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Severe pelvic fracture in the adult trauma patient

Clay Cothren Burlew, MD
Ernest E Moore, MD
Section Editor
Eileen M Bulger, MD, FACS
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Patients with severe pelvic fractures present many challenges for the trauma team. Pelvic injuries often occur in conjunction with other life-threatening injuries, and there is not universal agreement on all aspects of management. Following initial resuscitation, current management algorithms in the United States incorporate variable timeframes for bony stabilization and hemorrhage control using resuscitative endovascular balloon occlusion of the aorta (REBOA), preperitoneal pelvic packing or angioembolization. We suggest early fixation and pelvic packing for hemodynamically unstable patients, reserving angioembolization for noncoagulopathic patients who continue to bleed from a pelvic source in spite of pelvic packing. The management of severe pelvic fractures is optimized using a multidisciplinary approach involving the trauma surgeon, orthopedic surgeon, vascular interventionalist, anesthesiologist, and the transfusion services.    

Methods to treat severe pelvic fractures, including controlling ongoing hemorrhage, are reviewed here. The diagnosis and initial trauma management of patients with pelvic fractures are discussed elsewhere. (See "Pelvic trauma: Initial evaluation and management".)


Blunt injury to the pelvis can produce complex fractures that often result in moderate to severe hemorrhage. The Young and Burgess classification uses the force vector to categorize pelvic fractures as due to lateral compression (LC), anterior/posterior compression (APC), or vertical shear (VS) (figure 1 and table 1) [1,2]. Within each category, the amount of ligamentous injury, bony fracture, and overall displacement of the hemipelvis further categorizes the patient's pelvic injury from type I (less severe) to type III (most severe). However, a patient's fracture pattern may not adhere to a single category; a combination of LC, APC, and VS may be present. Higher grades, particularly APC and VS, are more commonly associated with hemodynamic instability and the need for transfusion and intervention. (See "Pelvic trauma: Initial evaluation and management", section on 'Fracture types'.)

Pelvic fractures can also be described as biomechanically stable or unstable within the Academy of Orthopedics/Orthopedic Trauma Association classification system [3]. Unstable pelvic fractures require two or more breaks in the pelvic ring. It is important to note that biomechanical instability of the pelvic fracture does not necessarily imply hemodynamic stability. The fracture components and ligamentous instability may result in a rotationally unstable (partially stable pelvis, type B) or a rotationally and vertically unstable (completely unstable, type C) pelvis (figure 2). Generally, APC I and II, and LC I, II, and III injuries are considered rotationally unstable while APC III, VS, and combined injuries are both rotationally and vertically unstable.

Fractures that create soft tissue defects are termed “open” fractures; however, the break can occur in the rectum, vagina, or skin and these associated injuries complicate management. (See 'Management of associated soft tissue injury' below.)

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Literature review current through: Sep 2017. | This topic last updated: Apr 19, 2016.
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