Define Pelvic Fractures. Describe its classification, clinical features, investigations and management.

Definition & Importance

The pelvis is a rigid osteoligamentous ring formed by the two innominate bones and the sacrum, bound by the strong posterior sacroiliac, sacrospinous and sacrotuberous ligaments. Because it is a ring, a displaced break at one point almost always implies a second break or ligament disruption elsewhere. High-energy pelvic fractures are important because of life-threatening haemorrhage (from the presacral venous plexus and internal iliac branches) and associated urogenital and visceral injuries.

The pelvic ring. An anteroposterior-compression (‘open-book’) injury widens the pubic symphysis and disrupts the anterior sacroiliac ligaments, greatly increasing pelvic volume.

Classification

Two systems are used. The Young–Burgess classification is based on the direction of force:

• anteroposterior compression (APC) — the ‘open-book’ injury that opens the symphysis and increases pelvic volume
• lateral compression (LC) — the commonest, impacting the ring
• vertical shear (VS) — the most unstable, with cranial displacement of a hemipelvis. The Tile classification groups fractures by stability: Type A stable, Type B rotationally unstable but vertically stable, Type C both rotationally and vertically unstable.

Clinical Features

Following high-energy trauma there is pelvic pain, bruising (perineum, scrotum, flanks), and instability on gentle pelvic compression (do not repeatedly ‘spring’ the pelvis — it dislodges clot). Look for signs of urethral injury: blood at the meatus, a high-riding prostate, a scrotal/perineal haematoma, and inability to pass urine. A per-rectal / per-vaginal examination detects open fractures and rectal tears. Assess distal neurovascular status (lumbosacral plexus, sciatic nerve).

Investigations

AP pelvic radiograph is part of the primary trauma survey; inlet and outlet views and, definitively, a CT scan (with angiography) define the fracture and any arterial bleeding. A retrograde urethrogram assesses suspected urethral injury; fast/CT evaluates associated abdominal injuries.

Management

Management follows ATLS priorities because these patients are polytraumatised. Resuscitation & haemorrhage control: apply a pelvic binder at the level of the greater trochanters to close an open-book injury, reduce pelvic volume and tamponade venous bleeding; give blood/massive transfusion. Persistent arterial bleeding is treated by angio-embolisation or surgical pre-peritoneal packing; an external fixator provides temporary mechanical stability. Definitive fixation: stable fractures are treated conservatively with early mobilisation; unstable Tile B/C injuries need internal fixation — anterior plating/external fixation of the symphysis/rami and posterior fixation (iliosacral screws) of the sacroiliac disruption. Associated urogenital and rectal injuries are managed jointly.

Complications

Haemorrhagic shock and death (the leading early cause), urethral and bladder injury (leading to stricture or incontinence), lumbosacral nerve injury, sexual dysfunction, malunion with pelvic obliquity/leg-length discrepancy, and chronic sacroiliac pain.

• Pelvis is a ring — one displaced break implies a second break/ligament injury.
• Young–Burgess: APC (open-book), LC (commonest), vertical shear (most unstable).
• Main killers: haemorrhage; main pitfalls: urethral & bladder injury.
• First aid = pelvic binder at trochanters; then embolisation/packing + external fixator.
• Unstable Tile B/C → anterior + posterior internal fixation.