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Pelvic Ring Fracture: Types, Evaluation, and Management

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Pelvic ring fractures are high-intensity hip bone fractures commonly associated with multiple traumatic injuries. Read this article to know more.

Medically reviewed by

Dr. Suman Saurabh

Published At December 20, 2022
Reviewed AtJuly 17, 2023

Introduction

A fracture of the pelvic bone involves fractures of three bones, the hip, sacrum, and coccyx, which together form the pelvic ring. The cohesive structure and mechanical strength make the pelvic ring a stable structure, because of which fracture of the pelvic ring is very uncommon.

What Is a Pelvic Ring?

The pelvic ring is made up of three bones, the sacrum and two fused bones (innominate bones); in which each of the fused bones is formed by bones called ilium (the uppermost and most significant area of the hip), ischium (bone forming lower and back part of the hip) and pubis (it serves as a bridge between the right and left hip bone).

What Are the Causes of Pelvic Ring Fracture?

Although the cause of pelvic ring fracture is said to be high-impact injuries, it is also seen in low-impact injuries in adolescents and young adults due to athletic injuries. In elders, it is seen as a fall injury. High-impact injuries are seen due to motorcycle accidents or falls from greater heights.

What Are the Incidences of Pelvic Ring Fractures?

The incidence of pelvic ring fracture is seen in thirty-seven people out of ten thousand men and women. The occurrence is commonly seen in men within the age of thirty-five and women above the age of thirty-five years, with the highest incidence from the age of 15 to 25.

What Are the Types of Pelvic Ring Fractures?

Because the pelvic ring is a solid structure, the fracture of the pelvis is often associated with injury to the associated ligaments or structures within or outside the pelvis. Based on the mechanism of injury, pelvic ring fracture is classified into three types. They are:

1. Anterior to Posterior Compression (APC): This fracture occurs due to compression from the front to the back. Here the ligaments fail from front to back, causing damage from symphyseal ligaments to sacrotuberous and sacrospinous ligaments extended up to the sacroiliac complex. Depending on the progression, APC injuries are divided into three types:

  • APC Type 1 - These are injuries defining disruption of only the symphyseal ligaments.

  • APC Type 2 - This is indicated in the disruption of symphyseal ligaments and ligaments of the pelvic floor. In the X-ray, the disturbed structure appears to be 2.5 cm (centimeter).

  • APC Type 3 - It is the disruption of the anterior and posterior sacroiliac ligaments and posterior sacroiliac complex.

2. Lateral Compression (LC) Injuries: This fracture occurs when the force is distributed from side to side. The fracture of the pelvic ring is more common in lateral compression injuries than anteroposterior compression. This fracture is called a rami fracture, which means fracture of a long projected part of the pelvic bone, which is also associated with fracture of the sacral ala bone or wing of the iliac bone. There are three types of lateral compression fractures, and they are:

  • LC type 1: This occurs due to a lateral force exerted on the poster side of the pelvic bone. It is seen as the ramus's fracture alongside the sacral ala's fracture.

  • LC Type 2: This fracture type occurs as a lateral compression fracture due to the exertion of a more anterior force exerted on the pelvis compared to type 1.

  • LC Type 3: This fracture type is also known as windswept pelvic fracture and is the most high-energy compression fracture of them all. It involves both type-1 and type-2 fractures along with pelvic rotation, and this fracture type is a very crucial case of lateral fracture, as it can even end up being fatal.

3. Vertical Shear Injuries (VS): This fracture occurs when the force is directed longitudinally or sagittal to the surface of the pelvic bone, which commonly occurs due to vehicle accidents or collision injuries. This fracture has a high risk for hypovolemic shock and has a fatality rate of 25 percent.

4. The force on the vertical shear fracture can be posterior or superiorly directed forces.

How Is Pelvic Ring Fracture Examined Clinically?

It is important to do a thorough physical checkup after an injury because of the force of impact. A complete checkup as per the ATLSP (advanced trauma life support) protocol is done to check for any significant or life-threatening injuries. Pelvic ring fractures are commonly seen alongside spine fractures; hence, it is essential to examine the spine and legs as well. The blood flow is carefully monitored as pelvic ring fractures can show sudden blood loss, even if it is a closed fracture. The bleeding is commonly seen within the chest, behind the stomach area, within the tissue, and within the stomach (intra-abdominal), the most common type of bleeding seen in almost 40 percent of cases. The bleeding occurs due to a rupture of the venous plexus (collective junction of the veins), which can hold clotted blood up to four liters. The soft tissue is checked then to rule out any tear in the stomach, rectum, or vagina to prevent contamination of the fracture from stools, urine, or other contaminating bodily substances. Neurological testing is conducted to rule out any liver damage involving the L5 or S1, S2-S5 (names of the spinal bones depending on their location) region, bowel or bladder functioning, and to rule out any sexual dysfunctions.

How Is Pelvic Ring Fracture Evaluated?

  • Computed Tomography (CT): A three-dimensional imaging system for any fracture, bleeding site, or pathology. In the case of pelvic ring fractures, CT provides the best images for studying the pelvic floor and the stomach region, both front and back, and to confirm any hip dislocation or associated fractures.

  • Radiographs: Although CT provides superior images for studying, the best diagnostic method in 90 percent of cases is by taking radiographs. X-rays are two-dimensional viewing images used commonly for assessing fracture lines, their extent, and the type of fracture that occurred.

  • Focus Assessment With Sonography for Trauma (FAST): It is a sonogram or stomach scan method used to rule out the presence of bleeding in the stomach.

  • Other Tests: Other Tests like retrograde urethrography and cryptography are done in both males and females to check for blood in the bladder. Pelvic angiography is done to check the arteries for any bleeding.

How Is Pelvic Ring Fracture Managed?

The management of pelvic ring fracture is done in two stages, one immediately after the injury and the other handling it after the emergency state. It is important to provide immediate treatment as the force causing pelvic fracture may also cause other serious complications, which can be life-threatening. The primary management includes fixing the fracture for stabilization, monitoring blood flow, hospitalization, putting the patient on painkillers and fluids, and monitoring the vital signs closely.

Surgical Management: The surgical treatments include stabilizing the pelvic bone using a pelvic binder. External fixation is done in patients with unstable blood flow. In cases of trauma with significant displacements, dental implants are placed.

Non-surgical Management: Non-surgical treatment is done in cases with minimal distortion, like APC type-1 and LC type 1, where stabilization is done and weight bearing is contraindicated. The patient is advised for bed rest until there is radiographic evidence of healing.

What Are the Complications of Pelvic Ring Fracture?

Patients with pelvic ring fractures go through deficits long after the injury. Almost 56 percent of the women show dyspareunia (painful intercourse) and cesarean delivery. And 61 percent of men suffer from sexual dysfunction, and 19 to 90 percent from erectile dysfunction, varying according to the degree of APC injuries.

How Is the Prognosis of Pelvic Ring Fracture Seen?

The prognosis is less significant in the first two years after the injury. The pelvic fracture is usually associated with adjacent injuries, which may compromise the forecast, but with surgical stabilization and rehabilitation, the patient shows significant improvement in the quality of life.

Conclusion

Pelvic ring fracture is complex as it is intertwined by the ligaments, which usually support and prevent fracture or displacement. However, the high-intensity fracture will most likely need medical and surgical attention. Although it is a complex process with a lengthy recovery period, patients lead a good quality of life though not to the pre-fracture life.

Frequently Asked Questions

1.

What Is the Healing Period for Pelvic Ring Fracture?

Because pelvic ring fractures are associated with multiple structures, the body takes a definitive healing time for soft tissues and bones. The healing period of pelvic ring fracture is around eight to twelve weeks.

2.

Is There Severe Bleeding and Loss of Blood Seen in Pelvic Ring Fracture?

Blood flow is carefully monitored in cases of pelvic ring fractures, as it can result in sudden blood loss. The bleeding is commonly due to the tear of the venous plexus behind the fractured segment. As a result, the blood is seen to pool behind the chest and stomach area.

3.

What Are the Types of Pelvic Ring Fractures?

Depending on the form of fracture occurred pelvic ring fracture can be divided into three major types. They are:
- Anterior to posterior compression.
- Lateral compression injuries.
- Vertical shear injuries.

4.

What Is a Pelvic Ring Fracture, and How Is It Seen Anatomically?

A pelvic ring fracture is the hip bone made up of three bones, the sacrum, and two fused bones, also known as innominate bones. The fused bones are formed together by the fusion of ilium, ischium, and pubis, forming the hip.

5.

How Is a Pelvic Ring Fracture Treated?

Pelvic ring fracture is treated both medically and surgically. The patient is initially monitored for pain, stabilization, and blood flow. The fractured segment is surgically managed by using a pelvic bone binder and fixing it externally with plates or implants. The nonsurgical management is done in patients with minimal hip displacement, and weight bearing is not advised.

6.

How Does a Pelvic Fracture Occur?

Pelvic ring fractures are commonly seen in young adults and older men, and the injury occurs due to
- Motor vehicle accidents. 
- Fall injuries. 
- High-impact trauma. 
- Crush injuries.

7.

When Is a Pelvic Ring Fracture Considered Unstable?

The completely unstable fractures are usually associated with severe injuries showing upward deformity of the pelvic bone, unstable muscles of the abdomen and back muscles, and injury involving pelvic floor muscles and posterior ligaments.
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Dr. Suman Saurabh
Dr. Suman Saurabh

Orthopedician and Traumatology

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