to increased mortality.[26]

Cited mortality in patients with any type of pelvic fracture ranges from 4 to 15%. The in-hospital mortality in patients with unstable fractures in the United States is 8.3%. Mortality is 21.3% in the subset of patients with open unstable fractures.[27]

One study of pelvic fractures in children aged 16 years or younger cited a mortality of 5%, with death most commonly due to hemorrhage or multiple injuries.[28]  In hemodynamically unstable patients, pelvic hemorrhage is venous in origin in 80-90% of cases.[29]

Despite aggressive intervention, elderly patients with pelvic fractures have a worse outcome than younger patients with similar injuries.[30, 27]

Ultimately, the patient's Injury Severity Score, not the nature of the pelvic fracture, is the best predictor of mortality. Hemorrhage, either pelvic or extrapelvic, and associated severe head injury are the most common causes of early death, whereas multisystem organ failure and sepsis resulting from soft tissue infection near the fracture site are the main causes of delayed death.[31]

Patients with pelvic fractures combined with acetabular fractures have higher Injury Severity Scores and mortality rates and a greater need for transfusions than patients with either type of fracture alone.[32]

The complication rate associated with pelvic fractures is significant and is related to injury of underlying organs, bleeding, and multiorgan system failure.[33]  Because of the tremendous force necessary to cause most unstable pelvic fractures, concomitant severe injuries are common and are associated with high morbidity and mortality.

Pelvic fractures also increase the incidence of pulmonary emboli.[34]

Lower long-term quality of life based on validated questionnaires has been reported in patients with pelvic fractures following high-energy trauma.[35, 36]

 

 

Presentation

History

Basic mechanism of significant blunt trauma should prompt consideration of a pelvic fracture.  Helpful historical features include inability to ambulate at the scene, bowel or bladder incontinence, and objective numbness or weakness of lower extremities. 

Pelvic apophyseal avulsion fractures generally occur in young athletes, and are commonly associated with sports involving rapid acceleration and deceleration, such as soccer, football, gymnastics, basketball, and baseball.[21]

Physical

In patients who are awake and alert, the presence of pelvic pain or tenderness to palpation has high sensitivity and specificity for the diagnosis of pelvic fracture: 74% and 97%, respectively. However, in patients who are not awake and alert to express pain and tenderness, physical exam is less useful.  Palpation of a pelvic deformity has a sensitivity of 30% for pelvic fractures and 55% for unstable pelvic fractures.  Palpating an unstable pelvic ring has a sensitivity of only 8%, but specificity of 99%. Thus, physical exam should not be used to rule out a pelvic fracture in unconscious patients, but it can nearly definitively rule it in.[10]  The clinical exam is useful in patients who are awake and alert, even with elevated ethanol levels, as long as their GCS is 14 or higher.[11]  Finally, extensive manipulation of a fractured pelvis can increase the patient's discomfort and potentially increase bleeding.

Other signs that may suggest a pelvic fracture include hematuria; a hematoma over the ipsilateral flank, inguinal ligament, proximal thigh, or in the perineum; neurovascular deficits in the lower extremities; or rectal bleeding. Digital rectal examination has a very low sensitivity for diagnosing pelvic fractures. In fact, in one study assessing the utility of routine digital rectal examinations to diagnose injury in 1401 trauma patients, the rectal examination missed 100% of the 67 pelvic fractures.[37]

Vaginal bleeding or palpable fracture line on careful bimanual examination suggests pelvic fracture in females.

Instability on hip adduction and pain on hip motion suggests an acetabular fracture, with or without an associated hip fracture.

The overall incidence of genitourinary injury associated with pelvic fracture is around 4.6% and is overall more common in men. Men with pelvic fractures are 10 times more likely to sustain urethral injuries.[25] Signs of urethral injury in males may include a scrotal hematoma and blood at the urethral meatus.  Assessment for a high-riding or boggy prostate on digital rectal examination has been shown to be unreliable.[38]

Pelvic apophyseal avulsion fractures generally present with acute onset of localized pain that is exacerbated by passive or active stretching of the involved muscle.  Patients will attempt to assume a position that incurs the least tension on the affected muscle.[21]

 

Causes

Adults with significant pelvic fracture:

  • Motor vehicle crash (50-60%)
  • Motorcycle crash (10-20%)
  • Pedestrian versus car (10-20%)
  • Falls (8-10%)
  • Crush (3-6%)

Children:

  • Pedestrian versus car (60-80%)
  • Motor vehicle crash (20-30%)

Complications

Complications of pelvic fracture include the following:

  • The incidence of deep venous thrombosis is increased.

  • Continued bleeding from fracture or injury to pelvic vasculature may occur.

  • GU problems from bladder, urethral, prostate, or vaginal injuries: The incidence of urethral injuries varies by the type of pelvic fracture. Sexual dysfunction may develop.

  • Infections from disruption of bowel or urinary system may develop.

  • Chronic pelvic pain, more so if the sacroiliac joints are involved, may occur.[39]  

 

DDx

 

Workup

Laboratory Studies

Lab studies include the following:

  • Serial hemoglobin and hematocrit measurements to monitor ongoing blood loss.
  • Blood type and screen in setting of hemodynamic instability to prepare for possible transfusion.

  • Urinalysis may reveal gross or microscopic hematuria.

  • Pregnancy test is indicated in females of childbearing age to detect pregnancy as well as potential bleeding sources (eg, miscarriage, abruptio placentae).

Imaging Studies

Radiography

​​Anteroposterior pelvic radiography is a basic screening test for pelvic fracture and has historically been indicated in all blunt trauma patients according to ATLS protocols. Plain pelvic radiographs should be performed in all hemodynamically unstable blunt trauma patients to uncover significant fractures and to allow early notification of interventional radiology and other consulting services. Studies of pelvic plain films in trauma patients have found them to be only 64-78% sensitive for identification of pelvic fractures. Therefore, in patients who are hemodynamically stable, it may be reasonable to forego pelvic plain films and rely on CT, as it will likely not change their management or outcome.[12, 13, 14]   

Anterior-posterior (AP) compression pelvic fractur Anterior-posterior (AP) compression pelvic fracture.

Computed tomography

CT scan is the best imaging study for evaluation of pelvic anatomy and degree of pelvic, retroperitoneal, and intraperitoneal bleeding (see the image below). CT scan also confirms hip dislocation associated with an acetabular fracture. CT scanning has largely replaced plain radiographs except for screening, and it has virtually eliminated the use of auxiliary views.[40, 41, 42]

Windswept pelvis (lateral compression injury) as s 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.

MRI

MRI may provide more definitive identification of pelvic fractures when compared to plain radiographs, thereby prompting patients to more timely and appropriate therapy. In one retrospective study, a large number of false positives and false negatives were noted when comparing plain films to MRI.[43]

Ultrasonography

As part of the Focused Assessment with Sonography for Trauma (FAST) examination, the pelvis should be visualized for intrapelvic bleeding/fluid.

In addition, the FAST examination may identify intraperitoneal bleeding to explain shock. However, some studies suggest that ultrasonography has a lower sensitivity for identifying hemoperitoneum in patients with pelvic fractures than previously reported.[44]   Therefore, keep in mind that although the positive predictive value of noting hemoperitoneum as part of a FAST examination is good, therapeutic decisions using FAST as a screening examination may be limited.

Urethrography

Retrograde urethrography is necessary for males with blood at the urethral meatus and for females in whom a Foley catheter cannot easily pass on gentle attempts.

This study should also be used in females with a vaginal tear or palpable fracture fragments adjacent to the urethra.

Arteriography

Consider this study in hemodynamically unstable patients when CT scanning or other appropriate diagnostic studies exclude significant intraperitoneal bleeding and after the external pelvis is stabilized.

Arteriography allows for determination of the bleeding site. In addition, embolization may be very effective for hemorrhage control.

Cystography

Consider this study in any patient with hematuria and an intact urethra.

Procedures

Use a suprapubic catheter for patients in whom urethral injuries are suspected but a urethrogram cannot be obtained.

Early application of an external pelvic fixator may be necessary to control hemorrhage.  

 

Treatment

Prehospital Care

Address acute life-threatening conditions. Be very aware that the amount of force necessary to cause a significant pelvic fracture is likely to have caused other significant injuries.

Application of an external compression device to a grossly unstable pelvis will provide mechanical stabilization while controlling hemorrhage from the fracture site. A sheet or one of a variety of inexpensive, commercial products may be used.[45]  

Avoid excessive movement of the pelvis.

Obtain large-bore intravenous (IV) access, and administer analgesia and fluids in accordance with local protocols.

Closely monitor vital signs.

Emergency Department Care

Treatment involves an algorithmic, multidisciplinary approach.

Investigate associated intra-abdominal and intrapelvic injuries. A FAST examination should be performed as soon as possible, as well as a chest radiograph to look for other injuries or bleeding sources, especially in the unstable patient.

Avoid excessive movement of the pelvis.

If not done by prehospital providers, the pelvis should be rapidly stabilized with a sheet or commercial pelvic external stabilizer. This is very important prior to neuromuscular blockade because the muscles may be the only thing maintaining pelvic stability. When stabilizing the pelvis, be sure to place the binder around the greater trochanters to provide adequate compression.

In some patients, such as those with truncal obesity, internal rotation of the lower extremities and taping together the knees may be more effective than a compression binder.[46]  

In the case of unstable pelvic fractures, early application of an external fixation device by the appropriate surgical consultant should be considered.

Administer fluid replacement and analgesics as needed.

Do not place a urinary catheter until urethral injury has been ruled out or determined to be unlikely by physical examination or retrograde urethrography.

Pelvic apophyseal avulsion fractures are generally managed conservatively with rest and ice, followed by incremental protected weight-bearing with crutches until symptoms improve.  Afterwards, progression to light stretching and full weight-bearing can proceed as tolerated with eventual return to full sports participation once full strength is regained.  Surgical intervention is rarely warranted, but may be necessary for large bony fragments with more than 2 cm of displacement.[21]

Elderly patients with isolated pubic rami fractures due to pelvic insufficiency can be safely discharged if they can be cared for at home or in another facility. They will require adequate pain management to allow them to ambulate, or they should have sufficient help. If they are nonambulatory, DVT prophylaxis should be considered.[47]

Consultations

Consult an orthopedic surgeon when a pelvic fracture is diagnosed. Hemodynamically unstable patients with unstable pelvic fractures require emergent orthopedic consultation for possible external fixation. Pelvic or retroperitoneal packing may be required for hemorrhage control.[48] .  Intra-aortic or intrailiac balloon occlusion may also have a role to control massive bleeding.[49, 50]  

Transcatheter embolization for hemorrhage control is being used with increasing frequency in patients with pelvic fractures.  If this is a consideration, an interventional radiologist should be consulted early in the patient's evaluation.[51, 52]

Consult a urologist for any suspected urethral injury.

Medical Care

Monitor patients with pelvic fracture for signs of ongoing blood loss and signs of infection. In addition, patients should be closely observed for development of neurovascular problems in the lower extremities. For example, injury to the sacral nerves, lower lumbar nerves, and sympathetic chain may occur.

Consider deep venous thrombosis (DVT) prophylaxis in all patients, especially those with traumatic injuries.

Pain management is very important to facilitate early mobilization, thereby reducing the risk of thromboembolic disease.

Management of urethral injuries should be directed by a urologic consultation. If a urinary catheter is required prior to the urologist's arrival, a suprapubic catheter should be placed.

Transfer all patients except those with minor pelvic fractures to a trauma center.  Trauma center care is associated with decreased mortality in patients with unstable pelvic fractures or complicated acetabular fractures.[53]

Application of a pelvic circumferential compression device prior to transfer has been shown to decrease the amount of tranfusions required and length of ICU stay at the receiving hospital and is therefore recommended.[54, 55]

If possible, hemorrhage should be controlled and the pelvis stabilized prior to transfer.

 

Guidelines

Guidelines Summary

Recommendations for diagnosis of pelvic trauma by the World Society of Emergency Surgery includes the following[15] :

  • The time between arrival in the emergency department and definitive bleeding control should be minimized to improve outcomes of patients with hemodynamically unstable pelvic fractures.

  • Serum lactate and base deficit represent sensitive diagnostic markers to estimate the extent of traumatic-hemorrhagic shock and to monitor response to resuscitation.

  • The use of pelvic x-ray and FAST in the emergency department is recommended in hemodynamic and mechanic unstable patients with pelvic trauma and allows to identify the injuries that require an early pelvic stabilization, an early angiography, and a rapid reductive maneuver, as well as laparotomy.

  • Patients with pelvic trauma associated with hemodynamic normality or stability should undergo further diagnostic workup with multiphasic CT scan with intravenous contrast to exclude pelvic hemorrhage.

  • CT scan with 3-dimensional bone reconstructions reduces the tissue damage during invasive procedures, the risk of neurologic disorders after surgical fixation, operative time, and irradiation and the required expertise.

  • Retrograde urethrogram or/and urethrocystogram with contrast CT scan is recommended in the presence of local perineal clinical hematoma and pelvic disruption at pelvic x-ray.

  • Perineal and a rectal digital examination are mandatory in case of high suspicion of rectal injuries.

  • In cases of a positive rectal examination, proctoscopy is recommended.

 

Medication

Medication Summary

The primary treatment of pelvic fracture is for pain with narcotic analgesics.  Avoid nonsteroidal anti-inflammatory drugs until hemorrhage has been excluded, as it is the most common cause of mortality in pelvic fractures.

If open pelvic fracture is diagnosed or suspected, empiric antibiotics should be given within 6 hours to prevent osteomyelitis. Initial therapy should target gram-positive organisms with antibiotics such as cefazolin.[16]

If there is concern for associated perforation of bowel or vagina, broad-spectrum antibiotic coverage against gram-negative and anaerobic pathogens should be considered.

Patients with open pelvic fractures should also receive prophylaxis against tetanus. 

Analgesics

Class Summary

Narcotic analgesics are the treatment of choice in the acute setting. Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures. Adequate pain control helps keep the patient quiet and avoids movement of the pelvis.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone. Administered IV, may be dosed in a number of ways and commonly is titrated until desired effect obtained. Titrated doses especially useful in trauma patients to avoid oversedation or hypotension. Caution in hypotensive patients as may worsen hypotension because of histamine release. Consider fentanyl in this setting.

Fentanyl (Sublimaze, Duragesic)

Excellent drug for analgesia in patients with hypotension or whose cardiovascular condition is unstable. Does not release histamine. Short-acting acutely, duration becomes longer with repetitive dosing.

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or those at high risk of bleeding, with upper GI disease, or taking oral anticoagulants. DOC for pain relief in noninflammatory conditions.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet, Tylox, Roxicet, Roxilox)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Oxycodone and aspirin (Percodan, Roxiprin)

Drug combination indicated for relief of moderately severe to severe pain. Avoid in early treatment because of platelet inhibition from aspirin and increased risk of bleeding. See discussion under NSAIDs above.