An overview of

Pelvic Trauma
Presented by:

Dr. Muhammad Daniyal Haider

Resident Surgical Unit II
 Introduction
Pelvic trauma is a serious medical condition that can have devastating
consequences. It is caused by a variety of factors, including blunt force
trauma and penetrating injuries. The pelvis is an important part of the body
that protects vital organs such as the bladder, rectum, and uterus. When the
pelvis is damaged, these organs can also be affected, leading to further
complications.

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 Epidemiology
• Pelvic trauma is a significant health concern, with an estimated incidence of 10-15% of all trauma
cases.

• Studies have shown that pelvic fractures are the third most common type of fracture in trauma patients.

• The prevalence of pelvic trauma is higher in males than in females, with a male-to-female ratio of
approximately 3:1.

• The most common age group affected by pelvic trauma is young adults between the ages of 20 and 40
years old. Motor vehicle accidents are the most common cause of pelvic trauma, accounting for
approximately 50% of cases.

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 Bony Anatomy of Pelvis
• Ring structure of pelvis consists of four bones as ilium, ischium, pubis and
sacrum.

• Anteriorly, ischium and pubic rami connect at pubic symphysis

• Posteriorly, sacrum is attached with ilium and ischium through sacroilial

ligament, sacrospinous ligament, sacrotuberous ligament and iliolumbar
ligament.

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 Bony Anatomy of Pelvis
• Ring structure of pelvis consists of four bones as ilium, ischium, pubis and
sacrum.

• Anteriorly, ischium and pubic rami connect at pubic symphysis

• Posteriorly, sacrum is attached with ilium and ischium through sacroilial

ligament, sacrospinous ligament, sacrotuberous ligament and iliolumbar
ligament.

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 Bony Anatomy of Pelvis
• Ring structure of pelvis consists of four bones as ilium, ischium, pubis and
sacrum.

• Anteriorly, ischium and pubic rami connect at pubic symphysis

• Posteriorly, sacrum is attached with ilium and ischium through sacroilial

ligament, sacrospinous ligament, sacrotuberous ligament and iliolumbar
ligament.

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 Visceral Anatomy of Pelvis
Following are the important structures which are found in pelvis and are
usually damaged in pelvic trauma:

• Visceral organs: Ureter, urinary bladder, urethra, prostate gland, large

intestine (sigmoid), uterus and vagina

• Vessels: Superior gluteal artery, internal pudendal artery, and pelvic veins

• Nerves: Lumbosacral plexus, sciatic nerve, and cauda equina

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 Visceral Anatomy of Pelvis
Following are the important structures which are found in pelvis and are
usually damaged in pelvic trauma:

• Visceral organs: Ureter, urinary bladder, urethra, prostate gland, large

intestine (sigmoid), uterus and vagina

• Vessels: Superior gluteal artery, internal pudendal artery, and pelvic veins

• Nerves: Lumbosacral plexus, sciatic nerve, and cauda equina

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 Visceral Anatomy of Pelvis
Following are the important structures which are found in pelvis and are
usually damaged in pelvic trauma:

• Visceral organs: Ureter, urinary bladder, urethra, prostate gland, large

intestine (sigmoid), uterus and vagina

• Vessels: Superior gluteal artery, internal pudendal artery, and pelvic veins

• Nerves: Lumbosacral plexus, sciatic nerve, and cauda equina

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 Etiology
• Pelvic trauma can be caused by a variety of mechanisms, including motor
vehicle accidents (60-80%), falls from heights (5-12%), and gunshot
wounds.

• Blunt trauma is the most common cause of pelvic fractures, while

penetrating trauma can result in injuries to abdominal viscera such as the
bladder, rectum, and uterus.

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 Tile’s Classification of Pelvic
Fractures
• Type A – Stable
• Type B – Partially Unstable
• Type C – Unstable

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 Type A Pelvic Fracture:
• Stable or posterior arch intact
• A1 – Avulsion injury
• A2 – Iliac wing or anterior arch
fracture caused by direct blow
• A3 – Transverse sacrococcygeal
fracture

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 Type B Pelvic Fracture:
• Partially unstable (incomplete disruption of
posterior arch)
• Rotationally unstable but vertically stable
• B1 – Open book injury (external rotation)
• B2 – Lateral compression injury (internal
rotation)
• B3 – Bilateral open book (B1/B2, B2,B2)

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 Type C Pelvic Fracture:
• Unstable (Complete disruption of posterior
arch)
• C1: Unilateral
• C2: Bilateral with one side type B and other
type C
• C3: Bilateral with both sides type C

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 Tile’s Classification of Pelvic
Fractures
• Type A – Stable
• Type B – Partially Unstable
• Type C – Unstable

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 Young-Burgess Classification 
Based on the direction of forces causing fracture,
associated instability of pelvis, and mechanism of
injury:
• Lateral compression
• Anterior-posterior compression
• Vertical shear
• Combined mechanism

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 Y-B: Lateral Compression:
• Sacral crush injury on ipsilateral side
• Sacral crush injury with disruption of posterior
sacroilial ligaments; iliac wing fracture may be
present (rotationally unstable)
• LC-1 or LC-II injury on side of impact,
contralateral side external rotation (open-book
injury) (rotationally unstable)

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 Y-B: Lateral Compression:
• Sacral crush injury on ipsilateral side
• Sacral crush injury with disruption of posterior
sacroilial ligaments; iliac wing fracture may be
present (rotationally unstable)
• LC-1 or LC-II injury on side of impact,
contralateral side external rotation (open-book
injury) (rotationally unstable)

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 Y-B: Anteroposterior Compression
• APC I: Slight widening of pubic symphisis (<2.5cm)
and/or anterior SI joint: intact posterior SI ligaments
• APC II: Symphysis diastasis >2.5 cm, sacrospinous,
sacrotuberous and anterior SI ligament disruption, intact
posterior SI ligaments (rotational instability)
• APC III: Symphysis diastasis >2.5 cm, with complete
disruption of the anterior and posterior SI ligament,
(complete rotational and vertical instability)

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 Y-B: Anteroposterior Compression
• Slight widening of pubic symphisis (<2.5cm) and/or
aneterior SI joint:intact posterior SI ligaments
• Symphysis diastasis >2.5 cm, sacrospinous, sacrotuberous
and anterior SI ligament disruption, intact posterior SI
ligaments (rotational instability)
• Symphysis diastasis >2.5 cm, with complete disruption of
the anterior and posterior SI ligament, (complete
rotational and vertical instability)

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 • Y-B: Vertical Shear- symphyseal diastasis or vertical
displacement anteriorly and posteriorly, usually through
the SI joint, occasionally through the iliac wing and/or
sacrum
• Y-B: Combined mechanism- combination of other injury
patterns. LC/VS most common.

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 Presenting Signs and Symptoms

• Pelvic pain and inability to bear weight

• Swelling of the pelvic area

• Hematoma in the area of the pelvic bone

• Pelvic deformity

• Uneven leg length or asymmetry of the iliac wings

• Numbness or tingling in the perineum or at the top of the thigh

• Perineal ecchymoses, scrotal or labial hematomas-Blood at the urethral meatus

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 Physical Examination

• Assess for other life threatening injuries using Primary Survey (ABCDE)

• Careful palpation of the posterior pelvis in awake patients can identify posterior pelvic
injuries.

• Rectal examination-high-riding prostate may indicate urethral tear. Palpation of the

sacrum for irregularity.

• Vaginal examination bleeding or lacerations indicating open fractures.

• Perineal skin-lacerations may indicate open fracture, scrotal, labial hematoma, swelling or
ecchymosis, flank hematoma
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 Imaging

• Radiographs

1. Anteroposterior pelvis part of the initial trauma series along with a chest and lateral
cervical spine X-ray can identify up to 90% of pelvic injuries.

2. Pelvic inlet view 40° to 45° caudal tilt. Shows anterior- posterior displacement
(rotational deformity), internal or external rotation of the hemipelvis; widening of SI
joint; sacral ala impaction.

3. Pelvic outlet view 40° to 45° cephalad tilt. Shows superior- inferior displacement
(vertical displacement) and visualizes the sacral foramen.
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 Imaging

• Radiographs

1. Anteroposterior pelvis part of the initial trauma series along with a chest and lateral
cervical spine X-ray can identify up to 90% of pelvic injuries.

2. Pelvic inlet view 40° to 45° caudal tilt. Shows anterior- posterior displacement
(rotational deformity), internal or external rotation of the hemipelvis; widening of SI
joint; sacral ala impaction.

3. Pelvic outlet view 40° to 45° cephalad tilt. Shows superior- inferior displacement
(vertical displacement) and visualizes the sacral foramen.
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 Imaging

• CT-scan:

CT is the diagnostic test of choice for detecting pelvic and intraabdominal injuries. Better
characterization of posterior ring injuries. Reveals bleeding in both the peritoneal and
retroperitoneal spaces. CT with intravenous contrast often can distinguish a stable hematoma
from ongoing bleeding from pelvic arteries.

• FAST:

Identify free intraperitoneal fluid in the trauma patient. FAST is not helpful for
evaluating the retroperitoneal space where pelvic hemorrhage occurs.
08/04/2023 Pelvic Trauma 27
Management of
pelvic trauma
How to treat a broken pelvis?
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08/04/2023 PRESENTATION TITLE 29

 Initial Management and Resuscitation
The initial management and resuscitation of patients with
pelvic trauma is a critical phase of care. Airway management
should be the first priority, followed by hemodynamic
stabilization and pain control. In some cases, intubation or
surgical airway may be necessary to ensure adequate
oxygenation. Hemodynamic stabilization involves aggressive
fluid resuscitation and blood transfusion as needed. Pain
control is also important, as uncontrolled pain can lead to
increased sympathetic activity and worsen hemodynamic
instability.
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 HD unstable patients: Hemorrhage
• Occurs in up to 75% of pelvic fractures
• Leading cause of death in patients with pelvic fractures.
• Three sources of bleeding- osseous, vascular, and visceral.
• Posterior pelvic venous plexus accounts for more than 80% of
haemorrhages.
• Intra-abdominal source of bleeding is present in up to 40% of cases.
• Arterial source of bleeding is present in only 10- 15% of cases.
• Retroperitoneal space can hold up to 4 L of blood.

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 HD unstable patients
Damage Control Orthopedics:
1. Temporary stabilisation of the pelvis
2. Resuscitation of Patients in Hypovolemic Shock (i/v fluids)
3. External Fixation- AEF, Pelvic C-Clamp
4. Open reduction and internal fixation when the patient's state of
health has stabilized:- ≥5 days or Acetabular fractures 5-10 days

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 Stabilization
• Pelvic Binder - Commercial device that can be used for prehospital
and emergent stabilization of pelvic fractures.- In APC ("open-
book") fractures, use of a pelvic binder will close the ring and
tamponade venous bleeding. An improvised binder can be made
using a sheet to provide circumferential compression around the
pelvis.
• Skeletal Traction - May be used to correct vertical displacement of
the hemipelvis.

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 Stabilization
• Pelvic Binder - Commercial device that can be used for prehospital
and emergent stabilization of pelvic fractures.- In APC ("open-
book") fractures, use of a pelvic binder will close the ring and
tamponade venous bleeding. An improvised binder can be made
using a sheet to provide circumferential compression around the
pelvis.
• Skeletal Traction - May be used to correct vertical displacement of
the hemipelvis.

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 Stabilization
• Pelvic Binder - Commercial device that can be used for prehospital
and emergent stabilization of pelvic fractures.- In APC ("open-
book") fractures, use of a pelvic binder will close the ring and
tamponade venous bleeding. An improvised binder can be made
using a sheet to provide circumferential compression around the
pelvis.
• Skeletal Traction - May be used to correct vertical displacement of
the hemipelvis.

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 External Fixation:
Anterior external fixator
• Anterior superior iliac spine (ASIS) pin and the anterior inferior iliac spine (AIIS)
pin.
• Two 5-mm pins are placed in between the iliac cortical tables and placement is
confirmed on fluoroscopy.
• Emergently placed in hemodynamically unstable patient who does not respond to
initial fluid resuscitation.
• Anterior external fixation alone does not provide adequate posterior stabilization if
the posterior ring is disrupted.•
• Indications- pelvic ring injuries with an external rotation component (APC, VS) :
unstable ring injury with ongoing blood loss.
• Contraindications - Ilium fracture that does not allow safe application

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 External Fixation: Pelvic Clamps
• Pelvic clamps have been developed to help control the posterior
pelvis in the resuscitation phase: the Ganz C-clamp
• These devices use large, percutaneously placed pins over the region
of the sacroiliac joint posteriorly..
• Pelvic C-Clamps-in original design, points of clamp applied to
posterior ilium in line with the sacrum.
• It requires fluoroscopy and technical expertise. Higher risk of
iatrogenic injury than standard anterior external fixator.

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 Pelvic Packing
• Patients who hemorrhage from both the pelvis
and the abdomen have mortality rates above
40%.
• Packing may aid in tamponading bleeding
from the posterior venous plexus.
• Pelvis should be stabilized before packing to
provide solid structural support against which
packing may be performed.
• Packs can be placed in the pre- peritoneal and
retro-peritoneal spaces.
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 Angiography/ embolization
• It is indicated for patients who remain HD unstable following
resuscitation, application of external fixator, and after other sources
of bleeding (abdomen, chest) are ruled out.
• Contrast material injected through the femoral artery on the less-
injured side or via the upper extremity.
• Transcatheter embolization with thrombogenic coils, foam, or
spherules.
• Arterial source of bleeding is present in only 10% to 15% of
patients.
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 HD stable patient
• Stable pelvic fracture- nonoperative treatment
• Unstable pelvic fracture-
1. External fixation- anterior external fixator/ Pelvic-clamps
2. Open Reduction and Internal Fixation

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 Non-operative Treatment
• Stable, non-displaced or minimally displaced fractures may be
treated nonoperatively (isolated pubic ramus fractures).
• Bed rest 2-3 weeks
• Lateral compresion fractures- weight bearing only on the unaffected
side.
• Vertically unstable fractures in which there is a contraindication to
operative treatment may be treated with skeletal traction.

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 Internal Fixation
• Indications:-
1. Symphysis diastasis > 2.5 cm
2. SI joint displacement > 1 cm
3. sacral fracture with displacement >1 cm
4. Pubic rami fractures >2 cm displacement
5. Displacement or rotation of hemipelvis
6. Open fracture- rotationally unstable pelvic injuries with significant
limb
7. Length discrepancy >1.5 cm or unacceptable pelvic rotational
deformity
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 Internal Fixation
• Tile type C pelvic injuries require anterior and posterior fixation to
regain rotational and vertical stability.
• Anterior ring stabilization - single superior plate
• Posterior ring stabilization
-anterior Sl plating
-iliosacral screws
-posterior SI "tension" plating

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08/04/2023 PRESENTATION TITLE 44
 Associated Injuries
• Hemorrhage 75%
• Chest injury 63%
• Long bone fractures 50%
• Head and abdominal injury 40%
• Spine fractures 25%
• Urogenital injuries (posterior urethral tear, bladder rupture) 12-20%
• Lumbosacral plexus injuries 8%

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 PROGNOSIS
• High prevalence of poor functional outcome and chronic pain
• Poor outcome associated with
1. SI joint incongruity of > 1 cm
2. high degree initial displacement
3. malunion or residual displacement
4. leg length discrepancy > 2 cm
5. nonunion
6. neurologic injury
7. urethral injury
• Mortality rate 1-15% for closed fractures, as much as 50% for open fractures  
• Hemorrhage is leading cause of death overall 

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Thank

you