INJURIES OF THE PELVIS

Anatomy
The pelvic ring is made up of the two innominate bones and the sacrum, articulating in
front at the symphysis pubis (the anterior or pubic bridge) and posteriorly at the sacroiliac
joints (the posterior or sacroiliac bridge). This basin-like structure transmits weight from
the trunk to the lower limbs and provides protection for the pelvic viscera, vessels and
nerves.
 Anatomy

The innominate bone is formed at maturity by the fusion of 3 ossification centers: the
ilium, the ischium, and the pubis through the triradiate cartilage at the dome of the
acetabulum.
 Anatomy
Pelvic Ligaments
Pelvic stability is conferred by ligamentous structures.
These may be divided into groups according to the ligamentous attachments:

•Sacrum to ilium: The strongest and most important

•Sacroiliac ligamentous complex: posterior (short and long) and anterior
•Sacrotuberous ligament
•Sacrospinous ligament
•Pubis to pubis: The symphysis pubis.
 Anatomy

Pelvic Ligaments

The transversely placed ligaments

Resist rotational forces.
Include the short posterior sacroiliac, anterior sacroiliac, iliolumbar, and sacrospinous
ligaments.

The vertically placed ligaments

Resist vertical shear.
Include the long posterior sacroiliac, sacrotuberous, and lateral lumbosacral ligaments.
 Definition of pelvic stability
The ability of the pelvis to withstand physiological forces without significant displacement.

An unstable injury may be characterized by the type of displacement as:

Rotationally unstable (open and externally rotated, or compressed and internally rotated).
Vertically unstable

Rotationally unstable Vertically unstable

 Vascular structures

•The iliac arterial and venous trunks

pass near the ventral aspect of the
sacro-iliac (SI) joints bilaterally.

•Disruption of the SI joints and

associated ligaments increases the
risk of vascular injury and resultant
hemorrhage, which usually arises
from the anterior and posterior
divisions of the internal iliac vessels.
 Mechanisms of injury
Anterior - posterior compression. This injury is usually caused by a frontal collision
between a pedestrian and a car. The pubic rami are fractured or the innominate bones are
sprung apart and externally rotated, with disruption of the symphysis – the so-called ‘open
book’ injury. The anterior sacroiliac ligaments are strained and may be torn, or there may
be a fracture of the posterior part of the ilium.
 Mechanisms of injury
Lateral compression. Side-to-side compression of the pelvis causes the ring to buckle and
break. This is usually due to a side-on impact in a road accident or a fall from a height.
Anteriorly the pubic rami on one or both sides are fractured, and posteriorly there is a
severe sacroiliac strain or a fracture of the sacrum or ilium, either on the same side as the
fractured pubic rami or on the opposite side of the pelvis. If the sacroiliac injury is much
displaced, the pelvis is unstable.
 Mechanisms of injury

Vertical shear. The innominate bone on one side is displaced vertically, fracturing the pubic
rami and disrupting the sacroiliac region on the same side. This occurs typically when
someone falls from a height onto one leg. These are usually severe, unstable injuries with
gross tearing of the soft tissues and retroperitoneal haemorrhage.
 Classification
The modified Tile AO Müller classification, like the original, divides pelvic fractures into three basic types according to stability based
on the integrity of the posterior sacroiliac complex. It takes into consideration the direction of the force involved. In type A, the fracture does not
involve the posterior arch. Type B fracture is a result of rotational forces that cause partial disruption of the posterior sacroiliac complex. Complete
disruption of the posterior complex (including the sacrospinous and sacrotuberous ligaments) occurs in type C fractures, that are both rotationally and
vertically unstable. Each basic type has three subtypes.
 Classification
Stable Ring (Type A)

A1: Fractures of the pelvis not involving the

ring; avulsion injuries

A2: Non-displaced or minimally displaced

pelvic ring fracture (eg, superior & inferior
pubic ramus fracture)

A3: Transverse fractures of the inferior sacrum

or coccyx with no disruption of the pelvic ring
 Classification
Rotationally unstable,
vertically stable (Type B)

B1: External rotation instability; open-

book injury

B2: Injury affecting only one side of the

pelvis, ipsilateral anterior and posterior
ring involvement with instability in
internal rotation

B3: Injury affecting both sides of the

pelvis; bilateral rotational instability
 Classification
Rotationally and vertically
unstable (Type C)

C1: Ipsilateral anterior and posterior injury

resulting in rotational and vertical instability of
the hemipelvis

C2: Bilateral injury resulting in rotational

instability on one side and vertical instability
on the other side

C3: Bilateral pelvic injury in which both sides

are rotationally and vertically unstable with an
associated acetabular fracture
 Diagnostics

•Severe pain, swelling.

•Forced position of the patient.

In fractures of the anterior part of the pelvis, there is often a flexion of the legs in the hip and knee
joints with dilating them. The patient, as it were, puts himself into the physiological position of the
"frog", relaxing the muscles that attach to the pelvic bones.

•With fractures of the anterior half-ring of the pelvis, it is determined that there is no possibility to
raise the leg (active) on the side of the fracture from the horizontal plane.

•Detection of abrasions, bruises and hematomas.

 Diagnostics

•Anterior-Posterior, Lateral Compression

test’s for pelvic instability should be
performed once only and involves rotating
the pelvis internally and externally.
This test can document pelvic instability
when AP and Lateral compression on the
iliac wings produces pain or rotational
instability.

•Pelvic instability may result in a leg-length

discrepancy involving shortening on the
involved side or a markedly externally
rotated lower extremity.
External rotation and shortening of one of
the lower extremities is a sign of “open-
book” or vertical shear (VS) injury.
 Diagnostics

•Tender abdomen due to bleeding or intrapelvic structure injuries.

•Inspect the patient for bleeding from the urethral meatus, vagina, or rectum.

•Neurological examination should be done to exclude sacral and lumber plexus injury.

•Symptoms and signs of bleeding and hemorrhagic shock.

 Neurologic Injury
•An accurate neurologic examination is often difficult to obtain secondary to the patient’s
inability to cooperate with the examination.
•Because the sciatic nerve and the branches of the sacral plexus are subject to injury with
pelvic fracture, it is important to document neurologic function if possible.
•Recording the presence of rectal tone and the bulbocavernosus reflex is important.
•Distal motor and sensory function at the foot and ankle should be assessed where
possible.
 Diagnostics

Catheterization of the bladder immediately upon admission to the clinic is an indispensable

rule.
When detecting macrohematuria in a patient with a pelvic fracture, the next step is
contrast cystography.

Intact Damaged
 Diagnostics

X-RAY

1. Anteroposterior view.
2. Pelvic inlet view in which the tube is cephalad to the
pelvis and tilted 45° downwards.
3. Pelvic outlet view in which the tube is caudad to the
pelvis and tilted 45° upwards.
4. Right oblique view.
5. Left oblique view.
 X-RAY
Antero-posterior view. Pelvic inlet view. Pelvic outlet view.

•AP translation of hemi pelvis. •Vertical shift of hemi pelvis.

•External/ Internal rotation of •Sacral fractures relative to
hemi pelvis. foramina.
•Opening of SI joint. •Flexion or Extension deformity of
•Impaction of sacral ala. pelvic ring
 CT Scan

CT scan gives accurate details and much information about the injury.
CT scanning is imperative in any suspected pelvic injury or in suspected sacral fractures.
 Haemodynamic Status
Treatment should not await full and detailed diagnosis. Doctor should move according to
the priority of life saving measures with the already available information.
Attention must be paid to signs of hypovolaemic shock.
Adequate access to the venous system for transfusion and fluid replacement must be
achieved in the first minutes of management.
 The primary assessment must focus on possible sources of bleeding, such as external
blood loss and internal bleeding in the thorax, abdomen or retroperitoneal space, including
disruption of the pelvic ring and multiple long-bone fractures, especially of the femoral shaft.
Retroperitoneal hemorrhage may be associated with massive intravascular volume loss.

Causes of retroperitoneal hemorrhage secondary to pelvic fracture

Disruption of the venous plexus in the posterior pelvis.
Large-vessel injury (external or internal iliac disruption)
Large-vessel injury causes rapid, massive hemorrhage with frequent loss of the distal pulse
and marked hemodynamic instability.
This often necessitates immediate surgical exploration to gain proximal control of the vessel
before repair.
 Haemodynamic Status

•Pelvic fracture hemorrhage results most frequently from the venous structures and
bleeding bone edges.

•This hemorrhage stops in most patients secondary to tamponade from increasing tissue
pressure in the pelvic retroperitoneal space.

•However, in patients who died of pelvic fracture hemorrhage, single or multiple arterial
lacerations were more likely to be present.

•Arterial bleeding can overcome the tamponade effect of the retroperitoneal tissues,
leading to shock; this is the most common cause of death related to the pelvic fracture
itself.

•Arterial bleeding usually arises from branches of the internal iliac system with the superior
gluteal and pudendal arteries being the most commonly identified
 Haemodynamic Status
Resuscitation
Hemorrhage in pelvic trauma may be life-threatening.

The site of bleeding is determined by peritoneal lavage, portable ultrasound, or CT.

In the resuscitative phase, control of hemorrhage must be rapid and may be lifesaving.

After exclusion or control of the intra-abdominal bleeding, it must be determined

whether the pelvic bleeding is located in the anterior or the posterior part of the ring,
whether it is mainly from the fracture site and whether it is venous or arterial.

Patients with an unstable pelvic disruption are at much greater general risk than those
with a stable pelvis.

Pelvic stabilization should be performed early, in the resuscitative phase of management.

 Haemodynamic Status
Options for immediate hemorrhage control

Pelvic binder Pelvic bandage Pelvic wrapped sheet

 Haemodynamic Status
Options for immediate hemorrhage control
Pelvic C-clamp
The pelvic C-clamp acts like a simple carpenter’s clamp and can exert transverse
compression directly across the sacroiliac joint.
The C-clamp is generally applied in the emergency department, if possible with the aid of
an image intensifier.
The typical site for pin placement is at the point of intersection of a line from the posterior
to the anterior superior iliac spine, with the extension of the longitudinal axis of the dorsal
border of femur.
C-clamp application can not only be difficult but dangerous in cases of comminuted sacral
fractures: neurovascular injury can occur due to crushing of the sacrum.
 Haemodynamic Status
Options for immediate hemorrhage control

External fixation
In the acute phase many advocate external fixation as a temporary device to achieve
stabilization of the fracture and a positive effect on haemorrhage.
 Haemodynamic Status
Options for immediate hemorrhage control

Consider angiography and embolization if hemorrhage continues despite closing of the

pelvic volume.
Treatment options—nonoperative/operative

Type A Operation rarely needed

Type B Anterior stabilization

Type C Stabilization of entire ring

 Fractures of the acetabulum
occur when the head of the femur is driven into the pelvis. This is caused either by a blow
on the side (as in a fall from a height) or by a blow on the front of the knee, usually in a
dashboard injury when the femur also may be fractured.
Acetabular fractures combine the complexities of pelvic fractures (notably the
frequency of associated soft-tissue injury) with those of joint disruption (namely, articular
cartilage damage, noncongruent loading and secondary osteoarthritis).
 Fractures of the acetabulum

Indications for conservative treatment

As a general rule, acetabular fractures are articular fractures, so they have to be treated
under the principles of anatomical reduction, stable internal fixation, and early
mobilization.

However, there are limited indications for conservative treatment:

•Medical contraindications
•Pre-existing osteoarthritis
•Local infections
•Osteopenia of the innominate bone
•Special fractures characteristics
Undisplaced fractures
Very low transverse or anterior column fractures
Both column fractures that achieve secondary congruence.
 Conservative treatment
After 6 weeks the iliac bone is completely healed. During the period after fracturing, patients are allowed to mobilize with crutches or a
walker, as soon as pain is released. Usually that happens after a few days of bed rest. Anticoagulation therapy is established during this
period. Once the fracture is healed, no further assistance is necessary.

Skeletal traction
If for any reason the residual amount of displacement is less than indicated for surgical procedure, or there is any contraindication to it,
the patient could be put under supracondylar skeletal traction. Usually the tractional weight is 1/7 of the body weight.
Skeletal traction has to be sustained for 6-8 weeks in acetabular and in bony pelvic injuries.

Functional therapy
Passive assisted and active range of motion are encouraged from the very beginning.
 Surgical treatment

The purpose of the operation for acetabular fractures (as with any other intraarticular
fractures) is to achieve an anatomical reposition and stable fixation without additional
immobilization with a plaster dressing or skeletal traction.

1. Solomon L, Warwick DJ, Nayagam S. Apley’s System of Orthopaedics and Fractures. CRC Press; 2010.
2. https://www.aofoundation.org