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Emergency and Acute Medicine – Pelvic Fracture
Pelvic fractures account for approximately 3% of all bony fractures but are associated with disproportionately high morbidity and mortality. The pelvis consists of the sacrum and two innominate bones, each formed by the ilium, ischium, and pubis. Stability of the pelvic ring depends on strong ligamentous, muscular, and soft tissue support. The anterior pelvis is stabilized by the symphysis pubis and pubic rami, while posterior stability is provided by the sacroiliac (SI) complex and pelvic floor. Because the pelvis protects major vascular structures as well as genitourinary, gastrointestinal, gynecologic, neurologic, and musculoskeletal systems, fractures often coexist with life-threatening injuries and require urgent recognition and management.
Most pelvic fractures result from high-energy trauma. Approximately 65% are caused by vehicular mechanisms, including pedestrians struck by automobiles, while falls and crush injuries account for another 20%. Athletic, penetrating, and nontraumatic causes are less common. Mortality ranges from 6–19% and increases significantly in open fractures or when hemorrhagic shock is present. Unstable fractures, particularly those involving the posterior pelvis, are prone to severe hemorrhage due to disruption of arterial branches and venous plexuses, often with associated retroperitoneal hematoma. In children, hemorrhage may be more severe, and nonaccidental trauma must be considered. In pregnancy, pelvic fractures pose additional risk to the gravid uterus, including uterine rupture.
Clinically, patients typically present with pelvic, hip, groin, or lower back pain, often accompanied by swelling, ecchymosis, and tenderness. Many have associated injuries involving the abdomen, genitourinary tract, neurologic system, or vascular structures. Signs of pelvic instability, deformity, limb shortening or rotation, and inability to bear weight are concerning. In severe cases, hemorrhagic shock may dominate the presentation, with tachycardia, hypotension, altered mental status, and cool, pale extremities. Bleeding from the urethra, rectum, or vagina, as well as open wounds over the pelvis, suggests an open pelvic fracture.
Initial evaluation follows standard trauma principles. A single anteroposterior (AP) pelvic radiograph is the most important early diagnostic test and should be obtained promptly when pelvic fracture is suspected. Additional views such as inlet, outlet, or Judet oblique projections may further define injury patterns, particularly involving the posterior pelvis or acetabulum. Computed tomography (CT) provides detailed assessment of fracture anatomy, retroperitoneal hematoma, and associated visceral injuries, and CT angiography can identify arterial bleeding in hemodynamically stable patients. Focused abdominal sonography for trauma (FAST) may help detect intraperitoneal bleeding but has limited ability to distinguish pelvic from abdominal sources. Laboratory studies include type and cross-match, hemoglobin and hematocrit, platelet count, and coagulation profile.
Pelvic fractures are commonly categorized using the Tile classification system, which helps guide management. Type A fractures are stable and include avulsion injuries, isolated pubic rami fractures, and transverse sacral fractures. Type B fractures are rotationally unstable but vertically stable, such as open-book and lateral compression injuries. Type C fractures are both rotationally and vertically unstable, including vertical shear (Malgaigne) fractures, and are associated with the highest risk of hemorrhage and mortality. Acetabular fractures represent a distinct subgroup requiring specialized orthopedic evaluation.
Management priorities focus on rapid resuscitation, hemorrhage control, and stabilization. Early application of a pelvic binder or improvised sheet wrap at the level of the greater trochanters is critical in suspected unstable fractures, as it reduces pelvic volume and limits bleeding. Fluid resuscitation with crystalloids and early blood transfusion is indicated for shock, avoiding lower extremity IV access when possible. External fixation, angiographic embolization, or surgical pelvic packing may be required for ongoing hemorrhage. Type A fractures are generally managed conservatively with analgesia and mobilization as tolerated, whereas Type B and C fractures require urgent orthopedic and trauma consultation, close monitoring, and often operative intervention.
Patients with hemodynamic instability, unstable pelvic fractures, acetabular fractures, pelvic hemorrhage, or associated injuries should be admitted, frequently to the intensive care unit. Hemodynamically stable patients with isolated, stable Type A fractures and no other injuries may be discharged with appropriate analgesia and close orthopedic follow-up. A key clinical principle is that pelvic fractures signal high-energy trauma; clinicians must maintain a high index of suspicion for associated abdominal, genitourinary, vascular, and neurologic injuries. Early stabilization of the pelvis and management decisions guided by hemodynamic status are essential to improving outcomes.
Pelvic fractures account for approximately 3% of all bony fractures but are associated with disproportionately high morbidity and mortality. The pelvis consists of the sacrum and two innominate bones, each formed by the ilium, ischium, and pubis. Stability of the pelvic ring depends on strong ligamentous, muscular, and soft tissue support. The anterior pelvis is stabilized by the symphysis pubis and pubic rami, while posterior stability is provided by the sacroiliac (SI) complex and pelvic floor. Because the pelvis protects major vascular structures as well as genitourinary, gastrointestinal, gynecologic, neurologic, and musculoskeletal systems, fractures often coexist with life-threatening injuries and require urgent recognition and management.
Most pelvic fractures result from high-energy trauma. Approximately 65% are caused by vehicular mechanisms, including pedestrians struck by automobiles, while falls and crush injuries account for another 20%. Athletic, penetrating, and nontraumatic causes are less common. Mortality ranges from 6–19% and increases significantly in open fractures or when hemorrhagic shock is present. Unstable fractures, particularly those involving the posterior pelvis, are prone to severe hemorrhage due to disruption of arterial branches and venous plexuses, often with associated retroperitoneal hematoma. In children, hemorrhage may be more severe, and nonaccidental trauma must be considered. In pregnancy, pelvic fractures pose additional risk to the gravid uterus, including uterine rupture.
Clinically, patients typically present with pelvic, hip, groin, or lower back pain, often accompanied by swelling, ecchymosis, and tenderness. Many have associated injuries involving the abdomen, genitourinary tract, neurologic system, or vascular structures. Signs of pelvic instability, deformity, limb shortening or rotation, and inability to bear weight are concerning. In severe cases, hemorrhagic shock may dominate the presentation, with tachycardia, hypotension, altered mental status, and cool, pale extremities. Bleeding from the urethra, rectum, or vagina, as well as open wounds over the pelvis, suggests an open pelvic fracture.
Initial evaluation follows standard trauma principles. A single anteroposterior (AP) pelvic radiograph is the most important early diagnostic test and should be obtained promptly when pelvic fracture is suspected. Additional views such as inlet, outlet, or Judet oblique projections may further define injury patterns, particularly involving the posterior pelvis or acetabulum. Computed tomography (CT) provides detailed assessment of fracture anatomy, retroperitoneal hematoma, and associated visceral injuries, and CT angiography can identify arterial bleeding in hemodynamically stable patients. Focused abdominal sonography for trauma (FAST) may help detect intraperitoneal bleeding but has limited ability to distinguish pelvic from abdominal sources. Laboratory studies include type and cross-match, hemoglobin and hematocrit, platelet count, and coagulation profile.
Pelvic fractures are commonly categorized using the Tile classification system, which helps guide management. Type A fractures are stable and include avulsion injuries, isolated pubic rami fractures, and transverse sacral fractures. Type B fractures are rotationally unstable but vertically stable, such as open-book and lateral compression injuries. Type C fractures are both rotationally and vertically unstable, including vertical shear (Malgaigne) fractures, and are associated with the highest risk of hemorrhage and mortality. Acetabular fractures represent a distinct subgroup requiring specialized orthopedic evaluation.
Management priorities focus on rapid resuscitation, hemorrhage control, and stabilization. Early application of a pelvic binder or improvised sheet wrap at the level of the greater trochanters is critical in suspected unstable fractures, as it reduces pelvic volume and limits bleeding. Fluid resuscitation with crystalloids and early blood transfusion is indicated for shock, avoiding lower extremity IV access when possible. External fixation, angiographic embolization, or surgical pelvic packing may be required for ongoing hemorrhage. Type A fractures are generally managed conservatively with analgesia and mobilization as tolerated, whereas Type B and C fractures require urgent orthopedic and trauma consultation, close monitoring, and often operative intervention.
Patients with hemodynamic instability, unstable pelvic fractures, acetabular fractures, pelvic hemorrhage, or associated injuries should be admitted, frequently to the intensive care unit. Hemodynamically stable patients with isolated, stable Type A fractures and no other injuries may be discharged with appropriate analgesia and close orthopedic follow-up. A key clinical principle is that pelvic fractures signal high-energy trauma; clinicians must maintain a high index of suspicion for associated abdominal, genitourinary, vascular, and neurologic injuries. Early stabilization of the pelvis and management decisions guided by hemodynamic status are essential to improving outcomes.
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