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Pelvic trauma: Initial evaluation and management

Pelvic trauma: Initial evaluation and management
Literature review current through: Jan 2024.
This topic last updated: Oct 27, 2023.

INTRODUCTION — Injuries to the pelvis range from benign to life threatening. They include pelvic ring fractures, acetabular fractures, and avulsion injuries. Most pelvic injuries in younger patients are due to high-energy blunt trauma, although frail and older adult patients may sustain such injuries from a low-energy mechanism (ie, fall from a standing position). High-energy trauma increases the likelihood of concomitant injuries, likely involving the abdominal and pelvic viscera.

Bony pelvic injuries are reviewed here. Pelvic insufficiency fractures, abdominal injuries, and other aspects of trauma, including initial management, are discussed separately. (See "Minor pelvic fractures (pelvic fragility fractures) in the older adult" and "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial management of trauma in adults".)

EPIDEMIOLOGY

Incidence and mortality — Pelvic fractures represent approximately 3 percent of skeletal injuries [1]. Overall mortality from pelvic fractures ranges from 5 to 16 percent, with the rate for unstable pelvic fractures approximately 8 percent [2,3]. Patients with pelvic fractures who are in shock at presentation have high mortality [4]. The mortality rate associated with acetabular fractures is 3 percent [5], while open pelvic fractures, which comprise 2 to 4 percent of all pelvic fractures, are associated with a mortality rate of up to 45 percent [1,2,6-8]. Most fatalities stem from associated internal injuries; deaths attributed solely to pelvic fractures range from 0.4 to 0.8 percent of trauma fatalities [3,7,9]. Patients older than 65 years of age with pelvic fractures have a mortality rate of approximately 20 percent [10]. Overall, pelvic fractures are associated with an increased risk of death among trauma patients [11,12].

An Australian study of pelvic ring fractures demonstrated an incidence of 23 per 100,000 persons per year, while a British study found the incidence of acetabular fractures to be 3 per 100,000 persons per year [13,14]. Reviews of two large trauma registries found the incidence of pelvic ring fractures among admitted trauma patients to be 8 and 9.3 percent, respectively [9,15].

Risk factors for pelvic fractures include low bone mass, smoking, hysterectomy, older age, and a propensity to fall [16]. Age greater than 60 years in patients with significant pelvic fractures predicts a higher likelihood of bleeding requiring angiography [17,18].

Mechanisms — The most common mechanisms for pelvic fractures include motor vehicle collisions and motorcycle accidents (43 to 58 percent), pedestrians struck by a motor vehicle (20 to 22 percent), and falls (5 to 30 percent) [9,13,19]. Similar mechanisms lead to acetabular fractures, but the percentage caused by motor vehicle collisions and motorcycle accidents is higher (80.5 to 83.6 percent) [5,20]. Avulsion fractures usually result from sudden, forceful contraction of a muscle in skeletally immature athletes aged 14 to 17 years [21].

One study looking at 1851 motor vehicle accident patients, of whom 511 had pelvic fractures, found a higher incidence of pelvic fractures among those who sustained near side lateral impacts and reported that the use of seat belts was associated with fewer pelvic fractures [22]. Another study of 240 motor vehicle accident victims, 38 with pelvic ring fractures, also found an association with near side lateral impact crashes but no decrease in pelvic ring injury with seat belt use [23]. The effect of near side lateral impact on injury rates may change with the introduction of side torso airbags in automobiles, which occurred subsequent to the collection of much of the data used for these studies.

Associated injuries — Pelvic injuries from high-energy trauma frequently cause concomitant internal injuries, which may include the following:

Hemorrhage – Life-threatening hemorrhage can occur, typically related to bleeding from the venous plexus (presacral, lumbar), but other sources of arterial and venous bleeding have been reported. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient".)

Venous plexus bleeding is the source in 80 to 90 percent of cases [24]. In one case series, 38.5 percent of hospitalized trauma patients with pelvic fractures required transfusion [15]. In another series, 34 percent of trauma patients with isolated pelvis and acetabulum fractures required blood transfusions [25]. Although complex pelvic injuries with major ligament disruption more often require transfusion, hemorrhage can accompany any pelvic fracture pattern [25,26]. Factors associated with hemorrhage requiring treatment with angiographic embolization include sacroiliac joint disruption, prolonged hypotension (defined as systolic blood pressure <100 mmHg), and female sex [27].

Arterial bleeding associated with pelvic trauma can be related to injury of the iliac vessels (artery, veins) [28-30]. The mechanism of injury is compression of the vessels against the pelvic brim or shearing that disrupts the integrity of the vessel wall.

A prospective observational study found that among patients with signs of blunt pelvic trauma, those who sustained pelvic fractures (n = 45) had more severe injuries overall and were more likely to be hypotensive [31].

Intra-abdominal – Such injury occurs in 16.5 percent of patients with pelvic trauma [15]. Both visceral organs (eg, liver, spleen) and bowel may be involved [8,15]. (See "Initial evaluation and management of blunt abdominal trauma in adults".)

Bladder and urethra – The bladder is injured in approximately 3.4 percent and the urethra in 1 percent of pelvic trauma cases [32]. Males are 10 times more likely to sustain urethral injuries (1.5 versus 0.15 percent). (See "Blunt genitourinary trauma: Initial evaluation and management".)

Neurologic – Nerve deficits associated with pelvic ring disruptions occur in 10 to 15 percent of pelvic trauma cases, with higher rates (up to 50 percent) in zone 3 sacral fractures (sacral fracture classification is defined below) [33,34]. (See 'Sacral fracture classification' below.)

The incidence increases with the degree of instability: 1.5 percent in stable fractures versus 14.4 percent in unstable fractures [35]. The most common sites include the L5 and S1 nerve roots and isolated peripheral nerves [35]. (See 'Fracture types' below.)

Thoracic aorta rupture – Dissection of the thoracic aorta occurs in 1.4 percent of blunt trauma patients with a pelvic fracture compared with 0.3 percent of all blunt trauma patients [15]. (See "Clinical features and diagnosis of blunt thoracic aortic injury".)

Acetabular fractures, even in isolation, are associated with similar rates of concomitant injuries and require thorough evaluation [20].

ANATOMY — The bony pelvis consists of the sacrum, coccyx, and three innominate bones: the ilium, ischium, and pubis. The ilium, ischium, and pubis fuse to form the acetabulum. The acetabulum is classically described as having an anterior column (composed of the anterior iliac wing, superior pubic ramus, and anterior wall of the acetabulum) and a posterior column (composed of the ischium, ischial tuberosity, and posterior wall of the acetabulum) (figure 1).

The strength and stability of the pelvis relies on the strong ligaments connecting the sacrum with the other pelvic bones. These ligaments include the sacroiliac ligament complex (anterior and posterior portions), sacrospinous, and sacrotuberous. Additional pelvic strength comes from the symphyseal ligaments running from pubis to pubis and ligaments between the lumbar spine and pelvic ring, such as the iliolumbar and lumbosacral. Disruption of these ligaments can lead to pelvic instability (figure 2 and figure 3).

Within the bony pelvis lie the pelvic viscera, an extensive vascular system, and a rich neural network. The pelvis contains the rectum, anal canal, and bladder. In females, the urethra, uterus, ovaries, and vagina also lie within the pelvis (figure 4). The prostate is found in males. All of these structures warrant consideration in patients with pelvic injuries.

The pelvic arterial system has anatomic variability, especially the internal iliac artery and its branches (figure 5). Usually, the two common iliac arteries divide at the level of the pelvic brim. The external iliac artery follows the pelvic brim to exit the pelvis underneath the inguinal ligament. The internal iliac artery lies more posterior in the pelvis, particularly the posterior division as it overlies the sacroiliac joint. The posterior branch divides into the superior gluteal, iliolumbar, and lateral sacral arteries. The anterior division has many more branches; most important are the obturator and internal pudendal arteries, which can be injured in pubic rami fractures (figure 6).

The pelvic venous system consists of veins that parallel the arterial system and a venous plexus that lies anterior to the sacrum (figure 7). This plexus contains many thin-walled veins. This plexus is highly susceptible to damage with sacroiliac injuries and is a common source of bleeding.

The neural network in the pelvis, the lumbosacral plexus, arises primarily from the nerve roots of L4 to S3 (table 1 and figure 8). The sacral nerves exit through the sacral neural foramina and can be injured with sacral fractures (figure 9). Injuries to these nerves can result in bladder, bowel, and sexual dysfunction (figure 6). Although they do not arise from the lumbosacral plexus, the femoral and obturator nerves lie within the pelvis and may be injured with pelvic trauma.

FRACTURE TYPES — Pelvic fractures include ring disruptions, sacral fractures, acetabular fractures, and avulsion injuries. Significant hemorrhage may accompany any fracture pattern. However, patients with stable fractures (no operative intervention required) and no other significant injuries who are hemodynamically stable at presentation seldom have major bleeding [36].

Pelvic ring disruptions — The bony pelvis forms a ring. When the ring is broken, two fractures most often occur. Therefore, clinicians should examine radiographs closely for additional injuries whenever a pelvis fracture is identified.    

Older adults and athletes represent two exceptions to the general principle of grouped pelvic fractures. Older adults can sustain isolated rami or sacral fractures due to minor trauma and osteopenia. In addition, isolated fractures are occasionally seen in low-energy falls and straddle-type injuries. Avulsion fractures from sudden, forceful contraction of a muscle may occur in skeletally immature athletes.

Several classification schemes for pelvic ring disruptions have been proposed. This review uses the Young-Burgess classification scheme because it incorporates the mechanism of injury and the direction of the involved forces (figure 10 and table 2) [37].

While Young and Burgess found a correlation between major ligamentous injury (lateral compression III, anteroposterior compression II/III) and an increased risk of hemorrhage [37], subsequent studies have failed to demonstrate a consistent correlation between injury type and mortality or the need for angiographic embolization [38-40]. However, the largest review, involving 1248 pelvic fractures, reported that patients with unstable fracture patterns (lateral compression II/III, anteroposterior compression II/III, vertical shear) required twice the transfusion rate of patients with stable injuries (4.9 versus 2.4 units) and sustained increased mortality (11.5 versus 7.9 percent) [40]. One prospective observational study found that sacroiliac joint disruption, regardless of the Young-Burgess classification, predicts the need for angiographic embolization (odds ratio [OR] 4.5; 95% CI 1.6-12.6) [27]. Overall, evidence suggests that patients who sustain a major injury to the posterior pelvic ring are more likely to have complications.

The Young-Burgess classification is as follows:

Lateral compression injuries

Type I – Most common lateral compression injury. Sacral compression fracture on the side of impact with either unilateral or bilateral rami fractures (image 1). Although less likely to cause severe complications, type I injuries can be unstable.

Type II – Crescent (iliac wing) fracture on the side of impact (image 2).

Type III – Type I or II injury on the side of impact, but the force extends to the opposite hemipelvis, creating an open-book injury on the side opposite the impact (also known as the "windswept pelvis") (image 3).

Anteroposterior compression injuries

Type I – Involves slight widening of the pubic symphysis, usually less than 2 cm, with intact posterior pelvic ring ligaments (image 4).

Type II – Widening of the anterior sacroiliac joint occurs due to disruption of the anterior portion of the sacroiliac, sacrotuberous, and sacrospinous ligaments. The anterior pelvic ring can demonstrate either widened pubic symphysis or rami fractures. The posterior portion of the sacroiliac ligament remains intact (image 5 and image 6).

Type III – Complete disruption of the sacroiliac joint with anterior pelvic ring injuries similar to type II (image 7).

Vertical shear injuries – The hemipelvis is displaced superiorly or posteriorly due to a longitudinal force applied to the pelvis. Anterior pelvic ring injuries can include either widening of the pubic symphysis or unilateral or bilateral rami fractures. Posterior pelvic ring injuries occur most commonly through the sacroiliac joint but can involve fractures of the iliac wing or sacrum (image 8 and image 9).

Combined mechanisms – Combinations of the injury patterns described above can occur. Lateral compression and vertical shear is the most common.

Open-book fracture – Open-book pelvic fracture is a common term used to describe pelvic ring disruptions (image 10 and image 11). This fracture encompasses an anterior injury (widening of the pubic symphysis, rami fractures, or both) and a posterior pelvic fracture or ligamentous injury. Lateral compression, anteroposterior compression, and vertical shear injuries may all be termed open-book based upon the extent of injury and anterior widening. When the anterior pelvic ring widens more than 2.5 cm, the posterior pelvis (especially the anterior portion of the sacroiliac ligamentous complex) is frequently injured, increasing the risk of hemorrhage.

Sacral fracture classification — Denis and colleagues further classified sacral fractures to assist with predicting neurologic injury [34]. Their classification scheme, along with the frequency of neurologic injury, is as follows (figure 11):

Zone I – Lateral to the sacral neural foramina (image 12) (5.9 percent, usually L5 root)

Zone II – Through the sacral neural foramina (image 13) (28.4 percent, predominately sciatica with rare bladder or bowel involvement)

Zone III – Medial to the sacral neural foramina through the central canal (image 14) (≥50 percent; most involve bowel, bladder, or sexual dysfunction)

Acetabular fractures — The classification scheme created by Letournel and Judet is used most often to describe acetabular fractures (figure 12) [41]. The plain radiograph views used to assess acetabular fractures are described in the attached figure (image 15). This scheme includes the following injury types:

Simple fractures – Five types (figure 13):

Posterior wall – Most common pattern (23.3 percent); fracture of the posterior articular surface with intact posterior column (image 16); look for associated posterior femoral head dislocation (image 17) [14]

Posterior column – Ilioischial disruption; fracture can be anywhere from the ischial spine to the sciatic notch; femoral dislocation when present tends to be medial (image 16)

Anterior wall – Fracture to a small area of the upper anterior acetabulum (image 18)

Anterior column – Disruption of the iliopectineal line; associated anterior femoral head dislocation common (image 19)

Transverse – Fracture line crosses through both columns, causing a separation of the acetabular articular surface (image 20)

Complex fractures – Combinations of simple fracture patterns (figure 14)

T-shaped – Combination of transverse fracture and a vertical fracture resulting in two ischiopubic fragments (image 21)

Posterior wall and posterior column – Posterior column and posterior wall significantly displaced from one another; risk of sciatic nerve injury from posterior hip dislocation often accompanies such injuries (image 22)

Transverse and posterior wall – Combination of transverse and posterior wall fractures (image 23)

Anterior column and posterior hemi-transverse – Anterior wall or column fracture with a posterior column fracture in a transverse pattern (image 24)

Both columns – Most complex acetabular fracture; "floating" acetabulum with anterior and posterior columns separated from one another and the central skeleton; the entire acetabulum is separated and can remain congruent with the femoral head (image 25)

Avulsion fractures — Avulsion fractures most often occur in skeletally immature athletes aged 14 to 17 years but may occur in high-energy trauma [21]. Sudden forceful muscular contraction is the usual cause. The most common sites and muscles involved are the anterior superior iliac spine (sartorius), anterior inferior iliac spine (rectus femoris), ischial tuberosity (hamstrings), and less commonly, the lesser trochanter (iliopsoas) (image 26). In adults, avulsion fractures in the absence of trauma should be considered pathological until proven otherwise.

PREHOSPITAL MANAGEMENT — As with all trauma patients, highest priority is given to stabilizing the airway, breathing, and circulation, and to minimizing on-scene time.

In pelvic trauma, the primary goal of emergency medical services (EMS) personnel is recognizing possible injuries based upon mechanism and physical assessment. Unstable pelvic injuries, such as "open-book" fractures involving disruption of the sacroiliac joints, are associated with retroperitoneal hemorrhage, which can be severe. (See 'Fracture types' above.)

The results of a large, retrospective study involving over 7000 trauma patients with pelvic fractures raise important questions about the accuracy of pre-hospital examination for detecting clinically unstable pelvic injuries [42]. Consequently, whether a pelvic injury is suspected or not in a hemodynamically unstable blunt trauma patient, we advocate that paramedics stabilize or "close" the pelvis by securing it with a sheet or by applying a commercial pelvic binder (picture 1 and picture 2). This reduces pelvic volume and stabilizes fracture fragments, thereby reducing the risk of major hemorrhage. Paramedics can also tie the legs together to stabilize the lower extremities in internal rotation, which reduces pelvic volume. Care should be taken not to tie or bind the pelvis too tightly. The goal of pelvic binding is stabilization, and existing injuries may be exacerbated by over-reduction. (See 'Pelvis injury' below.)

Proper instruction and communication with EMS personnel who place pelvic binders is important as binders may be placed incorrectly in up to 40 to 45 percent of cases [43,44]. Pelvic binders should wrap around the greater trochanters; often, they are placed too high (ie, too cephalad).

CLINICAL FEATURES

History — Many patients sustain pelvic injuries from high-energy trauma and may have multiple injuries to be addressed. Often, the condition of the trauma patient limits the clinician's ability to obtain a complete history. Prehospital providers can describe the likely mechanism of injury, accident scene (eg, intrusion into the passenger compartment of an automobile), and their initial assessment. In addition to the standard trauma history (eg, AMPLE: allergies, medications [especially anti-coagulants], past medical history, last meal, events), the following information is useful in the setting of possible pelvic trauma:

Mechanism of injury

Whether patient was ambulatory at the accident scene

Location of pain

Presence of bowel or bladder incontinence

Numbness or weakness

Bleeding: hematuria, rectal, or vaginal bleeding

Last menstrual period

Physical examination — Initial inspection should include a search for external bleeding, ecchymosis (flank, perineal, and scrotal), blood at the penile meatus, vaginal bleeding, and the position of the lower extremities and iliac crests. Do not neglect to inspect the back, gluteal region, and panniculus.

Palpation of bony landmarks, range of motion (if there is no obvious deformity or significant pain), and a thorough neurovascular examination should be performed. The important bony landmarks to palpate include the iliac crests, pubic symphysis, sacrum, sacroiliac joints, and greater trochanters.

Rectal and vaginal examinations should be carefully completed to assess for open fractures. These examinations should include evaluation for palpable bony fragments, integrity of the rectal and vaginal walls, gross blood, and a high-riding prostate. Care should be taken to avoid injury to the examiner from any bony fragments. Although the accuracy of the digital rectal examination in trauma patients is limited, assessing for open pelvic fractures represents one instance when it may provide useful information beyond clinical judgment in trauma [45]. Any pelvic fracture associated with blood on rectal or vaginal examination should be treated as an open pelvis fracture. The rectal examination in trauma is reviewed in detail separately. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'History, examination, and approach to testing'.)

As part of the examination, compression of the pelvis should be done once only and in a gentle manner in order to not displace fracture fragments or exacerbate injuries. Pressure should be directed posterior and medial. The goal is to feel an unstable fracture "closing," not to further displace ("open") an unstable injury. According to retrospective data, instability with compression of the pelvis has limited sensitivity for detecting a pelvic fracture (8 percent), including unstable pelvic fractures (26 percent) [46]. However, when present, such instability is highly specific for both stable and unstable fractures (approximately 99 percent for each).

In awake trauma patients (Glasgow Coma Scale score of 14 or 15), the physical examination is highly sensitive for significant pelvic fractures [31,46-48]. In a prospective study comparing a focused examination protocol with computed tomography (CT) scan, pain with palpation of the sacrum and sacroiliac joint had the greatest sensitivity (98 percent) for detecting posterior pelvic ring injuries [48].

The clinician should not rely upon the physical examination in severely injured or intubated trauma patients. In one prospective series, physical examination missed 20 percent of surgically significant pelvic fractures in such patients [49].

INITIAL MANAGEMENT

Initial assessment — In all trauma patients, stabilization of the airway, breathing, and circulation takes precedence. The initial management of trauma patients is reviewed separately. (See "Initial management of trauma in adults".)

Features of the history and physical examination identified during the primary and secondary surveys will direct attention to possible pelvic injuries. (See 'Clinical features' above.)

Special care should be taken with pregnant patients who sustain pelvic injuries, as the fetal mortality rate can be as high as 35 percent [50]. Early obstetrical consultation is prudent. (See "Initial evaluation and management of major trauma in pregnancy".)

Diagnostic tests

Ultrasound — A bedside ultrasound examination (ie, focused assessment with sonography in trauma [FAST]) is performed in the great majority of blunt trauma patients. The performance and utility of the FAST examination for trauma generally is discussed in detail separately (see "Emergency ultrasound in adults with abdominal and thoracic trauma"), its role in the overall assessment of pelvic trauma is described below (see 'Initial stabilization and approach' below), and its effectiveness in the assessment of pelvic trauma is reviewed here.

When a patient has a suspected or confirmed pelvic fracture, the primary role of the FAST examination is to help determine the presence of a concurrent intra-abdominal injury. When such patients are hemodynamically unstable, the FAST examination helps to guide care for two patient groups:

Hemodynamically unstable with a positive FAST examination who require treatment in the operating room for both pelvic injuries and concomitant intraperitoneal injury

Hemodynamically unstable with a negative FAST examination who are assumed to have life-threatening hemorrhage from pelvic trauma without intraperitoneal injury and require treatment in the operating room or interventional radiology suite, depending on the institution

The abdominal portion of the FAST examination is intended to detect intraperitoneal bleeding; it generally does not detect retroperitoneal bleeding within the pelvis [51]. A significant amount of bleeding in pelvic fractures is in locations not identified with FAST examination. Therefore, a FAST examination that reveals fluid (positive FAST) indicates the need to treat both pelvic and intraperitoneal injury, while a FAST examination without fluid (negative FAST) helps to direct management primarily toward pelvic injuries. Thus, in the hemodynamically unstable blunt trauma patient, a positive FAST suggests the need for laparotomy. Without signs of an intraperitoneal injury, clinicians can focus on management of the pelvic injury, including such interventions as angiography, pelvic stabilization, and preperitoneal pelvic packing [52-54].

Determining whether the FAST examination is well suited to the role described for patients with pelvic fractures depends on whether a negative FAST accurately precludes the need for exploratory laparotomy (ie, absence of fluid corresponds to the absence of intraperitoneal hemorrhage) and whether a positive FAST accurately predicts the need for laparotomy (ie, presence of fluid corresponds to the presence of injury). While evidence is limited, the results of several, largely small and retrospective, studies suggest that a negative FAST examination has a high negative predictive value for requiring exploratory laparotomy, with rates ranging from 90 to 99 percent in most studies [52,55-57], while one small study reported a rate of 63 percent [58]. These studies also suggest that a positive FAST identifies intraperitoneal bleeding in patients with pelvic fractures and the need for exploratory laparotomy with reasonable accuracy, although the positive predictive value is not as high as the negative predictive value, with rates ranging from 70 to 90 percent [55].

In the largest study to date involving 1456 patients with a pelvic fracture assessed at a single level one trauma center, the negative predictive value of the FAST examination for detecting intraperitoneal injury was 98.8 percent, while the positive predictive value was 78.4 percent. The gold standard for detecting bleeding was exploratory laparotomy or computed tomography (CT) [55].

Diagnostic peritoneal aspirate — The role of diagnostic peritoneal aspirate (DPA) in patients with pelvic fractures has changed over time. DPA is not used in the centers where the authors practice; its role has been supplanted by advanced imaging, primarily ultrasound and CT. In centers without access to these technologies, DPA may continue to have a role in management, as described below. The general role of DPA and diagnostic peritoneal lavage (DPL) in abdominal trauma is reviewed separately. (See "Initial evaluation and management of blunt abdominal trauma in adults", section on 'Diagnostic peritoneal lavage'.)

DPA can be used in patients with pelvic fractures and persistent hemodynamic instability to determine rapidly whether the source of bleeding is peritoneal or retroperitoneal. An aspirate of 10 mL or more of gross blood is considered positive for intraperitoneal bleeding.  

The results of the DPA are used in a manner similar to those of an ultrasound FAST examination in helping to guide patient management (see 'Ultrasound' above):

Hemodynamically unstable patient with a positive DPA requires treatment in the operating room for both pelvic injuries and concomitant intraperitoneal injury

Hemodynamically unstable patient with a negative DPA is assumed to have life-threatening hemorrhage from pelvic trauma without intraperitoneal injury and requires treatment in the operating room or interventional radiology suite, depending on the institution

The authors do not confirm positive FAST examinations with DPA for two reasons: first, the risk of missing an intraperitoneal bleed is too high; second, intraperitoneal bladder injuries require surgical repair regardless [59,60].

Plain radiograph — A plain radiograph of the pelvis is obtained in hemodynamically unstable patients (image 27); its utility in stable patients and those undergoing CT is negligible [61-63]. We do not routinely obtain a plain radiograph in patients who meet all the following criteria:

Glasgow Coma Scale score >13

No pelvic, abdominal, or back complaints

No tenderness in the lower abdomen, lower back, groin, or bony pelvis (see 'Physical examination' above)

Traditional teaching in advanced trauma life support (ATLS) is to obtain a portable anteroposterior (AP) pelvis radiograph in all trauma patients suspected to have a pelvis injury on the basis of mechanism or physical findings. However, many clinicians question the utility of a plain radiograph in screening for pelvis fractures in hemodynamically stable blunt trauma patients. Several observational studies have found plain radiograph to have limited sensitivity and no effect upon management in such patients [61,64,65]. One important caveat to these studies is that all patients underwent multidetector CT scans, which guided treatment. In hospitals without CT scanning and in hemodynamically unstable patients, portable pelvis radiographs should be performed.

The plain AP radiograph is used to assess for significant pelvic fractures, specifically displaced fractures, open-book injuries, and posterior pelvic injuries. Example radiographs for many pelvic injuries are provided above. (See 'Fracture types' above.)

Remember that when the pelvic ring is broken, at least two fractures most often occur, although this may not be the case in older adult patients. Also keep in mind that passive recoil of the pelvis due to intact muscular attachments (ie, pelvic recoil) can make it difficult to appreciate the extent of pelvic fracture displacement and contribute to the limited sensitivity of plain pelvis radiographs. In a study of 15 cadavers with simulated pelvic trauma, pelvic recoil was reported to occur in approximately 40 percent of open-book injuries and 80 percent of lateral compression injuries [66].

The posterior stability of the pelvic ring is enhanced by the iliolumbar ligaments that connect the L5 transverse process to the iliac crest. Any fracture of this transverse process weakens the attachment and suggests high-energy trauma to the pelvis. According to a retrospective case series, unstable pelvic fractures are approximately nine times more likely when an L5 transverse process fracture occurs [67].

Once the patient has been stabilized and other injuries have been appropriately managed, specialized radiographs may be performed. These views include inlet/outlet, Judet, and AP with patient in a lateral decubitus position. The inlet view (image 1 and figure 15) is obtained by projecting a radiograph beam tilted 40 degrees cephalad to better define the pelvic brim. Inlet views allow for better assessment of anterior-posterior displacement of unstable fractures. The outlet view (image 1 and figure 16) uses a radiograph beam tilted 40 degrees caudal to better evaluate the sacrum and SI joints and any superior-inferior displacement of unstable fractures.

To obtain Judet views (used to evaluate the acetabulum), the patient is rolled 45 degrees to each side, creating iliac oblique and obturator oblique views. The iliac oblique highlights the posterior column and the anterior wall of the acetabulum while the obturator oblique illustrates the anterior column and the posterior wall (image 17 and image 15). These views may be helpful for operative planning and postoperative monitoring.

AP radiographs taken in the lateral decubitus position can aid in the detection of occult instability from lateral compression type I injuries [68,69]. This can help to guide surgical treatment.

Computed tomography — The gold standard for diagnosing pelvic injuries is contrast-enhanced, multidetector CT due to its high sensitivity and detailed delineation of fractures. CT can determine concomitant injuries, areas of arterial bleeding, and the extent of retroperitoneal hemorrhage [70-72]. Most hemodynamically stable blunt trauma patients with a pelvic fracture should be evaluated with CT. Notable exceptions include older adult patients with isolated pubic rami fractures and athletes with avulsion fractures. (See 'Avulsion fractures' above.)

CT has some limitations assessing rotational instability in patients wearing a pelvic binder. Specific avulsion-type injuries to the inferolateral sacrum, ischial spines, and rectus abdominis insertion can act as markers, albeit uncommon ones, of rotational instability [73].

Clinicians should have a low threshold for obtaining a CT when an acetabular injury is suspected. These fractures can be subtle and difficult to appreciate on plain radiographs, particularly some involving the posterior acetabulum. Example CT images for a wide range of pelvic fractures are provided above. (See 'Fracture types' above.)

Retrograde cystourethrogram — If the physical examination reveals blood at the urethral meatus, a high-riding prostate, or gross hematuria, ATLS guidelines recommend that a retrograde urethrogram be performed prior to Foley catheter placement when possible. Genitourinary injuries are discussed separately. (See "Blunt genitourinary trauma: Initial evaluation and management".)

Management

Initial stabilization and approach — Both pelvic and acetabular fractures have a high incidence of associated internal injuries. A massive transfusion protocol should be initiated as indicated. Once resuscitated and stabilized, patients with major pelvic injuries initially managed at non-trauma centers should be transferred to a hospital with all necessary resources, including trauma surgery, orthopedic surgery, and (ideally) interventional radiology services. An algorithm for the management of blunt trauma patients with a significant pelvic fracture is provided (algorithm 1) [53,58,74-77]. (See "Initial management of trauma in adults" and "Initial management of moderate to severe hemorrhage in the adult trauma patient".)

For unstable patients with pelvic trauma, the results of the trauma ultrasound examination (ie, FAST) determine initial treatment:

Hemodynamically unstable patients with a positive FAST examination are assumed to have major pelvic and abdominal injuries and are treated with emergency laparotomy, pelvic stabilization, and preperitoneal packing.

Hemodynamically unstable patients with a negative FAST examination are assumed to have significant hemorrhage from their pelvic injuries without concomitant abdominal injury. Options for initial hemorrhage control include pelvic stabilization, preperitoneal packing, and resuscitative endovascular balloon occlusion of the aorta (REBOA) [78].

As over 85 percent of bleeding from traumatic pelvic fractures is venous, early surgical management of hemodynamically unstable patients begins with preperitoneal packing, while angiography is typically reserved for patients who remain unstable or when arterial bleeding is clearly identified on CT. Some trauma centers are incorporating interventional radiology capabilities into their surgical suites so that preperitoneal packing and angiography can be done at the same time. The surgical management of patients with severe pelvic fractures is reviewed separately. (See "Severe pelvic fracture in the adult trauma patient".)

Hemodynamically stable patients with significant pelvic fractures and either a positive or negative FAST examination are evaluated further with advanced diagnostic imaging (eg, CT, CT-angiography [CT-A]). A negative FAST examination alone is not a sufficient workup for patients with significant pelvic fractures [79].

Pelvis injury — If a significant pelvic injury is found or a patient with a pelvic fracture remains hemodynamically unstable, the pelvis should be "wrapped" with either a sheet or a commercial pelvic binder. "Wrapping" the pelvis reduces pelvic volume (creating a tamponade effect), stabilizes fracture fragments (reducing hemorrhage from the fracture sites), and improves patient comfort. Even fractures without an "open-book" component can be wrapped, the primary goal being fracture stabilization and not reduction.

The simplest method for reducing pelvic volume is to tape the legs together in internal rotation [80]. Alternatively, a sheet wrapped circumferentially around the greater trochanters and held in place with towel clamps is effective at reducing pelvic volume while permitting trauma assessment (picture 3 and picture 1) [81]. A video demonstrating techniques for applying a sheet is available in the following reference [82]. Commercial pelvic binders may also be used. Commercial devices include the Dallas Pelvic Binder, Geneva Belt, Stuart Splint, London Pelvic Splint, and the Trauma Pelvic Orthotic Device (TPOD) [83]. These splints are placed around the iliac crests (Dallas and Geneva) or the greater trochanters (London, TPOD, and simple sheets). To date, no controlled study has shown commercial devices to be clinically superior to sheets or taping.

Care should be taken not to over-reduce the fracture, especially with lateral compression injuries. Excessive reduction can create or increase an internal rotation deformity. Such a deformity places greater strain on the posterior pelvis, leading to greater diastasis, increased hemorrhage, and further injury. Over-reduction can be assessed clinically by the position of the patient's legs, greater trochanters, and patellae, which should lie in an anatomically neutral position.

Radiographs should be obtained after splint application to assess the adequacy of reduction. In severe lateral compression injuries, the sheet or splint is placed only to stabilize the pelvis, not to compress it. Three devices, the SAM Pelvic Sling (picture 2), TPOD, and the Pelvic Circumferential Compression Device (PCCD), limit the amount of force that can be applied, reducing the chance of internal rotation even in lateral compression injuries [83,84].

In addition to aggressive resuscitation, patients with open pelvic fractures (ie, bone is exposed or bone or blood is present on rectal or vaginal examination) require treatment with broad-spectrum intravenous (IV) antibiotics and prophylaxis against tetanus. Any pelvic fracture and an associated perineal wound or laceration should be considered open until proven otherwise. Cefuroxime is an appropriate choice. Vancomycin should be added if concern exists for infection with methicillin-resistant Staphylococcus aureus. Empiric treatment should be administered as soon as possible, ideally within six hours of the trauma and continued for 72 hours. (See "Osteomyelitis associated with open fractures in adults".)

Open fractures of the pelvis are not to be confused with pelvic open-book fractures (image 10 and image 11), which refer to injuries in which the pelvis has widened, and which may or may not be open fractures (see 'Fracture types' above). Open pelvic fractures generally require multidisciplinary management and extensive debridement in the operating room.

Acetabular injury — Patients with acetabular fractures have a high incidence of associated injuries, and a full trauma assessment should be performed. Management of the fracture can include relocation of the femoral head if there is an associated hip dislocation or the placement of a traction pin (performed in conjunction with an orthopedic surgeon). (See 'Acetabular fractures' above.)

Avulsion injury — Avulsion injuries are treated conservatively with rest, ice, protected weight-bearing, and analgesics. Disagreement exists about operative repair; generally, fragments displaced more than 2 cm are treated surgically on an urgent basis [21]. (See 'Avulsion fractures' above.)

Minor pelvic fractures in older adults — Older adult patients are at greater risk for occult pelvic fractures, primarily pubic rami and sacral insufficiency fractures. Advanced diagnostic imaging should be obtained for older adult patients in whom a fracture is suspected on clinical grounds despite negative plain radiographs. These issues are discussed in detail separately. Older adults can present with significant pelvic injury from minor mechanisms and present with deceptively benign exams. (See "Minor pelvic fractures (pelvic fragility fractures) in the older adult".)

Pitfalls and pearls

Treat patients with pelvic fractures as trauma patients. Pelvic injuries are associated with significant bleeding, concomitant internal injuries, and high mortality.

Do not assume that the extent of bleeding correlates with the severity of the fracture pattern [38]. Any pelvic fracture can cause significant bleeding. Older patients may have life-threatening hemorrhage from pelvic fractures sustained in low-energy falls. (See "Geriatric trauma: Initial evaluation and management".)

Do not underestimate the extent of the fracture based on plain radiographs. Posterior pelvic injuries (ligaments and sacral fractures) are difficult to assess on plain films; CT scanning is necessary.

Obtain subspecialty consultation early for concerning signs or injuries. The management of pelvic injuries can be complex and often requires surgical stabilization or angiography.

DEFINITIVE MANAGEMENT

Specialty consultation — Trauma and orthopedic surgeons should be involved early in the care of patients with significant pelvic injuries. Determining the best method for hemorrhage control and subsequent definitive treatment can be complex. Management options include preperitoneal pelvic packing, resuscitative endovascular balloon occlusion of the aorta (REBOA), operative stabilization of the pelvic fracture (internally or externally), and angiography for embolization of bleeding pelvic vessels. Emergency clinicians can assist their colleagues by starting the resuscitation (including massive transfusion protocol when indicated), evaluating for hemoperitoneum (eg, focused assessment with sonography in trauma [FAST] ultrasound examination), gathering resources, identifying associated injuries, and notifying the operating room and angiography suite early, including the interventional radiologist. (See "Severe pelvic fracture in the adult trauma patient" and "Endovascular methods for aortic control in trauma" and "Emergency ultrasound in adults with abdominal and thoracic trauma".)

Orthopedic surgery consultation should be obtained for isolated pelvic injuries following a negative trauma workup. Patients with minor injuries, such as avulsion fractures or isolated fractures of the pubic rami, can be discharged home, provided the patient can move adequately and follow-up is ensured.

Transfer — All trauma patients with significant pelvis injuries should be stabilized and transferred to a regional trauma center, ideally with interventional radiology capability. Complex, isolated pelvis injuries should be transferred for definitive orthopedic care at a level I trauma center, if possible. The mortality and complication rates associated with these injuries are lower when they are managed at level I trauma centers [85].

OUTCOMES — Mortality rates in patients with high-energy pelvic trauma are 10 to 16 percent and depend upon the severity of associated injuries [7]. Morbidity is also related to associated neurologic and genitourinary injuries. Overall, fewer than 50 percent of patients with pelvic injuries requiring operative repair return to their preinjury level of function [86]. Osteoarthritis develops in 26.6 percent of acetabular fractures, while 75.1 percent have a good functional outcome [5].

PEDIATRIC CONSIDERATIONS

Anatomy — Pediatric bones are covered by a thicker periosteum and are more pliable than adult bones. In addition, the ligaments of children are relatively stronger than the adjacent bone, as are the tendons compared with their related apophyses. Due to these differences, avulsion fractures of the pelvis and isolated pelvic ring fractures are more common in children, although the most likely location for such injuries does not differ from adults. Significant force is required for a child to sustain a complete pelvic ring disruption involving the posterior elements. (See 'Avulsion fractures' above and 'Pelvic ring disruptions' above.)

The presence of the triradiate cartilage, a secondary ossification center in the acetabular floor, can make the interpretation of plain radiographs of the pelvis difficult (image 28), but its presence indicates a skeletally immature pelvis. The triradiate cartilage fuses between the ages of 14 to 16.  

Epidemiology and mechanism — Little has been published concerning pediatric pelvic trauma. Pelvic fractures occur less frequently in children than adults, with pelvic ring disruptions and avulsion injuries most commonly described. The reported incidence of pelvic fractures among children admitted to the hospital following blunt trauma ranges from 2.4 to 7.5 percent [87,88]. According to one review that included 124 children with pelvic fractures, patients with such injuries represent 1.6 percent of all pediatric trauma admissions [87]. However, the true incidence of pediatric pelvic fractures is most likely higher, as suggested by a postmortem study of 66 blunt pediatric trauma deaths that found 93 percent had sustained posterior pelvic ring injuries [89]. In the review cited above, mortality among children with non-avulsion pelvic fractures was 5 percent. Unlike adults, children die less often from pelvic hemorrhage but more often from concomitant injuries [90].

With the exception of avulsion injuries, pediatric pelvic fractures generally result from high-energy mechanisms, most often involving a child being struck by a motor vehicle (57.8 percent), followed by motor vehicle crashes (17.8 percent) [91].

Avulsion fractures of the pelvis are more common in children and adolescents than adults and generally occur from less severe mechanisms, often sports-related trauma (eg, football [soccer]) [92,93]. Published studies likely under-represent avulsion fractures as children with these injuries typically do not require hospital admission. In a review of 719 cases of pelvic or hip avulsion fracture, the average patient age was just over 14 years, and nearly 80 percent occurred in males [93]. Common sites included the anterior superior and inferior iliac spines, lesser tuberosity of the femur, iliac crest, and ischial tuberosity; and most injuries were sustained while the patient was running or kicking.

Associated injuries — With the exception of avulsion fractures, pediatric pelvic fractures result from high-energy mechanisms that often cause significant concomitant injury. The rate of associated injury increases with the severity of the pelvic fracture, but data are limited, and thus it is difficult to characterize precisely which injuries occur and how frequently. Concomitant injuries may include the following:

Hemorrhage – Life-threatening hemorrhage caused directly by pelvic fractures is uncommon in children, occurring in less than 2 percent of cases according to one review [91]. However, bleeding from associated injuries does occur, as shown in one series in which 30 percent of patients required a blood transfusion [87]. The sites of bleeding are primarily intra-abdominal (eg, liver, spleen) and thoracic [91].

Head injuries – Head injuries, ranging from facial lacerations to intracranial hemorrhage, occur in as many as 40 percent of children with pelvic fractures [87]. In one series of 39 children with pelvic ring fractures, approximately 8 percent of associated head trauma involved parenchymal brain injury, and 10 percent were skull fractures [94].

Chest/abdomen – Approximately 15 to 33 percent of children with pelvic fractures sustain some type of thoracic or abdominal injury [87,91]. A retrospective review comparing over 7000 adult and pediatric pelvic fracture patients did not find a correlation between higher-grade pelvic fractures and the severity of spleen or hepatic injuries in children but did report a significantly higher rate of rectal injury among children with pelvic fractures [95].

Genitourinary – According to a systematic review of studies involving over 1000 total pediatric pelvic injuries, the overall incidence of genitourinary injury associated with pelvic trauma is 11 to 12 percent, including urethra (26.4 percent), vagina (14.9 percent), bladder (10.7 percent), and rectum (10.7 percent) [91]. As pelvic ring injuries become more extensive, the incidence of genitourinary injury increases to approximately 40 to 50 percent.

Neurologic – The incidence of neurologic injury to the lumbosacral plexus is lower than adults, ranging from approximately 0.8 to 6.1 percent [91]. The incidence of concomitant spinal cord injury is approximately 3.2 percent [91]. Overall, the range of concomitant neurologic injuries sustained by children with severe pelvic trauma is similar to adults.

Extremity – Fractures of the femur and tibia are the extremity injuries most often associated with pelvic trauma, occurring in approximately 18 and 10.7 percent of cases, respectively [91].

Imaging studies and fracture types — Plain radiographs have limited sensitivity for detecting pediatric pelvic fractures, ranging from approximately 50 to 80 percent [64,96,97]. Two groups have proposed decision rules for obtaining pelvic radiographs in pediatric trauma patients, but these have yet to be validated [98,99].

Computed tomography (CT) scan remains the gold standard for pelvic fracture diagnosis and assessment, but its advantages should be weighed against the long-term risks of cumulative radiation exposure in children. No definitive guidelines exist for CT scan indications; however, we recommend CT scan imaging for patients with pelvic ring injuries found on plain radiographs to better assess posterior involvement and for patients requiring further evaluation for abdominal trauma (eg, signs associated with intra-abdominal injury present on examination or ultrasound). In addition, CT imaging is warranted in patients with findings consistent with an unstable pelvis. Isolated avulsion fractures identified by plain radiograph generally do not warrant additional imaging with CT. (See "Radiation-related risks of imaging" and "Pediatric blunt abdominal trauma: Initial evaluation and stabilization".)

Most pelvic avulsion fractures can be diagnosed by plain radiograph. Magnetic resonance imaging (MRI) can be obtained if radiographs are indeterminate or there is high clinical suspicion despite negative plain radiographs [100].

Several classification schemes have been used for pediatric pelvic fractures, including Tile, Young-Burgess, and Torode and Zeig. The modified Torode and Zeig classification includes four types of pelvic injuries:

Type I – Avulsion injury

Type II – Iliac wing fracture

Type III – Simple ring fracture (stable)

Type IV – Unstable ring disruption

This system uses CT for better assessment of the posterior pelvic structures. Based upon the CT results, pelvic ring fractures are described as either IIIA (isolated anterior ring fractures) or IIIB (involving anterior and posterior ring, stable). Stable fractures are defined by pelvic stability with manual compression and less than 2 mm of displacement on CT. According to a retrospective study of 124 children with pelvic fractures, patients with type IIIB injuries were three times more likely to require intensive care unit admission and 3.5 times more likely to require a blood transfusion than patients with type IIIA injuries [87].

Acetabular fractures in young children pose another diagnostic challenge. The three bones that fuse to form the acetabulum (ischia, iliac, and pubic bones) form a growth plate called the triradiate physis. Prior to the ossification of this physis (which occurs at approximately 12 to 14 years of age), articular injuries may be difficult to diagnose on plain radiographs. Failure to diagnose these fractures may impair the growth of the acetabulum, resulting in dysplasia or lateral displacement. Therefore, focal hip pain in children related to trauma without a clear source on plain radiographs should be evaluated by a pediatric orthopedic specialist and advanced imaging (CT or MRI) [101,102].

Evaluation and management — The initial evaluation and management of pediatric pelvic trauma is similar to that performed in adults. Assessment and stabilization of the airway and breathing, circulation, and concomitant life-threatening injuries take precedence. (See 'Initial management' above and "Trauma management: Approach to the unstable child" and "Trauma management: Overview of unique pediatric considerations".)

Debate continues about the definitive surgical management of major pediatric pelvic fractures. In all cases, orthopedic consultation should be obtained and transfer made to a tertiary care center as needed.

Management of avulsion fractures of the pelvis is generally conservative [100,103,104]. Typically, the patient remains nonweightbearing or partial weightbearing with crutches during the initial two to three weeks following injury. Orthopedic surgery consultation is generally obtained for any avulsion fracture with fragment displacement greater than 15 mm. Limited evidence suggests that surgery may provide some benefit in ability to return to sport [104]. The average time needed to return to sport ranges from 44 to 62 days [100,103,104].

Outcomes — Outcome data regarding pediatric pelvic fracture are limited due to a lack of uniform treatment protocols and long-term follow-up. According to one review, over 30 percent of children will have some residual pain, limp, or scoliosis [105].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Pelvic trauma" and "Society guideline links: Lower extremity (excluding hip) fractures in adults" and "Society guideline links: Genitourinary tract trauma in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

Basics topic (see "Patient education: Pelvic fracture (The Basics)")

SUMMARY AND RECOMMENDATIONS

Mechanism of injury – Most pelvis injuries in non-geriatric patients require a significant amount of force. The most common mechanisms include motor vehicle collisions and pedestrians struck by a motor vehicle. Associated injuries are frequent, with the most common and worrisome being hemorrhage. (See 'Epidemiology' above and 'Anatomy' above.)

Pelvic fracture types include ring disruptions, sacral fractures, acetabular fractures, and avulsion injuries. Significant hemorrhage may accompany any fracture pattern. Classification schemes with example imaging studies are provided in the text. (See 'Fracture types' above.)

Physical examination findings associated with an increased risk of pelvic injury include:

Abnormal position of lower extremities

Flank, perineal, or scrotal ecchymosis

Tenderness over the bony pelvis, especially the sacrum and sacroiliac joints

Focal lower extremity weakness or diminished sensation

Hematuria or bleeding from the rectum or vagina

Physical examination cannot be relied upon to detect significant pelvis injuries in the patient who is severely injured, intubated, or manifesting an altered mental status. Examination of the pelvis to assess stability should be performed once and gently to avoid displacement of fractures and increased bleeding. (See 'Clinical features' above.)

Ultrasound examination – A bedside ultrasound examination (ie, focused assessment with sonography in trauma [FAST]) is performed in the great majority of blunt trauma patients. Its primary role in pelvic trauma is to determine the presence of abdominal injury and to help guide management. (See 'Ultrasound' above.)

Plain radiograph indications – A plain radiograph of the pelvis is obtained in hemodynamically unstable patients; its utility in stable patients and those undergoing computed tomography (CT) is negligible. We do not routinely obtain a plain radiograph in patients who meet the following criteria:

Glasgow Coma Scale score >13

No pelvic, abdominal, or back complaints

No tenderness in the lower abdomen, lower back, groin, or bony pelvis (see 'Plain radiograph' above)

CT imaging – Multidetector CT scan remains the preferred method for the evaluation of all hemodynamically stable patients with pelvic trauma. (See 'Computed tomography' above.)

Stabilization of injured pelvis – Significant pelvis injuries should be immobilized using either a sheet (picture 3 and picture 1) or a commercial pelvic binder (picture 2) wrapped circumferentially around the greater trochanters. The goal is to stabilize injuries; over-reduction of fractures by wrapping too tightly must be avoided. (See 'Pelvis injury' above.)

Management algorithm – An algorithm for the management of blunt trauma patients with a significant pelvic fracture is provided (algorithm 1). Initial management of unstable patients is as follows:

Hemodynamically unstable patients with a positive FAST examination are assumed to have major pelvic and abdominal injuries and are treated with emergency laparotomy, pelvic stabilization, and preperitoneal packing.

Hemodynamically unstable patients with a negative FAST examination are assumed to have significant hemorrhage from their pelvic injuries without concomitant abdominal injury. Options for initial hemorrhage control include pelvic stabilization, preperitoneal packing, and resuscitative endovascular balloon occlusion of the aorta (REBOA).  

For patients who remain unstable, pelvic angiography can be used to manage arterial injuries. (See 'Management' above and "Severe pelvic fracture in the adult trauma patient".)

Pediatric considerations – Major pelvic fractures require orthopedic evaluation. Avulsion fractures of the pelvis and hip, often sustained during running and kicking sports, can generally be managed conservatively. (See 'Pediatric considerations' above.)

Consultation and transfer – Major pelvic injuries require early consultation with trauma and orthopedic surgery or expeditious transfer to a regional trauma center. Early notification of the operating room and angiography suite staff, including the interventional radiologist, can save valuable time in the hemodynamically unstable patients with a pelvic fracture. (See 'Definitive management' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges James Fiechtl, MD, who contributed to an earlier version of this topic review.

  1. Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005; 36:1.
  2. Yoshihara H, Yoneoka D. Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: trends and in-hospital mortality. J Trauma Acute Care Surg 2014; 76:380.
  3. Vaidya R, Scott AN, Tonnos F, et al. Patients with pelvic fractures from blunt trauma. What is the cause of mortality and when? Am J Surg 2016; 211:495.
  4. Costantini TW, Coimbra R, Holcomb JB, et al. Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg 2016; 80:717.
  5. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br 2005; 87:2.
  6. Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg 2005; 190:830.
  7. Hauschild O, Strohm PC, Culemann U, et al. Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma 2008; 64:449.
  8. Cannada LK, Taylor RM, Reddix R, et al. The Jones-Powell Classification of open pelvic fractures: a multicenter study evaluating mortality rates. J Trauma Acute Care Surg 2013; 74:901.
  9. Giannoudis PV, Grotz MR, Tzioupis C, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma 2007; 63:875.
  10. Dechert TA, Duane TM, Frykberg BP, et al. Elderly patients with pelvic fracture: interventions and outcomes. Am Surg 2009; 75:291.
  11. Sathy AK, Starr AJ, Smith WR, et al. The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients. J Bone Joint Surg Am 2009; 91:2803.
  12. Schulman JE, O'Toole RV, Castillo RC, et al. Pelvic ring fractures are an independent risk factor for death after blunt trauma. J Trauma 2010; 68:930.
  13. Balogh Z, King KL, Mackay P, et al. The epidemiology of pelvic ring fractures: a population-based study. J Trauma 2007; 63:1066.
  14. Laird A, Keating JF. Acetabular fractures: a 16-year prospective epidemiological study. J Bone Joint Surg Br 2005; 87:969.
  15. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 2002; 195:1.
  16. Kelsey JL, Prill MM, Keegan TH, et al. Risk factors for pelvis fracture in older persons. Am J Epidemiol 2005; 162:879.
  17. Kimbrell BJ, Velmahos GC, Chan LS, Demetriades D. Angiographic embolization for pelvic fractures in older patients. Arch Surg 2004; 139:728.
  18. Martin S, Casey N. Haemorrhage requiring embolisation after low energy pelvic fracture in an elderly patient: a case report. Emerg Med J 2010; 27:722.
  19. Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma 2007; 21:31.
  20. Porter SE, Schroeder AC, Dzugan SS, et al. Acetabular fracture patterns and their associated injuries. J Orthop Trauma 2008; 22:165.
  21. Kocher MS, Tucker R. Pediatric athlete hip disorders. Clin Sports Med 2006; 25:241.
  22. Stein DM, O'Connor JV, Kufera JA, et al. Risk factors associated with pelvic fractures sustained in motor vehicle collisions involving newer vehicles. J Trauma 2006; 61:21.
  23. Rowe SA, Sochor MS, Staples KS, et al. Pelvic ring fractures: implications of vehicle design, crash type, and occupant characteristics. Surgery 2004; 136:842.
  24. Gänsslen A, Giannoudis P, Pape HC. Hemorrhage in pelvic fracture: who needs angiography? Curr Opin Crit Care 2003; 9:515.
  25. Magnussen RA, Tressler MA, Obremskey WT, Kregor PJ. Predicting blood loss in isolated pelvic and acetabular high-energy trauma. J Orthop Trauma 2007; 21:603.
  26. Elzik ME, Dirschl DR, Dahners LE. Hemorrhage in pelvic fractures does not correlate with fracture length. J Trauma 2008; 65:436.
  27. Salim A, Teixeira PG, DuBose J, et al. Predictors of positive angiography in pelvic fractures: a prospective study. J Am Coll Surg 2008; 207:656.
  28. Carrillo EH, Wohltmann CD, Spain DA, et al. Common and external iliac artery injuries associated with pelvic fractures. J Orthop Trauma 1999; 13:351.
  29. Pascarella R, Del Torto M, Politano R, et al. Critical review of pelvic fractures associated with external iliac artery lesion: a series of six cases. Injury 2014; 45:374.
  30. Tanizaki S, Maeda S, Ishida H, et al. Clinical characteristics of external iliac artery branch injury in pelvic trauma. Am J Emerg Med 2017; 35:1636.
  31. Duane TM, Tan BB, Golay D, et al. Blunt trauma and the role of routine pelvic radiographs: a prospective analysis. J Trauma 2002; 53:463.
  32. Bjurlin MA, Fantus RJ, Mellett MM, Goble SM. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. J Trauma 2009; 67:1033.
  33. Weis EB Jr. Subtle neurological injuries in pelvic fractures. J Trauma 1984; 24:983.
  34. Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988; 227:67.
  35. Schmal H, Hauschild O, Culemann U, et al. Identification of risk factors for neurological deficits in patients with pelvic fractures. Orthopedics 2010; 33.
  36. Bramos A, Velmahos GC, Butt UM, et al. Predictors of bleeding from stable pelvic fractures. Arch Surg 2011; 146:407.
  37. Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 1990; 30:848.
  38. Sarin EL, Moore JB, Moore EE, et al. Pelvic fracture pattern does not always predict the need for urgent embolization. J Trauma 2005; 58:973.
  39. Lunsjo K, Tadros A, Hauggaard A, et al. Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients. J Trauma 2007; 62:687.
  40. Manson T, O'Toole RV, Whitney A, et al. Young-Burgess classification of pelvic ring fractures: does it predict mortality, transfusion requirements, and non-orthopaedic injuries? J Orthop Trauma 2010; 24:603.
  41. Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res 1980; :81.
  42. Lustenberger T, Walcher F, Lefering R, et al. The Reliability of the Pre-hospital Physical Examination of the Pelvis: A Retrospective, Multicenter Study. World J Surg 2016; 40:3073.
  43. Bakhshayesh P, Risling DH, Enocson A. Three Dimensional Quality Assessments of Applied Pelvic Binders. Bull Emerg Trauma 2019; 7:156.
  44. Williamson F, Coulthard LG, Hacking C, Martin-Dines P. Identifying risk factors for suboptimal pelvic binder placement in major trauma. Injury 2020; 51:971.
  45. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma 2005; 59:1314.
  46. Shlamovitz GZ, Mower WR, Bergman J, et al. How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients? J Trauma 2009; 66:815.
  47. Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg 2002; 194:121.
  48. McCormick JP, Morgan SJ, Smith WR. Clinical effectiveness of the physical examination in diagnosis of posterior pelvic ring injuries. J Orthop Trauma 2003; 17:257.
  49. Pehle B, Nast-Kolb D, Oberbeck R, et al. [Significance of physical examination and radiography of the pelvis during treatment in the shock emergency room]. Unfallchirurg 2003; 106:642.
  50. Leggon RE, Wood GC, Indeck MC. Pelvic fractures in pregnancy: factors influencing maternal and fetal outcomes. J Trauma 2002; 53:796.
  51. Ballard RB, Rozycki GS, Newman PG, et al. An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. Focused Assessment for the Sonographic Examination of the Trauma patient. J Am Coll Surg 1999; 189:145.
  52. Christian NT, Burlew CC, Moore EE, et al. The focused abdominal sonography for trauma examination can reliably identify patients with significant intra-abdominal hemorrhage in life-threatening pelvic fractures. J Trauma Acute Care Surg 2018; 84:924.
  53. Tran TL, Brasel KJ, Karmy-Jones R, et al. Western Trauma Association Critical Decisions in Trauma: Management of pelvic fracture with hemodynamic instability-2016 updates. J Trauma Acute Care Surg 2016; 81:1171.
  54. Chaijareenont C, Krutsri C, Sumpritpradit P, et al. FAST accuracy in major pelvic fractures for decision-making of abdominal exploration: Systematic review and meta-analysis. Ann Med Surg (Lond) 2020; 60:175.
  55. Schwed AC, Wagenaar A, Reppert AE, et al. Trust the FAST: Confirmation that the FAST examination is highly specific for intra-abdominal hemorrhage in over 1,200 patients with pelvic fractures. J Trauma Acute Care Surg 2021; 90:137.
  56. Tayal VS, Nielsen A, Jones AE, et al. Accuracy of trauma ultrasound in major pelvic injury. J Trauma 2006; 61:1453.
  57. Verbeek DO, Zijlstra IA, van der Leij C, et al. The utility of FAST for initial abdominal screening of major pelvic fracture patients. World J Surg 2014; 38:1719.
  58. Friese RS, Malekzadeh S, Shafi S, et al. Abdominal ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture. J Trauma 2007; 63:97.
  59. Yeung LL, McDonald AA, Como JJ, et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2019; 86:326.
  60. Gomez RG, Ceballos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int 2004; 94:27.
  61. Kessel B, Sevi R, Jeroukhimov I, et al. Is routine portable pelvic X-ray in stable multiple trauma patients always justified in a high technology era? Injury 2007; 38:559.
  62. Vo NJ, Gash J, Browning J, Hutson RK. Pelvic imaging in the stable trauma patient: is the AP pelvic radiograph necessary when abdominopelvic CT shows no acute injury? Emerg Radiol 2004; 10:246.
  63. Paydar S, Ghaffarpasand F, Foroughi M, et al. Role of routine pelvic radiography in initial evaluation of stable, high-energy, blunt trauma patients. Emerg Med J 2013; 30:724.
  64. Obaid AK, Barleben A, Porral D, et al. Utility of plain film pelvic radiographs in blunt trauma patients in the emergency department. Am Surg 2006; 72:951.
  65. Barleben A, Jafari F, Rose J Jr, et al. Implementation of a cost-saving algorithm for pelvic radiographs in blunt trauma patients. J Trauma 2011; 71:582.
  66. Gardner MJ, Krieg JC, Simpson TS, Bottlang M. Displacement after simulated pelvic ring injuries: a cadaveric model of recoil. J Trauma 2010; 68:159.
  67. Starks I, Frost A, Wall P, Lim J. Is a fracture of the transverse process of L5 a predictor of pelvic fracture instability? J Bone Joint Surg Br 2011; 93:967.
  68. Parry JA, Salameh M, Maher MH, et al. The Lateral Stress Radiograph Identifies Occult Instability of Lateral Compression Pelvic Ring Injuries Without Sedation. J Orthop Trauma 2020; 34:567.
  69. Parry JA, Salameh M, Funk A, et al. Mobilization versus displacement on lateral stress radiographs for determining operative fixation of minimally displaced lateral compression type I (LC1) pelvic ring injuries. Int Orthop 2021; 45:1625.
  70. Mohseni S, Talving P, Kobayashi L, et al. The diagnostic accuracy of 64-slice computed tomography in detecting clinically significant arterial bleeding after pelvic fractures. Am Surg 2011; 77:1176.
  71. Dormagen JB, Tötterman A, Røise O, et al. Efficacy of plain radiography and computer tomography in localizing the site of pelvic arterial bleeding in trauma patients. Acta Radiol 2010; 51:107.
  72. Lee MJ, Wright A, Cline M, et al. Pelvic Fractures and Associated Genitourinary and Vascular Injuries: A Multisystem Review of Pelvic Trauma. AJR Am J Roentgenol 2019; 213:1297.
  73. Dreizin D, Nascone J, Davis DL, et al. Can MDCT Unmask Instability in Binder-Stabilized Pelvic Ring Disruptions? AJR Am J Roentgenol 2016; 207:1244.
  74. Davis JW, Moore FA, McIntyre RC Jr, et al. Western trauma association critical decisions in trauma: management of pelvic fracture with hemodynamic instability. J Trauma 2008; 65:1012.
  75. Burlew CC, Moore EE, Smith WR, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg 2011; 212:628.
  76. Magnone S, Coccolini F, Manfredi R, et al. Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery). World J Emerg Surg 2014; 9:18.
  77. Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review. J Trauma 2011; 71:1850.
  78. DuBose JJ, Burlew CC, Joseph B, et al. Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control. J Trauma Acute Care Surg 2021; 91:e93.
  79. Stengel D, Leisterer J, Ferrada P, et al. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. Cochrane Database Syst Rev 2018; 12:CD012669.
  80. Gardner MJ, Parada S, Chip Routt ML Jr. Internal rotation and taping of the lower extremities for closed pelvic reduction. J Orthop Trauma 2009; 23:361.
  81. Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma 2002; 16:45.
  82. Rajab TK, Weaver MJ, Havens JM. Videos in clinical medicine. Technique for temporary pelvic stabilization after trauma. N Engl J Med 2013; 369:e22.
  83. Lee C, Porter K. The prehospital management of pelvic fractures. Emerg Med J 2007; 24:130.
  84. Krieg JC, Mohr M, Ellis TJ, et al. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma 2005; 59:659.
  85. Oliphant BW, Tignanelli CJ, Napolitano LM, et al. American College of Surgeons Committee on Trauma verification level affects trauma center management of pelvic ring injuries and patient mortality. J Trauma Acute Care Surg 2019; 86:1.
  86. Durkin A, Sagi HC, Durham R, Flint L. Contemporary management of pelvic fractures. Am J Surg 2006; 192:211.
  87. Shore BJ, Palmer CS, Bevin C, et al. Pediatric pelvic fracture: a modification of a preexisting classification. J Pediatr Orthop 2012; 32:162.
  88. Demetriades D, Karaiskakis M, Velmahos GC, et al. Pelvic fractures in pediatric and adult trauma patients: are they different injuries? J Trauma 2003; 54:1146.
  89. Keshishyan RA, Rozinov VM, Malakhov OA, et al. Pelvic polyfractures in children. Radiographic diagnosis and treatment. Clin Orthop Relat Res 1995; :28.
  90. Ismail N, Bellemare JF, Mollitt DL, et al. Death from pelvic fracture: children are different. J Pediatr Surg 1996; 31:82.
  91. Gänsslen A, Hildebrand F, Heidari N, Weinberg AM. Pelvic ring injuries in children. Part I: Epidemiology and primary evaluation. A review of the literature. Acta Chir Orthop Traumatol Cech 2012; 79:493.
  92. Ortega HW, Reid S, Velden HV, et al. Patterns of injury and management of children with pelvic fractures at a non-trauma center. J Emerg Med 2014; 47:140.
  93. Ferraro SL, Batty M, Heyworth BE, et al. Acute Pelvic and Hip Apophyseal Avulsion Fractures in Adolescents: A Summary of 719 Cases. J Pediatr Orthop 2023; 43:204.
  94. Leonard M, Ibrahim M, Mckenna P, et al. Paediatric pelvic ring fractures and associated injuries. Injury 2011; 42:1027.
  95. Swaid F, Peleg K, Alfici R, et al. A comparison study of pelvic fractures and associated abdominal injuries between pediatric and adult blunt trauma patients. J Pediatr Surg 2017; 52:386.
  96. Guillamondegui OD, Mahboubi S, Stafford PW, Nance ML. The utility of the pelvic radiograph in the assessment of pediatric pelvic fractures. J Trauma 2003; 55:236.
  97. Kwok MY, Yen K, Atabaki S, et al. Sensitivity of plain pelvis radiography in children with blunt torso trauma. Ann Emerg Med 2015; 65:63.
  98. Lagisetty J, Slovis T, Thomas R, et al. Are routine pelvic radiographs in major pediatric blunt trauma necessary? Pediatr Radiol 2012; 42:853.
  99. Wong AT, Brady KB, Caldwell AM, et al. Low-risk criteria for pelvic radiography in pediatric blunt trauma patients. Pediatr Emerg Care 2011; 27:92.
  100. Moeller JL, Galasso L. Pelvic Region Avulsion Fractures in Adolescent Athletes: A Series of 242 Cases. Clin J Sport Med 2022; 32:e23.
  101. McDonnell M, Schachter AK, Phillips DP, Liporace FA. Acetabular fracture through the triradiate cartilage after low-energy trauma. J Orthop Trauma 2007; 21:495.
  102. de Ridder VA, Olson SA. Operative Treatment of Pediatric Pelvic and Acetabulum Fractures. J Orthop Trauma 2019; 33 Suppl 8:S33.
  103. Moeller JL. Pelvic Avulsion Fractures in Adolescent Athletes: Analyzing the Effect of Delay in Diagnosis. Clin J Sport Med 2022; 32:368.
  104. Eberbach H, Hohloch L, Feucht MJ, et al. Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC Musculoskelet Disord 2017; 18:162.
  105. Smith WR, Oakley M, Morgan SJ. Pediatric pelvic fractures. J Pediatr Orthop 2004; 24:130.
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