Pelvic ring injuries

The pelvis is a ring: a break in one place usually means a second injury elsewhere (often the sacroiliac joint or sacrum). Stability depends on the posterior ligaments. High-energy injuries can bleed massively from the venous plexus and fractured bone.

Mechanism

Low energy: falls in the elderly (pubic rami, sacral insufficiency). High energy: road traffic, crush, falls from height.

Clinical findings

• ATLS: pelvic binder centred on the greater trochanters for haemodynamic instability; do not spring the pelvis repeatedly.
• Look for urethral injury (blood at the meatus), rectal and vaginal injury (open fracture), and lumbosacral nerve deficits.

Imaging

• AP pelvis in the trauma bay.
• Inlet (40° caudal) and outlet (40° cephalic) views, or CT with reconstructions (standard in most centres).
• CT angiography if haemodynamically unstable and contrast blush is suspected; urethrogram if blood at the meatus.

• AP pelvis in the trauma bay; CT with contrast. Inlet and outlet views for displacement.

Classification

61A

Posterior arch intact (stable): avulsions, iliac wing, isolated rami.

61B

Incomplete posterior disruption (rotationally unstable): B1 open book, B2 lateral compression.

61C

Complete posterior disruption (rotationally and vertically unstable).

Young–Burgess

By mechanism: lateral compression (LC I–III), anteroposterior compression (APC I–III), vertical shear, combined.

Types shown in 3D

61A2 (rami)

Isolated pubic rami fractures, posterior arch intact: stable. Mobilise as pain allows (elderly). Look for an occult sacral fracture on CT.

61B1 open book (APC)

Anteroposterior compression: the symphysis opens and both hemipelves rotate outwards on intact posterior ligaments. Binder first; symphyseal plate.

61B2 lateral compression

A side impact crushes the hemipelvis inwards: rami fractures with internal rotation (and a sacral buckle). Often stable enough for non-operative care.

61C1 vertical shear

Complete posterior disruption: the hemipelvis migrates upwards and backwards. Unstable in every direction: traction, then iliosacral screws and anterior fixation.

Treatment

Stable (61A, LC I)

Analgesia, mobilise with weight bearing as tolerated; osteoporosis work-up in the elderly.

Bleeding patient

Binder, resuscitation with blood products, then angioembolisation and/or preperitoneal packing; external fixator or C-clamp.

Unstable (61B/C)

Definitive fixation: symphyseal plate for open book; iliosacral or transsacral screws, anterior plates or posterior tension band for posterior instability.

Aftercare

Protected weight bearing on the injured side 6–12 weeks for unstable injuries.

Complications

• Haemorrhage
• Urogenital injury, sexual dysfunction
• Chronic posterior pain, leg-length discrepancy
• Venous thromboembolism