Pelvic Fractures

Today’s Wednesday Blog gives an overview of pelvic fractures, a common exam and interview question.


Pelvic fractures account for approximately 3% of all fractures

They are due either to high energy injury, e.g. RTA’s and also low energy pubic rami fractures in the osteoporotic elderly population

Deforming forces on the injured pelvis come from 3 vectors:


Lateral Compression (most common)

Vertical shear


The pelvis is composed of the the hip bone (Ilium, pubis and ischium) and sacrum and coccyx. In trauma, due to it’s structure the pelvic ring can open at the front (the pubic symphysis) as in an open book fracture or at the SI joint at the back. Fractures tend to break the pelvic ring in two places and the close proximity of venous beds and arteries means that blood loss can be drastic.

ST3 Orthopaedic Interview

BOAST Guidelines

The BOAST 3 Guidelines helpfully summarise the current literature and agreed management pathways for the management of pelvic trauma in the United Kingdom.

The guidelines themselves can be broken down into their constituent sections to aid learning:

  • 1-3 ATLS
  • 4-6 Urology
  • 7-9 Definitive fixation
  • 10-13 Acetabular fractures

Assessment and Immediate Care

ATLS Principles

Detection and treatment of life-threatening injuries

Haemodynamic instability (bleeding into free space)

  • Posterior pelvic venous plexus (80%), superior gluteal artery or internal/external iliac branches
  • Immediate control with pelvic binder or sheet
  • Permissive hypotensive resuscitation
  • Non-responders MTP RBC:PLTs:FFP 1:1:1ratio
  • Look for bruising & haematoma

AP Pelvis and Assess for associated injuries:

Major urological injury 5-10%

  • Blood at urethral meatus
  • Difficulty passing catheter

Open Fractures <5%

  • Examine perineum & PR


BOAST 3 Summary:


Haemodynamically stable → CT

If Unstable

  • FAST/DPL if available in ED
  • Angiography/Pre-peritoneal packing/Laparotomy

Urological Injury

  • CT Urethography +/- cystography
  • Early involvement of Urologists

Open fracture

  • Urology and general surgery input for bladder drainage and potential colostomy

Definitive Pelvic Fixation in Specialist Unit within 5 days

ST3 Ortho Interview Pelvis


The Young & Burgess classification helps to guide management of pelvic fractures based on mechanism of injury

Lateral Compression (LC)

Type I: a posteriorly directed force causing a sacral crushing injury and horizontal pubic ramus fractures ipsilaterally. This injury is stable

Type II: a more anteriorly directed force causing horizontal pubic ramus fractures with an anterior sacral crushing injury and either disruption of the posterior sacroiliac joints or fractures through the iliac wing. This injury is ipsilateral

Type III: an anteriorly directed force that is continued and leads to a type I or type II ipsilateral fracture with an external rotation component to the contralateral side; the sacroiliac joint is opened posteriorly, and the sacrotuberous and spinous ligaments are disrupted

Anterior Posterior Compression (APC)

Type I: an AP-directed force opening the pelvis but with the posterior ligamentous structures intact. This injury is stable

Type II: continuation of a type I fracture with disruption of the sacrospinous and potentially the sacrotuberous ligaments and an anterior sacroiliac joint opening. This fracture is rotationally unstable

Type III: a completely unstable or a vertical instability pattern with complete disruption of all ligamentous supporting structures

Vertical Shear

Young and Burgess

The Tile classification is based on fracture stability:

Type A - stable

A1 – #s of the pelvis not involving the ring

A2 – minimally displaced #s of the ring

Type B – rotationally unstable, vertically stable

B1 - Open book

B2 – lateral compression: ipsilateral

B3 – lateral compression: contralateral

Type C – rotationally and vertically unstable

C1 – Unilateral vertical instability

C2 – Bilateral – both sides vertically unstable

C3 – Associated with acetabular fracture

Further Info:

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