Iliac Wing Fractures

The epidemiology, guidelines table and the Oberkircher evidence all invoke the elderly "fragility" pelvic fracture and the FFP (Rommens) classification, but the topic never develops this second, increasingly common population — and the distinction changes the whole management emphasis.

Two very different patients

• The classic Duverney fracture is a young, high-energy, direct-lateral-blow injury (side-impact crash, fall onto the side, crush). The concern is excluding ring/acetabular extension and associated visceral injury.
• The far more common fragility fracture of the pelvis (FFP) is a low-energy / insufficiency injury in an osteoporotic older adult (often after a trivial fall or even no clear trauma), presenting with hip/groin/low-back pain. Incidence in those over 60 is roughly 224 per 100,000 per year and rising.

The Rommens FFP classification (severity = instability)

• FFP I — isolated anterior ring fracture; FFP II — non-displaced posterior ring fracture: both usually stable → conservative.
• FFP III/IV — displaced / bilateral posterior instability: usually need surgical stabilisation (e.g. sacroiliac/transsacral screws, sacroplasty).

Why the emphasis differs

• In the older adult the enemy is immobility, not haemorrhage: one-year mortality is a striking 9.5 to 27 percent, driven by loss of mobility and independence. The goal is therefore early mobilisation with adequate analgesia, plus bone-health/osteoporosis work-up and falls prevention — the opposite priority to the polytrauma resuscitation focus of the young high-energy injury. (The sacral insufficiency component is covered in the sacral insufficiency fracture topic.)

The fixation section says to "preserve gluteal origins" and plate along the crest, and the abductor-weakness theme runs through the topic — so the neurovascular structures at risk during iliac-wing surgery, and the nerve behind the abductors, deserve to be explicit.

The abductor nerve (answers the recurring question)

• The hip abductors injured by these fractures — gluteus medius and minimus — are supplied by the superior gluteal nerve (L4-S1), which exits the pelvis through the greater sciatic foramen above piriformis with the superior gluteal vessels and runs forward between gluteus medius and minimus. Persistent post-fracture abductor weakness reflects injury to the muscle origin (and, rarely, this nerve), and produces a Trendelenburg gait.

Structures at risk during wing/crest fixation

• Superior gluteal neurovascular bundle at the greater sciatic notch — tethered as it exits the notch; aggressive posterior dissection or screws near the notch risk troublesome bleeding (retraction into the pelvis) and abductor denervation.
• Inner (pelvic) table: the L5 nerve root and lumbosacral trunk cross the ala just medial to the SI joint, and the iliac vessels lie on the inner table — at risk with medial dissection/screw penetration.
• Lateral femoral cutaneous nerve at/near the ASIS during anterior approaches (its injury causes meralgia paraesthetica, covered in that topic), and the explanation for the lateral-thigh numbness listed among the complications.

Imaging Atlas

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• Isolated Duverney: Excellent outcomes with conservative care.
• With Ring Involvement: Outcomes depend on overall ring stability.
• Hip Abductor Recovery: Usually good with rehab.

Global epidemiology:

• Isolated iliac wing (Duverney) fractures are uncommon relative to pelvic ring injuries and are typically high-energy (side-impact MVC, fall onto side, crush) in younger patients.
• In adults over 60, anterior/iliac fragility fractures are far more common: estimated incidence of osteoporotic pelvic fracture of around 224 per 100,000 per year and rising, with one-year mortality of 9.5-27% driven by loss of mobility (Oberkircher, Dtsch Arztebl Int 2018).

Side-by-side guidance:

Registries and practice variation:

• Pelvic and trauma registries (e.g. UK TARN, German Pelvic Trauma Registry, regional trauma databases) consistently show isolated wing fractures carry low transfusion and mortality compared with ring disruptions - underpinning conservative care.
• High-resource settings: routine whole-body or pelvic CT confirms isolation, enabling confident early mobilisation and same-admission discharge.
• Limited-resource settings: where CT is not readily available, inlet/outlet and Judet views plus careful clinical stability testing guide management; a low threshold for referral applies if SI-joint or acetabular extension cannot be excluded.
• Physiotherapy: early hip-abductor rehabilitation is the shared standard worldwide.