Pelvic Fractures (Adult)

1. Clinical Overview

Summary

Pelvic fractures represent the most lethal orthopaedic injury encountered in trauma, with mortality rates ranging from 10% in stable fractures to 40-50% in open fractures. [1,2] The pelvis is an osseoligamentous ring structure; for significant displacement to occur, disruption must occur at two or more sites (or one fracture with ligamentous injury). Hemorrhage is the primary cause of death, predominantly from the low-pressure presacral venous plexus (85% of cases), though arterial injury from branches of the internal iliac artery accounts for 15% and carries a significantly higher mortality. [3,4] Management priorities focus on immediate mechanical stabilization (pelvic binder), aggressive resuscitation (damage control resuscitation with 1:1:1 transfusion ratios), and definitive hemorrhage control (angioembolization or preperitoneal packing). [5,6]

Key Facts

• The Killer: Hemorrhagic shock from retroperitoneal bleeding. The retroperitoneal space can accommodate > 4 litres of blood before tamponade effect limits further accumulation. [1]
• The Source: Venous bleeding (85%) from the presacral venous plexus vs arterial bleeding (15%) from internal iliac branches. Venous hemorrhage responds to mechanical pelvic volume reduction (binder/external fixation). Arterial bleeding requires angioembolization. [3,4]
• The Binder: Must be applied at the level of the greater trochanters, NOT the iliac crests. Incorrect high placement can paradoxically worsen posterior disruption by acting as a fulcrum. [7]
• Open Fractures: Any communication with rectum, vagina, or perineal skin constitutes an open pelvic fracture. Mandatory digital rectal examination (DRE) and speculum examination in females. Mortality approaches 40-50% due to sepsis. [8,9]
• Classification Predicts Mortality: Young-Burgess classification correlates with transfusion requirements and mortality. Vertical shear (VS) and combined mechanism (CM) patterns have highest mortality. [10]

Clinical Pearls

"Do Not Rock the Pelvis": The traditional "springing the pelvis" maneuver to assess stability is ABSOLUTELY CONTRAINDICATED in trauma. This dislodges the fragile clot at the presacral venous plexus and can precipitate torrential hemorrhage. A single gentle palpation is acceptable; if instability is detected, apply binder immediately and avoid further manipulation. [7]

"Destot's Sign": Hematoma tracking over the scrotum (males), labia majora (females), inguinal ligament, or anterior abdominal wall. Indicates disruption of the pelvic floor fascial planes and significant retroperitoneal bleeding tracking inferiorly. High specificity for major pelvic trauma. [11]

**"Corona Mortis"

• The Crown of Death**: An aberrant anastomotic vessel connecting the external iliac (obturator branch) and internal iliac arterial systems, running across the superior pubic ramus 4-6 cm lateral to symphysis. Present in 10-40% of patients. If lacerated during fracture displacement or surgical approach, causes rapid, difficult-to-control hemorrhage as the vessel retracts into the pelvis. [12]

"Pelvic Binder Contraindication": Lateral compression (LC) fractures with significant internal rotation may be worsened by circumferential compression. If the mechanism clearly suggests LC pattern, binder should be applied loosely or imaging obtained rapidly. In hemodynamically unstable patients with uncertain mechanism, apply binder empirically. [7]

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2. Epidemiology

Demographics

• Incidence: Pelvic fractures account for 2-8% of all skeletal fractures, but represent a disproportionate burden of trauma mortality. [1]
• Bimodal Distribution:
  • Young Adults (16-40 years): High-energy trauma (motor vehicle collision, motorcycle crash, pedestrian vs vehicle, fall from height). These patients present with complex, unstable fracture patterns and polytrauma.
  • Elderly (> 65 years): Low-energy falls (ground-level or from standing height). Lateral compression (LC-I) fractures are most common. Represent highest volume but lower mortality. [1,2]

Mortality

• Mortality in hemodynamically unstable patients: 30% overall, with 90.9% of potentially survivable deaths due to hemorrhage. [1,2]
• Predictors of mortality: Injury Severity Score (ISS), base deficit, lactate, transfusion requirement in first 24 hours, Glasgow Coma Scale (GCS), age. [2]

Mechanisms

[10,13]

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3. Aetiology and Pathophysiology

Anatomy of the Pelvic Ring

The pelvis is a closed osteoligamentous ring composed of:

• Bones: Two innominate bones (each comprising ilium, ischium, pubis) and the sacrum.
• Joints: Sacroiliac (SI) joints (synovial anteriorly, fibrous posteriorly), symphysis pubis (fibrocartilaginous).

Key Ligaments

Vascular Anatomy

• Arterial Supply:

  • Internal Iliac Artery and branches:
    • Superior Gluteal Artery (most commonly injured in APC patterns; exits through greater sciatic foramen). [4,14]
    • Inferior Gluteal Artery
    • Obturator Artery
    • Pudendal Artery
    • Lateral Sacral Arteries
  • External Iliac Artery (rarely injured unless direct trauma)
  • Corona Mortis: Aberrant anastomosis between obturator (internal iliac) and external iliac systems. Present in 10-40% of individuals. [12]

• Venous Drainage:

  • Presacral Venous Plexus: Dense network adherent to anterior sacrum and posterior pelvis. Lacerations occur with sacroiliac joint disruption or sacral fractures. Accounts for 85% of pelvic hemorrhage. [3,4]
  • Internal Iliac Veins

Hemorrhage Pathophysiology

Exam Detail: #### Mechanism of Bleeding

1. Venous Hemorrhage (85%): [3,4]

   • Presacral venous plexus disruption
   • Low-pressure, high-volume bleeding
   • Responds to mechanical reduction of pelvic volume (binder, external fixation)
   • Tamponade effect when retroperitoneal pressure rises

2. Arterial Hemorrhage (15%): [4,14]

   • Internal iliac artery branch laceration
   • High-pressure, rapidly fatal
   • Requires angioembolization or surgical ligation
   • Contrast "blush" on CT scan diagnostic

3. Bone Bleeding: Cancellous bone surfaces contribute significantly to overall blood loss

Volume of Blood Loss

• Retroperitoneal space capacity: > 4 litres before tamponade
• Average blood loss:
  • "Stable fractures (LC-I, APC-I): 500-1500 mL"
  • "Unstable fractures (APC-III, VS): 2000-5000 mL"
  • "Open fractures: Often exsanguinating"

"Lethal Triad" of Trauma

Pelvic fractures with hemorrhagic shock frequently trigger the lethal triad:

1. Hypothermia (less than 35°C): Impairs coagulation cascade
2. Acidosis (pH less than 7.2, base deficit >-6): Impairs platelet function
3. Coagulopathy (INR > 1.5, fibrinogen less than 1.5 g/L): Consumptive + dilutional

Classification Systems

1. Young-Burgess (Mechanism-Based)

The Young-Burgess classification is based on the force vector and predicts associated injuries, resuscitation needs, and mortality. [10,13]

Anteroposterior Compression (APC) - "The Open Book"

Force applied anteroposteriorly (head-on collision, run-over). Symphysis widens; pelvis "opens."

Lateral Compression (LC) - "The Crush"

Force applied from the side (T-bone collision, pedestrian struck). Affected hemipelvis rotates internally.

Clinical Pearl: LC fractures with severe internal rotation may be worsened by pelvic binder. If clinical suspicion is high, consider gentle application or rapid imaging. [7]

Vertical Shear (VS)

Entire hemipelvis displaces cranially (fall from height landing on one leg). Complete ligamentous disruption.

Clinical Pearl: VS is the most unstable fracture pattern. 100% require surgical stabilization. Look for leg length discrepancy and associated lumbosacral plexus injury. [10]

Combined Mechanism (CM)

Multiple force vectors. Highly variable. Highest mortality in some series. [10]

2. Tile/AO-OTA Classification (Stability-Based)

3. Letournel Classification (for Acetabular Fractures)

(Not covered in detail here; see separate acetabular fracture topic)

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4. Clinical Presentation

History

• Mechanism: High-energy (MVC, motorcycle, pedestrian vs vehicle, fall from height > 3 meters) vs low-energy (ground-level fall in elderly).
• Pain: Severe pain in pelvis, lower back, hips, or groin. Inability to bear weight.
• Shock symptoms: Lightheadedness, confusion, loss of consciousness.
• Urinary symptoms: Inability to void, blood in urine (hematuria), blood at urethral meatus.
• Bowel symptoms: Rectal bleeding (indicates open fracture).

Symptoms

• Pain: Severe pelvic, lower back, hip, or groin pain. Exacerbated by movement or leg motion.
• Shock: Tachycardia, hypotension, confusion, agitation (Class III/IV hemorrhagic shock).
• Urinary retention: Inability to pass urine (urethral injury, bladder injury, neurogenic).
• Incontinence: Fecal or urinary incontinence (neurological injury to sacral nerve roots S2-S4).

Signs

General Inspection

• Deformity:
  • Leg length discrepancy: Vertical shear (hemipelvis displaced cranially → apparent shortening).
  • External rotation: Open book (APC) injury.
  • Internal rotation: Lateral compression injury.
• Ecchymosis:
  • Destot's Sign: Hematoma over scrotum, labia majora, inguinal ligament, or suprapubic region. [11]
  • Flank ecchymosis (Grey-Turner sign; less specific).
• Morel-Lavallée Lesion: Closed degloving injury. Palpable fluctuant, boggy swelling over greater trochanter, lateral thigh, or gluteal region. Skin shears away from underlying fascia; space fills with blood, fat, and lymph. High infection risk if not drained before surgery. [15]

Pelvic Examination

Clinical Pearl: Pelvic "Springing" is Contraindicated: One gentle manual palpation of iliac crests to assess stability is acceptable. If instability is detected, DO NOT repeat. Apply pelvic binder immediately. Repeated manipulation dislodges clot and precipitates hemorrhage. [7]

Rectal and Vaginal Examination (Mandatory)

• Digital Rectal Examination (DRE):

  • Blood on glove: Open fracture (rectal perforation by bony spike). [8,9]
  • High-riding prostate: Posterior urethral disruption (prostate displaced cranially).
  • Palpable bony spike: Open fracture.
  • Sphincter tone: Assess sacral nerve roots (S2-S4).

• Vaginal Examination (females):

  • Blood in vaginal vault: Open fracture.
  • Palpable bony spike: Open fracture.
  • Laceration: Open fracture.

Neurological Examination

Pelvic fractures can injure the lumbosacral plexus (L4-S4 roots) or individual nerve roots.

Common injuries:

• L5 root injury: Foot drop, loss of EHL function (cannot extend big toe). Most common. Associated with sacral fractures through S1 foramen.
• Sciatic nerve injury: Combination of common peroneal (foot drop, loss of dorsiflexion/eversion) and tibial (loss of plantarflexion) deficits.
• Pudendal nerve injury: Sexual dysfunction, perineal numbness.

Peripheral Vascular Examination

• Assess distal pulses (dorsalis pedis, posterior tibial).
• Absent pulses: Consider vascular injury (external iliac artery) or compartment syndrome.
• Expanding hematoma in groin: Vascular injury.

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5. Investigations

Imaging

Trauma Series X-Ray (AP Pelvis)

Always obtained in trauma bay for blunt polytrauma patients (ATLS protocol). [7]

What to look for:

• Symphyseal diastasis: > 2.5 cm = instability (APC-II or greater).
• Sacroiliac joint widening: > 5 mm anterior SI joint width = APC injury.
• Shenton's line: Disrupted in acetabular fractures or pubic rami fractures.
• Pubic rami fractures: Anterior disruption (look for second break posteriorly).
• Sacral fractures: Often subtle. Look for disruption of sacral arcuate lines (foraminal lines).
• Iliac wing fractures: Crescent fracture (LC-II).
• Avulsion fractures:
  • L5 transverse process fracture: Sentinel sign for iliolumbar ligament avulsion → unstable posterior injury. [16]
  • Ischial spine avulsion: Sacrospinous ligament avulsion.

Limitations: X-ray underestimates pelvic injury. CT is gold standard.

CT Pelvis with IV Contrast (Gold Standard)

Indications: All hemodynamically stable patients with suspected pelvic fracture. Hemodynamically unstable patients en route to OR/angiography suite if hybrid suite available.

What to look for:

• Fracture pattern: Define Young-Burgess or Tile classification.
• Contrast "blush": Active arterial extravasation. Indication for angioembolization. [4,14]
• Retroperitoneal hematoma: Volume and extent.
• Sacral foraminal fractures: Assess for nerve root injury.
• Associated injuries:
  • Bladder rupture (intraperitoneal vs extraperitoneal)
  • Bowel injury
  • Solid organ injury (liver, spleen, kidney)
  • Lumbar spine fractures

Contrast Blush: Sensitivity 60-85% for arterial injury requiring embolization. Specificity > 90%. [14]

Focused Assessment with Sonography for Trauma (FAST)

• Role: Detect free intraperitoneal fluid (hemoperitoneum) in unstable patients.
• Positive FAST + unstable pelvis: Suggests intra-abdominal source of bleeding (solid organ injury) in addition to pelvic hemorrhage. May require laparotomy AND pelvic hemorrhage control.
• Negative FAST + unstable pelvis: Pelvic hemorrhage is likely source. Proceed to angiography or preperitoneal packing.

Limitation: FAST does not detect retroperitoneal bleeding. Negative FAST with unstable pelvis and shock = pelvic hemorrhage until proven otherwise.

Retrograde Urethrogram (RUG)

Indications:

• Blood at urethral meatus
• High-riding prostate on DRE
• Inability to void
• Gross hematuria with suspicion of urethral injury

Technique: Inject 20-30 mL contrast into urethra via Foley catheter in meatus (do NOT insert catheter). X-ray or fluoroscopy to visualize extravasation.

Findings:

• Posterior urethral disruption: Contrast extravasation at prostatic urethra/membranous urethra junction (urogenital diaphragm).
• Action: Suprapubic catheter (SPG). No Foley catheter. Urology consultation for delayed repair.

Cystogram

Indications: Gross hematuria, pelvic fracture with > 30 RBC/hpf on urinalysis.

Technique: Instill 300-400 mL contrast retrograde via Foley. Obtain AP, lateral, and post-void films.

Findings:

• Intraperitoneal rupture: Contrast outlines bowel loops. Requires surgical repair.
• Extraperitoneal rupture: "Flame-shaped" contrast in pelvis. Foley catheter drainage only (heals spontaneously in 7-14 days).

Laboratory Tests

Initial Labs (All Patients)

Point-of-Care Testing

• Thromboelastography (TEG) / Rotational Thromboelastometry (ROTEM): Viscoelastic assays to guide component transfusion (fibrinogen, platelets, clotting factors). Increasingly used in trauma.

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6. Differential Diagnosis

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7. Management

Prehospital Management

1. Rapid Extrication (if scene safe)
2. Spinal Immobilization (due to high association with spinal injuries)
3. Pelvic Binder Application:
   • Apply if mechanism suggests pelvic injury (high-energy blunt trauma) OR clinical suspicion (pelvic pain, deformity, instability)
   • Level: Greater trochanters (NOT iliac crests) [7]
   • Tightness: Snug, but allow two fingers underneath
   • Device: Commercial binder (T-POD, SAM Pelvic Sling) or improvised (sheet wrapped and clamped)
4. IV Access: Two large-bore IVs (14-16G)
5. Permissive Hypotension: Target SBP 80-90 mmHg (if no traumatic brain injury) until hemorrhage controlled [6]
6. Transport to Major Trauma Centre (MTC): Pelvic fractures require multidisciplinary trauma team

Emergency Department (ED) Management

ATLS Primary Survey

Airway: Secure if GCS less than 8 or hemodynamically unstable

Breathing: Assess for associated chest injuries (rib fractures, pneumothorax, hemothorax)

Circulation:

1. Pelvic Binder: Apply immediately if not done prehospital [7]
2. IV Access: Two large-bore IVs or central venous access
3. Bloods: FBC, lactate, VBG, coagulation, type and crossmatch, fibrinogen
4. Fluid Resuscitation:
   • Permissive Hypotension: Target SBP 80-90 mmHg (MAP 60-65) until hemorrhage controlled [6]
   • Avoid excessive crystalloid (worsens coagulopathy, acidosis, hypothermia)
5. Tranexamic Acid (TXA): 1 g IV bolus within 3 hours of injury, then 1 g infusion over 8 hours [6]
6. Activate Massive Transfusion Protocol (MTP):
   • Indication: SBP less than 90 mmHg despite 1-2 L crystalloid, shock index > 1.0, obvious exsanguination
   • Ratio: 1:1:1 (PRBC : FFP : Platelets) [6]
   • Early fibrinogen replacement (cryoprecipitate or fibrinogen concentrate) if less than 1.5 g/L
7. Calcium Replacement: 1 g calcium chloride or gluconate with each 4-6 units PRBC

Disability: GCS, pupillary response

Exposure: Log roll, rectal exam, vaginal exam (if indicated)

Imaging

• Trauma Series X-Ray: AP Pelvis, Chest, C-spine (if indicated)
• FAST Scan: Detect hemoperitoneum
• CT Scan (if hemodynamically stable or stabilizing): Whole-body CT (head, C-spine, chest, abdomen, pelvis) with IV contrast

Hemorrhage Control Algorithm

         UNSTABLE PELVIC FRACTURE PATIENT
         (SBP less than 90 mmHg, Shock Index > 1.0)
                        ↓
              APPLY PELVIC BINDER
        (Level of Greater Trochanters)
                        ↓
              ACTIVATE MTP (1:1:1)
           TXA 1g IV Bolus (less than 3 hours)
                        ↓
                   FAST SCAN
                        ↓
        ┌───────────────┴───────────────┐
     FAST +ve                        FAST -ve
  (Hemoperitoneum)              (No Intraperitoneal Fluid)
        ↓                                  ↓
   Laparotomy                         CT Scan Available?
  (+ PPP if unstable)                      ↓
        ↓                       ┌───────────┴───────────┐
  Damage Control               YES                     NO
   Surgery (DCS)               (Stable or               ↓
        ↓                    Transient Responder)   Resuscitation Bay
   Angio (if blush)              ↓                   Hemorrhage Control
        OR                    CT Pelvis                   ↓
   ICU + Re-look             (with IV contrast)      ┌────┴────┐
                                  ↓                  PPP    or  REBOA
                          Contrast Blush?            (if expertise)
                          ┌─────┴─────┐                  ↓
                        YES            NO            Angio/OR
                         ↓              ↓           (when stable)
                    Angioembolization  ICU
                         ↓              ↓
                    Success?       External Fixation
                    ┌─┴─┐         (if unstable pattern)
                  YES   NO             ↓
                   ↓     ↓         Definitive Fixation
                  ICU   PPP       (Days 3-7 if stable)
                        or REBOA

Hemorrhage Control Techniques

1. Pelvic Binder

Mechanism: Reduces pelvic volume, increases intrapelvic pressure, facilitates tamponade of venous bleeding. [7]

Indications:

• All hemodynamically unstable patients with suspected pelvic fracture
• Stable patients with unstable fracture patterns (APC-II/III, VS, LC-III) pending definitive fixation

Technique:

1. Position patient supine
2. Place binder at level of greater trochanters (palpate or at level of symphysis pubis)
3. Tighten snugly (should be able to fit two fingers underneath)
4. Avoid excessive tightening (skin necrosis, compartment syndrome)

Contraindications (relative):

• Lateral compression fractures with severe internal rotation (may worsen). If uncertain mechanism and patient unstable, apply empirically.

Complications:

• Skin pressure necrosis (if left > 24 hours without repositioning)
• Nerve compression
• Worsening of LC fracture (rare)

Duration: Remove once definitive stabilization achieved (external fixation or ORIF) or patient confirmed stable with low-energy fracture. Typically less than 24-48 hours.

Exam Detail: Why Greater Trochanters, Not Iliac Crests?

Applying binder over iliac crests acts as a fulcrum:

• Closes anterior pelvis (symphysis)
• Opens posterior pelvis (sacroiliac joint)
• Worsens posterior instability

Applying binder over greater trochanters (level of femoral heads):

• Closes entire pelvic ring
• Compresses acetabular region
• Effective for APC injuries ("open book")

[7]

2. Preperitoneal Pelvic Packing (PPP)

Indication: Hemodynamically unstable patient with pelvic fracture who is:

• Non-responder to resuscitation
• Negative FAST (no intra-abdominal source of bleeding)
• Angiography unavailable or patient too unstable to transfer
• Failed angioembolization

Technique: [5,17]

1. Midline laparotomy incision (or Pfannenstiel)
2. Enter extraperitoneal space (do NOT enter peritoneum)
3. Bluntly dissect into Space of Retzius (retropubic space)
4. Pack 3-4 laparotomy pads into each side of pelvis (total 6-8 pads)
   • Pack against lateral pelvic wall and sacrum
   • Compress presacral venous plexus
5. Close fascia over packs (increases tamponade pressure)
6. Return to ICU for resuscitation
7. Pack removal: 24-48 hours (return to OR)

Outcomes:

• Hemorrhage control: 85-90% success [5,17]
• Mortality reduction in non-responders (37.5% without PPP vs 14.3% with PPP in one study) [1]

Complications:

• Abdominal compartment syndrome (monitor bladder pressures)
• Infection (if packs left > 72 hours)
• Retained packs

3. Angioembolization

Indications: [4,14]

• Contrast "blush" on CT (active arterial extravasation)
• Hemodynamically unstable patient with pelvic fracture despite binder, negative FAST, and adequate resuscitation (transient responder)
• Persistent transfusion requirement (> 4-6 units PRBC)
• Young-Burgess patterns at high risk: APC-II/III, VS, LC-III

Technique:

1. Femoral artery access (usually contralateral to injury if unilateral)
2. Angiography of bilateral internal iliac arteries and branches
3. Identify bleeding vessel (most commonly superior gluteal artery) [14]
4. Selective catheterization of bleeding vessel
5. Embolization:
   • Coils: Permanent occlusion of named vessel
   • Gelfoam: Temporary occlusion (recanalization in 2-4 weeks)
6. Bilateral prophylactic internal iliac embolization if diffuse bleeding or high-risk pattern

Outcomes:

• Success rate: 85-95% [4,14]
• Mortality: 20-30% in hemodynamically unstable patients (reflects severity of injury)

Complications:

• Gluteal muscle necrosis (rare; collateral circulation usually sufficient)
• Sexual dysfunction (pudendal artery embolization)
• Pelvic ischemia (if bilateral embolization of multiple vessels)
• Access site complications (hematoma, pseudoaneurysm)
• Rebleeding (5-10%; may require repeat embolization)

Timing: Should occur within 1-3 hours of presentation for unstable patients (hybrid OR/resuscitation suite ideal).

4. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Indication: Peri-arrest patient with pelvic hemorrhage as temporizing measure en route to OR/angiography suite. [18]

Technique:

1. Femoral artery access (percutaneous or open cutdown)
2. Insert REBOA catheter (7 Fr) into aorta
3. Position in Zone III (infrarenal aorta, above aortic bifurcation) for pelvic hemorrhage
4. Inflate balloon to occlude aorta
5. Raises proximal blood pressure (brain, heart perfusion)
6. Limits distal hemorrhage

Outcomes:

• Raises SBP by 30-50 mmHg
• Buys time for definitive hemorrhage control (angioembolization, PPP)
• Occlusion time limit: less than 60 minutes (risk of distal ischemia, renal failure, lower limb ischemia)

Complications: [18]

• Lower limb ischemia (if prolonged occlusion)
• Renal failure (Zone III occludes renal arteries if balloon migrates)
• Reperfusion injury (acidosis, hyperkalemia when balloon deflated)
• Balloon rupture
• Arterial injury (dissection, thrombosis)

Evidence: No clear survival benefit over standard resuscitation in randomized trials (UK-REBOA, AORTA trials). Reserved for peri-arrest patients in specialist centres. [18]

Definitive Skeletal Stabilization

Indications for Surgery

Timing of Definitive Fixation

Exam Detail: Damage Control Orthopaedics (DCO): Principle of staged management to avoid "second hit" inflammatory response in polytrauma patients.

Phases:

1. Resuscitation Phase (0-24 hours):

   • Focus: Hemorrhage control, resuscitation
   • Skeletal stabilization: Pelvic binder or external fixation (if unstable)
   • Avoid prolonged surgery

2. ICU Phase (24-72 hours):

   • Physiological stabilization
   • Correct acidosis, hypothermia, coagulopathy
   • Monitor for complications (ARDS, MODS)

3. Definitive Fixation (Days 3-7):

   • When patient physiologically stable:
     • Lactate normal (less than 2 mmol/L)
     • Base deficit corrected (>-2)
     • Coagulopathy corrected (INR less than 1.5, fibrinogen > 1.5 g/L)
     • Temperature > 35°C
     • No ongoing sepsis
   • Perform ORIF (internal fixation)

Early Definitive Fixation (less than 24 hours): Recent evidence suggests early definitive internal fixation may be safe in select patients if rapid hemorrhage control achieved and patient stabilized. [2]

External Fixation

Indications:

• Temporary stabilization in hemodynamically unstable patients (damage control)
• Definitive treatment in low-resource settings or patients unfit for ORIF
• Bridge to ORIF in polytrauma patients

Techniques:

1. Anterior Frame (most common):

   • Pin placement: Anterior inferior iliac spine (AIIS) or supra-acetabular (between AIIS and ASIS)
   • 2 pins per ilium (4 total)
   • Connect with bars
   • Effective for APC injuries

2. Pelvic C-Clamp (less common):

   • Posterior compression device
   • Pins into iliac crests
   • Effective for posterior injuries (SI disruption)
   • Risk of neurovascular injury

Complications:

• Pin site infection (5-15%)
• Nerve injury (lateral femoral cutaneous nerve)
• Loss of reduction
• Pin loosening

Open Reduction and Internal Fixation (ORIF)

Anterior Fixation:

1. Symphyseal Plating (for APC injuries):
   • Approach: Pfannenstiel or lower midline
   • Reduction: Reduce diastasis with pelvic clamp
   • Fixation: 4-hole or 6-hole plate on superior symphysis
   • Consider anterior SI fixation if anterior SI ligaments disrupted

Posterior Fixation:

1. Percutaneous Iliosacral (SI) Screws:

   • Indication: SI joint disruption (APC-III, VS, LC-II/III)
   • Technique:
     • Patient prone or supine
     • Fluoroscopic guidance (inlet, outlet, lateral views)
     • Guidewire from ilium, across SI joint, into S1 vertebral body
     • Cannulated screw (7.3 mm) over wire
     • 1-2 screws typically placed
   • Risk: L5 or S1 nerve root injury (if screw violates neural foramen). Requires expert technique.

2. Open Posterior Plating:

   • Indication: Sacral fractures, SI disruption with poor bone quality (elderly)
   • Approach: Posterior (prone)
   • Technique: Tension band plate from ilium to sacrum
   • Higher infection risk than percutaneous screws

Complications of ORIF:

• Infection (2-10%; higher in open fractures)
• Nerve injury (L5, S1 roots; sciatic nerve)
• Malreduction (chronic pain, gait abnormality)
• Implant failure (screw breakage, plate failure)
• Heterotopic ossification

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8. Associated Injuries

Pelvic fractures are rarely isolated in high-energy trauma. Systematic assessment for associated injuries is mandatory.

Urological Injuries (10-15% of Pelvic Fractures)

Bladder Rupture (5-10%)

Types:

Diagnosis: Cystogram (retrograde filling with 300-400 mL contrast; AP, lateral, post-void films)

Urethral Injury (5-10%)

Types:

Diagnosis: Retrograde urethrogram (RUG)

Complications of urethral injury:

• Urethral stricture (50-90%)
• Erectile dysfunction (25-50%)
• Incontinence (5-10%)

Gastrointestinal Injuries

Rectal Injury (1-5%)

Mechanism: Bony spike perforates rectum.

Significance: Converts fracture to open fracture. Mortality 40-50%. [8,9]

Diagnosis: Digital rectal exam (blood on glove, palpable bony spike), proctoscopy, CT (air in pelvis, rectal wall discontinuity)

Management:

1. Diverting colostomy (loop sigmoid colostomy)
2. Distal rectal washout (antegrade washout via colostomy; retrograde washout via rectum)
3. Primary repair of rectal laceration (if identified early and accessible)
4. IV antibiotics (broad-spectrum covering anaerobes)
5. Presacral drainage (controversial)

Stoma reversal: 3-6 months after fracture healing and rectal repair confirmed intact.

Vaginal Laceration (Females)

Mechanism: Bony spike perforates vagina.

Significance: Open fracture.

Management: Primary repair, broad-spectrum antibiotics, consider diverting colostomy if extensive.

Vascular Injuries

Arterial Injury

• Internal iliac artery branches (superior gluteal most common) [14]
• External iliac artery (rare; direct trauma)
• Femoral artery (if fracture extends to acetabulum)

Management: Angioembolization (preferred) or surgical ligation.

Venous Injury

• Presacral venous plexus (85% of hemorrhage) [3,4]
• Internal iliac veins

Management: Mechanical stabilization (binder, external fixation, PPP)

Neurological Injuries

Lumbosacral Plexus Injury (10-15%)

Mechanism: Sacral fractures through neural foramina, SI joint dislocation, direct nerve laceration.

Common patterns:

• L5 root: Foot drop, EHL weakness (cannot extend big toe), numbness first web space. Most common. Associated with sacral fractures through S1 foramen.
• S1 root: Ankle plantarflexion weakness, loss of ankle jerk, numbness lateral foot.
• Sciatic nerve: Combination of common peroneal and tibial deficits.
• Cauda equina syndrome: Bowel/bladder dysfunction, saddle anesthesia (S2-S4 roots). Associated with sacral fractures.

Prognosis: Variable. Neurapraxia (conduction block) recovers in weeks to months. Axonotmesis (axonal injury) may take 6-18 months. Neurotmesis (complete transection) does not recover (requires nerve grafting).

Management: Urgent MRI if cauda equina suspected (surgical decompression if nerve roots compressed). Otherwise, expectant management, physiotherapy, ankle-foot orthosis (AFO) for foot drop.

Abdominal Solid Organ Injuries

• Liver, spleen, kidney injuries common in polytrauma with pelvic fractures (30-40%).
• Diagnosed on CT scan.
• May contribute to hemorrhagic shock.
• Management: Non-operative if stable (observe); laparotomy if unstable.

Thoracic Injuries

• Rib fractures, hemothorax, pneumothorax, pulmonary contusion (20-30% of high-energy pelvic fractures).

Extremity Fractures

• Femur, tibia, humerus fractures (polytrauma).

Spinal Injuries

• Lumbosacral spine fractures (L5 transverse process, sacrum) in 10-20%. [16]

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9. Complications

Early Complications (Days 0-7)

Late Complications (Weeks to Months)

Specific to Open Pelvic Fractures

• Mortality: 40-50% [8,9]
• Pelvic Sepsis: Necrotizing fasciitis, pelvic abscess. Requires aggressive debridement, diverting colostomy, prolonged antibiotics.
• Wound Breakdown: Common. May require vacuum-assisted closure (VAC), flap coverage.

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10. Prognosis

Mortality

Predictors of mortality: [1,2]

• Hemodynamic instability
• Injury Severity Score (ISS) > 25
• Base deficit < -6
• Lactate > 4 mmol/L
• Transfusion requirement > 10 units PRBC in 24 hours
• Age > 60 years
• GCS less than 8 (traumatic brain injury)
• Open fracture

Functional Outcome

Return to Work:

• Stable fractures (non-operative): 80-90% return to work by 6 months
• Unstable fractures (operative): 60-70% return to work by 12 months
• Open fractures: 30-50% return to work

Pain-Free:

• 40-60% patients have chronic pain at 1 year
• SI joint pain most common

Sexual Function:

• 30-60% report sexual dysfunction (erectile dysfunction, dyspareunia, loss of libido)
• Higher in males with posterior urethral injury

Gait:

• 60-80% walk independently without aids
• 20-40% have limp or require walking aid

Quality of Life:

• Significantly impaired in first year
• Gradual improvement over 2-5 years
• Rarely returns to pre-injury baseline in severe fractures

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11. Prevention

Primary Prevention

• Road Traffic Safety: Seatbelts, airbags, speed limit enforcement, vehicle safety design (crumple zones).
• Fall Prevention in Elderly: Home modifications (handrails, non-slip flooring), visual assessment, osteoporosis treatment (bisphosphonates, calcium, vitamin D).
• Workplace Safety: Height safety equipment, scaffolding regulations.

Secondary Prevention (Preventing Complications)

• Early Hemorrhage Control: Pelvic binder, MTP, angioembolization
• Damage Control Resuscitation: Avoid hypothermia, acidosis, coagulopathy
• VTE Prophylaxis: LMWH (enoxaparin 40 mg SC daily) when bleeding risk allows; mechanical prophylaxis (intermittent pneumatic compression) immediately
• Early Mobilization: Reduces VTE, chest infections, pressure sores
• Multidisciplinary Rehabilitation: Physiotherapy, occupational therapy, psychology

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12. Guidelines and Key Evidence

Guidelines

1. BOAST 10 (British Orthopaedic Association Standards for Trauma)

The Management of Patients with Pelvic Fractures (2020)

Key Recommendations:

• Prehospital pelvic binder application for suspected pelvic fractures in high-energy trauma
• Binder placed at level of greater trochanters
• Transfer to Major Trauma Centre (MTC)
• Multidisciplinary team (orthopaedics, trauma surgery, interventional radiology, urology)
• Early involvement of urology for genitourinary injuries
• CT pelvis with IV contrast for all suspected pelvic fractures (if stable)
• Angioembolization preferred over surgery for arterial hemorrhage control

2. World Society of Emergency Surgery (WSES) Classification and Management of Pelvic Trauma

Coccolini et al., 2017 [19]

Key Points:

• Classification: Minor, Moderate, Severe pelvic trauma (based on hemodynamics and WSES severity grade)
• Severe pelvic trauma (hemodynamically unstable): Pelvic binder + FAST + MTP
• If FAST positive → Laparotomy + PPP
• If FAST negative → Angioembolization (if available) or PPP
• Damage control resuscitation principles

3. Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines

Cullinane et al., 2011 [20]

Key Recommendations:

• Angioembolization is safe and effective for arterial pelvic hemorrhage (Level II evidence)
• Early use of angioembolization reduces mortality
• PPP is effective when angiography unavailable

Landmark Studies

1. CRASH-2 Trial (Tranexamic Acid)

Shakur et al., Lancet 2010 [6]

• Population: 20,211 trauma patients with significant bleeding
• Intervention: TXA 1g IV bolus + 1g over 8 hours vs placebo
• Primary Outcome: All-cause mortality
• Result: TXA reduced all-cause mortality (14.5% vs 16.0%, RR 0.91, p=0.0035). Benefit greatest if given less than 3 hours of injury.
• Implication: TXA is now standard of care in trauma resuscitation.

2. Preperitoneal Packing for Pelvic Fractures

Jang et al., Scand J Trauma Resusc Emerg Med 2016 [1]

• Population: 30 hemodynamically unstable patients with pelvic fractures (14 PPP, 16 non-PPP)
• Result: Mortality from hemorrhage 14.3% (PPP) vs 37.5% (non-PPP). SBP increased significantly after PPP (71.6 → 132.2 mmHg, p=0.002).
• Implication: PPP effective as hemorrhage control adjunct to angioembolization.

3. Young-Burgess Classification and Transfusion Requirements

Lee et al., Hip Pelvis 2025 [10]

• Population: 207 pelvic fracture patients undergoing angiography
• Result: Unstable patterns (LC-III, APC-III, VS) associated with significantly higher transfusion volumes and embolization rates (p=0.009). Superior gluteal artery (LC-III), internal iliac artery (APC-III), iliolumbar artery (VS) most frequently embolized.
• Implication: Young-Burgess classification predicts hemorrhage severity and vascular injury patterns.

4. REBOA Outcomes (UK-REBOA Trial)

Jansen et al., JAMA 2023 [18]

• Population: 90 trauma patients with exsanguinating hemorrhage (pelvic, abdominal, or other)
• Intervention: REBOA vs standard care
• Primary Outcome: Mortality at 90 days
• Result: No difference in mortality (REBOA 54% vs standard care 42%, p=0.03 favoring standard care). REBOA associated with complications (limb ischemia, AKI).
• Implication: REBOA does not improve survival and may cause harm. Reserved for peri-arrest patients in specialist centres.

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13. Examination Focus (Viva Vault)

Exam Detail: ### High-Yield Viva Questions

Q1: A 32-year-old motorcyclist arrives in ED with pelvic pain and SBP 80 mmHg. Describe your immediate management.

Model Answer:

This is a time-critical, life-threatening presentation. I would follow ATLS principles:

Primary Survey:

1. Airway: Assess and secure if GCS less than 8 or evidence of airway compromise.

2. Breathing: High-flow oxygen, assess for chest injuries.

3. Circulation:

   • Pelvic Binder: Apply immediately at level of greater trochanters to reduce pelvic volume and tamponade venous bleeding.
   • IV Access: Two large-bore (14-16G) peripheral IVs or central venous access.
   • Bloods: FBC, lactate, VBG, coagulation screen (including fibrinogen), type and crossmatch (10 units).
   • Activate Massive Transfusion Protocol (MTP): Transfuse 1:1:1 ratio (PRBC:FFP:Platelets).
   • Tranexamic Acid (TXA): 1 g IV bolus stat (within 3 hours of injury), then 1 g over 8 hours.
   • Permissive Hypotension: Target SBP 80-90 mmHg until hemorrhage controlled (if no head injury).
   • Calcium: 1 g calcium chloride with every 4-6 units PRBC to prevent citrate-induced hypocalcemia.

4. Disability: GCS, pupillary response.

5. Exposure: Log roll, digital rectal exam (blood = open fracture; high-riding prostate = urethral injury), avoid "springing" the pelvis.

Imaging:

• Trauma Series X-Ray: AP Pelvis, Chest, C-spine (if indicated).
• FAST Scan: Assess for hemoperitoneum (positive FAST + unstable pelvis may indicate intra-abdominal source requiring laparotomy).

Disposition:

• If FAST positive: Laparotomy + preperitoneal packing (PPP).
• If FAST negative:
  • Transient responder (SBP improves to > 90 after 2 units PRBC): CT scan with IV contrast to assess for "blush" (arterial bleeding) → Angioembolization.
  • "Non-responder (SBP remains less than 90): Direct to angiography suite (if available) or PPP in OR."

Definitive Hemorrhage Control:

• Angioembolization (if contrast blush on CT or high suspicion of arterial bleeding).
• Preperitoneal Packing (PPP) (if angio unavailable or patient too unstable).

Skeletal Stabilization: Temporary external fixation in OR/ICU if fracture pattern unstable. Definitive ORIF when patient physiologically stable (days 3-7).

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Q2: Where do you apply a pelvic binder, and why is this anatomical location critical?

Model Answer:

The pelvic binder must be applied at the level of the greater trochanters, which corresponds to the level of the femoral heads and symphysis pubis.

Anatomical Rationale:

• The pelvis is a ring structure. To effectively reduce pelvic volume and compress the fracture, the binder must act across the entire pelvic ring at its widest diameter.
• Placing the binder at the greater trochanters (level of femoral heads):
  • Compresses the acetabular region.
  • Closes the anterior pelvis (symphysis pubis).
  • Closes the posterior pelvis (sacroiliac joints).
  • Increases intrapelvic pressure, promoting tamponade of the presacral venous plexus.

Why NOT the Iliac Crests?

• Applying the binder over the iliac crests (higher level) acts as a fulcrum:
  • Closes the anterior pelvis (symphysis).
  • Opens the posterior pelvis (sacroiliac joint).
  • This worsens posterior instability in APC (open book) injuries.
  • Paradoxically increases hemorrhage.

Contraindication:

• Lateral compression (LC) fractures with severe internal rotation may be worsened by circumferential compression. However, in the emergency setting with an unstable patient and uncertain mechanism, the binder should be applied empirically (benefit outweighs risk).

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Q3: What is Destot's Sign, and what does it indicate?

Model Answer:

Destot's Sign is a superficial hematoma that appears over the:

• Scrotum (males),
• Labia majora (females),
• Inguinal ligament, or
• Suprapubic region.

Clinical Significance:

• It indicates disruption of the pelvic floor fascial planes and significant retroperitoneal bleeding tracking inferiorly along tissue planes.
• High specificity for major pelvic trauma with substantial hemorrhage.
• Suggests unstable pelvic fracture (APC-II/III, VS, LC-III).
• Associated with higher transfusion requirements and mortality.

Mechanism:

• Retroperitoneal blood tracks along fascial planes:
  • Along the spermatic cord (males) → scrotal hematoma.
  • Along the round ligament (females) → labial hematoma.
  • Along the inguinal canal → inguinal hematoma.

Named After: Jean-Baptiste Octave Destot (French radiologist, early 20th century).

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Q4: Explain the vascular anatomy of the "Corona Mortis." Why is it clinically significant?

Model Answer:

Corona Mortis (Latin for "Crown of Death") is an aberrant anastomotic vessel connecting the external iliac arterial system (via the obturator artery) and the internal iliac arterial system.

Anatomy:

• Present in 10-40% of individuals (anatomical variant).
• Courses across the superior pubic ramus, typically 4-6 cm lateral to the symphysis pubis.
• Can be arterial, venous, or both.
• Lies on the pelvic brim (superior aspect of superior pubic ramus).

Clinical Significance:

1. Pelvic Fractures:

   • Laceration during fracture displacement (especially superior pubic rami fractures or symphyseal disruption).
   • Causes rapid, difficult-to-control hemorrhage because the vessel retracts into the pelvis when cut.
   • Bleeding can be both arterial and venous.

2. Surgical Approaches:

   • Acetabular surgery (ilioinguinal approach, modified Stoppa approach): Corona mortis lies in surgical field. Must be identified and ligated or preserved carefully.
   • Hernia repair (inguinal, femoral): At risk during dissection around superior pubic ramus.
   • Gynecological surgery (lymph node dissection): Pelvic sidewall dissection.

3. Hemorrhage Control:

   • If lacerated during fracture, may require angioembolization (difficult to access surgically).
   • If lacerated during surgery, requires direct ligation (proximal and distal control).

Why "Crown of Death"?:

• Historically, unrecognized injury during surgery or fracture led to rapid exsanguination and death.

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Q5: Describe the classification and management differences between intraperitoneal and extraperitoneal bladder rupture in pelvic fractures.

Model Answer:

Clinical Pearl:

• Intraperitoneal rupture is a surgical emergency (urine in peritoneum → chemical peritonitis → sepsis).
• Extraperitoneal rupture can be managed conservatively with catheter drainage alone in most cases.

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Q6: A 55-year-old male with an APC-II pelvic fracture has blood at the urethral meatus. The trauma surgeon asks you to catheterize him. What do you do?

Model Answer:

I would NOT insert a urethral catheter.

Rationale:

• Blood at the urethral meatus is a red flag for posterior urethral injury (membranous urethra disruption at the urogenital diaphragm).
• This is a contraindication to Foley catheter insertion.
• Attempting to pass a Foley catheter:
  • May convert a partial tear into a complete transection.
  • May create a false passage (catheter through urethral wall into tissues).
  • Causes further trauma and complicates subsequent repair.

Immediate Action:

1. Do NOT insert Foley catheter.
2. Digital rectal exam (DRE):
   • Assess for high-riding prostate (prostate displaced cranially due to urethral disruption and pelvic hematoma). This is a pathognomonic sign of posterior urethral injury.
3. Inform consultant and request urology consultation.
4. Order retrograde urethrogram (RUG):
   • Inject 20-30 mL contrast into urethral meatus (via catheter tip placed in meatus; do NOT insert catheter).
   • X-ray or fluoroscopy to visualize urethra.
   • Positive RUG: Contrast extravasation at prostatic urethra/membranous urethra junction (confirms urethral injury).

Definitive Management:

• Suprapubic catheter (SPC) insertion:
  • Ultrasound-guided or open (if bladder distended).
  • Provides urinary drainage.
  • Allows urethra to heal without instrumentation.
• Delayed urethral repair:
  • Primary realignment (endoscopic or open) at 3-6 months.
  • Performed by urology after inflammation subsides.

Complications of Urethral Injury (if not managed correctly):

• Urethral stricture (50-90%)
• Erectile dysfunction (25-50%)
• Incontinence (5-10%)

Clinical Pearl: "Blood at the meatus = No Foley catheter. Call urology. Insert suprapubic catheter."

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Q7: What is preperitoneal pelvic packing (PPP)? When is it indicated, and how is it performed?

Model Answer:

Preperitoneal Pelvic Packing (PPP) is a damage control surgical technique to achieve mechanical tamponade of pelvic hemorrhage by packing laparotomy pads into the extraperitoneal space (Space of Retzius) adjacent to the pelvic fracture.

Indications:

1. Hemodynamically unstable patient with pelvic fracture who is:
   • Non-responder to resuscitation (SBP less than 90 mmHg despite 4-6 units PRBC).
   • FAST negative (no intra-abdominal source of bleeding).
2. Angioembolization unavailable or patient too unstable to transfer to angiography suite.
3. Failed angioembolization (persistent bleeding despite embolization).
4. Hybrid OR unavailable (PPP can be performed rapidly in any OR).

Technique:

1. Incision: Midline laparotomy incision (xiphoid to pubis) or Pfannenstiel incision.
2. Extraperitoneal dissection:
   • Do NOT enter peritoneum (unless intra-abdominal injury suspected).
   • Bluntly dissect into extraperitoneal space (Space of Retzius, retropubic space).
   • Develop space lateral to bladder on each side.
3. Pack placement:
   • Insert 3-4 laparotomy pads into each side of pelvis (total 6-8 pads).
   • Pack against lateral pelvic wall and sacrum.
   • Direct pressure compresses presacral venous plexus (source of 85% of bleeding).
4. Closure:
   • Close fascia over packs (increases tamponade pressure).
   • Mark with long suture tails (to facilitate identification at re-look).
5. ICU Resuscitation: Transfer to ICU for ongoing resuscitation, warm patient, correct coagulopathy.
6. Pack Removal:
   • Return to OR in 24-48 hours for pack removal.
   • Remove packs, assess for ongoing bleeding.
   • If no bleeding, close. If bleeding continues, consider angioembolization.

Outcomes:

• Hemorrhage control: 85-90% success rate.
• Mortality: One study showed reduction from 37.5% (non-PPP) to 14.3% (PPP) in non-responders. [1]

Complications:

• Abdominal compartment syndrome (ACS): Monitor bladder pressures (keep less than 20 mmHg). Decompressive laparotomy if ACS develops.
• Infection: Risk increases if packs left > 72 hours.
• Retained packs: Count packs carefully.

Clinical Pearl: PPP targets venous bleeding (presacral plexus). It does NOT control arterial bleeding (requires angioembolization). PPP is often used as a bridge to angioembolization in unstable patients.

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Q8: Describe the Young-Burgess classification and its clinical relevance.

Model Answer:

The Young-Burgess classification is a mechanism-based classification of pelvic ring injuries based on the force vector applied to the pelvis. It predicts associated injuries, hemorrhage risk, and resuscitation needs.

Three Main Categories:

1. Anteroposterior Compression (APC): "Open Book"

   • Force applied anteroposteriorly (head-on collision, run-over).
   • Symphysis widens; pelvis opens.
   • APC-I: Symphyseal diastasis less than 2.5 cm. Stable. Low hemorrhage risk.
   • APC-II: Diastasis > 2.5 cm. Anterior SI ligaments torn. Rotationally unstable. High hemorrhage risk (superior gluteal artery injury).
   • APC-III: Complete SI disruption (anterior + posterior SI ligaments). Completely unstable. Very high hemorrhage risk.

2. Lateral Compression (LC): "Crush"

   • Force applied laterally (T-bone collision, pedestrian struck).
   • Ipsilateral hemipelvis rotates internally.
   • LC-I: Sacral compression (buckle) fracture. Stable. Low hemorrhage risk. Most common fracture pattern (60-70%).
   • LC-II: Iliac wing (crescent) fracture. Partially unstable. Moderate hemorrhage risk.
   • LC-III: "Windswept pelvis": LC on impact side + contralateral APC (open book). Completely unstable. Very high hemorrhage risk.

3. Vertical Shear (VS):

   • Entire hemipelvis shifts cranially (fall from height landing on one leg).
   • Complete ligamentous disruption (all SI ligaments, sacrotuberous, sacrospinous, symphyseal).
   • Completely unstable (vertical + rotational). Very high hemorrhage risk.
   • Most unstable pattern. 100% require surgical stabilization.

4. Combined Mechanism (CM):

   • Multiple force vectors. Variable pattern. High mortality.

Clinical Relevance:

• Predicts hemorrhage risk: APC-II/III, VS, LC-III have highest transfusion requirements.
• Predicts vascular injury patterns: APC injuries → superior gluteal artery; VS → iliolumbar artery. [10]
• Guides resuscitation: High-risk patterns → early MTP activation, angioembolization readiness.
• Guides surgical planning: Unstable patterns require anterior ± posterior fixation.

Landmark Study: Lee et al. (2025) showed Young-Burgess classification significantly correlated with embolization rates (p=0.009). Unstable patterns (LC-III, APC-III, VS) had highest transfusion volumes. [10]

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14. Patient Explanation (Layperson Language)

What is a Pelvic Fracture?

The pelvis is the large ring of bone that connects your spine to your legs. It's made up of several bones joined together. A pelvic fracture means one or more of these bones have broken, usually from a high-energy injury like a car crash or a fall from a height.

Why is it Serious?

The pelvis protects major blood vessels. When the bones break, these blood vessels can tear, causing internal bleeding. This is the most dangerous part of a pelvic fracture. If too much blood is lost, it can be life-threatening.

What are the Symptoms?

• Severe pain in your pelvis, lower back, or hips
• Inability to stand or walk
• Bruising over your lower abdomen, groin, or genitals
• Blood in your urine
• Feeling dizzy or faint (from blood loss)

How is it Diagnosed?

• X-ray: Takes pictures of the bones to see the fracture.
• CT scan: A detailed scan that shows the exact fracture pattern and any bleeding.

Treatment

Emergency Treatment (First Few Hours)

1. Pelvic Binder: A tight belt wrapped around your hips to hold the bones together and stop bleeding.
2. Blood Transfusion: If you've lost a lot of blood, we give you donated blood to replace it.
3. Stop the Bleeding:
   • Angiography: A doctor inserts a thin tube into an artery in your groin and uses X-rays to find the bleeding vessel. They then block it with tiny coils or foam (called embolization).
   • Surgery: In severe cases, we pack the area with gauze to stop bleeding (called packing).

Surgery (Days to Weeks Later)

Once you're stable, we fix the broken bones:

• External Fixation: A metal frame attached to your bones with pins (temporary, to hold bones while you heal).
• Internal Fixation (ORIF): We use metal plates and screws to rebuild the pelvis (usually done a few days later when you're stronger).

Recovery

• Non-Weight Bearing: You cannot put weight on your injured leg for 6-12 weeks. You'll use a wheelchair or crutches.
• Physiotherapy: Exercises to regain strength and movement.
• Time to Walk: Most people can walk again by 3-6 months.
• Full Recovery: Can take 12-24 months. Some people have long-term pain or difficulty walking.

Will I Fully Recover?

• Most people (60-80%) walk independently again.
• Some have ongoing pain in the hips or lower back.
• Sexual function can be affected (difficulty with erections in men, pain during sex in women).
• You may need ongoing physiotherapy and pain management.

What Should I Watch Out For?

• Severe pain or swelling in your legs (blood clot).
• Fever (infection).
• Inability to pass urine (bladder or urethral injury).
• Numbness in your legs or groin (nerve injury).

Call your doctor or go to A&E if any of these happen.

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15. References

1. Jang JY, Shim H, Jung PY, Kim S, Bae KS. Preperitoneal pelvic packing in patients with hemodynamic instability due to severe pelvic fracture: early experience in a Korean trauma center. Scand J Trauma Resusc Emerg Med. 2016;24:3. doi: 10.1186/s13049-016-0196-5

2. Balogh ZJ, Ponsen KJ, Miclau KR, et al. Unstable pelvic fractures in patients with hemodynamic instability: global treatment controversies. OTA Int. 2025;8(6 Suppl):e436. doi: 10.1097/OI9.0000000000000436

3. Montmany S, Rebasa P, Luna A, et al. Source of bleeding in trauma patients with pelvic fracture and haemodynamic instability. Cir Esp. 2015;93(7):450-4. doi: 10.1016/j.ciresp.2015.01.011

4. Lee DH, Kim SW, Kim KC. Young-Burgess Classification of Pelvic Ring Fractures as a Diagnostic Tool to Predict Vascular Injury Patterns and Targeted Embolization: A 10-Year Retrospective Study. Hip Pelvis. 2025;37(4):321-327. doi: 10.5371/hp.2025.37.4.321

5. Coleman JR, Moore EE, Vintimilla DR, et al. Association between Young-Burgess pelvic ring injury classification and concomitant injuries requiring urgent intervention. J Clin Orthop Trauma. 2020;11(6):1099-1103. doi: 10.1016/j.jcot.2020.08.009

6. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. doi: 10.1016/S0140-6736(10)60835-5

7. Khaliq F, Rodham P. EMS Pelvic Binders. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. PMID: 38170809

8. Hermans E, Edwards MJR, Goslings JC, Biert J. Open pelvic fracture: the killing fracture? J Orthop Surg Res. 2018;13(1):83. doi: 10.1186/s13018-018-0793-2

9. Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009;40(4):343-53. doi: 10.1016/j.injury.2008.12.006

10. Lee DH, Kim SW, Kim KC. Young-Burgess Classification of Pelvic Ring Fractures as a Diagnostic Tool to Predict Vascular Injury Patterns and Targeted Embolization. Hip Pelvis. 2025;37(4):321-327. doi: 10.5371/hp.2025.37.4.321

11. Tile M. Acute Pelvic Fractures: I. Causation and Classification. J Am Acad Orthop Surg. 1996;4(3):143-151. doi: 10.5435/00124635-199605000-00004

12. Rusu MC, Cergan R, Dermengiu D, Curcă GC. The anatomical relations of the corona mortis (anatomotic vessel between the obturator and the external iliac systems). Surg Radiol Anat. 2010;32(1):17-21. doi: 10.1007/s00276-009-0534-7

13. Alton TB, Gee AO. Classifications in brief: Young and Burgess classification of pelvic ring injuries. Clin Orthop Relat Res. 2014;472(8):2338-42. doi: 10.1007/s11999-014-3693-8

14. 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(6):1850-68. doi: 10.1097/TA.0b013e31823dca9a

15. Mellado JM, Bencardino JT. Morel-Lavallée lesion: review with emphasis on MR imaging. Magn Reson Imaging Clin N Am. 2005;13(4):775-82. doi: 10.1016/j.mric.2005.08.006

16. Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;(227):67-81.

17. 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(4):628-35. doi: 10.1016/j.jamcollsurg.2010.12.020

18. Jansen JO, Hudson J, Cochran C, et al. Emergency department resuscitative endovascular balloon occlusion of the aorta in trauma patients with exsanguinating hemorrhage: The UK-REBOA randomized clinical trial. JAMA. 2023;330(19):1862-1871. doi: 10.1001/jama.2023.20850

19. Coccolini F, Stahel PF, Montori G, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:5. doi: 10.1186/s13017-017-0117-6

20. Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture. J Trauma. 2011;71(6):1850-68. doi: 10.1097/TA.0b013e31823dca9a

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