Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Pelvic trauma: Initial evaluation and management

James Fiechtl, MD
Section Editors
Maria E Moreira, MD
Richard G Bachur, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


Pelvis injuries range from the benign to life threatening. They include pelvic ring fractures, acetabular fractures, and avulsion injuries. The majority of pelvis injuries are due to high energy blunt trauma, although frail and elderly patients may sustain such injuries from a low energy mechanism (ie, fall). High energy trauma increases the likelihood of concomitant injuries, likely involving the abdominal and pelvic viscera.

Bony pelvic injuries in adults will be reviewed here. Abdominal injuries and other aspects of trauma, including initial management, are discussed separately. (See "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial management of trauma in adults".)


Incidence and mortality — Pelvic fractures represent approximately 3 percent of skeletal injuries [1]. Overall mortality from pelvic fractures ranges from 5 to 16 percent, with the rate for unstable pelvic fractures approximately 8 percent [2,3]. Patients with pelvic fractures who are in shock at presentation have high mortality [4]. The mortality rate associated with acetabular fractures is 3 percent [5], while open pelvic fractures, which comprise 2 to 4 percent of all pelvic fractures, are associated with a mortality rate of up to 45 percent [1,2,6-8]. Most fatalities stem from associated internal injuries; deaths attributed solely to pelvic fractures range from 0.4 to 0.8 percent of trauma fatalities [3,7,9]. Patients aged greater than 65 with pelvic fractures have a mortality rate of approximately 20 percent [10]. Overall, pelvic fractures are associated with an increased risk of death among trauma patients [11,12].

An Australian study of pelvic ring fractures demonstrated an incidence of 23 per 100,000 persons per year, while a British study found the incidence of acetabular fractures to be 3 per 100,000 persons per year [13,14]. Reviews of two large trauma registries found the incidence of pelvic ring fractures among admitted trauma patients to be 8 and 9.3 percent, respectively [9,15].

Risk factors for pelvic fractures include low bone mass, smoking, hysterectomy, older age, and a propensity to fall [16]. Age greater than 60 years in patients with significant pelvic fractures predicts a higher likelihood of bleeding requiring angiography [17,18].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: May 6, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005; 36:1.
  2. Yoshihara H, Yoneoka D. Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: trends and in-hospital mortality. J Trauma Acute Care Surg 2014; 76:380.
  3. Vaidya R, Scott AN, Tonnos F, et al. Patients with pelvic fractures from blunt trauma. What is the cause of mortality and when? Am J Surg 2016; 211:495.
  4. Costantini TW, Coimbra R, Holcomb JB, et al. Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg 2016; 80:717.
  5. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br 2005; 87:2.
  6. Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg 2005; 190:830.
  7. Hauschild O, Strohm PC, Culemann U, et al. Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma 2008; 64:449.
  8. Cannada LK, Taylor RM, Reddix R, et al. The Jones-Powell Classification of open pelvic fractures: a multicenter study evaluating mortality rates. J Trauma Acute Care Surg 2013; 74:901.
  9. Giannoudis PV, Grotz MR, Tzioupis C, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma 2007; 63:875.
  10. Dechert TA, Duane TM, Frykberg BP, et al. Elderly patients with pelvic fracture: interventions and outcomes. Am Surg 2009; 75:291.
  11. Sathy AK, Starr AJ, Smith WR, et al. The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients. J Bone Joint Surg Am 2009; 91:2803.
  12. Schulman JE, O'Toole RV, Castillo RC, et al. Pelvic ring fractures are an independent risk factor for death after blunt trauma. J Trauma 2010; 68:930.
  13. Balogh Z, King KL, Mackay P, et al. The epidemiology of pelvic ring fractures: a population-based study. J Trauma 2007; 63:1066.
  14. Laird A, Keating JF. Acetabular fractures: a 16-year prospective epidemiological study. J Bone Joint Surg Br 2005; 87:969.
  15. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 2002; 195:1.
  16. Kelsey JL, Prill MM, Keegan TH, et al. Risk factors for pelvis fracture in older persons. Am J Epidemiol 2005; 162:879.
  17. Kimbrell BJ, Velmahos GC, Chan LS, Demetriades D. Angiographic embolization for pelvic fractures in older patients. Arch Surg 2004; 139:728.
  18. Martin S, Casey N. Haemorrhage requiring embolisation after low energy pelvic fracture in an elderly patient: a case report. Emerg Med J 2010; 27:722.
  19. Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma 2007; 21:31.
  20. Porter SE, Schroeder AC, Dzugan SS, et al. Acetabular fracture patterns and their associated injuries. J Orthop Trauma 2008; 22:165.
  21. Kocher MS, Tucker R. Pediatric athlete hip disorders. Clin Sports Med 2006; 25:241.
  22. Stein DM, O'Connor JV, Kufera JA, et al. Risk factors associated with pelvic fractures sustained in motor vehicle collisions involving newer vehicles. J Trauma 2006; 61:21.
  23. Rowe SA, Sochor MS, Staples KS, et al. Pelvic ring fractures: implications of vehicle design, crash type, and occupant characteristics. Surgery 2004; 136:842.
  24. Gänsslen A, Giannoudis P, Pape HC. Hemorrhage in pelvic fracture: who needs angiography? Curr Opin Crit Care 2003; 9:515.
  25. Magnussen RA, Tressler MA, Obremskey WT, Kregor PJ. Predicting blood loss in isolated pelvic and acetabular high-energy trauma. J Orthop Trauma 2007; 21:603.
  26. Elzik ME, Dirschl DR, Dahners LE. Hemorrhage in pelvic fractures does not correlate with fracture length. J Trauma 2008; 65:436.
  27. Salim A, Teixeira PG, DuBose J, et al. Predictors of positive angiography in pelvic fractures: a prospective study. J Am Coll Surg 2008; 207:656.
  28. Bjurlin MA, Fantus RJ, Mellett MM, Goble SM. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. J Trauma 2009; 67:1033.
  29. Weis EB Jr. Subtle neurological injuries in pelvic fractures. J Trauma 1984; 24:983.
  30. Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988; 227:67.
  31. Schmal H, Hauschild O, Culemann U, et al. Identification of risk factors for neurological deficits in patients with pelvic fractures. Orthopedics 2010; 33.
  32. Bramos A, Velmahos GC, Butt UM, et al. Predictors of bleeding from stable pelvic fractures. Arch Surg 2011; 146:407.
  33. Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 1990; 30:848.
  34. Sarin EL, Moore JB, Moore EE, et al. Pelvic fracture pattern does not always predict the need for urgent embolization. J Trauma 2005; 58:973.
  35. Lunsjo K, Tadros A, Hauggaard A, et al. Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients. J Trauma 2007; 62:687.
  36. Manson T, O'Toole RV, Whitney A, et al. Young-Burgess classification of pelvic ring fractures: does it predict mortality, transfusion requirements, and non-orthopaedic injuries? J Orthop Trauma 2010; 24:603.
  37. Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res 1980; :81.
  38. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma 2005; 59:1314.
  39. Shlamovitz GZ, Mower WR, Bergman J, et al. How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients? J Trauma 2009; 66:815.
  40. Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg 2002; 194:121.
  41. Duane TM, Tan BB, Golay D, et al. Blunt trauma and the role of routine pelvic radiographs: a prospective analysis. J Trauma 2002; 53:463.
  42. McCormick JP, Morgan SJ, Smith WR. Clinical effectiveness of the physical examination in diagnosis of posterior pelvic ring injuries. J Orthop Trauma 2003; 17:257.
  43. Pehle B, Nast-Kolb D, Oberbeck R, et al. [Significance of physical examination and radiography of the pelvis during treatment in the shock emergency room]. Unfallchirurg 2003; 106:642.
  44. Leggon RE, Wood GC, Indeck MC. Pelvic fractures in pregnancy: factors influencing maternal and fetal outcomes. J Trauma 2002; 53:796.
  45. Friese RS, Malekzadeh S, Shafi S, et al. Abdominal ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture. J Trauma 2007; 63:97.
  46. Tayal VS, Nielsen A, Jones AE, et al. Accuracy of trauma ultrasound in major pelvic injury. J Trauma 2006; 61:1453.
  47. Davis JW, Moore FA, McIntyre RC Jr, et al. Western trauma association critical decisions in trauma: management of pelvic fracture with hemodynamic instability. J Trauma 2008; 65:1012.
  48. Kessel B, Sevi R, Jeroukhimov I, et al. Is routine portable pelvic X-ray in stable multiple trauma patients always justified in a high technology era? Injury 2007; 38:559.
  49. Vo NJ, Gash J, Browning J, Hutson RK. Pelvic imaging in the stable trauma patient: is the AP pelvic radiograph necessary when abdominopelvic CT shows no acute injury? Emerg Radiol 2004; 10:246.
  50. Paydar S, Ghaffarpasand F, Foroughi M, et al. Role of routine pelvic radiography in initial evaluation of stable, high-energy, blunt trauma patients. Emerg Med J 2013; 30:724.
  51. Obaid AK, Barleben A, Porral D, et al. Utility of plain film pelvic radiographs in blunt trauma patients in the emergency department. Am Surg 2006; 72:951.
  52. Barleben A, Jafari F, Rose J Jr, et al. Implementation of a cost-saving algorithm for pelvic radiographs in blunt trauma patients. J Trauma 2011; 71:582.
  53. Gardner MJ, Krieg JC, Simpson TS, Bottlang M. Displacement after simulated pelvic ring injuries: a cadaveric model of recoil. J Trauma 2010; 68:159.
  54. Starks I, Frost A, Wall P, Lim J. Is a fracture of the transverse process of L5 a predictor of pelvic fracture instability? J Bone Joint Surg Br 2011; 93:967.
  55. Mohseni S, Talving P, Kobayashi L, et al. The diagnostic accuracy of 64-slice computed tomography in detecting clinically significant arterial bleeding after pelvic fractures. Am Surg 2011; 77:1176.
  56. Dormagen JB, Tötterman A, Røise O, et al. Efficacy of plain radiography and computer tomography in localizing the site of pelvic arterial bleeding in trauma patients. Acta Radiol 2010; 51:107.
  57. Burlew CC, Moore EE, Smith WR, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg 2011; 212:628.
  58. Magnone S, Coccolini F, Manfredi R, et al. Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery). World J Emerg Surg 2014; 9:18.
  59. Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review. J Trauma 2011; 71:1850.
  60. Martinelli T, Thony F, Decléty P, et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures. J Trauma 2010; 68:942.
  61. Gardner MJ, Parada S, Chip Routt ML Jr. Internal rotation and taping of the lower extremities for closed pelvic reduction. J Orthop Trauma 2009; 23:361.
  62. Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma 2002; 16:45.
  63. Rajab TK, Weaver MJ, Havens JM. Videos in clinical medicine. Technique for temporary pelvic stabilization after trauma. N Engl J Med 2013; 369:e22.
  64. Lee C, Porter K. The prehospital management of pelvic fractures. Emerg Med J 2007; 24:130.
  65. Krieg JC, Mohr M, Ellis TJ, et al. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma 2005; 59:659.
  66. Durkin A, Sagi HC, Durham R, Flint L. Contemporary management of pelvic fractures. Am J Surg 2006; 192:211.
  67. Shore BJ, Palmer CS, Bevin C, et al. Pediatric pelvic fracture: a modification of a preexisting classification. J Pediatr Orthop 2012; 32:162.
  68. Demetriades D, Karaiskakis M, Velmahos GC, et al. Pelvic fractures in pediatric and adult trauma patients: are they different injuries? J Trauma 2003; 54:1146.
  69. Keshishyan RA, Rozinov VM, Malakhov OA, et al. Pelvic polyfractures in children. Radiographic diagnosis and treatment. Clin Orthop Relat Res 1995; :28.
  70. Ismail N, Bellemare JF, Mollitt DL, et al. Death from pelvic fracture: children are different. J Pediatr Surg 1996; 31:82.
  71. Gänsslen A, Hildebrand F, Heidari N, Weinberg AM. Pelvic ring injuries in children. Part I: Epidemiology and primary evaluation. A review of the literature. Acta Chir Orthop Traumatol Cech 2012; 79:493.
  72. Ortega HW, Reid S, Velden HV, et al. Patterns of injury and management of children with pelvic fractures at a non-trauma center. J Emerg Med 2014; 47:140.
  73. Leonard M, Ibrahim M, Mckenna P, et al. Paediatric pelvic ring fractures and associated injuries. Injury 2011; 42:1027.
  74. Guillamondegui OD, Mahboubi S, Stafford PW, Nance ML. The utility of the pelvic radiograph in the assessment of pediatric pelvic fractures. J Trauma 2003; 55:236.
  75. Kwok MY, Yen K, Atabaki S, et al. Sensitivity of plain pelvis radiography in children with blunt torso trauma. Ann Emerg Med 2015; 65:63.
  76. Lagisetty J, Slovis T, Thomas R, et al. Are routine pelvic radiographs in major pediatric blunt trauma necessary? Pediatr Radiol 2012; 42:853.
  77. Wong AT, Brady KB, Caldwell AM, et al. Low-risk criteria for pelvic radiography in pediatric blunt trauma patients. Pediatr Emerg Care 2011; 27:92.
  78. Smith WR, Oakley M, Morgan SJ. Pediatric pelvic fractures. J Pediatr Orthop 2004; 24:130.
Topic Outline