Emergent Care / Stabilization:

• Initial assessment according to Advanced Trauma Life Support (ATLS). This should include assessment of the patient's hemodynamic and pelvic stability.
  • Assess for obvious signs of hemorrhage. In hemodynamically unstable patients with no clear hemorrhage, careful examination of the pelvis is necessary even in the setting of normal pelvic imaging.
  • Assess for pelvic stability, making note of deformity of pelvis, limb length discrepancy, or malrotation.
• Emergent hemodynamic and mechanical management of unstable pelvic ring fractures will require:
  • Application of a pelvic binder
    • Facilitates reduction of pelvic fractures.
    • Increases intrapelvic pressures by reducing pelvic volume in order to promote clot formation.
  • Optimal fluid resuscitation
  • Use of tranexamic acid (TXA)
    • Helps to control bleeding by inhibiting fibrinolysis.
  • Other methods of hemorrhage control include pelvic packing, external fixation, and angiographic embolization.
  • Resuscitative endovascular balloon occlusion of the aorta (REBOA) can be used as an adjunct in very severe cases.
• Effective management requires a multidisciplinary approach, including prehospital providers, nursing, imaging technicians, emergency medicine, orthopedics, intervention radiology, trauma, etc.

Causes / typical injury mechanism: The most common cause of pelvic ring fractures is high-energy impact, including falls from a great height, sports injuries, and motor vehicle accidents. However, low-energy trauma can also cause pelvic fracture in older populations.

Classic history and presentation: Patients often present in the setting of a high-energy-impact trauma, and most patients present with polytrauma. Patients may have bony tenderness, overlying soft tissue injury, and/or genitourinary injury. Severely deformed fractures may present with leg length discrepancy and rotational abnormalities of the hip.

Prevalence: Pelvic ring fractures are rare injuries, comprising 2%-8% of all skeletal trauma injuries. In the United States, 50% of pelvic fractures occur in patients older than 75 years.

Risk factors: The most important risk factor is the presence of a bone-weakening disease such as osteoporosis.

Pathophysiology: Pelvic ring fractures can cause instability and a subsequent increase in internal volume. This expansion may disrupt surrounding soft tissue and vascular structures, which can facilitate and worsen hemorrhage in the retroperitoneal space. Pelvic ring instability can also create a space for up to several liters of blood to accumulate.

Grade / classification systems:
Tile classification of pelvic disruptions

• Type A – Stable
  • A1: fractures of the pelvis not involving the ring
  • A2: stable, minimally displaced fractures of the ring
  • A3: transverse sacral or coccyx fractures
• Type B – Rotationally unstable, vertically stable
  • B1: open book injury
  • B2: lateral compression, ipsilateral injury
  • B3: lateral compression, contralateral injury
• Type C – Rotationally and vertically unstable
  • C1: unilateral injury
  • C2: bilateral injury, one side rotationally unstable, contralateral side vertically unstable
  • C3: associated with an acetabular fracture, both sides vertically unstable

J.W. Young and A. Burgess system

• Direction of disruptive force
  • Anteroposterior compression
  • Lateral compression
  • Vertical shear
  • Combined mechanism injury

WSES Classification

• Minor (WSES grade I): Hemodynamically and mechanically stable lesions.
• Moderate (WSES grade II, III): Hemodynamically stable and mechanically unstable lesions.
• Severe (WSES grade IV): Comprising hemodynamically unstable lesions independently from mechanical status.