High Yield Overview
Iliac Wing Fractures
Duverney Fracture | Stable Pelvic Injury
StablePelvic Ring Intact
DirectTrauma Mechanism
ConservativeMost Treatment
AbductorsAt Risk
Iliac Wing Fracture Types
Duverney (Isolated)
PatternFracture confined to iliac wing. Pelvic ring intact.
TreatmentConservative (NWB)
With Ring Involvement
PatternExtends to SI joint or acetabulum. Unstable.
TreatmentORIF
Critical Must-Knows
- Definition: Fracture of the iliac wing not involving the pelvic ring or acetabulum.
- Stability: STABLE injury. Pelvic ring intact. Weight-bearing through sacrum/acetabulum.
- Mechanism: Direct lateral trauma (Side impact MVA, Fall onto side, Crush).
- Treatment: Conservative - Protected weight-bearing, Analgesia, Physio.
- Risk: Hip abductor weakness (Gluteus medius/minimus attachment).
Examiner's Pearls
- "Duverney fracture is STABLE because the pelvic ring is intact.
- "Direct lateral force is the mechanism (vs AP or LC for ring injuries).
- "Must rule out extension to SI joint or acetabulum on CT.
- "Hip abductor weakness may occur (Gluteus Med/Min origin from iliac wing).
Iliac Wing Fracture Pitfalls
Ring Involvement
Check the Ring. CT to ensure fracture doesn't extend to SI joint or pubic rami. Ring involvement = Unstable.
Acetabular Extension
Assess Acetabulum. Fracture may extend into acetabulum. CT essential.
Abdominal Injury
Associated Injury. Direct lateral trauma can also cause intra-abdominal injury. FAST/CT Abdomen.
Abductor Weakness
Gluteus Med/Min. Fracture at gluteal origin may cause hip abductor weakness. Monitor and rehab.
At a Glance: Iliac Wing vs Ring Fractures
| Feature | Iliac Wing (Duverney) | Pelvic Ring (LC/AP/VS) |
|---|---|---|
| Stability | STABLE | UNSTABLE (varies) |
| Ring Intact | Yes | No |
| Mechanism | Direct Lateral | AP, LC, VS, CM |
| Treatment | Conservative | Often ORIF / Ex-Fix |
| Hemorrhage Risk | Low | High |
Mnemonic
WINGDuverney Features
W
Wing
Iliac Wing (Ala)
I
Intact
Pelvic Ring Intact
N
Non-Surgical
Usually Conservative
G
Gluteus
Abductor weakness possible
Memory Hook:Duverney = WING fracture.
Mnemonic
CT SAPCheck for Extension
C
CT
CT Scan essential
T
Through
To look through pelvis
S
SI Joint
Extension to SI joint?
A
Acetabulum
Extension to Acetabulum?
P
Pubis
Associated pubic rami fracture?
Memory Hook:CT to check ring integrity.
Mnemonic
NWB-PAConservative Protocol
N
Non-Weight-Bearing
Initially NWB or TTWB
W
Week 2-4
Progress weight-bearing
B
By Week 6
FWB as tolerated
P
Physio
Hip abductor rehab
A
Analgesia
Pain management
Memory Hook:Conservative treatment protocol.
Overview and Epidemiology
Definition: An iliac wing fracture (Duverney fracture) is an isolated fracture of the iliac ala (wing) that does NOT disrupt the pelvic ring. The fracture is contained within the iliac bone, not extending to the SI joint, acetabulum, or contralateral side.
Historical Note: Named after Joseph Guichard Duverney (1648-1730), a French anatomist.
Epidemiology:
- Mechanism: Direct lateral trauma (Side-impact MVA, Fall onto side, Crush injury).
- Demographics: All ages. Often part of polytrauma.
- Frequency: Less common than pelvic ring injuries.
Anatomy and Pathophysiology
Anatomy:
- Iliac Wing (Ala): Broad, fan-shaped bone. Provides attachment for:
- Gluteus Medius/Minimus: Hip abductors.
- Iliacus: Hip flexor.
- Abdominal Wall Muscles: External/Internal Oblique, Transversus Abdominis.
Pelvic Ring: The pelvic ring consists of:
- Sacrum.
- Two Innominate Bones (Ilium, Ischium, Pubis).
- Joints: SI joints, Pubic Symphysis.
Why Stable:
- The fracture is confined to the iliac wing.
- The ring (SI joints, symphysis) is INTACT.
- Weight-bearing is through the sacrum and unfractured columns.
Muscle Attachments:
- Gluteus Medius/Minimus Origin: Outer iliac wing. Fracture can cause dysfunction.
Classification
Simple Classification
- Isolated Duverney: Fracture confined to iliac wing. Ring intact.
- With Ring Extension: Fracture extends to SI joint, pubic rami, or acetabulum. Not purely Duverney.
CT is essential to confirm the fracture is isolated.
Clinical Assessment
History:
- Mechanism: Direct lateral trauma (Side-impact, Fall, Crush).
- Pain Location: Lateral pelvis, Hip.
Physical Examination:
- Inspection: Bruising over lateral pelvis/flank.
- Palpation: Tenderness over iliac crest.
- Compression/Distraction: May elicit pain (but ring is stable).
- Hip ROM: Painful hip abduction.
- Neurovascular: Check sciatic, femoral, lateral cutaneous nerve.
- Associated Injuries: Abdominal exam (risk of intra-abdominal injury from lateral trauma).
Investigations
Imaging:
- X-ray (AP Pelvis): May show wing fracture. Can miss subtle injuries.
- CT Pelvis: Essential. Confirms fracture pattern. Rules out ring/acetabular extension.
- CT Abdomen: If concern for intra-abdominal injury.
Key Findings (Duverney):
- Fracture line through iliac wing.
- SI joints intact.
- Pubic rami/symphysis intact.
- No acetabular involvement.
Imaging Gallery
Click to expand
Click to expand
Management Algorithm
📊 Management Algorithm
Click to expand
Conservative (Standard for Isolated Duverney)
- Initial: Bed rest 1-2 days if needed for pain.
- Weight-Bearing: Protected/TTWB initially. Progress as tolerated.
- Analgesia: Multimodal (NSAIDs, Paracetamol, Opioids PRN).
- DVT Prophylaxis: Mechanical + Chemical.
- Physiotherapy: Hip ROM. Abductor strengthening (when pain allows).
- Follow-up: X-ray at 4-6 weeks. Clinical assessment.
Most heal well with conservative care.
Surgical Technique
Iliac Wing ORIF (Rare)
Indications:
- Large displaced fragment affecting hip abductor function
- Associated injuries requiring surgical approach
- Significantly comminuted requiring stabilization
Approach:
- Lateral window of Ilioinguinal approach
- Alternatively, direct lateral approach
- Preserve gluteal muscle origins where possible
Fixation:
- Reduce fracture fragments
- Apply reconstruction plate along iliac crest
- 3.5mm cortical or locking screws
- Layered closure with drain
Most isolated Duverney fractures heal without surgery.
Complications
Complications
| Complication | Risk Factor | Management |
|---|---|---|
| Hip Abductor Weakness | Gluteal origin injury | Physiotherapy |
| Malunion | Large displacement | Rarely symptomatic |
| DVT/PE | Immobility | Prophylaxis |
| Lateral Cutaneous Nerve Injury | Direct trauma | Usually resolves |
| Intra-abdominal Injury | Associated | Trauma workup |
Postoperative Care
Conservative Care:
- Progress weight-bearing as tolerated.
- Physiotherapy: Focus on hip abductors.
- DVT prophylaxis until mobile.
Post-Surgery (if performed):
- Weight-bearing per protocol (usually TTWB 6-8 weeks).
- Wound care.
- DVT prophylaxis.
Outcomes
- Isolated Duverney: Excellent outcomes with conservative care.
- With Ring Involvement: Outcomes depend on overall ring stability.
- Hip Abductor Recovery: Usually good with rehab.
Evidence Base
Duverney Fracture
Key Findings:
- Described Duverney as an isolated, stable fracture.
- Ring is not disrupted.
- Conservative management standard.
Clinical Implication: Duverney is stable - treat conservatively.
Limitation: Expert opinion / Textbook
Pelvic Fracture Classification
Key Findings:
- Developed Young-Burgess classification.
- Described mechanism-based approach to pelvic ring injuries.
- Isolated wing fractures are not ring injuries.
Clinical Implication: Differentiate ring vs isolated wing injuries.
Limitation: Descriptive
Conservative Outcomes
Key Findings:
- Reviewed outcomes of stable pelvic fractures.
- Good outcomes with conservative management.
- Focus on mobilization and DVT prophylaxis.
Clinical Implication: Conservative care is effective for stable fractures.
Limitation: Retrospective
Hip Abductor Injury
Key Findings:
- Noted risk of hip abductor weakness with iliac wing fractures.
- Rehabilitation is key.
- Most recover well.
Clinical Implication: Warn patients about possible hip weakness. Physio is important.
Limitation: Case series
CT for Pelvic Fractures
Key Findings:
- CT is standard for evaluating pelvic fractures.
- Defines ring involvement.
- Guides management.
Clinical Implication: CT is essential to confirm isolated Duverney.
Limitation: Guideline
Viva Scenarios
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
VIVA SCENARIOStandard
The Side-Impact MVA
EXAMINER
"What is your diagnosis and management?"
EXCEPTIONAL ANSWER
**Likely Duverney Fracture (Isolated Iliac Wing).**
1. **Confirm Diagnosis**:
- X-ray suggests isolated wing fracture. Ring may be intact.
- BUT: Must get CT Pelvis to confirm ring is intact (check SI joints, rami, acetabulum).
2. **Trauma Workup**:
- ATLS. Check for associated injuries (abdominal - FAST/CT).
3. **If Truly Isolated Duverney**:
- *Conservative*: Protected weight-bearing. Analgesia. DVT prophylaxis.
- *Physio*: Hip abductor focus.
4. **If Ring Involvement Found on CT**:
- Re-classify as pelvic ring injury. Manage accordingly.
5. **Follow-up**: Clinical + X-ray at 4-6 weeks.
KEY POINTS TO SCORE
CT to confirm ring intact
Duverney = Stable
Conservative management
Risk: Hip abductor weakness
COMMON TRAPS
✗Missing ring extension
✗Missing abdominal injury
LIKELY FOLLOW-UPS
"What if CT shows SI widening?"
"What muscles attach to iliac wing?"
VIVA SCENARIOStandard
The Stable vs Unstable Discussion
EXAMINER
"Explain the stability of Duverney fracture."
EXCEPTIONAL ANSWER
**The Pelvic Ring is Intact.**
1. **Pelvic Ring**: Formed by Sacrum + 2 Innominate Bones + SI Joints + Symphysis.
2. **Duverney Fracture**:
- Fracture is confined to the iliac wing (ala).
- Does NOT extend to SI joint.
- Does NOT extend to pubic rami or symphysis.
3. **Stability**:
- The ring is a closed loop of bones and ligaments.
- Weight is transmitted through the intact ring (Sacrum to Ilium to Acetabulum).
- The iliac wing is essentially a 'bystander' to this weight-bearing axis.
4. **Conclusion**: Because the ring is intact, the pelvis remains stable under load. No surgical stabilization is needed.
**Contrast with Ring Injuries**: If SI or rami are involved, the ring is disrupted and is UNSTABLE.
KEY POINTS TO SCORE
Ring = Sacrum + Innominates + Joints
Duverney = Wing only
Ring intact = Stable
Weight-bearing unaffected
COMMON TRAPS
✗Not understanding the ring concept
✗Assuming all pelvic fractures are unstable
LIKELY FOLLOW-UPS
"What makes an LC-1 different?"
"What is the surgical indication for ring injuries?"
VIVA SCENARIOStandard
The Hip Abductor
EXAMINER
"Explain the cause and management."
EXCEPTIONAL ANSWER
**Gluteus Medius/Minimus Origin Injury.**
1. **Anatomy**:
- Gluteus Medius and Minimus originate from the outer surface of the iliac wing.
- Fracture disrupts this origin.
2. **Mechanism of Weakness**:
- Direct contusion/hematoma at muscle origin.
- Scarring or tethering of muscle.
- Disuse atrophy during recovery.
3. **Management**:
- *Physiotherapy*: Intensive hip abductor strengthening (Gluteus Med exercises).
- *Gait Training*: Correct Trendelenburg gait.
- *Time*: Most recover fully by 6-12 months.
4. **If Persists**:
- Consider MRI to assess muscle/tendon integrity.
- Rarely, surgical repair if frank avulsion.
KEY POINTS TO SCORE
Gluteus Med/Min origin on iliac wing
Fracture injures origin
Physiotherapy is key
Most recover
COMMON TRAPS
✗Not recognizing the cause
✗Not prescribing appropriate rehab
LIKELY FOLLOW-UPS
"What is Trendelenburg gait?"
"What nerve innervates Gluteus Medius?"
MCQ Practice Points
Stability
Q: Why is a Duverney fracture stable? A: The pelvic ring is intact. The fracture is confined to the iliac wing and does not disrupt the SI joint, symphysis, or rami.
Mechanism
Q: What is the typical mechanism for Duverney fracture? A: Direct lateral trauma (e.g., side-impact MVA, fall onto side, crush injury).
Treatment
Q: What is the treatment for isolated Duverney fracture? A: Conservative - Protected weight-bearing, Analgesia, DVT prophylaxis, Physiotherapy.
Imaging
Q: What imaging is essential for iliac wing fractures? A: CT Pelvis - to confirm the fracture is isolated and does not extend to the SI joint, rami, or acetabulum.
Complication
Q: What muscle weakness can occur with iliac wing fractures? A: Hip abductor weakness (Gluteus Medius/Minimus) due to injury at their origin on the iliac wing.
Australian Context
- Trauma System: Managed at trauma centers. Part of multi-system trauma workup.
- CT Access: CT is standard for pelvic fractures in Australia.
- Physiotherapy: Early involvement for hip abductor rehab.
High-Yield Exam Summary
Definition
- •Duverney = Iliac Wing fracture
- •Ring INTACT (key criterion)
- •STABLE fracture pattern
- •AO Type A (Stable Pelvic Ring)
Mechanism
- •Direct lateral trauma
- •Side-impact MVA
- •Fall onto side
- •Crush/compression injury
Treatment
- •Conservative standard
- •Protected WB
- •DVT prophylaxis
- •Physio (Abductors)
Check
- •CT for ring integrity
- •SI joint extension?
- •Acetabular extension?
- •Intra-abdominal injury?