Pelvic fractures can be simple or complex and can involve any part of the bony pelvis. Pelvic fractures can be fatal, and an unstable pelvis requires immediate management.
Pelvic fractures can be seen in any group of patients. Like much trauma, there is a bimodal distribution with younger male patients involved in high-energy trauma and older female patients presenting after minor trauma.
Patients tend to present following trauma with pelvic/hip pain. They will often be immobilised by ambulance crews on arrival and potentially have other life-threatening conditions associated with high-energy trauma.
Most pelvic fractures result from trauma 3:
- motor vehicle collision (~50%)
- pedestrian vs. motor vehicle (~30%)
- fall from height (~10%)
- motorbike collisions (~4%)
- other e.g. sports injury, low-energy fall
Pelvic insufficiency fractures are common in the elderly.
The type of fracture that occurs is a result of the type of injury (impact or compression), the energy involved and the strength of the bones.
The potential morbidity associated with these fractures is related to the involvement of the pelvic ring. Injuries that result in disruption of the pelvic rings result in a significantly worse prognosis.
Direct impact low-to-moderate energy injuries usually result in a solitary and localised fracture. Compression injuries tend to cause fractures that involve the pelvic ring and are unstable.
Four main forces have been described in high-energy blunt force trauma that results in unstable pelvic fractures 1, 3, 5:
- anteroposterior compression: result in an open book or sprung pelvis fractures
- lateral compression: result in a windswept pelvis
- vertical shear: results in Malgaigne fracture or bucket handle fracture
- combined mechanical: occur when two different force vectors are involved and results in a complex fracture pattern
Isolated stable pelvic fractures can also occur in the context of lower energy mechanisms or sporting injuries:
- acetabular fracture
- pubic ramus fracture
- iliac wing fracture (Duverney fracture)
- avulsion fractures (e.g. ASIS, iliac crest, ischial tuberosity)
Pelvic fractures carry a significant risk of uncontrolled pelvic bleeding and exsanguination from pelvic fractures is a real possibility. This may result in pelvic, thigh and/or retroperitoneal haemorrhage. Pelvic angio-embolisation should be considered in patients with evidence of persistent blood loss with no evidence of intra-abdominal bleeding prior to surgical fixation 3, 4.
Other complications include 4:
The radiographic features are varied and even for serious and severe injuries can be subtle on plain radiographs.
X-ray is a quick and simple test that will detect the majority of pelvic fractures. They can be difficult to assess because of the complexity of the shape of the sacrum, pelvis and proximal femora.
CT is the modality of choice for accurately depicting complex acetabular or pelvic ring fractures. After an initial plain radiograph, a CT is often required to make an accurate assessment of the fracture.
Treatment and prognosis
Treatment and prognosis depend on the type of injury. Simple ramal fractures are treated by immobilisation. Multi-part acetabular fractures require reconstruction by an experienced operator. Complex pelvic ring fractures may require external fixation. In these patients, their prognosis is partly dependent on their comorbidities and other related injuries.
Pelvic fractures carry a significant mortality and morbidity. It has been reported that ~75% of pre-hospital deaths from motor vehicle collisions are secondary to pelvic fractures 3.
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- 2. Durkee NJ, Jacobson J, Jamadar D et-al. Classification of common acetabular fractures: radiographic and CT appearances. AJR Am J Roentgenol. 2006;187 (4): 915-25. doi:10.2214/AJR.05.1269 - Pubmed citation
- 3. Broadwell SR, Ray CE. Transcatheter embolization in pelvic trauma. Semin Intervent Radiol. 2004;21 (1): 23-35. doi:10.1055/s-2004-831402 - Free text at pubmed - Pubmed citation
- 4. Kool DR, Blickman JG. Advanced Trauma Life Support. ABCDE from a radiological point of view. Emerg Radiol. 2007;14 (3): 135-41. doi:10.1007/s10140-007-0633-x - Free text at pubmed - Pubmed citation
- 5. Dähnert W. Radiology Review Manual. Lippincott Williams & Wilkins. (2011) ISBN:1609139437. Read it at Google Books - Find it at Amazon