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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.
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, shown in the radiograph below, involve
symphyseal diastasis or longitudinal rami fractures.
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 severe pelvic fractures.
A recent analysis of a database of more than 63,000 trauma patients showed that pelvic
fracture was associated with higher mortality.2
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.3
Despite aggressive intervention, elderly patients with pelvic fractures have a worse outcome
Sex
In a 2007 study of a trauma registry in the United Kingdom, 58% of patients sustaining
a pelvic ring fracture were male.6 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.7
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.6
In children, a recent study found that pelvic fractures were more likely when any of 4 factors
were present: Caucasian, aged 5-14 years, a pedestrian struck by a vehicle, or an occupant in
a motor vehicle crash.8
Clinical
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. However,
while physical examination is specific for pelvic instability, it has a low sensitivity.9
Furthermore, in the later stages of pregnancy, the pelvic ligaments become stretched,
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%)
Laboratory 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.
Windswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The patient
sustained a left lateral compression injury with internal rotation of the left hemipelvis
and a characteristic sacral buckle fracture. Note the concomitant left sacroiliac joint
diastasis. The lateral force vector continued across the pelvis to produce external
rotation of the right hemipelvis and diastasis of the right sacroiliac joint. The
combination of injuries resulted in a windswept pelvis.
MRI may provide more definitive identification of pelvic fractures when compared to plain
radiographs, thereby prompting patients to more timely and appropriate therapy. In one
retrospective study, a large number of false positives and false negatives were noted when
Procedures
Use a suprapubic catheter for patients in whom urethral injuries are suspected but a
urethrogram cannot be obtained.
Early application of an external pelvic fixator may be necessary to control hemorrhage.
Treatment
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.
Application of an external compression device to a grossly unstable pelvis will provide
mechanical stabilization while controlling hemorrhage from the fracture site. A sheet or one
of a variety of inexpensive, commercial products may be used.13
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.
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.
If not done by prehospital providers, 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 some patients, such as those with truncal obesity, internal rotation of the lower extremities
and taping together the knees may be more effective than a compression binder.14
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.
Consultations
Medication
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 lifethreatening complication of pelvic fractures, avoid nonsteroidal anti-inflammatory drugs in initial
treatment. They may be considered later if inflammation is a concern.
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.
Precautions
Adult
Dosing
Interactions
Contraindications
Precautions
Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS
depressants may potentiate adverse effects
Dosing
Interactions
Contraindications
Precautions
Dosing
Interactions
Contraindications
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention;
caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may
increase ventricular response rate
Precautions
Adult
Dosing
Interactions
Contraindications
Precautions
Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse
effects
Dosing
Interactions
Contraindications
Precautions
Dosing
Interactions
Contraindications
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention;
idiosyncratic reaction, known as chest wall rigidity syndrome (never reported in analgesic dosages,
<200-mcg bolus), may require neuromuscular blockade to increase ventilation
Dosing
Interactions
Contraindications
Precautions
Adult
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Dosing
Interactions
Contraindications
Precautions
Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may
increase hepatotoxicity
Dosing
Interactions
Contraindications
Precautions
Dosing
Interactions
Contraindications
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is
contained in many OTC products and combined use with these products may result in cumulative
acetaminophen doses exceeding recommended maximum dose
Dosing
Interactions
Contraindications
Precautions
Adult
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone
bitartrate; not to exceed 5 doses/d
Dosing
Interactions
Contraindications
Precautions
Dosing
Interactions
Contraindications
Precautions
Dosing
Interactions
Contraindications
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on
opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe
renal or hepatic dysfunction; be careful when adding to other drugs that contain acetaminophen
Dosing
Interactions
Contraindications
Precautions
Adult
Contraindications
Precautions
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants
increase toxicity
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity
Dosing
Interactions
Contraindications
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen
patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver
toxicity
Dosing
Interactions
Contraindications
Precautions
Adult
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, thereby reducing the risk
of thromboembolic disease.
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.
Transfer
If possible, hemorrhage should be controlled and the pelvis stabilized prior to 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 antidrunk driving programs and laws.
Complications
Complications of pelvic fracture include the following:
The incidence of deep venous thrombosis is increased.
Continued bleeding from fracture or injury to pelvic vasculature may occur.
GU problems from bladder, urethral, prostate, or vaginal injuries: The incidence of urethral
injuries varies by the type of pelvic fracture. Straddle fractures associated with sacroiliac
diastasis have the highest incidence (odds ratio of 24). Without diastasis, the odds ratio
dropped to 3.85. Urethral injuries are uncommon in patients with fractures not involving the
ischiopubic rami.
Sexual dysfunction may develop.
Infections from disruption of bowel or urinary system may develop.
Chronic pelvic pain, more so if the sacroiliac joints are involved, may occur.17
Prognosis
Lower long-term quality of life based on validated questionnaires has been reported in
patients with pelvic fractures following high-energy trauma.18
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
Medicolegal Pitfalls
Failure to diagnose concomitant genitourinary, intra-abdominal, or retroperitoneal injuries
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 assess for 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 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.