Pelvic Fractures: Diagnosis

• Pelvic fractures can result from high-energy trauma in younger individuals or low-energy trauma such as falls in the elderly.
• Fracture patterns include lateral compression, vertical shear, and anteroposterior compression.

Clinical Features

• Symptoms include pain and inability to bear weight.
• Local swelling, tenderness, and lower extremity deformity may be present.
• Pelvic instability is a key sign.

Investigations

• X-rays should include AP pelvis, inlet and outlet views, and Judet views for acetabular fractures.
• Judet views include obturator and iliac oblique views.
• There are 6 cardinal radiographic lines of the acetabulum to assess.
• The 6 cardinal radiographic lines are: ilioischial line, iliopectineal line, teardrop, roof, posterior rim, and anterior rim.
• CT scans are valuable for evaluating posterior pelvic injuries and acetabular fractures.
• Assess for genitourinary injury via rectal exam, vaginal exam, and evaluation for hematuria or blood at the urethral meatus.
• Involvement of genitourinary structures signifies an open fracture.

Tile Classification of Pelvic Fractures

Type A

• Rotationally stable and vertically stable.
• A1: Fractures not involving the pelvic ring, such as avulsion or iliac wing fractures.
• A2: Minimally displaced fractures of the pelvic ring, like ramus fractures.
• A3: Transverse sacral fractures.

Type B

• Rotationally unstable but vertically stable.
• B1: Open book fracture (external rotation).
• B2: Lateral compression, ipsilateral.
• B2-1: With anterior ring rotation/displacement through ipsilateral rami.
• B2-2: With anterior ring rotation/displacement through non-ipsilateral rami (bucket-handle).
• B3: Bilateral.

Type C

• Rotationally and vertically unstable.
• C1: Unilateral.
• C1-1: iliac fracture, C1-2: sacroiliac fracture-dislocation, C1-3: sacral fracture
• C2: Bilateral, with one side Type B and one side Type C.
• C3: Bilateral, both sides Type C.

Treatment

• Initial management focuses on ABCDEs (Airway, Breathing, Circulation, Disability, Exposure).
• Non-operative treatment includes protected weight-bearing and is suitable for stable fractures.
• Elderly patients with fractures from falls may be candidates for non-operative management.
• Emergency management involves IV fluids/blood, pelvic binder/sheeting, external fixation or emergent angiography/embolization.
• Laparotomy may be necessary if FAST/DPL is positive.
• Operative treatment includes open reduction and internal fixation (ORIF).
• Indications for operative treatment are: unstable pelvic ring injury, disruption of anterior and posterior SI ligaments, symphysis diastasis >2.5 cm, vertical instability of the posterior pelvis, and open fractures.

Specific Complications

• Hemorrhage can be life-threatening.
• Injury to rectum or urogenital structures can occur.
• Obstetrical difficulties, sexual and voiding dysfunction can result.
• Persistent SI joint pain is a potential complication.
• Post-traumatic arthritis of the hip can occur with acetabular fractures.
• There is a high risk of DVT/PE.