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J O T R
SYMPOSIUM ON PELVIC TRAUMA

Classification of pelvic fractures and its clinical relevance

Rehan Ul Haq, Ish K Dhammi, Amit Srivastava

Department of Orthopaedics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
Address for correspondence: Dr. Rehan Ul Haq, Department of Orthopaedics, University College of Medical Sciences and Guru Teg
Bahadur Hospital, Delhi-110 095, India. E-mail: docrehan1975@gmail.com

ABSTRACT
Pelvic fractures are one of the common cause of mortality in polytrauma patients, especially following
high velocity trauma. The management in emergency requires good clinical judgment and access to
radiological modalities. There are various classifications to define the pattern of injury in pelvic fractures.
Previously, fracture patterns were described on the basis of anatomical fracture pattern on radiographs.
With the introduction of concept of force vector and stability defined by Pennal and Tile, which was further
modified by Young and Burgess, the corrective forces required to reduce such fractures were defined. With
the introduction of these newer classification systems along with the introduction of external fixators, the
mortality and morbidity has significantly reduced in pelvic fractures.

Key words: Classification, pelvic fractures, ring injuries

INTRODUCTION On the basis of these views along with computer

Pelvic fractures constitute 3% of all skeletal injuries.[1-6]
Its incidence amongst polytrauma patients ranges from
25% to 30%. It is one of the most common causes
of mortality in polytrauma patients and these rates
have been found to be in the range of 16-19% in
such patients.[1-6] The most common cause of death in
these patients is hemorrhagic shock or coagulopathy
(60-65%), thus, control of hemorrhage is of utmost
importance. Additional causes of death are sepsis in
pelvic hematoma and acute renal failure.[7]
Management of pelvic fractures in emergency requires
good quality radiographs, which is quite a task in
such patients as they cannot be lifted and turned
repeatedly. Anterioposterior view, oblique views and
“inlet” and “outlet” views should be done.[8-12] These
views provide useful information regarding pelvic ring
fractures and associated sacroiliac (SI) disruption.
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tomography (CT) scan of pelvis, we can identify stable
or unstable fracture patterns, and thus manage the
patient accordingly.[9-12] CT scan better defines the
posterior pelvic injury, better delineates rotation of
fragments and comminution of the bone.
ANATOMY
The pelvis is a ring with two parts; each part is formed
by ilium, ischium, and pubis. These units do not have
inherent stability but rely on ligamentous support
for stability. The stability of pelvic ring depends on
the SI joints and the pubic symphyses, both of which
are fibrous joints and only allow minimal movements.
The sacrum and ilium are attached to each other
by short interosseous ligaments, short posterior
ligaments, and long anterior ligaments. In addition
to these ligaments, further stability is provided by
sacrotuberous ligament (arising from lateral border
of the sacrum to the ischialtubeosity) and sacrospinal
ligament (from lateral border of sacrum to the spinous
process of the pelvis).[1,6]

CLASSIFICATION
DOI:
10.4103/0975-7341.133997 The spectrum of pelvic fractures ranges from pubic
ramus fractures, which are low energy fractures to high

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Haq, et al.: Classification of pelvic fractures
energy unstable fractures, which can result in massive
blood loss and associated morbidity and mortality.
Fracture classification systems must identify and
describe the fracture pattern, must aid in treatment
protocol, and help in predicting the treatment
outcome. There are classifications of pelvic fracture
which adequately define the injury pattern and assist
in management planning, but are associated with
inter- and intraobserver variations.[10]
The various classification systems which are commonly
used in pelvic fracture are:
A. Anatomical classification by Letournel.
B. Classification based on stability and deformity.
C. Orthopedic Trauma Association classification —
mainly useful for research.
D. Classification based on vector force and associated
injuries by Young and Burgess.
Anatomical Classification by Letournel
Letournel defined the fracture pattern on the basis
of the area of pelvic bone involved. He divided all
fractures in two groups — anterior and posterior.[13]
Anterior fractures include
• Ramus fractures
• Symphyseal disruption
Posterior fractures include
• Iliac wing fracture
• Iliac wing/SI joint fracture (crescent fracture)
• SI joint fracture
• Sacrum/SI joint fracture
• Sacrum fracture
This classification defined the fracture pattern, but
it did not mention the stability of the fracture and
therefore is not useful in deciding the management
protocol or outcome of these fractures. This
classification was introduced at the time when CT
scans had not been introduced and there were limited
surgical options for managing such fractures. Thus,
most of the fractures were treated conservatively by
skeletal tractions, slings, or abdominal binders.
Classification based on stability and deformity
by Pennal, Bucholz, and Tile
With the introduction of external fixators, there
was marked improvement in managing pelvic
fractures.[14-17] The concept of “force vector” causing
the fracture and “counter force” required to reduce
the fracture was understood. This concept was
introduced by Pennel in 1961 and was further
modified by Bucholz and Tiles, who added the
concept of stability in the classification.
Journal of Orthopaedics, Traumatology and Rehabilitation ⋅ Vol-7 ⋅ Issue-1 ⋅ Jan-Apr 2014
Pennal et al.,[9] described the fracture pattern on the
basis of mechanism of injury:
• Anteroposterior compression (APC) injury
• Lateral compression (LC) injury
• Vertical shear (VS) injury pattern
All classifications prior to this were dependent on
radiographs for describing the pelvic injuries. They only
gave documentation of individual fracture pattern and
were not found to be useful in further management of
patients. With the introduction of this classification the
concept of force vector was introduced, which aided in
the surgical management of patients.
Bucholz described three fracture patterns.[2]
Group 1
Displaced anterior ring fractures with minimally
displaced, stable fracture, or incomplete tearing of
anterior SI ligament.
Group 2
Anterior pelvic ring injury associated with rotational
opening of SI joint with disruption of only SI ligament.
Group 3
Complete disruption of anterior and posterior
hemipelvis.
Tile modified the Pennel classification, and
categorized the injuries as “stable” and “unstable”.
The alphanumeric system defined by Tiles is one of
the most commonly used classifications.
Stability
It is ability of pelvic ring to withstand physiologic forces
without abnormal deformation. Forty percent of the
pelvic stability is provided by the anterior ring and 60%
by posterior ring. Stability of the pelvis following trauma
is assessed by clinical and radiological parameters.[1,8,9]
Clinically, stability is examined by pelvic compression
and distraction test.
Radiological criteria of instability are:[1,10-12]
• SI displacement of 5 mm in any plane
• Posterior fracture gap (rather than impaction)
• Avulsion of fifth lumbar transverse process, lateral
border of sacrum (sacrotuberous ligament), or
ischial spine (sacrospinous ligament).
According to Tiles classification [Figure 1], fracture
pattern was classified as follows:
• Type A: Stable fracture.
These are the fractures with intact soft tissues
around the pelvis, not disrupting the ligaments. It
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Haq, et al.: Classification of pelvic fractures
includes — avulsion fractures and transverse fracture
of sacrum and coccyx.
• Type B: Rotationally unstable, but vertically stable.
These fractures are rotationally unstable and
vertically stable. There is less than 1 cm rotation of
the hemiplevis. These types of injuries are caused by
external or internal rotational forces. The external
rotational forces produce ‘open book’ injury pattern.
There is disruption of pubis symphysis associated with
unilateral or bilateral SI joint disruption. The posterior
SI ligaments remain intact, thus the pelvis is vertically
stable.
• Type C: Rotationally and vertically unstable.
These injuries are characterized by disruption of
posterior SI ligaments as well as pelvic floor, this result
in gross displacement of pelvis. These injuries are due
to VS forces, resulting in the mark displacement of the
SI joint. There is complete disruption of both SI and
sacrotuberous ligament leading to rotationally and
vertically unstable fracture pattern.
Orthopedic Trauma Association Classification is a
further modification of the Tiles classification:
• A — Lesion sparing (or with no displacement of) the
posterior arch
• B — Incomplete disruption at posterior arch;
partially stable
• C — Complete disruption of posterior arch; unstable
Type A
• A-1 — Fracture of innominate bone; avulsion
• A-2 — Fracture of innominate bone; direct blow
• A-3 — Transverse fracture of sacrum and coccyx
Type B — Partially stable pelvic ring injuries
• B-1 — Unilateral partial disruption of posterior
arch, external rotation (“open book” injury)
• B-2 — Unilateral, partial disruption of posterior
arch, internal rotation (LC injury)
• B-3 — Bilateral, partial lesion of posterior arch
b1
a b2
Figure 1: (a) Stable fractures. (b1 and b2) Rotationally unstable and
vertically stable. (c) Rotationally and vertically unstable
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Type C — Complete disruption of posterior arch
• C-1 — Unilateral, complete disruption of posterior
arch
• C-2 — Bilateral, ipsilateral complete, contralateral
incomplete
• C-3 — Bilateral, complete disruption
This classification system has been found to be
advantageous in comparing studies in literature rather
than being used in emergency situation.
Young and Burgess classification
The concept of direction of forces causing
fracture, associated instability of pelvis and its
surgical management was further refined by the
introduction of this classification. In association
with clinical examination, this classification
provided the logical approach to the pelvic trauma
management.[18]
Four mechanisms of injury were defined in this
classification[10] [Figure 2].
• Lateral compression (LC) (implosion)
• Anteroposterior compression (APC) (external rotation)
• Vertical shear (VS)
• Combined injury
Koo et al. and Furey AJ et al., found that inter- and
intraobserver reliability of this classification is better
than Tiles classification.[19,20]
The pattern of fracture and mechanism of injury
according this classification are as follows:
• LC fracture of anterior ring plus:
LC-I — Compression fracture of anterior sacrum
LC-II — Iliac wing fracture posteriorly (unstable)
LC-III — Windswept pelvis (contralateral SI
joint injury)
c
Figure 2: LC = Lateral compression injury, APC = anteroposterior
compression injury, VS = vertical shear force injury
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Haq, et al.: Classification of pelvic fractures

• APC TYPE II INJURY

APC-I — Partial disruption
APC-II — Posterior SI ligaments intact Additional anteroposterior force causes splaying of
APC-III — Posterior SI ligaments disrupted anterior pelvis with external rotation of iliac wings.

• VS — Cephalad and posterior displacement

• Combined mechanism — LC and VS most common

LC INJURY
The LC fracture is the most common pattern in pelvic
fractures.[21-23]

LC-I fracture pattern

The direction of force of injury is from the side and
is associated with either horizontally oriented pubic
fracture and/or impacted fracture of the sacrum.
Thus, this fracture pattern is associated with impacted
fracture of posterior SI complex and may be unstable Figure 3: Lateral compression (type I) injury pattern, showing
[Figure 3]. impaction of sacrum with superior and inferior pubic rami fracture
ipsilaterally
LC II fracture pattern
With increasing lateral force on the anterior pelvis,
the major fracture fragment is rotated inwards, with
anterior sacrum acting as the pivot. This gives rise
to the disruption of the posterior SI joint associated
with or without oblique fracture of posterior ilium
extending lateral to the SI joint [Figure 4].

LC III fracture pattern

This is the most severe form of LC fracture. There is
further continuation of LC force which continues on
the contralateral pelvis. This lateral force becomes a
distracting force for the contralateral hemipelvis and
causes its external rotation. This external rotation Figure 4: Lateral compression (Type II) injury. Oblique fracture
occurs due to SI, sacrotuberous, and sacrospinous of posterior ilium, superior and inferior pubic rami with posterior
ligament disruption. This leads to unstable pelvic dislocation of hip, and fracture shaft of femur
injury with associated hemorrhage and neurological
injury [Figure 5].

APC FRACTURE
The direction of force is from the front of the pelvis.
These forces disrupt the anterior pelvis and as the
force vector progresses there is disruption of posterior
pelvis leading to unstable pelvic injury.

TYPE I INJURY
There is vertical fracture of pubic rami with rupture of
the ligament of pubic symphysis, associated stretching
of posterior ligaments. There is less than 2.5 cm of Figure 5: Lateral compression (Type III). Posterior iliac blade with both
symphyseal diastasis [Figure 6]. rami fracture and associated sacrospinous ligament tear

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Haq, et al.: Classification of pelvic fractures

The iliac wings hinge at the posterior SI joint. There is
rupture of sacrotuberous, sacrospinous, and symphyseal
ligaments with intact posterior SI ligaments (open book
pattern). Symphyseal diastasis of more than 2.5 cm is
seen, vertical stability is maintained [Figure 7].
TYPE III INJURY PATTERN
There is complete disruption of all ligaments associated
with posterior SI ligament. This results in rotational
instability and lateral displacement of pelvis. This type
of injury pattern is highly unstable and is associated
with highest rate of vascular injuries [Figure 8].[21,22]
VS INJURY PATTERN
This injury occurs because of fall from height on the
extended lower limbs. There is associated disruption of
sacrospinous, sacrotuberous, SI, and pubic symphysis
ligaments, which leads to gross instability of the pelvis
more commonly in the cephaloposterior direction. This
injury is also associated with neurovascular injury and
hemorrhage [Figure 9].
COMPLEX FRACTURE PATTERN
This fracture pattern is seen in 23% of all cases of
pelvic fracture. The direction of force vector is both in
anteroposterior and lateral plane.[21,22]
This classification is useful in predicting the resuscitation
requirements and further surgical reconstruction
because of the better understanding of the structures
injured and energy the pelvis has absorbed. For
example, APC injuries are associated with bladder and
other visceral organ injuries, which are associated with
extensive blood loss. On the other hand, LC-I type
injury rarely require surgical intervention.

Figure 7: Anteroposterior compression injury pattern (Type II). Shows

Figure 6: Anteroposterior compression injury (Type I). Shows rupture symphyseal diastasis >2.5 cm, with disruption of sacrospinous,
of pubic symphisis ligament (<2.5 cm symphyseal diastasis) sacrotuberous, and symphisis ligaments

Figure 8: Anteroposterior compression injury pattern (Type III). Shows Figure 9: Vertical shear injury pattern. Shows complete disruption
complete disruption of all ligaments along with posterior SI ligament of all ligaments in ipsilateral side associated with disruption of pubic
and SI disruption symphisis, with vertical displacement of hemipelvis

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Haq, et al.: Classification of pelvic fractures
CLINICAL RELEVANCE OF CLASSIFICATION
Classification system helps in predicting hemodynamic
stability, pelvic instability, visceral, and genitourinary
injuries. It also helps in understanding the mechanism
of injury, force vector of injury, and surgical tactic for
reduction.[23-26]
The definitive management is decided on the basis of
clinical features and fracture pattern.
Conservative treatment
Following indications are considered for conservative
treatment:
• Most LC and anteroposterior type I injuries are
treated conservatively
• Pubic symphysis diastasis less than 2.5 cm
• Pubic rami fracture with no posterior displacement.
Patients are kept on protected weight bearing and followed
up by serial radiographs and clinical examination.
Absolute indications of surgery:[24-26]
• APC-III, LC-III, and VS type of fracture pattern
• Open pelvic fractures
• Associated visceral injury
• Hemodynamic instability
A total of 20-25% of mortality is seen in APC-III
fracture pattern followed by LC-III pattern (7%).[27,28]
These unstable pelvic fractures are managed in casualty
by application of anterior or posterior pelvic external
fixators, depending on the fracture pattern.[23-29]
In case of vertical instability, associated traction is also
given by using upper tibial skeletal traction or Ganz
fixator system.
In conclusion pelvic fractures are one of the major causes
of mortality in polytrauma patients. With the advent of
classification system along with better imaging modalities
(CT scan), there has been marked improvement in
management and rehabilitation of patients.
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How to cite this article: Haq RU, Dhammi IK, Srivastava A. Classification
of pelvic fractures and its clinical relevance. J Orthop Traumatol Rehabil
2014;7:8-13.
Source of Support: Nil, Conflict of Interest: None declared.
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