Presentation
Overview
· High‑energy trauma mechanism; commonly associated with polytrauma
· Associated injuries are common (chest, head, abdominal, orthopedic)
· Non‑pelvic bleeding sources must be ruled out
· Mortality is usually related to non‑pelvic injuries
Radiographic Evaluation
· AP pelvis radiograph
· Inlet view: evaluates AP displacement of SI joint and rotational deformity
· Outlet view: evaluates vertical displacement and hemipelvis flexion
· CT is often required because many fractures are missed on AP pelvis only
· APC patterns: higher rate of urethral and bladder injury; liver, spleen, bowel and pelvic vascular injury
· LC injuries, often associated with brain, lung, and abdominal trauma
· Vertical shear — similar mortality to high‑grade APC injuries
· Urogenital injury is common
· Most common complication without prophylaxis — DVT
Classification & Treatment
1) Young–Burgess Classification — Expanded Detail
Anterior–Posterior Compression (APC)
· Mechanism: External‑rotation force with anterior opening of pelvis; increases pelvic volume → bleeding risk
· Typical scenarios: motorcycle, pedestrian vs vehicle, head‑on MVC
· Progressive injury pattern with sequential posterior ligament failure
· APC I
- Symphysis diastasis < 2.5 cm OR anterior SI ligament sprain
- Posterior SI ligaments intact → rotationally stable
- Usually hemodynamically stable
· APC II
- Symphysis diastasis ≥ 2.5 cm
- Disruption of anterior SI + sacrotuberous + sacrospinous ligaments
- Posterior SI ligaments intact → vertically stable but rotationally unstable
- Higher association with urethral / bladder injury
· APC III
- Complete disruption of anterior AND posterior SI ligaments
- Rotational + vertical instability (hemipelvic dissociation)
- High hemorrhage risk and multisystem injury
Lateral Compression (LC)
· Mechanism: Lateral impact causing internal rotation of hemipelvis
· Common mechanism in side‑impact MVC
· LC I
- Ipsilateral sacral compression fracture
- Ipsilateral pubic rami fractures (impaction pattern)
- Rotationally unstable but vertically stable
- Often treated non‑operatively
· LC II
- Crescent fracture of iliac wing with partial SI fracture‑dislocation
- Increased posterior instability
- Frequently associated with thoraco‑abdominal trauma
· LC III (Windswept Pelvis)
- Ipsilateral internal rotation + contralateral external rotation
- Bilateral ring disruption
- Hemodynamically high‑risk pattern
Vertical Shear (VS)
· Mechanism: Axial load through hemipelvis (fall from height, crush)
· Complete posterior arch disruption with superior migration of hemipelvis
· Rotational and vertical instability
· Often associated with major hemorrhage → usually operative
Combined Mechanism
· Features of ≥ two mechanisms (e.g., APC + LC)
· Clinical course determined by most unstable component
2) Tile Classification — Stability Framework
Type A — Stable
· Posterior arch intact
· Examples: avulsion fractures, isolated iliac wing fractures, transverse sacral fractures
· Functionally stable → generally non‑operative management
Type B — Rotationally Unstable, Vertically Stable
· Partial posterior arch disruption
· Subtypes include external‑rotation (open‑book) and lateral‑compression patterns
· Treatment aim: restore rotational stability and pelvic symmetry
Type C — Rotationally & Vertically Unstable
· Complete posterior arch disruption (unilateral or bilateral)
· Highest mechanical and hemodynamic instability
· Requires definitive surgical stabilization
Associated Injuries & Complications
· APC patterns: higher rate of urethral and bladder injury; liver, spleen, bowel and pelvic vascular injury
· LC injuries : often associated with brain, lung, and abdominal trauma
· Vertical shear: similar mortality to high‑grade APC injuries
Urogenital injury is common
· Most common complication without prophylaxis is DVT
3) Treatment
Initial / Damage‑Control Management
· Primary goals: hemorrhage control + provisional stabilization
· Most bleeding venous (≈85%); remainder arterial
· Pelvic binder or sheet wrapping for early closure of pelvic volume
· Resuscitation with balanced transfusion strategy
· Angiographic embolization for persistent arterial bleeding
· Pre‑peritoneal pelvic packing for venous bleeding tamponade
· External fixation PRIOR to emergent laparotomy when indicated
· Skeletal traction for vertically unstable hemipelvis
Non‑Operative Management
· Stable Type A injuries
· APC I and LC I without mechanical instability
· Isolated anterior ring injuries → weight bearing as tolerated
· Ipsilateral anterior + posterior injuries → protected weight bearing
Operative Indications (Posterior / Global Instability)
· Symphysis diastasis > 2.5 cm
· Disruption of both anterior and posterior SI ligaments
· Vertical instability of hemipelvis
· Sacral fracture displacement > 1 cm
· Progressive deformity or failure of conservative treatment
Anterior Ring Fixation Options
· ORIF with symphyseal plate fixation
· External fixation (AIIS pins biomechanically stronger than iliac wing pins)
· Risk to lateral femoral cutaneous nerve during pin placement
· Anterior subcutaneous internal fixator — possible femoral nerve / LFCN irritation
Posterior Ring Fixation Options
· Percutaneous iliosacral screw fixation (gold standard in many patterns)
· Posterior trans‑iliac bars or sacral plating for select fractures
· Spinopelvic fixation for bilateral sacral fractures / spinopelvic dissociation
· Most stable construct in vertically unstable injuries: anterior ring fixation + percutaneous SI screw
Complications
Hemorrhagic & Vascular Complications
· Massive pelvic hemorrhage, most life‑threatening complication
· Bleeding source: ~85% venous plexus / marrow, ~15% arterial (internal iliac branches)
· Risk highest in APC II–III, LC III, and Vertical Shear patterns
· Pelvic volume expansion → worsens hemorrhage in open‑book injuries
· Late diagnosis or inadequate stabilization increases mortality
Urogenital & Reproductive Complications
· Common due to proximity of urethra, bladder, vagina, prostate
· Men: posterior urethral disruption → urethral stricture, erectile dysfunction
· Women : dyspareunia, pelvic pain, higher likelihood of cesarean delivery
· Bladder rupture may accompany symphyseal diastasis
· Requires early urologic evaluation and catheter strategy planning
Neurologic Complications
· L5 and S1 nerve roots at greatest risk in posterior pelvic instability
· Vertically unstable sacral fractures → higher risk of neurologic deficit
· Iliosacral screw malposition may injure L5 nerve root
· Symptoms: radicular pain, sensory deficit, foot weakness
· CT‑guided planning and outlet/inlet imaging reduce risk
Thromboembolic Complications
· Deep vein thrombosis (DVT) is the most common complication without prophylaxis
· Hypercoagulable state + immobilization + pelvic venous injury increase risk
· Pulmonary embolism risk persists during prolonged rehabilitation
· Routine pharmacologic thromboprophylaxis recommended unless contraindicated
Infectious & Wound Complications
· External fixation pin‑tract infection
· Deep infection risk increases with open injuries and combined abdominal trauma
· Anterior subcutaneous internal fixator — heterotopic ossification common (often asymptomatic)
· Soft‑tissue compromise may delay definitive fixation
Malunion, Nonunion & Mechanical Failure
· Vertical malunion → leg‑length discrepancy, gait disturbance, chronic pain
· Rotational malunion → pelvic obliquity, impaired sitting / standing balance
· Loss of fixation risk higher in vertically oriented sacral fractures
· Failure more likely with inadequate posterior fixation in unstable patterns
· Early recognition via follow‑up radiographs is essential
Functional & Long‑Term Complications
· Chronic pelvic pain and decreased mobility
· Sacroiliac joint arthrosis
· Sexual dysfunction and dyspareunia
· Persistent gait disturbance in vertically unstable injuries
· Psychological and quality‑of‑life impact in polytrauma survivors