Radiologic Management

of Pelvic Ring Fractures

Systematic Radiograph'c Diagnosis

Jeremy W. R. Young, M.A., B.M., B.Ch., P.R. C.R

Chief, Orthopedic Radiology
Department of Diagnostic Radiology
University of Maryland Medical Systems, Baltimore

Andrew R. Burgess, M.D.

Chief, Orthopedic Trauma Surgery
The Shock Trauma Center of the Maryland Institute of Emergency Medical
Services Systems, Baltimore

Urban & Schwarzenberg . Baltimore - Munich· 1987

 to
William B. Young
A fine radiologist, father, and friend
As a statewide referral center for adult multi trauma
victims and as a specialty center for spinal cord and head
injuries, the Shock Trauma Center of the Maryland
Institute for Emergency Medical Services Systems
admits more than 2,500 severely ill or injured patients
each year. The relatively small staff of this institution,
augmented by resources (such as the Radiology Depart-
ment) shared with the University of Maryland Medical
Systems Hospital, is thus exposed to very high concen-
trations of critical injuries that require immediate and
multiple lifesaving interventions. The distillate of this
exposure provides unique insights into the value of
different diagnostic and therapeutic procedures.
One such insight is the value of the plain radiograph.
Experience at the Shock Trauma Center indicates that
a plain radiograph can supply not only an adequate
representation of certain injuries but also, in some cases,
information unobtainable with the computed tomogra-
phy (CT) scan. Plain radiographs have other advantages
as well. They are readily available, easily and quickly
handled, relatively inexpensive, and, when read by a
physician knowledgeable in anatomy, radiography, and
accident etiology, competently diagnostic.
The efficacy of the plain radiograpli, in an age when
expensive CT equipment has become almost a require-
ment in higher echelon care centers and when all medi-
cal facilities are reviewing expenses with regard to
insurance reimbursements and diagnosis related groups,
is good news for those facilities that do not have access
to such equipment. It can also represent a significant
cost saving for those facilities that do - without lessen-
ing the fl-uality of care.
State-of-the-art care, especially for life-threatening
injuries, without additional risk to the patient or undue
expense is a worthwhile goal for any medical facility.
Utilization of the plain radiograph at the Shock Trauma
Center helps this institution attain that goal.
R. Adams Cowley, M.D.
Professor and Director
Maryland Institute for Emergency Medical
Services Systems
Foreword. . . . . . . . . . VII
Acknowledgements ... . VIII

Chapter 1: Introduction . . . . . . . . . . 1
Chapter 2: Anatomy and Stability of the Pelvis . 9
Chapter 3: Injury Force Patterns . . . . . . 15
Chapter 4: Lateral Compression Fractures. . . . 17
Chapter 5: Anteroposterior Fractures . . . . . . 41
Chapter 6: Vertical Shear and Complex Fracture Patterns . 55
Chapter 7: Fractures of the Pubic Rami 67
Chapter 8: Complications. . . . . . . . 77
Chapter 9: Assessment and Utilization . 91
 Chapter 1
Introduction
:::ractures and fracture dislocations of the pelvic ring
generally result from severe trauma. Management of
::hese injuries must include treatment not only of the
- -eletal trauma, but also of the associated shock and
,:omplications. Rapid and appropriate treatment of the
~umatized pelvis is of vital importance to overall
_ tient management because pelvic injury is often a
:::lajor contributor to the fatal outcome in many trauma
_atients. Faulty or delayed assessment can lead to in-
.:orrect treatment, possibly causing further soft tissue
::.nd vascular damage, creating rather than arresting
~ditional blood loss, and putting the patient at greater
.--k. On the other hand, prompt recognition of the
:racture pattern and early pelvic stabilization with
:-ealignment of the bony structures can often reduce
:lood loss, lead to homeostasis, and increase the pa-
:::ent's chances for survival.
Classically, pelvic fracture management has con-
--ted of pelvic slings, postural reduction, skeletal trac-
"':on, or internal fixation; more recently, management
:....hniques have expanded to include external fixation.
:::x:ternalfixators have become increasingly important to
::i:le orthopedic surgeon's armamentarium because they
~ble the surgeon to apply stabilizing devices rapidly
2:ld to exert on the pelvis virtually any type of force
~ompressive, distracting, or rotational) necessary to
:-edress in part the effects of the injuring mechanism.
To determine the correct counterforce to apply, how-
='o-er,the surgeon must first understand the direction of
::ie injuring force. Given the fact that the patient is a
=mltitrauma victim, the surgeon will have already
=yaluated the injury as a high-velocity insult, most likely
.=. m a blunt trauma incident such as vehicular accident.
~e surgeon can obtain such information from two
= urces: 1) the accident history, either from the prehos-
:;:r.al providers or from the police report; and 2) the
_Wiographic evaluation.
Ylodern technologic advances have provided
_ umatologists with a variety of radiographic techniques
:: ~ evaluating the injured pelvis, and each method
.::zs its advantages and disadvantages. In the past, plain
::::::J1l radiography formed the mainsray of evaluation, but
-LXiaysome traumatologists prefer computed tomogra-
phy (CT), which provides additional information about
the soft tissues of the pelvis and, thereby, can indicate
organ damage or hematoma formation. CT, however, is
also more time-consuming than plain film radiography
and necessitates additional patient movement and trans-
fer, which can exacerbate existing injuries. In addition,
despite the fact that CT may indicate the presence of
hematoma, it cannot provide a detailed analysis of the
vascular system, so angiography may still be required.
Plain radiographs, on the other hand, are readily
available, ir;expensive, and easy to obtain. Our experi-
ence with patients presenting to the Shock Trauma
Center with pelvic ring trauma indicates that, although
CT may occasionally provide additional information
and is therefore still used for some cases, the vast
majority of pelvic injuries can be interpreted correctly
by careful analysis of plain films, combined with a full
understanding of the anatomy of the pelvis and its
supporting structures. Indeed, accurate plain film analy-
sis has considerably reduced our reliance on CT,
facilitating undelayed implementation of the treatment
plan and avoiding the additional destabilizing maneu-
vers involved in transport to and from the CT location.
In addition to the immediate problems of pelvic
injury, the morbidity of patients with severe pelvic ring
disruption is not inconsiderable, involving predomi-
nantly sacroiliac or anterior pubic arch pain. Often this is
so severe that it prevents return to normal occupations.
Therefore, correct management of the pelvic fracture
is imperative, not only for its immediate lifesaving
potential, but also for long term success.
One of the main problems in implementing this
management concept has been the lack of clear fracture
classifications based on the force causing the injury. The
literature, for example, supplies confusing delineations
which, with the exception of the recent work by Pennal
and Tile, do not incorporate mechanisms of injury or
direction of the causative force but, rather, consist of
histQrical documentation of observations about indi-
vidual fracture patterns.
The concept of classification of pelvic fractures
according to force patterns was originally described by
Pennal. More recently other authors have adopted this
idea, but the concept has been slow to gain acceptance.
In the past this may have been due to a general lack of
trauma centers, with an insufficient volume of pelvic
injury to arouse adequate interest. However, in the
modem high speed world, with increasing incidence of
severe trauma, and with a concurrent upsurge of interest
in trauma, treatment of trauma, and preventive plan-
ning, an understanding of mechanisms of injury is
becoming increasingly important.
The goal of this book is to define the whole pelvic ring
and to identify specific fracture patterns with their
causative force vectors so that the orthopedic surgeon
can select the appropriate fixation device and, thus, can
apply the appropriate corrective counter forces. To that
end, we have herein expanded the emergent causative
classification system by relating the radiographic
appearances of the various pelvic fractures to the disrup-
tive forces producing the injuries. Each pelvic fracture
reported in this book (deliberately excluding "pure"
acetabular fractures on the basis that they may occur as
isolated injuries or may be at least outside the integral
portion of the pelvic ring) was analyzed by fracture
pattern, nature of injury, and relation to the injury force
vector. We have found that this approach of analyzing
plain films in the light of complete pelvic anatomy yields
an accurate assessment not only of the nature of the
injury, but also of the type of injurious force, vital
information for the implementation of appropriate surgi-
cal management of the traumatically injured pelvis.
The Maryland Institute for Emergency Medical Serv-
ices Systems (MIEMSS) is a coordinated statewide
emergency medical network incorporating communica-
tions, prehospital care and triage, transportation, treat-
ment, education, and certification. Referral centers are
both geographically- and specialty-oriented so that each
one of the state's five regions has at least one Level I
trauma center, and there are statewide referral centers
for pediatric trauma, replantation surgery, eye injuries,
thermal injuries, perinatal emergencies, and the most
complex adult trauma. The Shock Trauma Center is the
statewide specialty referral unit for the most serious
adult trauma, as well as for head and spinal cord injuries.
The Shock Trauma Center is a state-funded facility
with a dedicated admitting area and operating rooms. It
is staffed 24 hours a day by full time trauma surgeons,
anesthesiologists, intensive care specialists, neurosur-
geons, plastic surgeons, orthopedic surgeons, nurses,
and ancillary personnel who are burdened by no other
medical tasks except the resuscitation and treatment of
the trauma patient.
Most trauma (85%) in the sta~ is managed at local
hospitals; 10% is referred to area Level I trauma centers;
and only 5% is serious enough to warrant transport and
admission to the statewide specialty referral centers. In
its function as an adult trauma unit, the Shock Trauma
Center treats approximately 2000 severely injured pa-
tients per year. This concentrated population enables the
Shock Trauma Center staff to amass quantities of infor-
mation and experience in diagnosing and treating
sp cific injuries such as pelvic fractures, in addition to •
amassing data about the overall needs of the trauma
patient. This experience has produced a correlation
between radiographic patterns of injury and impact
dynamics, systemic sequelae, and eventual clinical
course and has resulted in the integration of this correla-
tion into the Shock Trauma Center's clinical format.
Every patient presenting to the Shock Trauma Center
receives a single anteroposterior (AP) view of the pel vis.
This view provides reasonable general assessment, and
anatomical detail of the pel vis (Fig. 1-1). However,
occasional subtle fractures can be missed. Therefore, in
each patient in whom pelvic injury is either clinically
suspected or previously diagnosed, amongst other films
for concurrent multiple trauma, two additional views of
the pelvis are obtained. These are a pelvic "inlet" view,
with the patient supine and the x-ray tube angled 45
degrees caudad and the beam centered on the umbilicus
(Fig. 1-2), and an "outlet" view, with the tube angled 45
degrees cephalad, and the beam centered on the symphy-
sis (Fig. 1-3). Of course, in all views it is important to
include the entire pelvis on the radiograph, from the iliac
crests through the inferior pubic rami. As in all radiolo-
gical investigations, additional views may be indicated.
For example, in cases of acetabular fracture or when
acetabular fracture is associated with fractures of the
pelvis, oblique views (Judet views) may also be taken.
But these are always complemented by computed to-
mography (CT) , which is the method of choice for
evaluation of acetabular fractures with respect to defini-
tive surgical correction. This is beyond the scope of the
current text.
 Figure 1-2 Inlet View: The tube is angled 45° caudad and
centered on the umbilicus. This gives an excellent view of the
"ring" of the pelvis.

/
=igure 1-1 AP View: This view must include the whole pelvis,
;.. m iliac crests to inferior pubic rami.

From our experience with more than 350 cases of

ute pelvic ring trauma, we have determined that the
;:orrect diagnosis can be made using the AP view alone
in 90% of cases (Fig. 1-4). However, the inlet view
~rovides an overall assessment of the pelvic ring, and is
. eful for determining the amount of distortion and the
extent of displacement of fracture fragments (Fig. 1-5).
In addition, the inlet view may be instrumental in
detecting the "horizontal" nature of fractures of the
ubic ramus in cases of lateral compression, where the
_-\1' view is inconclusive (see Chapter 4), and we also
ave found that the inlet view may clarify crush fractures
of the sacrum, and associated defects in the sacral
cuate lines (Fig. 1-6A+B). As will be seen below,
Ibis is of some importance in the differentation of lateral
~ompression fractures from AP compression injuries,
'bich require totally different corrective forces. Figure 1-3 Outlet View: The tube is angled 45° cephalad.
The outlet view provides information as to superior or This view demonstrates the vertical orientation of the hemipel-
inferior displacements of the fracture fragments, and is vic components relative to the sacrum.
articularly useful in cases of vertical shear injuries
Fig. 1-7). plete posterior displacement of the left hemipelvis. By
The importance of taking multiple views can be use of these three films, therefore, a complete analysis
recognized as demonstrated in Fig. 1-8 A + B. The fron- of the integrity of the pelvic ring can be obtained.
:at view demonstrates what appears to be a normal Orientation of each integrated component is easily seen,
pelvis. The inlet view, however, demonstrates the com- and discrepancies and displacements are readily visible.
Figure 1-4 Good overview of the pelvis, from iliac wings to the pubic rami. In this case fractures of the left iliac
wing and right acetabulum are seen (arrowheads), with diastasis of the left SIJ (arrow).

Figure 1-5 Inlet View: This gives an

overall view of the pelvic ring. In this
case, obvious "flattening" of the right
hemipelvis is seen. This view also de-
monstrates the horizontal/coronal na-
ture of the pubic rami fractures, with
clear overlap of the fragments. The
sacral crush fracture (open arrow) is
also seen. These findings confirm la-
teral compression.
Figure 1-6A On the AP view, the left sacral
crush fractu re is difficult to see because of overly-
ing bowel gas (open arrow). The right superior
pubic ramus fracture could be misinterpreted as
a vertical fracture.

Figure 1-68 The inlet view clearly demon-

strates the coronal/horizontal nature of this frac-
ture and the left sacral fracture (large arrow-
head).
A
Figure 1-8 No obvious abnormality is seen on a frontal view (A). The inlet projection, however (8), taken with the pelvis in the
identical position, shows posterior displacement of the right hemipelvis.

Connolly W. B., Medberg E. A.: Observations on fractures of the
pelvis. J Trauma 9: 104-111, 1969.
Dunn A. W., Morris M. D.: Fractures and dislocations of the pelvis.
J Bone Joint Surg 50A: 1634-1648, 1968.
Harris J. M., Harris W. M.: The Radiology of Emergency Medicine,
ed2.Williams&Wilkins. Baltimore, London,pp. 533-554, 1981.
Holdsworth F. W.: Dislocation and fracture dislocation of the pelvis.
J Bone Joint Surg 30B: 461-466, 1948.
Looser K. G., Crombie M. D.: Pelvic fractures: an anatomic guide to
severity of injury. Am J Surg 132: 638, 1976.
YIonahan P. R. W., Taylor R. G.: Dislocation and fracture disloca-
tion of the pelvis. Injury 6: 325-333, 1975.
Peltier L. F.: Complications associated with fractures of the pelvis.
J Bone Joint Surg 47A: 1060-1064, 1965.
Pennal G. F., Tile M., Waddell J. P., Garside H.: Pelvis disruption:
assessment and classification. Clin Orthop Rel Res 151: 12-21,
1980.
Rogers L. F.: Radiology of Skeletal Trauma. Churchill-Livingstone.
New York, p. 634-649, 1982.
Thaggard A., Marle T. S., Carlson V.: Fractures and dislocations of
the bony pelvis and hip. Semin Roentgen 13(2): 117 -134, 1978.
Tile M.: Fractures of the Pelvis and Acetabulum. Williams &
Wilkins. Baltimore, London, 1984.
Young J. W. R., Burgess A. R., Brumback R. J., Poka A.: Pelvic
fractures: value of plain radiography in the early assessment and
management. Radiology 160(2): 445-451, 1986.
 Chapter 2

Anatomy and Stability of the Pelvis

One of the most valuable skills in analyzing fractures of
the pelvic ring is a thorough understanding of the
anatomy of the pelvis. Initially this requires a know-
ledge not only of the bony structures, but also of the
important supporting ligaments. In addition, one must
bear in mind the soft tissues, particularly the vascular
and nervous structures and organs, which are in close
proximity to the bones, and which are potentially at risk
in any disruption of the pelvic ring. An integration of
this information with the radiographic appearance of the
fracture will give an accurate impression of the soft
tissue injuries which may occur.
The main anatomical features which are of import-
ance in an understanding of the pelvic structure and
stability are outlined below.
The pelvis is basically a ring comprised of three bony
components: the sacrum and two lateral components
formed by the ilium, ischium, and pubis. These units
together have no inherent stability and rely totally on
ligamentous support for their integrity. The stability of
this ring depends upon the stabilizing structures of the
sacroiliac joints (SIJs), with the symphysis acting more
as a supporting "strut." Absence of this "strut" does not
lead to insta.bility, as can be seen after trauma"or in cases
of congenital malformation, provided that the posterior
ligamentous structures are intact (Fig. 2-1).

Figure 2-1 Congenital extrophy of the bladder with absence of the anterior pelvis. These patients, despite
incomplete pelvic rings, show no signs of pelvic instability, because of the presence of normal posterior
supporting ligaments.
The SIJs are divided into two parts: the lower, articular
portion, and the upper tuberosities. The articular portion
is covered by a thin layer of cartilage. Due to the very
strong supporting ligaments of the sacroiliac joint, only
very limited movement is possible.
The ligaments fall into two main groups: 1) those
bridging the SIJ itself, and 2) those which support the
floor of the pelvis and anchor the sacrum to the iliac and
Figure 2-2 Diagrammatic View of the Pelvis: The posterior
ischial spines.
sacroiliac ligaments are shown traversing the posterior aspect
of the SIJ (P). The anterior sacroiliac ligaments (A) cross the
anterior portion of the joint. The sacrotuberous and sacrospin-
ous ligaments are also shown (T).

These are short ligaments that unite the tuberosities of

the ilium and sacrum. They are the strongest in the body,
and act to stabilize the sacroiliac complex.

As their name suggests, these ligaments stabilize the

posterior aspect of the sacroiliac joint. They comprise
two groups: the first and shorter fibers arise from the
posterior superior and inferior spine of the ilium and run
obliquely to the ridge of the sacrum; the second, longer
fibers run to the lateral portion of the inferior sacrum,
intermingling with the sacrotuberous ligament. Figure 2-3 Posterior view of the pelvis: PSI = posterior sac-
roiliac ligaments. ST = sacrotuberous ligaments.

These ligaments overlie and stabilize the anterior aspect

of the sacroiliac joint. The fibers pass from the anterior
surface of the sacrum to the adjacent anterior ilium.
In addition to these sacroiliac joint ligaments, two
groups of inferior connecting ligaments further stabilize
the posterior pelvis.

These extremely strong ligaments extend from the lat-

eral border of the sacrum, intermingling with fibers of
the posterior sacroiliac ligaments from the posterior iliac Figure 2-4 Anterior view of the pelvis: ASI = anterior sac-
spines to the ischial tuberosity. They run alongside, and roiliac ligaments. SS = sacrospinous ligaments. ST = sac-
in places become contiguous with, the sacrospinous rotuberous ligaments.
ligaments. The medial border forms a portion of the are fractured-particularly when displacement of fracture
pelvic outlet. fragments is seen. Separation of the sacroiliac joints, or
of posterior fractures of the iliac wings extending to the
iliac notch, raise the possibility of trauma to the internal
iliac and superior gluteal arteries. In practice, it is
generally the superior gluteal artery that is damaged, as
These ligaments als'o derive from the lateral border of its path leaves it open to shearing injuries of the sac-
the sacrum, deep to the sacrotuberous ligaments, and roiliac joints, because it "hooks" under the sciatic notch
pass directly to the ischial spine. in close proximity to this joint. •
Conversely, anterior injuries with disruption of the
symphysis and fractures of the pubic rami are likely to
cause damage to the anterior vessels, in particular the
pudendal and vesical branches.
Finally, stability of the pelvis to the spine is provided by
the iliolumbar and lateral lumbosacral ligaments (which
run between the 5th lumbar transverse process and
superior border of the ilium) and the sacrum.
In the symphysis pubis, the opposing bone is covered
with hyaline cartilage, support~d by fibrocartilage and
fibrous tissue. Inferiorly, the inferior pubic ligament
adds support. These ligaments add some support but, as
mentioned above, the anterior pelvis and symphysis are
not vital to pelvic support or stability.

Although this text is concerned primarily with the

radiographic analysis of the bones of the pelvic ring, it is
impossible to divorce pelvic ring injury from injury to
the soft tissues of the pelvis, which may be clinically far
more serious than the bony injury. A brief description of
Figure 2-5 Lateral Section of the Pelvis: The major blood
the major anatomical features of commonly involved vessels are demonstrated; their proximity to the bony pelvis
soft tissues follows. can be appreciated. ii: = internal iliac; sg = superior gluteal;
ig = inferior gluteal; 0 = obturator; p = pudendal.

The major vascular structures of the pelvis are the iliac

arteries, both internal and external, and the branches of
the internal iliac arteries. Those which lie in close
proximity to bone are most likely to be injured. These
include the superior gluteal artery, particularly as it
passes through the sciatic notch; the pudendal and vesi-
cal branches, as they pass along the anterior and lateral
walls of the pelvis; and the median sacral, lateral sacral,
and iliolumbar vessels as they run in close proximity to
the sacrum (Fig. 2-5). Understanding the paths ofthese
vessels allows consideration of possible injury when the
bones of the pelvic ring (which lie in close relationship)
The ureters, bladder and urethra are positioned in close
proximity to the bones of the pelvis, and also are prone
to damage in pelvic trauma. The bladder and urethra are
particularly prone to damage from trauma involving the
symphysis pubis or pubic rami (Fig. 2-6). The ureters
potentially are at risk from disruptive fractures of the
posterior pelvis, with either diastasis of the sacroiliac
joints or separation of fractures ofthe sacrum. However,
in our experience, injury to the ureters is extremely rare.
Figure 2-6 There is mild diastasis of the symphysis pubis and fracture of the right pubis. Contrast extravasation from the urethra
is seen. Also of note is a fracture of the left femur and fractures of the right pubic rami. A sacral fracture is only poorly seen on this
film.

from the L4 through S3 nerve roots, exits the pelvis

The most important nerves of the posterior pelvis - and
the most susceptible to damage - are those of the
lumbosacral plexus. This is composed of a branch ofthe
L4 root, together with the roots of L5 to S4.
Fractures of the sacrum, particularly because they
frequently involve the neural foramina, are a potential
source of injury to the nerve roots. In addition, the
branch of the L4 root is at risk as it crosses the lateral
process of L5. The L5 root crosses the superior sacrum
and unites with the L6 branch just medial to the sac-
roiliac joint. The sciatic nerve, which receives fibers
between the lower border of the piriformis muscle and
the ischial border of the greater sciatic notch. This nerve
may therefore be damaged in pelvic injury, particularly
if there is disruption of the posterior pelvis or even pos-
terior dislocation of the hip.
The pudendal, superior gluteal, inferior gluteal, and
other collateral nerves (such as the nerve to obturator
intemus, and posterior femoral cutaneous nerve) also
exit the pelvis in close proximity to the sciatic nerve in
the greater sciatic notch, and are also at risk in posterior
pelvic injuries. In addition, the perforation of the
cutaneous nerve, which supplies the skin of the lower
buttock, pierces the sacrotuberous ligament and may be
injured in ruptures of this ligament.

Much has been written on the subject of pelvic stability,
and many of the classifications of pelvic fractures are
based on this feature. Although our classification system
is not based upon stability, it is appropriate to under-
stand points that contribute to a stable or unstable pelvis,
as this has a bearing on whether pelvic immobilization
will be necessary. We classify pelvic fractures accord-
ing to the direction of the injurious force; but, at the
same time, the radiographic picture will provide the
indication of stability or lack of it.
Stability of the pelvis depends upon the integrity of
the supporting ligaments. Tile has demonstrated that
division of the symphysis ligaments, with intact post-
erior ligaments, allows the anterior pelvis to "open"
approximately 2.5 cm, the posterior structures prevent-
ing further movement. Additional division of the an-
terior sacroiliac, sacrospinous, and sacrotuberous liga-
ments will allow further "opening" until the iliac spines
abut the sacrum. Furthermore, division of the posterior
sacroiliac ligaments gives rise to complete pelvic insta-
bility, as the iliac wings may now be separated freely
from the sacrum. It is important to remember this when
presented with pelvic ring fractures with obvious dias-
tasis of the symphysis, as it will give some indication as
to likely damage to the posterior pelvis and posterior
ligamentous structures.
As mentioned above, most traditional classifications
of pelvic fractures stress whether the fracture is stable or
unstable. However, because this takes no account of the
direction of disruptive vectors, it is of only limited value
in corrective management of the injury. Stability does
not in itself guarantee immunity from significant soft
Berquist T. H. (ed.): Diagnostic Imaging of the Acutely Injured
Patient. Urban & Schwarzenberg. Baltimore, Munich, 1985.
Gray H.: Anatomy of the Human Body, Charles Mayo Gross (ed.),
ed. 28, Lea & Febiger. Philadelphia, pp. 318-320, 1966.
Hall-Craggs E. L. B.: Anatomy as a Basis for Clinical Medicine.
Urban & Schwarzenberg, Baltimore, Munich, 1985.
Harris J. M., Harris W. M.: The Radiology of Emergency Medicine,
ed. 2. Williams & Wilkins. Baltimore, London, pp. 533-554,
1981.
Holdsworth F. W.: Dislocation and fracture dislocation of the pelvis.
J Bone Joint Surg 30B: 461-466, 1948.
tissue injury, although unstable lesions are more likely
to be assoc"iated with greater soft tissue injury. Severe
bleeding, usually from the internal iliac artery or its
branches, is associated more commonly with posterior
injury, with or without instability. This is not surprising;
most of these injuries are due to blunt trauma, and large
forces are required to damage the posterior pelvis,
particularly in young patients. It is therefore clear that
accompanying injuries, both at adjacent and remote
sites, are to be expected.
Also, significant injury to anterior branches of the
internal iliac arteries, or to the bladder and urethra, are
not infrequent accompaniments of pelvic fractures, par-
ticularly the anterior injuries. These structures lie in
close proximity to the anterior bony pelvis, and may be
damaged either by shearing forces or by direct puncture
from bone fragments.
Finany, as will be seen later, it is not always possible
to judge stability by the criteria developed in traditional
radiographic classification methods. This means that, in
some instances, manual manipulation would be needed
to determine this important feature. However, because
this has the significant risk of exacerbating pelvic bleed-
ing from damaged vessels (either by dislodging clot or
disrupting a naturally formed tamponade), such pro-
cedures should be discouraged unless absolutely
necessary. We feel that the correct diagnosi§ made by
examination of radiographs alone should be the goal of
the radiologist and clinician, and hopefully should ne-
gate the need for potentially harmful manipulations in
most cases. To this end, we hope that the classification
of pelvic ring fractures that we present will give an
accurate picture of stability or instability of the pelvic
ring in the majority of cases.
Huittinen V. M., Slatis P.: Nerve injury in double vertical pelvic
fractures. Acta Chir Scand 138: 571-575, 1972.
Peltier L. F.: Complications associated with fractures of the pelvis.
. :J Bone Joint Surg 47A: 1060-1064, 1965.
Pennal G. F., Tile M., Waddell J. P., Garside H.: Pelvic disruption:
assessment and classification. Clin Orthop Rel Res 151: 12-21,
1980.
Rogers L. F.: Radiology of Skeletal Trauma. Churchill-Livingston,
New York, pp. 634-649, 1982.
Tile M.: Fractures of the Pelvis and Acetabulum. Williams &
Wilkins. Baltimore, London, 1984.
 Chapter 3

Injury Force Patterns

There are three main types of force that may produce

pelvic fractures. These are lateral compression, AP
compression, and vertical shear. In practice, it is not
uncommon to find a combination of forces acting on the
pelvis at the time of injury. In general, where there is
more than one force vector, there is one dominant vector
which is responsible for the major injury - although on
occasion it might not be possible to define a single
dominant vector pattern. We term these fractures "com-
plex patterns."
The major force vectors a:t:eoutlined below.

Figure 3-2 Direct lateral force delivered by impaction

This is the injury to the pelvic ring that we have
encountered most often. It comprised 49% of the pelvic
fractures seen in the Shock Trauma Center over a two
year period. The majority of these were stable injuries
with little significant associated soft tissue injury (see
Chapter 4). As the name suggests, the force is delivered
from the side. This most commonly occurs in motor
vehicle accidents with a direct blow on the side, as when
a car is "broadsided" or when a pedestrian is struck from
the side by an oncoming vehicle (Figs. 3-1,3-2). It may
also occur with a secondary impact with the ground.
against an oncoming vehicle, This type of incident also
accounts for a large number of anterior compression injuries if
the pedestrian is hit "front-on",
This accounted for 21 % of the pelvic ring fractures seen
over the same two year period. These injuries tended to
be associated with greater internal injury. The force is in
either an AP or, less commonly, a posteroanterior direc-
tion. This generally occurs in traffic accidents where the
pedestrian strikes head-on against the oncoming vehicle
(Fig. 3-2), oris crushed against the dashboard of his own
vehicle-often in the hip flexed position. The force,
therefore, may be applied either indirectly through the
femur and acetabulum, or directly onto the pelvis.

These are the least common injuries seen at our institu-

Figure 3-1 Driver struck from the side experiences
force vector, imparted to the pelvis,
tion, accounting for only 6% of pelvic ring fractures.
The injurious force is vertically oriented, usually arising
as the result of a fall or a jump from a height, where the
force is delivered over the inferior aspect of the pelvis
via the extended femurs (Fig. 3-3). Conversely, these
a lateral fractures may occur when a downward force is delivered
over the upper body, driving the spine and sacrum
16 Radiologic Management of Pelvic Ring Fractures

downwards against a fixed pelvis. Such an injury may

(
/
" occur, for example, when a tree or a heavier object falls
onto the back or shoulders, and is more commonly seen
in lumbering and mining areas.

l
DOC
II
DOC This is mixed force vector, usually predominantly of the
lateral compression type, with either an element of AP
compression or vertical shear. These injuries clearly
occur when the force vector is directed at an angle to

\
DOC either the AP or the lateral direction. In general, there is
usually a dominant vector, but we have encountered
injuries in which classical patterns of both AP and lateral
ompression injuries are seen.

DOL
Figure 3-3 Falling from a height onto an extended leg will
cause vertical shear injuries.

Pennal G. F., Tile M., Waddell J. P., Garside H.: Pelvic disruption:
assessment and classification. Clin Orthop Rei Res 151: 12-21,
1980.
Tile M: Fractures of the Pelvis and Acetabulum. Williams &
Wilkins. Baltimore, London, 1984.
Young J. W. R., Burgess A. R., Brumback R. J.: Lateral compres-
sion fractures ofthe pelvis: The importance of plain radiographs in
the diagnosis and surgical management. Skelet Radiol 15:
102-109, 1986.
• Young J. W. R., Burgess A. R., Brumback R. J., Poka A.: Pelvic
fractures: Value of plain radiography in the early assessment and
management. Radiology 160(2): 445-451, 1986.
 Chapter 4

Lateral Compression Fractures

Lateral compression fractures accounted for 49% of our

ases, and were associated with fractures of the pubic
rami (100% in our series), sacrum (88%), and iliac wing
19%). Central hip dislocations (medial acetabular frac-
rures) may also occur (19%) The characteristic associ- In this type of injury, the force is delivered laterally over
red fractures are shown in Table 4-1. The fracture the posterior aspect of the pelvis and minimal distortion
pattern depends to a large extent upon the position along of the pelvic ring is seen (Figs. 4-1,4-2,4-3, 4-4A + B,
Ibe lateral aspect of the pelvis at which the force is 4-4A + B). Fractures of the pubic rami (either unilateral
pplied (Figs. 4-1, 4-6 A + B, 4-11A + B). Three distinct or bilateral were evident in 100% of the cases in our
"atterns of lateral compression injury are apparent, series. Crush or buckle fractures of the sacrum may be
epending upon the bony and ligamentous injury sus- seen, but no significant pelvic instability is to be ex-
Iained by the pelvis. As the forces are predominantly pected because of the ligamentous "checkreins" remain-
-ompressive, ligamentous injury may be minimal due to ing intact. This type of fracture is of a pure crushing
:he fact that, in general, the ring of the pelvis is being nature and is the least serious of the lateral compression
crushed or closed (Fig. 4-2). However, due to the injuries.
cnatomy of the sacroiliac joint, rupture of the posterior
sacroiliac ligaments may occur if the compressive force
'. delivered anteriorly, causing leverage on the posterior
sacroiliac ligament complex (Figs. 4-2, 4-11A+B,
-:'-10).

~ sociated Bony Injury

::::Llbicramus fractures 100
Sacral fracture 88
ac wing fracture 19
~entral hip dislocation 19
(fracture of quadrilateral Figure 4·1 Type I - Lateral Compression Fracture: The lat-
late) eral force is applied posteriorly (arrow). This causes a crush
::::sterior acetabular pillar effect on the SIJ: this may be visible radiographically as a
sacral fracture (A). The characteristic fracture pattern of the
"facture
pubic rami will be seen (B) No ligamentous injury is seen.
18 Radiologic Management of Pelvic Ring Fractures

Figure 4-2 Type I - Lateral Compression Fracture: Inlet view. These are fractures of the left superior and inferior pubic rami
and right pubis. The left superior ramus fracture (arrow) is clearly "horizontal", indicating lateral compression. No sacral
fracture is seen and there is no displacement of the fractures or pelvic ring.
Figure 4-3 Type I - Lateral Compression Fracture: There is a crush fracture of the left sacrum (small open arrowhead), and a
typical "overlap" fracture of the left superior pubic ramus, oriented in the horizontal plane (closed arrowhead). No gross
ligamentous disruption has occurred. A fracture of the proximal femur has also occurred (large open arrowhead).
Figure 4-4A Type 1- Lateral
Compression Fracture: This
is a crush fracture of the left
sacrum, demonstrated by the
interrupted arcuate lines
(arrow). In this case, bilateral
fractures of the pubic rami
have occurred, which on the
right demonstrate the typical
horizontal orientation of the
fracture lines with a degree of
overlap. The pelvis has been
slightly deformed by internal
displacement of the left side.

Figure 4-4B CT scan of the

same patient. This slice
through the sacrum and iliac
wings demonstrates the
crush fracture of the sacrum
and internal rotation of the left
iliac wing. The SIJ, however,
is intact; there is no posterior
diastasis, indicating intact
posterior ligaments of the
Type I fracture pattern.
Figure 4-5 Type 1- Lateral Compression Fracture: This crush fracture of the left sacrum (open arrow) is notable. In this case, the
initial diagnosis was anterior compression injury because the horizontal nature of the right superior pubic ramus fracture was not
appreciated. Further examination, however, revealed the sacral fracture. The inlet view demonstrates the true horizontal
orientation of the pubic ramus fracture.

The lateral force is applied more anteriorly, tending to
cause medial displacement of the ipsilateral anterior
hemipelvis, and thus, potentially, external rotation of
the posterior hemipelvis, with the anterior part of the
sacroiliac joint acting as a pivot (Fig. 4-6, 4-7A+B,
4-8, 4-9). As well as the typical pubic rami fractures
which occur in all cases of lateral compression injuries,
crush fractures of the sacrum ipsilateral to the injury site
may be seen.
These injuries show two distinct fracture patterns. In
Type IIA injuries, the rotational force of the hemipelvis
causes rupture of the ipsilateral posterior sacroiliac
Figure 4-6A Type II - Lateral Compression Fracture: The
force is applied anteriorly (arrow), causing the typical anterior
pubic rami fractures (B). In this case, however, rotation of the
pelvis around the anterior sacral margin may occur, causing
rupture of the posterior sacroiliac ligaments (R). A crush
fracture of the sacrum may also be seen (A).
ligaments, as demonstrated by diastasis of the posterior
SIJ (Figs. 4-6A, 4-7A+B). Conversely, in Type IIB
injuries, the same internal rotation of the anterior
hemipelvis occurs, but the posterior force "exits"
through an iliac wing fracture, extending from either the
sciatic notch or from some point along the sacroiliac
joint (Figs. 4-6B, 4-8, 4-9). In either case, the effect
is the same; that is, significant internal rotation and
displacement of the anterior hemipelvis; with loss of
integrity of the anterior hemipelvis from the posterior
pelvis, manifested either by posterior SIJ disruption
(IIA) or iliac wing fracture (II B). These fractures are
therefore unstable.
Figure 4-68 Alternatively a fracture of the iliac wing may
occur, which dissipates the rotational forces and thus leaves
the posterior ligaments intact.
Figure 4-7A Type II A - Lateral Compression Fracture: The force was delivered over the
anterior pelvis, causing a central dislocation of the left femoral head, with a fracture extending
through the quadrilateral plate. There is also a crush fracture of the left sacrum (large closed
arrowheads) and a "horizontal" fracture of the left symphysis (small arrowheads). Diastasis of
the left SIJ is suspected (open arrow), suggesting posterior sacroiliac ligament injury.

Figure 4-78 CT scan of the same case demonstrates the crush fracture of the left sacrum
and diastasis of the posterior SIJ line, indicating rupture of the posterior ligamentous complex.
Figure 4-8 Type II B - Lateral Compression Fracture: "Horizontal" and overlap fractures of the right pubic rami are seen with
internal displacement of the right hemipelvis. There is a comminuted fracture of the right iliac wing, extending laterally from the
SIJ. This allowed the rotational force to exit through the iliac wing, sparing the posterior SIJ. Nevertheless, there is still instability,
due to disruption of the posterior ring at the fracture site.
Figure 4-9 CT scan of a Type II B lateral compression fracture demonstrates a crush fracture of the left anterior sacrum, and
fractures throught the left iliac wing. The left SIJ has been spared posteriorly because the rotation of the pelvis occurred at the
site of the iliac wing fracture, resulting in compression at the site and causing internal displacement of the anterior hemipelvis.
Figure 4-10 Type II - Lateral Compression Fracture: These are typically horizontal, and overlap fractures of the pubic rami
(small arrows). In addition, there is a crush fracture of the anterior margin of the right sacrum (large closed arrow), with diastasis
of the (posterior) right SIJ (large open arrow), due to internal rotation of the right pelvis, around the anterior margin of the sacrum.

This is the most severe form of lateral compression
injury, with bilateral disruption of the pelvic ring and
instability posteriorly. Two possible mechanisms may
cause this injury. In the first case, the lateral force of
injury on one side of the pelvis causes severe internal
displacement of the ipsilateral hemipelvis. This dis-
placement gives rise to externally directed pressure on
the contralateral hemipelvis, causing disruption of the
contralateral anterior sacroiliac, sacrotuberous, and sac-
rospinous ligaments (Figs. 4-11A + B, 4-12, 4-13, 4-14).
Alternatively, this type of injury is seen in patients
who are "rolled over" by a heavy object (Fig. 4-15). We
Figure 4-11 A Type III - Lateral Compression Fracture: The
'orce is applied anteriorly (arrow), causing internal rotation of
l1e anterior hemipelvis. Continuing through to the contralateral
nemipelvis (arrow), the force causes it to rotate externally. The
result is a pattern of lateral compression on the ipsilateral side,
.vith apparent AP compression on the contralateral side. This
results in rupture of the posterior sacroiliac ligaments on the
'psilateral side (R) and sacrospinous/sacrotuberous complex
(T) and anterior ligaments (A) on the contralateral side. Typical
pubic rami fractures (B) are to be expected.
have seen this. in patients crushed and rolled under a
horse during a riding accident (Fig. 4-16) and in pedes-
trians rolled over by a vehicle (Fig. 4-17 A + B).
The result of this type of injury is a pelvic fracture
pattern which may at first appear confusing. On the side
ipsilateral to the injury force, there is a severe lateral
compression pattern of injury, with posterior sacroiliac
instability and consequent medial displac)ment and in-
ternal rotation of the anterior hemipelvis. On the con-
tralateral side, however, there is external rotation of the
hernipelvis, with anterior sacroiliac ligament rupture-
more typical of an AP compression injury. We have
termed this injury pattern the "windswept pelvis".
Figure 4-11 B Alternatively, as in Type II B fractures, there
may be an iliac wing fracture, sparing the posterior SIJ on the
ipsilateral side.
Figure 4-12 Type III - Lateral Compression Fracture, "Windswept Pelvis": The crush fracture of the right sacrum (closed
arrow), fracture of the right quadrilateral plate (large arrowhead), and buckle fracture of the left superior pubic ramus (small
arrowhead), indicate a lateral compression injury. Diastasis of the left SIJ (open arrow) and shift of the whole anterior pelvis to
the left indicate a Type III injury. This lateral shift can be appreciated easily by dropping a perpendicular from the sacral
midpoint (dotted line). This indicates displacement of the anterior pelvis to the left, giving the "windswept" appearance.
Figure 4-13 There is a "windswept" appearance of the pelvis with an obvious horizontal fracture of the right superior pubic
ramus and diastasis of the left SIJ. The right hemipelvis is internally rotated, and the symphysis is displaced to the left of the
vertical midline (dotted line). This indicates external rotation of the left hemipelvis and left anterior sacroiliac ligament
disruption
Figure 4-14 Type 111-Lateral Compression Fracture: A pattern similar to that in Figure 4-12 is seen, There is displacement of
the anterior pelvis to the left with coronal/horizontal and overlap fractures of the pubic rami, a severe crush fracture of the right
sacrum (closed arrows), and diastasis of the left anterior SIJ (open arrow),

Figure 4-15 A patient rolled over by a wheel or other heavy object may sustain a Type III lateral compression fracture if the
original force vector is lateral.
Figure 4-16 Severe Type III - Lateral Compression Fracture: The typical "windswept" pattern is seen. The right anterior
hemipelvis is internally rotated, but the posterior SIJ is spared by the fracture through the right iliac wing. Marked external
rotation and displacement of the left hemipelvis is seen, with diastasis of the anterior SIJ.
Figure 4-17A Type 111-Lateral Compression Fracture: The "windswept" nature of this injury
is readily apparent. The sacral fracture (closed arrowheads) and right anterior SIJ diastasis
(open arrow) are seen. Fractures of the pubic rami are of the "buckle" and overlap types.

Figures 4-178 CT scan of the same patient (after application of the external Hoffmann
device), indicates the opening of the right anterior SIJ, and crush fracture of the left sacrum.

The importance of recognizing these fracture patterns is
in differentiating them from fractures caused by other
force vectors. Fractures of the pubic rami in lateral
compression must be differentiated from AP compres-
sion injuries, so that the appropriate corrective forces are
applied.
Of importance in making this differentiation is the
definitive radiologic appearance of the fractures of the
pubic rami, and particularly of the superior pubic ramus.
The various radiographic views indicate a distinctive
appearance of the pubic rami fractures, no matter what
associated bony injuries are present. These distinctive
fractures are not vertical or irregularly vertical, but
either run obliquely through the bone in a horizontal
direction because the fracture is in a coronal plane (Fig.
4-18) or present as a type of "buckle" fracture, with
coronal elements seen in the additional views. This
pattern, which was seen in 80% of AP radiographs, in
86% of inlet views, and 100% of the time using both
views, was not seen in any pure AP compression or
vertical shear fractures and is therefore specific to lateral
compression force vectors.
Although the fracture pattern is marginally better-
depicted on the inlet view, it may be determined from
the frontal view by awareness of this type of injury-par-
ticulary in cases where, for technical reasons, the inlet
view is unsatisfactory. This is because the fractures of
the rami, which can be seen on the side ipsilateral to the
injury, as well as on the contralateral or both sides,
presented with one of three appearances:
Fracture Pattern A (80% of cases): The horizontal line is
visible on the AP view (Figs. 4-7A, 4-19, 4-20).
Fracture Pattern B (16% of cases): The fracture appears
vertical or irregular on the AP view and horizontal on the
inlet view (Fig. 4-8 B). This is in fact due to overlap
fragments of the oblique fractures and may be identified
by a typical overlap pattern of the fracture fragment
(Figs. 4-20, 4-21).
Fracture Pattern C (14% of cases): The fracture appears
"buckled" on the AP view. A "horizontal" or coronal
chip fracture fragment may again be seen at the fracture
site on the inlet view (Figs. 4-19, 4-22B).
Of considerable importance is the common association
of lateral compression injuries with crush fractures of
the sacrum. We make it a habit to examine the sacral
arcuate lines carefully whenever we encounter pubic
rami fractures. In practice, sagittally orientated vertical
rami fractures are not associated with lateral compres-
sion injury. However, inexperience may lead to misdia-
gnosis. Crush fractures of the sacrum (which occurred in
88% of our cases of lateral compression injury) are
manifested by disruption or subtle breaks of the arcuate
lines (Figs. 4-6,4-7,4-8,4-9,4-12,4-17,4-19- 4-22).
This sign, together with the pubic rami fra~ture, is
diagnostic of lateral compression injury.
Fractures of the medial aspect of the acetabulum, the
quadrilateral plate, with or without central dislocation of
the femoral head, are also a feature of lateral compres-
sion fractures. Indeed, when this type of injury is seen,
the diagnosis of a lateral compression force vector can
be made. This should immediately lead to a search for
other fractures or disruptions of the lateral compression
fracture comple . In particular, evidence of ipsilateral
posterior sacroiliac joint disruption of Type II B lateral
compression fractures and contralateral anterior sac-
roiliac joint disruption of Type III lateral compression
fractures must be excluded.
It must be remembered that, as mentioned above,
sacroiliac diastasis ipsilateral to the force vector may be
seen in lateral compression injuries. This is due to
rupture of the posterior ligaments by internal rotation of
the hemipelvis around the anterior sacral line. When
there is SIJ diastasis seen on a radiograph, it is important
to determine the presence or absence of the additional
features shown below:
1. Is there an associated pubic ramus fracture, and if so,
is it horizontal or vertical?
2. Is there a sacral crush fracture?
3. Is there a fracture of the quadrilateral plate of the
acetabulum, or central hip dislocation?
If the SIJ diastasis is associated with a crush fracture of
the sacrum, or central hip dislocation, or if there is a
horizontal pubic ramus fracture, the injury is lateral
compression.
If, however, the SIJ diastasis is clearly anterior, or if
vertical pubic rami fractures are present and no medial
acetabular fracture is seen, then the injury is AP com-
pression (see page 41).
If the significance of these injury patterns is missed,
the injury may be misdiagnosed as an AP compression
injury and incorrect compressive forces may be applied.
This would lead not only to increased morbidity, due to
incorrect healing (Fig. 4-23), but may well exacerbate
pelvic bleeding, by disrupting hematoma.
Figure 4-18 CT scan through the level of the inferior pubic rami in a case of lateral compression fracture. The coronal plane of
the fractures is well demonstrated.
Figure 4-19 Type 1- Lateral Compression Fracture: The typical pattern is identified, with central dislocation of the left femoral
head, crush fracture of the left sacrum, horizontal fracture of the left superior pubic ramus (closed arrow), and buckle fracture of
the right ischium (open arrow).
Figure 4-21 Lateral Compression Fracture: Typical overlap horizontally oriented fracture of the left superior ramus. The fracture
of the inferior pUbic ramus is also of the overlap type, but is more difficult to appreciate.
Figure 4-22A Type III - La-
teral Compression Fracture:
Typical buckle or crush frac-
ture of the left superior pubic
ramus, Right sacral crush
fracture (closed arrow) ans
left SIJ diastasis (open arrow)
also visible,

Figure 4-228 This is better

appreciated on the inlet view
where horizontal/coronal com-
ponents of the fracture can be
identified, A right sacral crush
fracture is again seen (arrow).
Figure 4-23 The significance of the injury pattern was missed in this patient. The initial film was read as an AP compression
fracture because of some diastasis of the right SIJ and a pubic ramus fracture. In fact, this was a Type II lateral compression
injury. Even on this posthealing film, the horizontal nature of the right symphysis fracture can be seen. The diastasis of the right
SIJ was due to internal rotation of the right hemipelvis, causing separation of the posterior sacroiliac ligaments. The result has
been internal displacement of the right anterior hemipelvis.

Pennal G. F., Tile M., Waddell J. P., Garside H.: Pelvic disruption:
assessment and classification. Clin Orthop Rel Res 151: 12-21,
1980.
Tile M.: Fractures oj the Pelvis and Acetabulum. Williams &
Wilkins. Baltimore, London, 1984.
Young J. W. R., Burgess A. R., Brumback R. J.: Lateral compres-
sion fractures of the pelvis: the importance of plain radiographs in
the diagnosis and surgical management. Skelet Radial 15:
103-109, 1986.
 Chapter 5
Anterior/Posterior (AP) Compression Fractures
AP compression fractures (21 % of our cases) are due to
direct anteroposterior or posteroanterior force (Figs. 5-1,
5-5, 5-9). This type of force frequently gives rise to
fractures of the pubic rami and may cause ligamentous
injury involving the ligaments of the symphysis, the
anterior sacroiliac ligaments, sacrospinous and sac-
rotuberous ligaments, and posterior sacroiliac complex
or all four groups. AP compression injuries are also
responsible for the clinical "open book" or "sprung
pelvis" type of injury, which occur with or without
fractures of the pubic rami. In our series, when pubic
rami fractures were present, they were vertically
oriented in every case of AP compression. This is an
important differentiating feature from lateral compres-
sion injuries, where the fracture line is in the horizontal
Table 5.1 . AP Compression Injury
Associated Bony Injury
Pubic ramus fracture
Sacral fracture
Iliac wing fracture
Central hip dislocation
Posterior acetabular pillar fracture
Anterior pillar fracture
or coronal plane (see page 33). Additional associated
fractures are identified in Table 5-1.
Opening of the symphysis indicates rupture of the
ligaments of the symphysis. However, as noted pre-
viously (page 13), it has been shown that the symphysis
can be opened up to 2.5 cm without rupture of the
posterior ligaments of the pelvis. Therefore, with sym-
physis separation ofless than 2.5 cm, the radiologist may
not be able to determine the integrity of the posterior
ligamentS on plain films unless obvious sacroiliac joint
diastasis is present. CT is more sensitive in this instance,
and can show subtle sacroiliac j oint diastasis. However, it
may be that CT is too sensitive; even in minor anterior
opening of the symphysis (which can occur without
posterior ligamentous rupture) mild opening of the an-
terior sacroiliac joint is to be expected. On occasion, we
are forced to rely on gentle manual examination in such
cases to determine whether the pelvis is stable or un-
stable. We also use CT when patient stabilitY..allows a
more leisurely approach to definitive treatment. Bucholz
has designated three groups of AP fractures depending
upon the extent of posterior injury. We have applied this
concept to the radiographic appearances and have de-
vised a three stage classification of AP compression
lllJunes.
The injury causes anterior pelvic injuries, consisting of
minor diastasis of the symphysis pubis, and/or vertical
fractures of one or more pubic rami (Figs. 5-2,5-3,5-4).
These fractures do not indicate posterior injury or insta-
bility.

Figure 5-1 Type 1- AP Compression Fracture: The force is

delivered in an AP direction (large arrow), tending to "open"
the pelvis. This gives rise to mild splaying of the symphysis,
due to rupture of the anterior sacroiliac ligaments.

Figure 5-2 Type I - AP Compression Fracture: Mild diastasis of the symphysis pubis is seen. The pelvis was stable due to
intact posterior ligaments. There is a fracture through the left acetabular posterior pillar.
Figure 5-3 Type I - AP
Compression Fracture: 2 cm
diastasis of the symphysis,
and vertical fractures of the
left pubic rami. Very mild
posterior SIJ diastasis is sug-
gested, but the hemipelvis is
stable, indicating that the
sacrotuberous and sacroiliac
ligaments are intact. There is
a fracture of the posterior pil-
lar of the left acetabulum.

Figure 5-4 Type I - AP

Compression Fracture: The
symphysis is opened 2.5 cm.
The SIJs are normal, and
were possibly "spared" by
the fracture of the left
acetabulum, and hip disloca-
tion.
These fractures are more severe and are indicated by a
separation of the symphysis of 2.5 cm or more, with
some posterior instability. The involvement of the an-
terior sacroiliac and probably the sacrospinous and sac-
rotuberous ligaments allows "opening" of the pelvis
(Figs. 5-6A + B, 5-7, 5-8A + B). Diastasis of the sac-
roiliac joint may be difficult to determine. However, we
have noticed that, in a normal pelvis, there is continuity
of a line drawn around the second sacral arcuate line to
the internal margin of the iliac bone. If this is interrupted
(Figs. 5-6A + B, 5-7), there is a strong suspicion of
sacroiliac disruption involving at least the anterior liga-
ments.
Figure 5-5 Type 11- AP Compression Fracture: The AP force
vector (large arrow) has caused further "opening" of the
a1'iferior pelvis, with additional rupture of the anterior sac-
roiliac, sacrotuberous, and sacrospinous ligaments (arrow-
heads).
Figure 5-6A Type II - AP
Compression Fracture: There
is only 2.5 cm diastasis of the
symphysis pubis. However,
diastasis of the (anterior)
right SIJ is seen, indicating
anterior ligamentous rupture.
This is appreciated by the in-
terruption of the dotted line
on the right, drawn from the
second sacral arcuate line. A
vertical fracture of the left in-
ferior pubic ramus is seen.

Figure 5-68 CT scan of the

same patient (A) demon-
strates the widening of the
anterior right SIJ, indicating
anterior ligamentous rupture.
Figure 5-7 Type 11- AP Compression Fracture: There is diastasis of the symphysis and left anterior SIJ (dotted line). A fracture
of the posterior pillar of the left acetabulum is also seen (arrow).
Figure 5-8A Type II - AP
Compression Fracture: Only
1.6 cm diastasis of the sym-
physis is seen (large arrow).
However, there is diastasis of
the right SIJ (small arrow).
The anterior sacroiliac liga-
ments are ruptured. Probably
the sacrospinous and sacro-
tuberous ligaments on the
right are ruptured also.

Figure 5-88 CT scan of the

same patient demonstrated
the "opening" of the right an-
terior SIJ.
 further pelvic movement would be expected to exacer-
bate the injury and possibly cause further blood loss,
These injuries occur when there is an associated total either by dislodgement of blood clot or reduction of
disruption of the sacroiliac joint, involving both the tamponade.
anterior and posterior ligamentous complexes (Figs.
5-lOA+B, 5-11, 5-12A+B). There is often wide dias-
tasis of the symphysis, but we have seen severe SIJ
diastasis with apparent minimal symphysis injury (Figs.
5-11, 5-12A+B). We suggest that this is due to one of
three alternatives: the force may be directed in the
posteroanterior direction; causing the "pelvis opening"
to hinge at the symphysis rather than the more usual
patterns where the force is AP (hinging the pelvis at
the sacrum) (Fig. 5-13); the symphysis may have re-
coiled to a more natural position, following initial
wide separation and rupture of the ligaments; or all the
force may have been delivered predominantly over -
one side of the pelvis, causing a true posterior dis-
placement of the ipsilateral hemipelvis. Because these
are potentially serious injuries if the film shows gross
Figure 5-9 Type III-AP Compression Fracture: There is total
disruption, we do not feel that there is justification in disruption of the SIJ due to wide "opening" of the pelvis. All
manual manipulation to prove the point. Where there supporting ligament groups, including the posterior sacroiliac
is already severe posterior instability and damage, ligaments, may be disrupted.
Figure 5-1 OA Type 111- AP Compression Fracture: Wide diastasis of the symphysis and left
SIJ is seen.

Figure 5-108 CT scan of the same patient (A) reveals total disruption of the left SIJ, both
anterior and posterior, with some posterior displacement of the iliac bone.
Figure 5-11 Type III - AP Compression Fracture: Minimal diastasis of the symphysis is seen. However, there is marked
diastasis of the left SIJ, involving both anterior and posterior parts (open arrow). This indicates total ligamentous disruption.
There is a fracture through the posterior pillar of the right acetabulum (arrowhead).
 Anteroposterior Compression Fractures 51

Figure 5-12A Type 111- AP Compression Fracture: Almost identical case to that of Figure 5-
11. Total disruption of the left SIJ is seen (large arrow). There is also a fracture of the anterior
pillar of the right acetabulum (arrowhead), as well as a fracture of the superior rim of the left
iliac wing.
Figure 5-13 CT scan: posteroanterior (PA) compression fracture demonstrates total disrup-
tion of the right SIJ. There is anterior displacement of the iliac wing, however, due to a PA force
vector.
This three stage classification correlates well with both
Bucholz's work and our own observations. In Type I
injuries, opening ofthe symphysis ofless than 2.5 cm is
to be expected because no posterior ligamentous injury
is present. In Type II injuries the symphysis may be
"opened" more than 2.5 cm; the anterior sacroiliac joint
will also be "opened" because of anterior sacroiliac
ligament disruption and, probably, sacroiliac and sac-
rospinous rupture. In Type III injuries there will be
disruption of the whole sacroiliac joint involving an-
terior and posterior groups.
Even in the absence of widening of the symphysis,
AP compression can be diagnosed radiographically by
the vertical appearance of the pubic rami fractures, if
there is no evidence of vertical displacement of fracture
fragments (Figs. 5-3, 5-4, 5-6). In our series, 20% of AP
compression injuries were of Type I, with less than
2.5 cm splaying of the symphysis and no demonstrable
posterior instability. Eighty percent of the AP compres-
sion injuries, however, haq posterior instability demon-
strated. Half of these were Type II; in 90% of these
cases, opening of the symphysis of 2.5 cm or more was
demonstrated radiographically. In the other 10%, sym-
physis separation was less than 2.5 cm, but sacroiliac
disruption was suspected or proven on the radiographs.
Forty percent of the cases demonstrated total sacroiliac
disruption and were therefore Type III injuries.
Of interest is the finding of posterior pillar acetabular
fractures in 52% and anterior pillar fractures in 8% of
AP compression injuries (Figs. 5-2, 5-3, 5-4, 5-7,
5-lOA + B, 5-11, 5-12A + B). This is most likely due to
anterior compression on a flexed femur at the time of
injury, causing the femoral head to be driven backwards
into the posterior column of the acetabulum, or to direct
trauma onto the ischiopubic junction, causing anterior
pillar fractures. This injury pattern, with the femur being
driven backwards and into the posterior column of the
acetabulum, was not seen in lateral compression in-
juries, where acetabular fractures are of the central
dislocation type or involve the medial aspect of the
acetabulum (see page 17).
Of interest also was the finding of avulsion of the
lateral aspect of the sacrum in a small number of Type III
injuries (Fig. 5-14A+B). This is due to avulsion of the
insertion of the sacrospinous/sacrotuberous complex,
and again is associated with total hemipelvic instability.
Figure 5-14 A, B Type III -
AP Compression Fracture:
There is wide diastasis of the
symphysis and left SIJ (A)
with avulsion of the left sa-
crum (B).
Bucholz R. W.: The pathological anatomy of malgaigne fracture
dislocations of the pelvis. J Bone Joint Surg 63A: 400-404,1981.
Pennal G. F., Tile M., Waddell J. P., Garside H.: Pelvic disruption:
assessment and classification. Clin Orthop Rei Res 151: 12-21,
1980.
Tile M.: Fractures of the Pelvis and Acetabulum. Williams &
Wilkins. Baltimore, London, 1984.
Young J. W. R., Burgess A. R., Brumback R. J.: Lateral compres-
sion fractures of the pelvis: the importance of plain radiographs in
the diagnosis and surgical management. Skelet Radial 15:
103-109, 1986.
 Chapter 6

Vertical Shear and Complex Fracture Patterns

This is the least common type of injury, accounting for

only 6% of our cases. As its name suggests, this injury is
caused by a severe vertical disruptive force delivered
over one or both sides of the pelvis lateral to the midline
(Fig. 6-1). It is associated with severe disruption of the
posterior elements, manifesting itself either as a fracture
of the sacrum or medial iliac wing, or by a total disrup-
tion of the SIJ. This will therefore give rise to gross
pelvic instability.
If the force is on one side, the injury will demonstrate
ipsilateral instability, manifested either as ipsilateral
disruptions of the symphysis pubis and sacroiliac joints,
Figure 6-1 Vertical Shear Vector: The injury force vector is
or fractures of the pubic rami, sacrum, posterior iliac delivered in a vertical plane (large arrow), causing disruption
wing, or possibly a combination of these three (Figs. along this line. Fractures of the pubic rami are usually seen
6-2, 6-3A+B). If the for<:e is more evenly deployed, a anteriorly, while fractures of the sacrum, SIJ, or iliac wing are
similar fracture dislocation pattern may be seen bilater- usually seen posteriorly. The fractures are vertical and are
associated with vertical displacement of fragments. Ligament-
ally (Figs. 6-4,6-5). The vertically orientated fractures
ous injury to the posterior (R) and anterior (A) sacroiliac
of the posterior elements and pubic rami are due to the ligaments may be seen, as well to sacrospinous/sacrotuber-
inferior-superior direction of the force vector. Vertical ous (T), and (possibly) symphysis ligaments.
displacement of the fracture fragment can usually be
appreciated on the AP view, but is best visualized by the
outlet view, which indicates the severity of the superior
displacement (Fig. 6-6A + B).
Figure 6-2 Vertical Shear: Vertical fractures of the left SIJ and right pubic rami are seen with superior displacement of the left
hernipelvis. There is also a vertical fracture of the left acetabulum.
Figure 6-3A Vertical Shear Fracture: Ver-
tical fractures through the left sacrum and
right pubis are seen with mild diastasis of
the symphysis and a small degree of verti-
cal displacement of the left hemipelvis.

Figure 6-38 CT scan de-

monstrates the sagittally
oriented fracture of the left
sacrum, with no evidence of
lateral or medial displace-
ment.
Figure 6-4 Vertical Shear Fracture: There are vertical fractures of the left iliac wing (adjacent to, and partly including the SIJ)
(small open arrows), left pubic rami (small closed arrowheads), and a right SIJ (large open arrow). Obvious superior
displacement of the right hemipelvis is seen.
Figure 6-5 Vertical Shear: Vertical fractures of all four pubic rami. There is also a vertical fracture through the left sacrum and
superior displacement of the major left pelvic fragment. The right SIJ is disrupted.
Figure 6-6A Mixed pattern-
Lateral Compression and
Vertical Shear: The horizontal
left superior pubic ramus
fracture and left iliac wing
fracture suggest a Type Illat-
eral compression injury.

Figure 6-68 The outlet view

displays superior displace-
ment of the anterior left pelvic
fragment, indicating a com-
ponent of vertical shear.

In 14% of our cases, we encountered a complex pattern
of injury, where at least two different force vectors were
applied. In the majority of these cases, the force vector
was predominantly of the lateral compression type, with
AP or (rarely) vertical shear as the additional force
vector (Figs. 6-6A + B, 6-7).
In such cases, the surgeon must be made aware of the
complex nature of the injury because correcting forces
must reflect opposition to the original force vector. In
cases of mixed anterior and lateral compression, there
must be an element of posteroanterior stability applied
by the stabilizing device, as well as pure lateral reduc-
tion (Fig. 6-8A + B). Similarly, where an element of
vertical shear is identified by the outlet view, some
inferior corrective force must be supplied.
Here again, the importance of the three views can be
seen. In these cases of a mixed pattern of injury, there is
great potential for error in application of the fixators. If,
based on an AP view, Figure 6-7 is misinterpreted as
Vertical Shear and Complex Fracture Patterns 61
pure lateral compression because of the horizontal na-
ture of the pubic rami fracture, inappropriate reduction
will take place without regard to the pronounced
superior displacement of the left pelvic fragment.
It is important to realize that, because of the anatomi-
cal structure, shape, and directional orientation of the
sacroiliac joint, it is possible to obtain a shearing force
along the line of the joint from force vectors, which are
anterolateral (Fig. 6-9A+B). In the illustrations, the
force is from the anterolateral aspect. The direction of
the force is therefore delivered along the axis of the
ipsilateral sacroiliac joint, giving rise to a shearing force
along the sacroiliac joint. This disruption of the sac-
roiliac joint may lead to the erroneous diagnosis of Type
III AP compression injury. The difference from the true
Type III AP compression injury, however, is in the fact
that the sacrospinous and sacrotuberous ligaments will
be intact (Figs. 6-10,6-11). This is because the disrup-
tion is along the plane of the joint, and no "opening" of
the pelvis which would result in sacrospinous and sac-
rotuberous ligament injury occurs.
Figure 6-7 Mixed pattern - Lateral Compression and Vertical Shear: The horizontal pubic ramus fractures suggest lateral
compression. However, examination of the film reveals elevation of the left iliac wing in relation to the sacrum (dotted lines).
Elevation of the anterior left pelvis is also appreciated.
 Figure 6-8A Fracture dislo-
cation of the right sacrum
(arrowheads), misinterpreted
as total SIJ disruption to-
gether with pubic rami frac-
tures, and left SIJ disruption
(open arrow) was misdiag-
·nosed as a Type III AP com-
pression injury. The horizon-
tal symphysis fracture on the
right, however, argues for la-
teral compression Type III.
The right hemipelvis is
slightly elevated, as can be
seen at the lower closed
arrow. This indicates a mild
vertical shear component of
the injury

Figure 6-88 Incorrect treat-

ment led to pelvic deformity.
Figure 6-10 A left sacral crush fracture and horizontal left pubic rami fractures indicate lateral compression. However, there is
a vertical fracture of the left superior pubic ramus, and total left SIJ diastasis. This indicates a component of AP compression,
with rupture of the anterior and posterior sacroiliac ligaments from a shearing force. The sacrotuberous/sacrospinous complex
will be intact.
Pennal G. F., Tile M., Waddell J. P., Garside H.: Pelvic disruption:
assessment and classification. Clin Orthop Rei Res 151: 12-21,
1980.
Tile M.: Fractures of the Pelvis and Acetabulum. Williams &
Wilkins. Baltimore, London, 1984.
Young J. W. R., Burgess A. R., Brumback R. J.: Lateral compres-
sion fractures of the pelvis: the importance of plain radiographs in
the diagnosis and surgical management. Skelet Radial 15:
103-109, 1986.
 Chapter 7

Fractures of the Pubic Rami

•
Once again, in dealing with these fractures, It IS
highly important to recognize the fracture type. The
Many of the classical classifications of pelvic fractures pictorial image of these fractures is so characteristic that
mention pubic rami fractures as separate entities that the nature of the injurious force and, hence, likely
usually occur with no significant additional injuries. associated injury (either to the pelvic ring elsewhere or
Although we concede that an isolated fracture of one of to soft tissues) can be anticipated. Lateral compression
the pubic rami may occur from minor force applied injuries will be indicated by the horizontal orientation of
directly to the site of fracture, fractures of both pubic the pubic rami fractures; anterior compression and verti-
rami on one side should always lead to further investiga- cal shear . Juries will be associated with vertically
tion and careful radiological examination. Gertzbein orientated fractures, as previously seen.
and Chenoweth have elegantly .demonstrated that an-
terior fractures of the pelvic ring are always associated
with posterior injury which may be either ligamentous or
% Occurrence
an undiagnosed fracture. Furthermore, we have only
Unilateral Bilateral
encountered double pubic rami fractures in significant
pelvic trauma (Figs. 7-1, 7-2, 7-3). The concept that Lateral compression injuries
unilateral pubic rami fractures are of minor significance Type I 61 39
should be abandoned. Type II 28 73
In our experience, unilateral pubic rami fractures
Type III 56 46
were seen in 49% of our c~ses, being subdivided accord- AP compression injuries
ing to lateral compression, AP compression, vertical Type I 36 18
shear or complex injuries as shown in Table 7-1. It is, Type II 42 23
therefore, clear that unilateral fractures of the pubic rami Type III 21 5
are not infrequently associated with serious and even Vertical shear injuries 43 48
devastating posterior injury.
Mixed pattern 54 8
Figure 7-1 Type I - Lateral Compression Fracture: There is a crush fracture of the sacrum (small open arrow), and a typical
"overlap" fracture of the left superior pubic ramus, oriented in the horizontal plane (closed arrow). No gross ligamentous
disruption has occurred. A fracture of the proximal femur has also occurred (large open arrow). There is a probable fracture of
the left inferior pubic ramus.
Figure 7-2 Type II B - Lateral Compression Fracture: "Horizontal" and overlap fractures of the pubic rami are seen with
internal displacement of the right hemipelvis. There is a comminuted fracture of the right iliac wing, extending laterally from the
SIJ. This allowed the rotational force to exit through the iliac wing, sparing the posterior SIJ. Nevertheless there is still instability,
due to disruption of the posterior ring at the fracture site.

In our experience, the so-called isolated "straddle" frac-
ture of all four pubic rami does not occur per se, but may
occur in lateral compression, anterior compression, ver-
tical shear, or mixed pattern fractures.
In cases of anterior compression injury (indicated by
the vertical orientation of the pubic rami fractures with-
out vertical displacement of the pelvis, see Fig. 7-4),
signs of diastasis of the SI joint indicative of a Type II or
Type III injury should be sought in addition to evidence
of pubic rami fractures.
In fractures due to lateral compression, not only will
the pubic rami fractures demonstrate the classical hori-
zontal/coronal orientation, but compressive injury to the
SI joint or sacrum may be seen (Figs. 7-5, 7-6).
In cases of vertical shear injury, the pubic rami
fractures will be vertical, and there will be evidence of
vertical displacement of fracture fragments (Fig. 7-7).
In other words, pubic rami fractures by themselves
are not indicative of the severity of injury. They are an
invaluable clue to the force vector and type of injury, but
other evidence must be sought if an accurate overall
assessment of the pelvic ring injury is to be obtained.
Figure 7-4 Bilateral Double Vertjcal Pubic Rami Fractures: There is no superior displacement of any portion of the pelvis. This
is an AP compression fracture.
Figure 7-5 Bilateral Double Horizontal Fractures of the Pubic Rami: There are "horizontal" fractures of the superior pubic rami,
and an overlap fracture of the left inferior ramus. This indicates a lateral compression fracture, confirmed by the right sacral
crush fracture (arrows).
Figure 7-6 This is another example of multiple pubic rami fractures with lateral compression The fractures are horizontal and
interruption of the left sacral associate lines indicates a sacral crush fracture.
Figure 7-7 Multiple Vertical Pubic Rami Fractures: There is also diastasis of the left SIJ, and elevation of the left hemipelvis,
seen both anteriorly and at the sacroiliac junction. This is a vertical shear fracture.
Gertzbein S. D., Chenoweth D. R.: Occult injuries of the pelvic ring.
Clin Orthap Rei Res 128: 201-207, 1977.
Pennal G. E, Tile M., Waddell J. P., Garside H.: Pelvic disruption:
assessment and classification. Clin Orthap Rei Res 151: 12-21,
1980.
Tile M.: Fractures of the Pelvis and Acetabulum. Williams &
Wilkins. Baltimore, London, 1984.
Young J. W. R., Burgess A. R., Brumback R. J.: Lateral compres-
sion fractures of the pelvis: the importance of plain pdiographs in
the diagnosis and surgical management. Skelet Radial 15:
103-109, 1986.
 Chapter 8

Complications

It is beyond the scope of this book to provide a detailed addition, in our institution, rapid pelvic i~obilization
analysis of the complications associated with pelvic has led to a low incidence of severe pelvic hemorrhage.
fractures. This has been well covered in the literature. The incidence of significant and life-threatening hemor-
However, a short resume of our own experience is rhage and local complications associated with the vari-
appropriate. ous types of fractures is indicated in Table 8-1.
Complications of pelvic ring injury can be subdivided
into two main categories: local and distant. Local in-
Table 8-1 Local Associated Injuries
juries include hemorrhage, urologic injury, neurologi-
cal injury, and fractures of the acetabulum. Distant % Occurrence
complications include fractures of limbs, abdominal and Severe Bladder Urethra
thoracic injury, head injury, and spinal injury. As would Hemorrhage Rupture
be expect~d, the number of associated complications Lateral compression
increases with the severity of the pelvic injury. We will fractures
briefly discuss the local complications only, because of Type I 0.5 4.0 2.0
their relevance to the concepts of this book. Type II 36.0 7.0 0.0
It has been shown that, in multiple trauma cases Type III 60.0 20.0 20.0
including pelvic fractures, it is generally the pelvic AP compression
injury and its immediate complications that lead to a fractures
fatal outcome. Hemorrhage has been singled out as the Type I 1.0 8.0 12~0
predominant cause of death. Indeed, the quoted inci- Type II 28.0 11.0 23.0
dence of deaths from hemorrhage in pelvic trauma cases Type III 53.0 14.0 36.0
is as high as 30%. The need for transfusion has been Vertical shear
quoted at from 40 to 71 % of cases of pelvic trauma. The fractures 75.0 15.0 25.0
advent of transcatheter embolization, however, has sig-
Mixed patterns 58.0 16.0 21.0
nificantly decreased the severity of hemorrhage. In
78 Radiologic Management of Pelvic Ring Fractures
------------------------------
In our evaluation, hemorrhage was described as moder-
ate when more than 10 units of blood were required at
transfusion, and severe when more than 20 units of
blood were needed.
It will be noted from Table 8-1 that only rarely did
severe blood loss occur in Type I lateral compression or
AP compression injuries (Figs. 8-1, 8-2). Urological
damage is also uncommon, but can be seen with associ-
ated pubic rami fractures or mild symphysis diastasis
(Fig. 8-3, also see below).
Type II injuries of both the lateral compression and
AP compression variety, both of the anterior and post-
erior pelvis, demonstrate a significant complication
rate.
As would be expected, the AP compression is the
more damaging injury. Not only is there rupture of the
anterior pelvis, with the bladder in close proximity, but
also the injury to the posterior pelvis is of the "opening"
variety, causing a shearing force on the soft tissue
structures adjacent to the sacroiliac joint (notably the
superior gluteal artery and other branches of the internal
iliac artery). On the other hand, the pure lateral com-
pression injury imparts a crushing force with little, if
any, shearing effect on these structures.
In .lateral and AP compression, Type III injuries,
vertical shear injuries, and combination mixed injuries,
there is a high association with significant hemorrhage
(Figs. 8-4A+B, 8-5A+B, 8-6), as would be expected
by the gross disruption. Even so, we found some cases
of apparently catastrophic injury where only minor
hemorrhage occurred, possibly due to tamponade.
The radiologic picture and ,typing of pelvic ring
fractures can thus give an indication of the likelihood of
significant vascular injury; although angiography is
clearly the only means of obtaining a detailed assess-
ment. However, unless catastrophic hemorrhage is
occurring, with an immediate life-threatening potential,
we advocate initial pelvic stabilization with an external
Hoffmann frame. We have found that in a significant
number of cases this has led to cessation of hemorrhage,
t~eby nullifying the need for interventional angiogra-
phy. The importance of accurate pl~lin film radiologic
assessment is thus emphasized, as it is vital to apply the
correct countering forces to the Hoffmann frame; in-
correct forces brought about by misinterpretation of the
radiographs will not only provide deterioration in align-
ment of the bony pelvis, but may exacerbate an already
serious hemorrhage. Radiologic diagnosis is therefore
paramount in the acute management of the injuries, as
well as in the long term realignment of the pelvis.
Figure 8-1 Type 1- Lateral Compression Fracture: Despite minimal apparent injury, there is hemorrhage occurring at the left
pubic ramus with damage to pudendal branches. Overlap fractures of the right pubic rami and a right femoral fracture are
seen.
Figure 8-2 Despite minimal apparent symphysis injury with diastasis of only 8 mm, massive hemorrhage occurred. This
patient lost over 50 units of blood before angiography revealed a small anterior "bleeder" (arrow). Following successful
embolization, blood loss dropped to less than 10 units over the next 24 hours.
 Figure 8-4A, B The films
show vertical shear fracture
with diastasis of the right SIJ
joint and symphysis, frac-
tures of the right pubic rami
and left acetabulum, and
superior displacement of the
left iliac wing. There is
traumatic occlusion of the
superior gluteal artery bilater-
ally (arrows).
Figure 8-5 Mixed Lateral Compression
Vertical Shear Fracture: A: Despite external
stabilization, there is brisk hemorrhage from
the pudendal vessels on the left, most likely
due to direct damage from the sharp bone
fragment (arrow). This caused the large
hematoma displacing the bladder to the
right and superiorly seen on an earlier cys-
togram (8). Apparent superior displace-
ment of the bladder neck also suggests
rupture of the urethra at the base of the
bladder
Figure 8-6 Type 111- AP Compression Fracture: There is wide diastasis of the right SIJ, with severe trauma to the internal iliac
artery and its branches, particularly the superior gluteal artery.

Urologic injury closely parallels damage to the anterior
pelvis, although it is not always possible to decide from
the plain films whether bladder injury, urethral injury,
or both, are likely. When significant anterior injury is
seen, with either displaced fractures of the pubic rami or
disruption of the symphysis pubis, further radiologic
investigation is warranted. Various rates of incidence of
urogenital injury in association with pelvic trauma are
quoted in the literature, ranging from 4 to 17% for all
pelvic fractures, to 20% with "purely" anterior arch
fractures. As would be expected, the anterior compres-
sion injuries, with the likely associated anterior pelvic
disruption, are, in practice, more damaging to the uro-
genital system (Figs. 8-3, 8-7) than lateral compression
fractures. However, as is apparent from the earlier text,
lateral compression injuries may also be associated with
significant damage to pubis and pubic rami. Table 8-1
demonstrates our incidence of trauma to the urogenital
system. Our figures concur with the various reported
incidences and again demonstrate that the fractures with
little anterior disorganization (as in Type I lateral com-
pression injuries) have a low but definite incidence of
urogenital injury (Fig. 8-8), with the incidence increas-
ing to a maximum in vertical shear fractures (where
anterior disruption is generally severe) (Fig. 8-9A + B).
The damage to the urologic tract may be from several
causes. A direct heavy blow or crushing force on a filled
bladder is likely to cause rupture (Figs. 8-3, 8-8).
Penetration of the bladder may occur in any type of
fracture in which sharp fragments of bone are displaced
internally. This may occur in any type of fracture in
which "splintering" of the pubic rami occurs.
Shearing injuries may cause rupture to the base of the
bladder, or to the proximal urethra. This occurs most
commonly in vertical shear and anterior compression
fractures, but can be seen in any fracture where there is
disruption of the symphysis. It can, therefore, be seen in
lateral compression injuries, particularly the Type III
variety where such shearing may focus on the base of the
bladder, and in cases of anterolateral compression where
a shearing of the symphysis may be seen (Fig. 8-10).
86 Radiologic Management of Pelvic Ring Fractures

Figure 8-7 Mixed AP CompressionNertical Shear Fracture: Mixed pattern injury with fractures of the pubic rami on the right.
There is gross extravasation from a ruptured urethra, with venous filling.
Figure 8-8 This film shows rupture of the bladder with contrast extravasation. This was a mixed AP and lateral compression
fracture.
Figure 8-9A Vertical shear
injury with superior displace-
ment of the right hemipelvis.

Figure 8-98 Gross urethral

extravasation indicates a sig-
nificant urethral rupture.
Figure 8-10 Mixed Pattern - Anterolateral Compression: A large hematoma is displacing the bladder to the left. There is also
extravasation of contrast on the left. A rupture of the bladder neck was found.

Ayella R. J.: Radiologic Management of the Massively Traumatized
Patient. Williams & Wilkins. Baltimore, London, 1978.
Berquist T. H. (ed.): Diagnostic Imaging of the Acutely Injured
Patient. Urban & Schwarzenberg, Baltimore, Munich, 1985.
Flaherty J. J., Kelley R., Burnett B. et al.: Relationship of pelvic
bone fracture patterns to injuries of the urethra and bladder. J
Trauma 9: 297, 1968.
Harris J. M., Harris W. M.: The Radiology of Emergency Medicine,
ed 2. Williams & Wilkins. Baltimore, London, pp. 533-554,
1981.
Hawkins L., Pomerantz M., Erseman B.: Laparotomy at the time of
pelvic fractures. J Trauma 10: 619, 1970.
Holdsworth F W.: Injury to the genitourinary tract associated with
fractures of the pelvis. Proc R Soc Med 56: 1044, 1963.
Matalon T. S. A., Athanasoulis C. S., Margolies M. W. et al.:
Hemorrhage with pelvic fractures. Efficacy of transcatheter em-
bolization. AJR 133: 859, 1974.
Morehouse M. M., MacKinnon K. J.: Urological injuries associated
with pelvic fractures. J Trauma 9: 479, 1969.
Rogers L. F: Radiology of Skeletal Trauma. Churchill-Livingstone,
New York, pp. 634-649, 1982.
Rothenberger D. A., Fischer R. P., Strate R. G., Velasco R., Perry
J. F: The mortality associated with pelvic fractures. Surgery 84:
356-361, 1978.
Tile M.: Fractures of the Pelvis and Acetabulum. Williams &
Wilkins. Baltimore, London, 1984.
 Chapter 9

Assessment and Utilization

Plain films are of considerable importance in cases of

severe pelvic trauma. Many patients are too unstable for
computed tomographic assessment, and CT may not be
available. Appreciation of the types of pelvic fracture,
direction of force producing them, and likely ligamen-
tous injury, can be achieved rapidly and inexpensively
from plain films. This will indicate to the surgeon the
type of disruptive force, thus allowing appropriate
corrective procedure planning.
Fractures of the pubic rami warrant immediate assess-
ment of the posterior structures. The configuration by
itself may indicate the type of force vector producing the
fracture. Horizontal pubic rami fractures indicate lateral
compression and should lead to careful inspection of the
sacrum for additional evidence of sacral compression,
and to determine the extent of posterior injury. Verti-
cally oriented pubic rami fractures indicate AP compres-
sion or vertical shear and should lead to examination of
the posterior pillars of the acetabuli, as well as of the
sacrum and sacroiliac joint, for further evidence of AP
compression or vertical shear.
•
Sacroiliac diastasis may occur in any form of pelvic
injury. Confirmation of the type can be obtained by
evaluation of the additional fracture patterns, and by a
careful evaluation as to whether it is the anterior, pos-
terior, or both components of the sacroiliac joint that are
involved.
Distinguishing features of the various types of pel vic
ring fracture are shown in Table 9-1.
Rapid ~sessment of the fracture pattern will allow a
timely application of external stabilizers, should the
fracture require stabilization. In this way, pelvic bleed-
ing may also be controlled, in many cases, without the
need for angiography.
To utilize plain films most effectively in the manage-
ment of the multiply injured patient or the patient with
the risk of isolated pelvic injury, the following scheme is
suggested:
1. All "poly trauma" patients or victims of high energy
blunt trauma should have a screening AP film of the
pelvis.

Table 9-1 Distinguishing Features of Pelvic Ring Fractures

Injury Lateral Compression AP Compression Vertical Shear

Pubic ramus fracture Always present Sometimes present Sometimes present
Horizontal Vertical Vertical

Usually present Rare Sometimes present

Buckle/crush Vertical or avulsion Vertical
Sometimes present Often present Sometimes present
(posterior) Anterior or anterior and Anterior and posterior.
Type II and III posterior Type II and III

Symphysis pubis Sometimes present Often present Sometimes present

diastasis Type III Type II and III

Iliac wing fractures Sometimes present Sometimes present

Type II and III Associated with posterior
acetabular fractures

Sometimes central Often posterior pillar

dislocation (posterior dislocation)
2. Evidence of any pathology in the pelvic ring (an-
teriorly in the pubis or posteriorly in the ilium, SIJ, or
sacrum) should automatically require inlet and outlet
views. Thoughtful interpretation of the plain films,
based on knowledge of pelvic anatomy and of the
traumatic incident, can enable the surgeon to define
the amount of pelvic skeletal disruption and identify
the vector of the injurious force.
3. Assessment of the disruption, with regard to fracture
pattern and force vector, permits a reasonably accu-
rate estimate of the concurrent soft tissue damage,
with reference to the risk to intrapelvic vasculature,
peripheral nervous structures, genitourinary tissues,
and other viscera.
Incorporation of this systematic use of plain pelvic films
will promote rapid treatment of potentially lethal pelvic
injuries by early and aggressive skeletal immobilization.
We believe that this rapid analysis and implementa-
tion of therapy is in part responsible for the fact that in
more than 350 cases of severe pelvic trauma presenting
•
to the Shock Trauma Center over the past three years,
there has not been a single fatality due to the pelvic
injury itself within the first 24 hours after admission.
 Fracture: See Specific type. straddle fracture, 70
femoral head central dislocation, 33 Type 1,17-21,35,68,79
Acetabulum fracture, 2, 3, 77
quadrilateral plate, 33 Type II, 22, 26, 39 •
anterior pillar, 51, 52
Type II A, 23
distinguishing features, 91
Type II B, 24, 25, 69
posterior pillar, 17,41,42,50,52
Type III, 27-32, 38
Angiography, 1
Genitourinary system, 11, 12 Lateral compression injury
Anterior compression fracture, Type I,
Gluteal artery, superior, 11, 82, 84 blood loss, 78
42-43,70
Gluteal nerve pubic ramus fracture, 67
Anterior compression injury, 85
inferior, 12 Lumbosacral ligament, lateral, 11
straddle fracture, 70
superior, 12 Lumbosacral plexus, 12
Anterior/posterior compression, Type II,
44-47
Anterior/posterior compression fracture,
39,41-53,43,52,71,86,91
associated injuries, 77 Hematoma, 83, 89 Maryland Institute for Emergency Medi-
Type III, 48-53,63, 84 Hemipelvis cal Services Systems, 2-3
Anterior/posterior compression injury displacement, 39, 56, 88 Mixed force vector, 16
blood loss, 78 posterior displacement, 7
pubic ramus fracture, 67 superior displacement, 6
Anterolateral compression, 89 Hemorrhage, 77, 78, 79, 80
Anteroposterior view, 2, 3, 5 Hip dislocation, central, 17,41
Artery: See Specific type.

Iliac artery Oblique view, 2

Bladder, 11, 13, 83, 89 external, 11 Obturator, 11
Bladder neck, 89 internal, 13, 84 Obturator internus nerve, 12
Bladder rupture, 87 pudendal branch, 11 Outlet view, 2, 3, 6, 92
Buckle fracture, 17, 33, 38 vesical branch, 11
Iliac wing fracture, 4, 17, 22, 24, 25, 27,
31,41,51,58,60,62,69
distinguishing features, 91
Pelvic ring fracture
Classification, pelvic stability, 13 Iliolumbar ligament, 11
classification, 1-2
Complex (mixed) pattern, 16,60-64 Iliolumbar vessel, 11
diagnosis, 1-2
associated injuries, 77 Ilium, 9
etiology, 1-2
blood loss, 78 Injury force pattern, 15-16
Pelvic sling, 1
pubic ramus fracture, 67 anteroposterior compression, 15
Pelvis
Complications, 77-89 complex (mixed) pattern, 16
anatomy, 9-11
Computed tomography, drawbacks, 1 lateral compression, 15
neuroanatomy, 12
Crush fracture, 17, 19,20,25,26,28, vertical shear, 15-16
normal, 3, 7
30, 33, 35, 38, 64, 68 Inlet view, 2, 3, 4, 5, 33, 92
stability, 13
Internal fixation, 1
classification, 13
Ischium, 9
windswept, 28, 29, 31, 32
buckle fracture, 35
Pillar fracture, anterior, 41
Plain radiograph
advantages, I
assessment, 91
utilization, 91-92
Femoral cutaneous nerve, posterior, 12 Postural reduction, 1
Femoral head dislocation, 23 Pubic ramus fracture, 17-19,21,22,24,
central, 33, 35 26,27,28-30,35-39,41-43,56,
Femur fracture, 68 Lateral compression fracture, 3, 4, 58,59,60,62-64,67-74,86
Force pattern, 1-2 17-39,34,72,73,83,85,91 anterior/posterior compression injury,
Force vector, 92 associated injuries, 77 67
 bilateral, 70-75
complex (mixed) pattern, 67
differentiation, 33-39
distinguishing features, 91
horizontal, 91
lateral compression injury, 67
unilateral, 67
vertical, 52, 91
vertical shear, 67
Pubis, 9
Pubis fracture, 18,36,57
Pudendal nerve, 12
Sacral vessel
lateral, 11
median, 11
Sacroiliac joint, 10,20,22,23-32,
43,45-47,48-53,55,56,58,59,
63,64,69,70,74,82,84,91
diastasis, 41, 50
distinguishing features, 91
Sacroiliac joint disruption, 48
Sacroiliac ligament, 48, 64
anterior, 10, 13, 27, 44
interosseous, 10
posterior, 10, 13, 17
sacrotuberous ligament, 10-11, 13
Sacrospinous ligament, 10, 11, 13, 27,
44,61
Sacrotuberous ligament, 27, 44, 61
Sacrum
crush fracture, 3, 5
lateral avulsion, 52
Sacrum fracture, 9,17,19,20,23,25,
26,28,30,33,35,38,41,57,59,62,
63,64, 68
distinguishing features, 91
Sciatic nerve, 12
Sciatic notch, II, 22
greater, 12
Shock Trauma Cent~ 2-3
patient population, 2
radiographic technique, 2-3
statewide coordination, 2
39, Skeletal traction, I
Straddle fracture
anterior compression injury, 70
lateral compression, 70
vertical shear, 70
Symphysis, 9, 23
Symphysis diastasis, 46, 47, 48, 49, 50,
53
Symphysis fracture, 39, 63
Symphysis ligament, 13
Symphysis pubis diastasis, 42, 45
distinguishing features, 91
Ureter, 11
Urethra, 11, 13,83
ruptured, 81, 86, 88
Urologic injury, 77, 85-89
Vascular injury, 78 ,
Vertical shear, 6, 55-60, 74, 83, 85, 86,
91
associated injuries, 77
blood loss, 78
pubic ramus fracture, 67
straddle fracture, 70
0J (L~
[0 Lrrbr-t?
(j D 1;tGv ?t u