AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Pelvic fracture is a disruption of the bony structures of the pelvis. In elderly persons, the most common cause is a fall from a standing position. However, fractures associated with the greatest morbidity and mortality involve significant forces such as from a motor vehicle crash or fall from a height.

For related information, see Medscape’s Fracture Resource Center.

For a CME/CE activity, see CME/CE - Patients May Need Better Pain Interventions After Traumatic Injury.

Pathophysiology

The bony pelvis consists of the ilium (ie, iliac wings), ischium, and pubis, which form an anatomic ring with the sacrum. Disruption of this ring requires significant energy. Because of the forces involved, pelvic fractures frequently involve injury to organs contained within the bony pelvis. In addition, trauma to extra-pelvic organs is common. Pelvic fractures are often associated with severe hemorrhage due to the extensive blood supply to the region.

Pelvic fractures are most commonly described using one of two classification systems.

The Tile classification system is based on the integrity of the posterior sacroiliac complex.

• In type A injuries, the sacroiliac complex is intact. The pelvic ring has a stable fracture that can be managed nonoperatively.
• Type B injuries are caused by either external or internal rotational forces resulting in partial disruption of the posterior sacroiliac complex. These are often unstable. 
• Type C injuries are characterized by complete disruption of the posterior sacroiliac complex and are both rotationally and vertically unstable. These injuries are the result of great force, usually from a motor vehicle crash, fall from a height, or severe compression.  

The Young classification system is based on mechanism of injury: lateral compression, anteroposterior compression, vertical shear, or a combination of forces. Lateral compression (LC) fractures involve transverse fractures of the pubic rami, either ipsilateral or contralateral to a posterior injury.

• Grade I - Associated sacral compression on side of impact
• Grade II - Associated posterior iliac ("crescent") fracture on side of impact
• Grade III - Associated contralateral sacroiliac joint injury

Anterior-posterior compression (APC) fractures involve symphyseal diastasis or longitudinal rami fractures.

• Grade I - Associated widening (slight) of pubic symphysis or of the anterior sacroiliac (SI) joint, while sacrotuberous, sacrospinous, and posterior SI ligaments remain intact
• Grade II - Associated widening of the anterior SI joint caused by disruption of the anterior SI, sacrotuberous, and sacrospinous ligaments; posterior SI ligaments remain intact
• Grade III (open book) - Complete SI joint disruption with lateral displacement and disrupted anterior SI, sacrotuberous, sacrospinous, and posterior SI ligaments

Vertical shear (VS) involves symphyseal diastasis or vertical displacement anteriorly and posteriorly, which is usually through the SI joint, though occasionally through the iliac wing or sacrum. Combined mechanical (CM) fractures involve a combination of these injury patterns, with LC/VS being the most common.

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. 

Falls in elderly persons may involve fractures (usually of the pubic rami) without disruption of the ring.

Frequency

United States

Pelvic fractures represent 3% of all skeletal fractures and 1-2% of fractures seen by orthopedists who care for children. Single pubic rami and avulsion fractures are most common.

Mortality/Morbidity

Over half of all pelvic fractures occur as a result of minimal-to-moderate trauma, such as a fall from a standing position. Of these, 95% are minor. On the other hand, the more severe pelvic fractures involve significant trauma. Most of this discussion relates to the more severe pelvic fractures.

• Cited mortality rates for pelvic fractures range from 3-20%. One study of pelvic fractures in children aged 16 years or younger cited a mortality rate of 5%, with death most commonly due to hemorrhage or multiple injuries.¹ 
• 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, or associated severe head injury are the most common causes of early death, whereas multisystem organ failure and secondary infection are the main causes of delayed death.
• The complication rate associated with pelvic fractures is significant and is related to injury of underlying organs and bleeding. 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 increase the incidence of pulmonary emboli.

Sex

• In a 2007 study of a trauma registry in the United Kingdom, 58% of patients sustaining a pelvic ring fracture were male.² A trauma registry review that same year from New South Wales, Australia, revealed that most patients sustaining high-energy pelvic ring fractures, such as from an motor vehicle crash (MVC), were male, whereas females predominated in low-energy injuries.³
• Associated genitourinary (GU) injuries vary greatly between men and women and are discussed in other articles. For many years, it was believed that women did not suffer urethral injuries. It is now known that, while women suffer urethral injuries at a much lower incidence than men, injuries do occur. Women suffer partial lacerations and partial disruption. Complete urethral disruption is rare.

Age

• Age distribution largely matches that of motor vehicle crashes, with car-car injuries more prevalent in adults, especially younger adults, and car-pedestrian injuries more likely to cause injury in children. The other group is the elderly, who tend to suffer pubic rami fractures without internal injuries as a result of falls from a standing position.
• In a 2007 study of a trauma registry in the United Kingdom, the median age of patients sustaining a pelvic ring fracture was 39 years.² 
• Urethral injuries vary widely by age with injuries to the prostatic urethra and bladder neck limited to children. Direct lacerations to the urethra occur only in boys (small prostate) and women.
• The incidence of urethral injuries also varies by the type of pelvic fracture. Straddle fractures associated with sacroiliac diastasis have the highest incidence (odds ratio of 24). Without diastasis, the odd ratio dropped to 3.85. Urethral injuries were essentially nonexistent for fractures not involving the ischiopubic rami.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

• Basic mechanism of significant blunt trauma should prompt consideration of a pelvic fracture.

Physical

• Tenderness, laxity, or instability on palpation of the bony pelvis suggests fracture. 
• Extensive manipulation of a fractured pelvis can increase patient discomfort and potentially increase bleeding, elaborate diagnostic maneuvers should be avoided. 
• Remember that, in the later stages of pregnancy, the pelvic ligaments become stretched, mimicking bony instability.
• Instability on hip adduction and pain on hip motion suggests an acetabular fracture, with or without an associated hip fracture.
• Signs of urethral injury in males include a high-riding or boggy prostate on rectal examination, scrotal hematoma, or blood at the urethral meatus.
• Vaginal bleeding or palpable fracture line on careful bimanual examination suggests pelvic fracture in females.
• 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.
• Note that digital rectal examination has a very low sensitivity for diagnosing pelvic fractures. In fact, in a 2007 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.⁴

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%)

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• Serial hemoglobin and hematocrit measurements monitor ongoing blood loss.
• 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 radiograph is the basic screening test and uncovers 90% of pelvic injuries. However, as severely injured trauma patients often routinely undergo CT scans of the abdomen and pelvis, plain pelvic radiographs in this patient population are most appropriate for hemodynamically unstable patients to allow for rapid diagnosis of pelvic fractures and early notification of interventional radiology.
  • Plain radiographs may also be used in patients who otherwise would not have a CT scan of the abdomen and pelvis performed.
• Computed tomography  
• • CT scan is the best imaging study for evaluation of pelvic anatomy and degree of pelvic, retroperitoneal, and intraperitoneal bleeding. 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.
• 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, recent studies suggest that ultrasonography has a lower sensitivity for identifying hemoperitoneum in patients with pelvic fractures than previously reported.⁵ 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 a displaced or boggy prostate or 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, peritoneal tap, or other appropriate diagnostic studies excludes significant intraperitoneal bleeding and after the external pelvis is stabilized.
  • This study allows for determination of the bleeding site and, potentially, embolization as a means of 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.
• Use an external compression device or sheets to control bleeding and temporarily stabilize the pelvis. A variety of inexpensive, commercial products are available for both prehospital and hospital use.   
• External pelvic fixation may be necessary to decrease bleeding and prevent further damage.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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.
• Consider application of an external compression device to mechanically stabilize the pelvis if grossly unstable.
• 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

• 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.
• 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.
  • 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.
• Obtain a CT scan of the pelvis as soon as practical.
• Consider early angiography in unstable patients without other identified bleeding sources.

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.
• Consult an interventional radiologist for embolization in the unstable patient.
• Consult a urologist for any suspected urethral injury.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Primary treatment of pelvic fracture is for pain with narcotic analgesics. Administer antibiotics whenever disruption of bowel, vagina, or urinary tract is suspected. Since bleeding is the major life-threatening complication of pelvic fractures, avoid nonsteroidal anti-inflammatory drugs in initial treatment. They may be considered later if inflammation is a concern.

Drug Category: Analgesics

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.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• Monitor patients with pelvic fracture for signs of ongoing blood loss and signs of infection.
• Monitor patients with pelvic fracture for development of neurovascular problems in the lower extremities. The sacral nerves, lower lumbar nerves, and sympathetic chain can be injured.
• Consider deep venous thrombosis (DVT) prophylaxis in all patients. Pelvic fractures give an odds ratio for venous thromboembolic events (VTE) of 2.93.
• Pain management is very important to facilitate early mobilization and reduce risk of thrombophlebitis. Early pelvic stabilization is important for pain control and to limit bleeding.
• The degree and timing of mobilization depends on the type of pelvic fracture as well as associated injuries and should be determined by the surgeons managing the patient's care. 
• 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.

Further Outpatient Care

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

In/Out Patient Meds

• Inpatient medications should be determined by the orthopedic specialist or trauma surgeon depending on associated injuries. Pain medications as outlined above will be required (see Medication); other medications depend on associated injuries.

Transfer

• Achieve hemodynamic stabilization and consider pelvic stabilization before transfer.
• Transfer all patients except those with minor pelvic fractures to a trauma center.
• Complex acetabular fractures may require transfer to a specialist in acetabular fractures.

Deterrence/Prevention

• Encourage use of seat belts, airbags, and other protective gear.
• Promote anti–drunk driving programs and laws.

Complications

Complications of pelvic fracture include the following:

• Increased incidence of deep venous thrombosis
• Continued bleeding from fracture or injury to pelvic vasculature
• GU problems from bladder, urethral, prostate, or vaginal injuries
• Sexual dysfunction, may be a long-term problem
• Infections from disruption of bowel or urinary system
• Chronic pelvic pain following surgery for pelvic fractures

Prognosis

• Prognosis varies depending on severity of fracture and associated injuries.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Total Hip Replacement.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Failure to diagnose an underlying injury, especially urethral disruption
• Failure to consider a urethral injury in a female
• Failure to clinically (or radiographically) exclude urethral injury prior to attempting to insert a urinary catheter or to cease attempts at Foley catheterization after encountering resistance
• Failure to obtain urethroscopy in women with suspected urethral injuries
• Failure to document the presence or absence of vaginal bleeding in a female with a pelvic fracture
• Failure to diagnose a hip dislocation associated with an acetabular fracture
• Failure to appreciate ongoing blood loss
• Failure to diagnose concomitant intra-abdominal or retroperitoneal injuries
• Failure to obtain prompt orthopedic consultation for an unstable pelvic fracture
• Failure to promptly apply external stabilization to an unstable pelvic fracture

Special Concerns

• Pregnant patients
• • While the welfare of the fetus is most dependent on the clinical outcome of the mother, diagnostic imaging and therapeutic options may need to be modified in the pregnant patient. 
  • Patients in later stages of pregnancy are at increased risk for complications.
  • Placental abruption and uterine rupture are a concern.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Charles W Sheppard, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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Article Last Updated: Aug 11, 2008