Pelvic Ring Injuries

Young-Burgess is a mechanism classification. Its value is that it predicts direction of force, likely ligament failure, bleeding risk and initial fixation direction.

Tile is a stability classification. It is especially useful when explaining why an anterior-only construct may be inadequate.

Fragility fractures of the pelvis are low-energy injuries in osteoporotic bone. The treatment goal is not only union; it is pain control, restoration of mobility and prevention of loss of independence.

A non-responder remains shocked despite binder, blood products and correction of reversible trauma physiology.

Management direction

1. Confirm binder over the greater trochanters.
2. Continue balanced transfusion, warming, calcium replacement and coagulopathy correction.
3. Exclude immediately treatable thoracic, abdominal and extremity bleeding.
4. If pelvic venous or cancellous bleeding is likely, proceed to urgent preperitoneal packing with mechanical stability.
5. If arterial bleeding is suspected, persistent or demonstrated by CTA, use angioembolisation when physiology and access permit.
6. Do not let CT delay haemorrhage control in a crashing patient.

A transient responder improves with binder and blood products but deteriorates again.

Management direction

1. Treat as active bleeding until proven otherwise.
2. CT with arterial phase is useful only if the patient can safely tolerate the scanner.
3. A blush favours angioembolisation, but venous bleeding and mechanical instability still need stability and packing.
4. Early senior decision-making is required because local resources decide sequence.

A responder stabilises after binder and resuscitation.

Management direction

1. Obtain CT pelvis with appropriate vascular and urological imaging when indicated.
2. Define the posterior ring, sacral fracture, SI joint, acetabulum and soft tissue envelope.
3. Document neurology and urology before definitive fixation.
4. Plan fixation by mechanical instability rather than AP pelvis appearance alone.

An open pelvic fracture adds contamination and soft tissue failure to haemorrhage and instability.

Management direction

1. Give broad antibiotics and tetanus prophylaxis early.
2. Control haemorrhage with binder, packing, external stability or angio as required.
3. Inspect perineum, rectum and vagina; involve colorectal, urology and gynaecology when relevant.
4. Debride devitalised tissue and control contamination.
5. Use staged fixation if definitive implants would cross contaminated or compromised tissue.

Indication: suspected unstable pelvic ring injury during early resuscitation.

Technique

1. Place the binder centred over the greater trochanters.
2. Do not place it over the abdomen or iliac crests.
3. Internally rotate and tape the legs only if it helps reduction and does not compromise other injuries.
4. Reassess skin, abdomen access, distal perfusion and imaging interpretation.
5. Transition to fixation or another haemorrhage-control strategy as soon as clinically appropriate.

Pitfalls: high binder position, prolonged pressure injury, masking instability on CT, and failure to escalate when shock persists.

Indication: temporary anterior control in APC, vertical shear or combined injuries; damage-control stability; contaminated anterior soft tissue where internal plating is unsafe.

Technique

1. Supine position with access for trauma and abdominal teams.
2. Maintain binder control until pins and bar can provide stability.
3. Choose supra-acetabular pins or iliac crest pins based on anatomy and imaging.
4. For supra-acetabular pins, use fluoroscopy to keep the pin in the safe bony corridor above the acetabulum and away from the sciatic notch.
5. Connect bars, reduce external rotation and lock the frame.
6. Recheck haemodynamics, abdominal access, limb neurology and skin pressure.

Pitfalls: pin malposition, lateral femoral cutaneous nerve irritation, femoral vessel or nerve risk, inadequate posterior control and assuming the frame treats vertical shear alone.

Indication: unstable anterior ring disruption, especially APC-2 or APC-3 patterns after resuscitation.

Technique

1. Supine position, usually through a Pfannenstiel or anterior approach.
2. Protect bladder and corona mortis region.
3. Debride interposed tissue if needed and reduce the symphysis anatomically.
4. Apply a superior symphyseal plate with secure fixation on both sides.
5. Assess posterior stability; APC-3 needs posterior fixation as well.

Pitfalls: treating APC-3 as anterior-only, bladder injury, corona mortis bleeding, plate failure when posterior instability is not controlled, and infection in contaminated wounds.

Indication: SI disruption, unstable sacral fracture, vertical shear, crescent fracture or posterior instability after reduction.

Technique

1. Study CT for sacral dysmorphism, fracture line, foramina, neural corridor and safe screw path.
2. Reduce the posterior ring before fixation. Screws maintain reduction better than they create it.
3. Use inlet, outlet and lateral sacral views or navigation according to local practice.
4. Insert iliosacral or trans-sacral screws only through a confirmed safe corridor.
5. Add anterior fixation when rotational control remains inadequate.
6. Document neurological status after fixation.

Pitfalls: L5 or sacral root injury, screw malposition, accepting poor reduction, relying on one screw for vertical shear when stronger fixation is required, and ignoring dysmorphic sacrum.

Indication: haemodynamically unstable pelvic fracture with suspected venous or cancellous pelvic bleeding, especially when the patient cannot safely wait for angio.

Technique

1. Coordinate trauma surgery, orthopaedics, anaesthesia, blood bank and critical care.
2. Maintain binder or external stability.
3. Use a lower midline approach to the preperitoneal space.
4. Pack both sides deep in the true pelvis, including presacral and pelvic brim regions.
5. Avoid opening the peritoneum unless abdominal injury requires it.
6. Plan re-look, pack removal and definitive fixation once physiology improves.

Pitfalls: packing without mechanical stability, missing intra-abdominal bleeding, delayed arterial control, bladder injury and pelvic sepsis.