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Pelvic Ring Fracture: Causes, Symptoms & Treatment

A pelvic ring fracture is a break in the bony ring of the pelvis. It is often caused by severe trauma and requires prompt medical attention.

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A pelvic ring fracture is a break in the bony ring of the pelvis. It is often caused by severe trauma and requires prompt medical attention.

What is a Pelvic Ring Fracture?

A pelvic ring fracture is a break involving the bony ring of the pelvis, which is formed by the sacrum, the two hip bones (ilium, ischium, and pubis), the sacroiliac joints, and the pubic symphysis. The pelvic ring plays a critical role in stabilizing the trunk, transferring forces between the spine and the legs, and protecting the pelvic organs.

Pelvic ring fractures range from stable, minimally displaced breaks to highly unstable injuries associated with life-threatening hemorrhage. They are considered serious injuries in trauma surgery and require rapid, structured management.

Causes

Pelvic ring fractures are most commonly caused by significant mechanical force. Typical causes include:

High-energy trauma: Traffic accidents (e.g., motorcycle or car collisions), falls from height
Occupational accidents: Crushing injuries from machinery or heavy objects
Stress fractures: Particularly in older individuals with osteoporosis or in competitive athletes
Insufficiency fractures: Occurring in weakened bone due to osteoporosis or malignancy, sometimes without significant trauma

Classification

The most widely used classification systems are the AO/OTA classification and the Tile classification, both of which assess pelvic ring stability:

Type A (stable): Fracture without disruption of the posterior pelvic ring, e.g., isolated pubic ramus fracture
Type B (rotationally unstable, vertically stable): Partial disruption of the pelvic ring, e.g., open-book injury from external rotation force
Type C (rotationally and vertically unstable): Complete disruption of both the anterior and posterior pelvic ring, often associated with massive hemorrhage

Symptoms

The symptoms of a pelvic ring fracture vary depending on the severity of the injury:

Severe pain in the pelvis, groin, or lower back
Tenderness on palpation over the pelvic ring and sacroiliac joints
Visible deformity or asymmetry of the pelvis
Inability or difficulty with weight-bearing and walking
Swelling and bruising (hematoma) over the pelvis or perineum
In severe cases: signs of hemorrhagic shock (circulatory failure due to blood loss)
Possible associated injuries: bladder, bowel, or vascular injuries, and nerve damage

Diagnosis

Diagnosis is established through a combination of clinical examination and imaging:

Clinical examination: Assessment of pelvic stability (compression and distraction tests), neurological evaluation
Pelvic X-ray: First-line imaging in the trauma bay, provides an overview of fracture type
Computed tomography (CT): Gold standard for detailed assessment of fracture pattern, displacement, and associated injuries
Ultrasound (FAST): To rule out free fluid in the abdomen in polytrauma patients
Angiography / CT angiography: When active bleeding from pelvic vessels is suspected

Treatment

Emergency Management

In unstable pelvic ring fractures, hemorrhage control is the top priority. Measures include:

Application of a pelvic binder or pelvic clamp for emergency stabilization
Transfusion of blood products and coagulation factors
Angioembolization: Interventional radiology procedure to control arterial bleeding
Preperitoneal pelvic packing: Surgical hemorrhage control through direct tamponade of the pelvis

Surgical Treatment

Once stabilized, unstable fractures are treated surgically:

External fixation: Temporary stabilization using an external fixator frame
Internal fixation: Definitive treatment using plate osteosynthesis, iliosacral screws, or combined techniques
Minimally invasive techniques: Percutaneous screw fixation, particularly in elderly patients

Conservative Treatment

Stable fractures (Type A) may be managed conservatively with pain management, bed rest, and subsequent physiotherapy. Early mobilization is encouraged to prevent complications such as deep vein thrombosis.

Rehabilitation and Prognosis

Rehabilitation following a pelvic ring fracture involves physiotherapy, gait training, and, where needed, occupational therapy. The prognosis depends on the fracture type, the extent of associated injuries, and the age of the patient. Stable fractures typically heal completely. Severe unstable injuries may result in chronic pain, restricted mobility, or persistent neurological deficits.

References

Tile M, Helfet DL, Kellam JF: Fractures of the Pelvis and Acetabulum. 3rd edition. Lippincott Williams & Wilkins, 2003.
Flint L, Cryer HG: Pelvic fracture: the last 50 years. Journal of Trauma. 2010;69(3):483-488.
American College of Surgeons: Advanced Trauma Life Support (ATLS) Student Course Manual. 10th edition. Chicago, 2018.

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