• The pelvis is a ring of bones located at the lower end of the trunk—

between the spine and the legs. The pelvic bones include the:
• Sacrum (the large triangular bone at the base of the spine)
• Coccyx (tailbone)
• Hip bones
• The pelvis helps anchor the muscles and protect the organs in the lower
abdomen.
• Each hip bone contains three bones—the ilium, ischium, and pubis—that
are separate during childhood but fuse together as we grow older. These
three bones meet to form the acetabulum—the hollow cup that serves
as the socket for the ball-and-socket hip joint.
• Bands of strong connective tissues called ligaments join the pelvis to the
sacrum, creating a bowl-like cavity below the rib cage.
• Major nerves, blood vessels, and portions of the bowel, bladder, and
reproductive organs all pass through the pelvic ring. The pelvis protects these
important structures from injury. It also serves as an anchor for the muscles of
the hip, thigh, and abdomen.
• To Top
• Description
• Because the pelvis is a ring-like structure, a fracture in one part of the structure
is often accompanied by a fracture or damage to ligaments at another point in
the structure. Doctors have identified several common pelvic fracture patterns.
The specific pattern of the fracture depends upon the direction in which it was
broken and the amount of force that caused the injury.
• In addition to being described by the specific fracture pattern, pelvic fractures
are often described as "stable" or "unstable," based on how much damage has
occurred to the structural integrity of the pelvic ring.
• Stability of the pelvis: The stability of the pelvic ring
depends, posteriorly on the sacro-iliac joints
• and anteriorly on the symphysis pubis. The sacroiliac
• joints are bound in front and behind by the
• strong, band-like, sacro-iliac ligaments (Fig-17.2).
• The pubic symphysis is reinforced by ligamentous
• fibres above and below it. Accessory ligaments
• of the pelvis, such as ilio-lumbar ligament, sacrotuberous
• ligaments and sacro-spinous ligaments
• provide additional stability to the ring.
• Nerves in relation to the pelvis: The
obturator
• nerve and the sacral plexus pass over the ala
of the
• sacrum, and cross the pelvic brim. These are
likely
• to suffer injury in fractures in this region
• History
• Pelvic fractures usually occur due to high-velocity
• trauma following a road traffic accident (RTA) or
• due to fall from a height.
• The relative incidences are as follows:
• • RTA—80.7 percent.
• • Fall—16.1 percent.
• • Compression fracture—rest.
• .
• Mechanism of Injury
• There are four mechanisms by which pelvic ring
• fractures are produced:
• • Lateral compression (Fig. 23.2A).
• • Anteroposterior compression (Fig. 23.2B).
• • Vertical shears forces.
• • Inferior forces (e.g. fall on buttocks).
• The first two mechanisms are common in RTA
• and may cause stable or unstable fractures. Vertical
• shear forces are due to fall from a height and will
• cause grossly unstable fracture
 CLASSIFICATION

• Marvin Tile (1988) classifies pelvis fractures on the basis of stability into three types:
• TYPE A: Stable
• • A1 – Fractures of the pelvis not involving the ring
• • A2 – Stable, minimally displaced fractures of the ring
• TYPE B: Rotationally unstable, vertically stable
• • B1 – Open-book type
• • B2 – Lateral compression – ipsilateral
• • B3 – Lateral compression – contralateral
• (Bucket-handle type)
• TYPE C: Rotationally and vertically unstable
• • C1 – Unilateral
• • C2 – Bilateral
• • C3 – Associated with acetabular fracture
• TYPE A: Stable, minimally displaced fractures: In
• this type, the pelvic ring is stable and displacement
• is insignificant. These are avulsion fractures of
• the parts of pelvis and fractures of the iliac wing,
• pubic rami fractures and undisplaced fractures
• of the acetabulum. These are generally treated
• conservatively, and have good prognosis
• TYPE B: Unstable fractures - rotationally unstable
• but vertically stable: In this type of injury, the
• pelvis is unstable. Rotational displacement can
• occur but no vertical displacement can occur.
• Open-book injury is an example of this type where
• an antero-posterior force causes disruption of
• symphysis pubis, and thus tends to open up the
• pelvis (Fig-17.3). There is no vertical displacement.
Type B pelvis injury. Rotational displacement, no
vertical displacement
• Type C: Unstable - rotationally and vertically:
• These are the most unstable injuries, the
essential
• feature being vertical instability
• TYPE A INJURY — ISOLATED FRACTURES
• This is the commonest injury but the least serious
• of the three types. Any part of the pelvis may be
• affected. The essential feature being that the pelvis
• remains stable. Complications are uncommon in
• these relatively minor fractures of the pelvis. The
• following are some of the fractures included in
• this group:
• Key and Conwell’s Classification
• Fracture of Individual Bones without a Break
• in the Pelvic Ring
• • Avulsion fracture of the:
• – Anterosuperior iliac spine
• – Anteroinferior iliac spine
• – Ischial tuberosity.
• • Fracture of pubis or ischium.
• • Fracture wing of ilium (Duverney).
• • Fracture sacrum.
• • Fracture or dislocation of coccyx.
• .
• Single Break in the Pelvic Ring
• • Fracture of both ipsilateral rami.
• • Fracture near or subluxation of symphysis pubis.
• • Fracture near or subluxation of sacroiliac joints.

• Double Breaks in the Pelvic Ring

• • Double vertical fracture or dislocation of pubis
• (Straddle fracture).

• • Double vertical fracture or dislocation of pelvis

• (Malgaigne’s fracture).
• Acetabulum Fractures
• • Undisplaced.
• • Displaced
• Ischio-Pubic Rami Fracture
• These are the commonest of pelvic fractures. One or
• more rami may be fractured on one or both sides;
• the latter is called as straddle fracture. Displacement
• is usually minimal. The fracture of rami may extend
• into the acetabulum. There may be an associated
• injury to the urethra or bladder.
• Clinical Tests
• Compression test: When a compressive force is
• applied through the two iliac bones, the patient
• complains of pain in pelvic fracture (Fig. 23.6A).
• Distraction test: When distraction force is applied
• to the two iliac bones at the anterosuperior iliac
• spine, the patient complains of pain (Fig. 23.6B).
• Direct pressure test: Direct pressure over the symphysis
• pubis elicits pain (Fig. 23.6C).
• Clinically the patient presents with pain and
• tenderness over the fracture site. Sometimes,
• a patient with multiple injuries may not have
• any complaint referring to this fracture, and it
is
• detected by the routine pelvic compression
test
• (see page 124).
• Radiologically, once an ischio-pubic rami
• fracture is detected, one must carefully rule out
• an associated fracture in the posterior half of the
• pelvic ring (i.e. fracture through sacrum, sacroiliac
• joint or ilium). It is only after this is done
• that a diagnosis of ‘isolated’ pubic rami fracture
• can be made.
• Treatment: These fractures pose no problems
• in successful union. Treatment is basically for
• relief of pain. Bed rest for 1-3 weeks is usually
• sufficient
 Iliac Wing Fracture

• This is a relatively uncommon fracture resulting

• from direct injury to the wing of the ilium (e.g. in
• a road traffic accident). Sometimes, these patients
• may lose so much blood from ‘vascular ’ iliac
• wings that they develop hypovolaemic shock. The
• fractures are otherwise without complications, and
• unite in 4-6 weeks with rest and analgesics.
Avulsion Fracture of Anterior Inferior Iliac Spine

• The straight head of the rectus femoris muscle

• takes its origin from the anterior inferior iliac spine.
• Sometimes, due to a violent contraction of this
• muscle, as may occur during a jump, the anterior
• inferior iliac spine may be pulled off (avulsed). The
• fracture unites quickly in 3-4 weeks without any
• complications
• Acetabular Fractures
• Some of the undisplaced or minimally displaced
• fractures of the acetabulum can be considered in
• this group of relatively ‘benign’ fractures. These
• fractures usually unite without any compli-cations.
• Late, secondary osteoarthritis develops in some
• cases because of the irregularity of the articular
• surface following the injury.
• TYPES B AND C INJURIES (RING DISRUPTION
INJURIES)
• These are uncommon but more important
injuries
• because of the higher incidence of associated
• complications. Road traffic accidents are the
• commonest cause of such injuries.
• P
• PATHOANATOMY
• If a portion of the pelvic ring is broken, and the
• fragments displaced, there must be a fracture or
• dislocation in another portion of the ring. The
• following combinations of fracture and dislocation
• in anterior and posterior halves of the pelvis may
• occur:
• Anterior Posterior
• • Fracture of superior • Fracture through ala
• and inferior pubic rami of sacrum
• • Dislocation through
• SI joint
• • Disruption of pubic • Fracture through
• symphysis ilium
• Displacements: It is generally slight. The type of
• displacement depends upon the force causing the
• fracture. The following displacements may occur:
• a) External rotation of the hemi-pelvis (openbook
• type): The pelvic ring is opened up from
• the front like a book. There may be a pubic
• symphysis disruption or rami fractures in front
• and damage to the sacro-iliac joint behind.
• b) Internal rotation of hemi-pelvis: This may result
• from a lateral compression force. There may
• be an overlap anteriorly with or without a
• posterior lesion.
• c) Rotation superiorly (bucket-handle type):
• The hemi-pelvis rotates superiorly along a
• horizontal antero-posterior axis.
• d) Vertical displacement: This results from a vertical
• force causing upward displacement of half of
• the pelvis.
• Differential Diagnosis
• Pelvic fractures rarely occur as a single injury. They should be differentiated
from, or could be accompanied by many disorders like:  (levels of evidence: 4)
- avascular necrosis of the femoral head
- cancer
- hip dislocation
- hip fractures
- osteomyelitis
- osteoporosis
- genito-urinary injuries
- bowel injury
- muscular injuries
- neurovascular injuries
- bladder injury
- urethral injury
• Outcome measures
•
To measure the outcome of patients with pelvic fractures many questionnaires
can be used. They can be divided in disease specific or patient specific
outcome measures. 
• Disease specific:
• - Harris Hip score
- Mayo Hip scores

• Patient specific:
• - Oxford Hip scores,
- SF-36,
- WOMAC
- iHOT
• DIAGNOSIS
• Clinical examination: Pelvic fractures are major
• injuries, often with little or no clinically obvious
• deformity. It may be one of the fractures in a
• seriously injured patient where the surgeon's
• attention may be diverted to other injuries with
• more obvious manifestations. A pelvic fracture must
• be carefully looked for in all cases of road accident,
• especially in those with multiple injuries, those
• associated with hypovolaemic shock, and those
• with major lower limb fractures (fracture of the
• femur etc.). The pelvic compression test is a useful
• screening test in all such cases.
• .
• Pelvic compression test: The patient lies supine on the
• couch. The examiner compresses both iliac crests of
• the patient's pelvis towards each other. Any pain
• during this manoeuvre or a ‘springy’ feeling, is an
• indicator of pelvic fracture. A pelvic distraction test
• may reveal similar findings
• In displaced pelvic fractures there may be shortening
• of one of the lower limbs. The limb may lie in
• external rotation. There may be a haematoma in
• the region of pubic symphysis or at the back, in the
• region of sacro-iliac joints. Palpation may reveal
• a localised tenderness or crepitus. A gap at the
• symphysis pubis is occasionally felt. There may
• be signs due to associated injury to the urethra,
• bladder or intestine etc., as discussed on page 127.
• There may be anaesthesia or weakness of one leg
• due to injury to the sciatic plexus.
• Radiological examination: Pelvis with both
• hips-AP
• TREATMENT
• The importance of treatment of pelvic fractures
• lies in identifying the possibility of life threatening
• hypovolaemic shock and associated visceral
• injuries. The patient should be moved as little as
• possible, as movement at the fracture site may
result
• in further bleeding or fat embolism.
• O
• Further treatment of
• the pelvic fracture depends on the type of fracture
• and presence of associated complications. In case
• a complication like urethral injury etc. is present,
• emergency treatment for the same is executed. A
• pelvic fracture may fall into one of the following
• three categories from the treatment viewpoint:
• a) An injury with minimal or no
displacement:
• The patient is advised absolute bed rest for
• 3-4 weeks. Once the fracture becomes ‘sticky’
• and the pain subsides, gradual mobilisation
• and weight bearing is permitted. It takes from
• 6-8 weeks for the patient to be up and about.
• b) :
• An injury with anterior opening of the pelvis
• (open-book injury): A minimal opening up
• (less than 2.5 cm) does not need any special
• treatment, and is treated on the lines of (a).
• Reduction is needed if the opening is more than
• 2.5 cm. This is done by manual pressure on the
• two iliac wings so as to ‘close’ the pelvic ring.
• The reduction thus achieved is maintained by
• one of the following methods
• External fixator: This is a reliable and
• comfortable method. Two or three pins
• threaded at the tip (Schanz pin) are inserted
• in the anterior part of the wing of the iliac
• bone on each side.
• Internal fixation: The pubic symphysis
• disruption may be reduced and internally
• fixed with a plate.
• • Hammock-sling traction (Fig-17.5a): It was a
• popular method in the past but poses nursing
• problems. The patient requires prolonged
• hospitalisation
• Internal fixation: The pubic symphysis
• disruption may be reduced and internally
• fixed with a plate.
• • Hammock-sling traction (Fig-17.5a): It was a
• popular method in the past but poses nursing
• problems. The patient requires prolonged
• Hospitalisation

• Injuries with vertical displacement: These are

• the most difficult pelvic injuries to treat. These
• are treated by bilateral upper tibial skeletal
• traction.
Treatment plan for pelvic ring disruption
injuries
• COMPLICATIONS
• 1. Rupture of urethra
• 2. Rupture of bladder:
• 3. Injury to rectum or vagina: There may be
• disruption of the perineum with damage to
• the rectum or vagina.
• 4. Injury to major vessels: This is a rare but serious
• complication of a pelvic fracture. The common iliac
• artery or one of its branches may be damaged by a
• spike of bone
• 5. Injury to nerves: In case of major disruption of
• the pelvic ring with marked vertical displacement
• of half of the pelvis, it is common for the nerves of
• the lumbo-sacral plexus to be injured. The damage
• may be caused by a fragment pressing on the
• nerves, or by stretching
• 6. Rupture of the diaphragm
A comparative study of different types of pelvic fractures, their
clinical features and treatment is presented here

Type 1 Type of pelvic Clinical features Treatment

fracture

Avulsion of Pain on trying to Bed rest , hip spica

anterosuperior flex and abduct the
iliac spine thigh
• Physical therapy is an important part of the
rehabilitation in both, low-energy and high-energy pelvic
fractures. Low-energy injuries are usually managed with
conservative care. This includes bed rest, pain control
and physical therapy. [8] High-energy injuries, especially
the unstable fractures must be reduced by surgical
treatment. Afterwards physical therapy includes the
same treatment as in low-energy fractures. Early
mobilisation is very important because prolonged
immobilisation can lead to many complications,
including respiratory and circulatory dysfunctions.
Physical therapy helps the patient to get out of bed as
soon as possible
• The goals of the physical therapy program
should provide the patient with an optimal
return of function by improving functional skills,
self-care skills and safety awareness. [23] The
main goals are to improve the pain level,
strength, flexibility, speed of healing, and the
motion of the hip, spine and leg. Another
important goal is to shorten the time needed to
return to activity and sport.
• The intensity of the rehabilitation depends on
whether the fracture was stable or unstable.
• In people with surgical treatment, physical
therapy starts after 1 or 2 days of bed rest. It is
initiated with training of small movements,
transfers and exercise training. The following
exercises can start immediately after surgery
and should be done at least four times a day
(unless told otherwise). The number of
repetitions are guidelines and can vary with
every patient.
• Plantar flexion and dorsiflexion of the feet
Sit up or lie down. Keep your legs straight and
move your feet up and down at the ankles,
pointing your toes and then relaxing.
Repeat 10 – 15 times every hour.
• Abduction of the hip
Move your leg out to the side and then back to
the middle.
Repeat both sides 10 times
• Contraction of the quadriceps
Keep your legs flat on the bed. Push the knee down
so that your leg is straight and then tighten your
thigh muscle and hold for five seconds.
Repeat 5 – 10 times
• Extension of the knee: lying
Lie on your back. Put a rolled towel under your knee.
Tighten your thigh muscles and straighten your knee,
lifting your heel off the bed. Hold your leg straight for
five seconds and lower it gently
• Short-term goals for patients after surgery are: independence with transfers and
wheelchair mobility. Depending on the medical status of the patient these goals
can be achieved in 2 to 6 weeks. The physical therapy program can be continued
in the hospital or at home. The home-based program includes basic range of
motion, stabilising and strengthening exercises intended to prevent contracture
and reduce atrophy.
• During the non-weight bearing status the patient performs isometric exercises of
the gluteal muscle and quadriceps femoris muscle, range of motion exercises and
upper-extremity resistive exercises (for example shoulder and elbow flexion and
extension) until fatigued. The number of repetitions can vary with the patient. [25] 
• Once weight-bearing is resumed, physical therapy consists of gait training and
resistive exercises for the trunk and extremities, along with cardiovascular
exercises (for example treadmill or bicycle training). Stabilisation exercises and
mobility training should also be remained in the program. [26] Aquatherapy is also
good and helpful when available.