Pelvic Fractures

Major pelvic fractures result from very high energy trauma and require urgent hospital treatment. However more minor, stable fractures may only require a period of rest and analgesia followed by gradual mobilisation.

2/100,000 population per annum. Approximately 1-3% of all skeletal injuries and 60% occur in men.¹
• In elderly persons, the most common cause is a fall from a standing position. Isolated pubic ramus fractures are common and often missed in the elderly.
• However, the most significant fractures involve significant forces such as a car crash or fall from a significant height.²

• Any history of significant blunt trauma should raise the consideration of a pelvic fracture.
• Tenderness, bruising, swelling and crepitus of pubis, iliac bones, hips and sacrum.
• Attempts to 'spring the pelvis' to assess stability should be avoided as this is unreliable and may cause additional haemorrhage or injury.
• A thorough assessment for associated wounds and other injuries is essential.
• Rectal examination: for anal tone, palpable fractures and to detect bleeding, rectal tears and urethral damage (high riding, boggy prostate).
• Instability on hip adduction and pain on hip motion suggests an additional fracture of the acetabulum.
• Signs of urethral injury in males include a high-riding or boggy prostate on rectal exam, scrotal haematoma, or blood at the urethral meatus.
• A pelvic fracture in females is suggested by vaginal bleeding or a palpable fracture line on bimanual examination.
• Other signs of pelvic fracture include:
  • Haematuria
  • Rectal bleeding
  • Large hematoma or palpable fracture line felt on rectal examination
  • Haematoma above the inguinal ligament, or over the proximal thigh or perineum
  • Retroperitoneal bleeding leads to loin bruising
  • Neurological and vascular abnormalities in either or both legs

• Type A:
  • Stable injuries: include avulsion fractures, isolated pubic ramus fractures, iliac wing fractures or single stable fractures elsewhere in pelvic ring.
  • Avulsion fractures occur at the point of attachment of muscles:
  • Anterior inferior iliac spine: rectus femoris; often resulting from a mis-kick into the ground.
  • Anterior superior iliac spine: sartorius.
  • Ischial tuberosity: hamstrings.
• Type B:
  • Rotationally unstable but vertically stable.
  • B1: 'open book' antero-posterior compression fractures, causing separation of the pubic symphysis and widening of one or both sacroiliac joints.
  • B2: ipsilateral compression causing the pubic bones to fracture and override.
  • B3: contralateral compression injury resulting in pubic rami fractures on one side and compression sacroiliac injury on the other side.
• Type C:
  • Rotationally and vertically unstable.
  • The pelvic ring is completely disrupted or displaced at 2 or more points.
  • Associated with massive blood loss and a very high mortality.
  • Subdivided into:
    • C1: unilateral
    • C2: bilateral
    • C3: involving acetabular fracture

• Urinalysis: may show gross or microscopic haematuria.
• Pregnancy test is indicated in females of childbearing age if any uncertainty whether pregnant.
• Serial haemoglobin and haematocrit measurements to monitor ongoing blood loss; group and cross-match.
• X-rays:
  • Anteroposterior pelvic x-ray diagnoses the vast majority of pelvic injuries.
  • Destruction of normal pelvis contours (Shenton's lines), asymmetry and widening of the pubic symphysis or sacroiliac joints.
• CT Scan:
  • To determine whether any other injury is present.
  • For evaluation of pelvic anatomy and degree of pelvic, retroperitoneal, and intraperitoneal bleeding.
  • Also confirms possible acetabular fracture and hip dislocation.
• Ultrasound:
  • To detect intrapelvic bleeding or fluid.
• Urethrography:
  • Retrograde urethrography is necessary for males with a displaced or boggy prostate or blood at the urethral meatus and for females in whom a urethral catheter cannot easily pass.
  • For females with a vaginal tear or palpable fracture fragments adjacent to the urethra.
• Arteriography:
  • If patient haemodynamically unstable and ultrasound, CT scan or peritoneal tap excludes significant intraperitoneal bleeding.
  • Allows for determination of the bleeding site and potentially embolisation as a means of control.
• Cystography:
  • If haematuria and an intact urethra.

Stable type A injuries

• Refer to orthopaedics for analgesia, initial bed rest and then mobilisation (usually after 3 to 6 weeks).
• Avulsion fractures: usually only require rest and pain relief.
• Larger avulsions, especially of the ischial tuberosity, may require internal fixation to avoid complications such as non-union.

Unstable type B and C fractures

• An orthopaedic emergency: resuscitate as for any major injury.
• Assess for and treat hypovolaemia, anticipate coagulopathy and ensure blood is rapidly available as a massive transfusion may be required.
• Avoid rolling the patient and instead perform a straight lift with a number of helpers.
• Minimise movement and support an obviously unstable pelvis fracture associated with severe haemorrhage using e.g. using a MAST suit.
• Reduction and immobilisation using an external fixator may be required to stop the bleeding; angiography and selective embolisation may also be required.
• Do not catheterise if urethral injury is suspected.
• Diagnostic peritoneal lavage may be required and should be performed by a supra-umbilical approach as a pelvic haematoma may track up the abdominal wall.

Malunion or non-union, leg-length discrepancy, low back pain. Can be disabling in up to half of patients.
• Nerve injury occurs in approximately 10% of cases and is easily missed (e.g. avulsion of lumbar nerve roots or injury to superior gluteal, obturator, sciatic or pudendal nerves).³
• Increased incidence of thrombophlebitis.
• Intrapelvic compartment syndrome.
• Continued bleeding from fracture or injury to pelvic blood vessels.
• Associated bladder, urethral prostate or vaginal damage is common.
• Associated thoracic and abdominal injuries occur in 10-20%; massive internal haemorrhage may occur.
• Sexual dysfunction may be a long-term problem.⁴

• Prognosis varies depending on severity of fracture and associated injuries.
• Severe compound fractures of the pelvis lead to a mortality rate of over 50%.

• Car safety - seat belts, air bags.
• Any safety procedure to reduce risk of falls from high levels.
• The use of bisphosphonates where appropriate.