High-yield overview
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).
Clinical 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 |
| W | Wing Iliac Wing (Ala) | N | Non-Surgical Usually Conservative |
| I | Intact Pelvic Ring Intact | G | Gluteus Abductor weakness possible |
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? |
| C | CT CT Scan essential | A | Acetabulum Extension to Acetabulum? |
| T | Through To look through pelvis | P | Pubis Associated pubic rami fracture? |
| S | SI Joint Extension to SI joint? |
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 |
| N | Non-Weight-Bearing Initially NWB or TTWB | P | Physio Hip abductor rehab |
| W | Week 2-4 Progress weight-bearing | A | Analgesia Pain management |
| B | By Week 6 FWB as tolerated |
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.
Differential Diagnosis: What Mimics an Isolated Iliac Wing Fracture
| Diagnosis | Distinguishing Feature | Key Test | Stability |
|---|---|---|---|
| Crescent fracture (LC-II) | Posterior wing fracture extends INTO the SI joint | CT - SI joint disruption | UNSTABLE |
| LC-I sacral fracture | Anterior rami + sacral ala impaction | CT - sacral fracture line | Usually stable |
| Acetabular fracture (anterior column) | Fracture line reaches the joint surface | CT - articular involvement | Joint-threatening |
| Iliac apophyseal avulsion (ASIS/AIIS) | Adolescent, sprinting/kicking, growth plate | Plain film + age | Stable |
| Iliac crest contusion / muscle strain | No fracture line on imaging | CT/MRI negative for fracture | Stable |
| True isolated Duverney | Confined to ala; ring, SI joint, acetabulum intact | CT confirms isolation | STABLE |
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
Management Algorithm
Algorithm
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.
Controversies and Areas of Uncertainty
Is the wing fracture truly isolated?
The central controversy is diagnostic, not therapeutic. A posterior wing fracture that reaches the SI joint is a crescent (LC-II) injury (Day classification), which is unstable and surgical. The label "Duverney" should only be applied after CT excludes SI, ramus, and acetabular extension.
Weight-bearing protocol
No high-level evidence dictates a single protocol. Practice ranges from immediate weight-bearing as tolerated to a short non-weight-bearing period. Cohort data (Gaski, Soni) show good outcomes regardless of weight-bearing status for stable injuries, so pain and comfort can guide progression.
Surgery for the displaced fragment
Whether a large, displaced wing fragment with hip-abductor compromise benefits from fixation is decided case-by-case on expert opinion alone; there are no comparative trials. Most are still managed conservatively.
Borderline lateral-compression injuries
The genuine operative-versus-non-operative debate (TULIP feasibility RCT) concerns LC1 injuries with a complete sacral fracture - the unstable end of the spectrum - not the isolated wing fracture.
Evidence Base
Crescent Fracture-Dislocation: Day Classification
Key Findings:
- Defined the crescent fracture-dislocation as a lateral-compression injury combining SI joint disruption with a posterior iliac wing fracture - the key unstable mimic of a benign wing fracture.
- Three types by crescent fragment size: Type I (large fragment, under one-third of SI joint dislocated), Type II (intermediate, one- to two-thirds), Type III (small fragment, most of joint dislocated).
- 16 patients managed by this scheme achieved good functional results at approximately 2 years; classification guides surgical approach and reduction.
Clinical Implication: A posterior iliac wing fracture extending into the SI joint is a crescent injury, NOT a stable Duverney fracture - it requires reduction and fixation.
Limitation: Small single-centre case series (n=16); SF-36/MFA confounded by associated high-energy injuries.
Nonoperative LC1 with Complete Sacral Fracture
Key Findings:
- 104 intermediate-severity LC1 injuries (complete sacral fracture, under 1 cm displacement); 50 assessed at mean 33 months.
- Mean Majeed score 85.5 (33 excellent, 9 good, 5 fair, 3 poor); no fracture displaced over 1 cm on follow-up radiographs.
- Patients with concurrent lower-limb injury had significantly lower Majeed scores (p = 0.01); weight-bearing status did not affect outcome.
Clinical Implication: Minimally displaced stable lateral-compression pelvic injuries reliably do well non-operatively, supporting conservative care of the truly isolated iliac wing fracture.
Limitation: Retrospective, single Level I centre, 48% follow-up rate.
LC1 Non-operative Functional Outcome (Majeed)
Key Findings:
- 46 LC1 injuries with incomplete sacral fracture managed non-operatively (non-weight-bearing 3 weeks, then weight-bearing as tolerated).
- Mean Majeed score 82.6 (27 excellent, 19 good); no mortality in any subgroup.
- Best functional outcome reached within 12 months and did not change thereafter.
Clinical Implication: A short period of protected weight-bearing followed by progression to tolerance gives reproducibly good results for stable low-energy lateral-compression pelvic injuries.
Limitation: Retrospective record review; no operative comparator arm.
Mechanism Predicts Pelvic Trauma Severity (Young-Burgess)
Key Findings:
- In complete pelvic ring disruptions, APC-mechanism injuries required far more transfusion than vertical-shear (15/18 needed 10 or more units vs 11/14 of VS needing under 10).
- APC group: 39% mortality and higher multi-organ failure vs 0% mortality in VS group.
- Confirms the Young-Burgess principle that injury mechanism drives haemorrhage risk and outcome.
Clinical Implication: Mechanism-based (Young-Burgess) thinking separates the low-haemorrhage isolated wing fracture from high-risk ring disruptions - the central exam discriminator.
Limitation: Small retrospective cohort (n=38) limited to complete ring disruptions.
Haemorrhage in Major Pelvic Disruption
Key Findings:
- Of 4712 pelvic fractures, only 7.3% required angiography; overall mortality among those was 18%.
- Nearly 80% of deaths were attributable to early uncontrolled haemorrhage, emphasising the danger of unstable ring injuries.
- Supports early haemostasis (packing, REBOA, embolisation) for the bleeding pelvis.
Clinical Implication: Frames why isolated iliac wing fractures are reassuring - they lack the venous plexus and ring-disruption bleeding that drives pelvic mortality.
Limitation: Single-centre retrospective registry review.
Osteoporotic / Fragility Pelvic Fractures (FFP)
Key Findings:
- Estimated incidence of osteoporotic pelvic fracture over age 60 of 224 per 100,000 per year and rising.
- Rommens FFP classification: isolated anterior (FFP I) and non-displaced posterior (FFP II) injuries are usually stable and treated conservatively; FFP III/IV are unstable and usually need surgery.
- One-year mortality 9.5-27%, driven by loss of mobility and independence.
Clinical Implication: In older patients an iliac wing/anterior fragility fracture is usually stable, but the goal is early mobilisation with adequate analgesia to avoid the high mortality of immobility.
Limitation: Narrative review; FFP scheme based on level IV evidence.
Operative vs Non-operative LC1 (TULIP Feasibility RCT)
Key Findings:
- Feasibility RCT randomising LC1 injuries with complete sacral fracture to operative vs non-operative care to inform a definitive trial.
- Acknowledges equipoise: some complete sacral fractures may displace over time, and surgery may allow faster pain-free mobilisation.
- Highlights that the operative threshold sits at the unstable end of the lateral-compression spectrum, not the isolated wing fracture.
Clinical Implication: The genuine surgical debate is reserved for borderline-unstable lateral-compression injuries; the truly isolated Duverney fracture is not part of this controversy.
Limitation: Feasibility study (protocol/design); not powered for clinical outcomes.
Viva Scenarios
Clinical Decision Scenarios
Use these scenarios to practise clinical reasoning and management decisions
CLINICAL SCENARIOStandard
The Side-Impact MVA
CLINICAL PROMPT
"What is your diagnosis and management?"
PRACTICAL APPROACH
**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 CLINICAL POINTS
CT to confirm ring intact
Duverney = Stable
Conservative management
Risk: Hip abductor weakness
COMMON PITFALLS
Missing ring extension
Missing abdominal injury
FURTHER QUESTIONS
"What if CT shows SI widening?"
"What muscles attach to iliac wing?"
CLINICAL SCENARIOStandard
The Stable vs Unstable Discussion
CLINICAL PROMPT
"Explain the stability of Duverney fracture."
PRACTICAL APPROACH
**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 CLINICAL POINTS
Ring = Sacrum + Innominates + Joints
Duverney = Wing only
Ring intact = Stable
Weight-bearing unaffected
COMMON PITFALLS
Not understanding the ring concept
Assuming all pelvic fractures are unstable
FURTHER QUESTIONS
"What makes an LC-1 different?"
"What is the surgical indication for ring injuries?"
CLINICAL SCENARIOStandard
The Hip Abductor
CLINICAL PROMPT
"Explain the cause and management."
PRACTICAL APPROACH
**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 CLINICAL POINTS
Gluteus Med/Min origin on iliac wing
Fracture injures origin
Physiotherapy is key
Most recover
COMMON PITFALLS
Not recognizing the cause
Not prescribing appropriate rehab
FURTHER QUESTIONS
"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.
Guidelines, Registries & Global Practice
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:
How Major Bodies Frame Stable vs Unstable Pelvic Injury
| Body | Imaging | Stable wing/anterior injury | Surgical trigger |
|---|---|---|---|
| AO Foundation / OTA | AP pelvis + CT | Type A (stable, ring intact) - conservative | Type B/C ring instability |
| BOA / BOAST (UK) | CT in major trauma pathway | Mobilise, analgesia, VTE prophylaxis | Haemodynamic instability or ring displacement |
| AAOS / EAST (US) | CT defines ring involvement | Non-operative for isolated stable patterns | Open book / vertical shear / bleeding pelvis |
| Rommens FFP (fragility) | CT +/- MRI in elderly | FFP I-II usually conservative | FFP III-IV instability |
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.
Clinical 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?