Pelvic Fractures 🦴🚨 are high-risk injuries often associated with major trauma, haemorrhage, and multi-organ injury. 👉 Mortality ≈10% in closed fractures, up to 50% in open fractures. Always consider associated injuries and hidden blood loss → involve the major trauma centre early.

📖 About

Pelvis = bony ring formed by sacrum, SI joints, innominate bones, and pubic symphysis.
Fractures usually occur in ≥2 places due to ring structure.
Mechanism: high-energy trauma (RTA, fall from height, crush). Low-energy fragility fractures in elderly/osteoporotic patients.

⚙️ Aetiology

High force → RTA, falls, crush injuries.
Low force → osteoporotic or pathological fractures.
Structures at risk: bladder, urethra, vessels, rectum, uterus/vagina.

🩺 Clinical Features

Shock from haemorrhage (may be hidden retroperitoneal).
Severe pelvic/hip pain, bruising, swelling.
Urethral injury signs: blood at meatus, high-riding prostate (on PR).
PV/PR bleeding may indicate vaginal/rectal injury.
Always assess for other trauma (head, chest, abdomen, spine).

🔎 Predictors of Major Haemorrhage

Hct < 30% 📉
HR > 130 bpm ❤️‍🔥
Displaced obturator ring fracture
Wide pubic symphyseal diastasis

📊 Tile Classification

Type A	Stable: avulsion fractures, isolated pubic ramus, iliac wing fractures. Often low-energy, muscle avulsion (e.g. AIIS → rectus femoris, ASIS → sartorius, ischial tuberosity → hamstrings).
Type B	Rotationally unstable but vertically stable. B1 = “open book” (AP compression). B2 = ipsilateral compression (overriding pubic bones). B3 = contralateral compression (pubic rami fracture one side + SI compression other side).
Type C	Rotationally + vertically unstable. Ring disrupted in ≥2 places. Massive blood loss, high mortality. C1 unilateral, C2 bilateral, C3 with acetabular involvement.

🧾 Simple Classification

Stable: single break, minimal bleeding, bones remain aligned.
Unstable: ≥2 breaks, moderate–severe bleeding, deformity.

⚠️ Complications

Massive haemorrhage, intrapelvic compartment syndrome.
Bladder, urethral, vaginal, rectal injuries.
Venous thromboembolism.
Sexual dysfunction, impotence.
Chronic instability, deformity, pain.
Infection/osteomyelitis (esp. open fractures).

🧪 Investigations

Bloods: FBC, U&E, coagulation, group & crossmatch.
Urinalysis (haematuria → bladder/urethral injury).
X-ray: AP pelvis (trauma screen).
CT: pelvic inlet/outlet, evaluate associated injuries.
Retrograde urethrogram if urethral injury suspected.
Angiography: for ongoing bleeding (>0.5 units/hr) → embolisation.

💊 Management

Initial: ATLS protocol, balanced resuscitation, analgesia.
Pelvic binder: apply if haemodynamic instability suspected → reduces pelvic volume, promotes clot formation. Keep on until definitive management.
Do not roll in unstable B/C fractures → use straight lift with ≥4 helpers.
Avoid urethral catheter if blood at meatus/high-riding prostate → consider suprapubic catheter.
Open wounds: IV antibiotics, tetanus, urgent debridement. May need colostomy if bowel involved.
Definitive:
- Type A: usually conservative → analgesia, rest, mobilisation with aids. Fixation if acetabulum involved.
- Type B/C: external fixation (pins + frame) or internal fixation (plates/screws). Consider angiography/embolisation if persistent bleeding.

📌 OSCE / Exam Pearls

Pelvic fracture = assume massive blood loss until proven otherwise.
Blood at urethral meatus 🚨 → do NOT catheterise → retrograde urethrogram first.
Apply pelvic binder early in shocked trauma patient with pelvic injury suspicion.
Stable vs unstable classification is high-yield in exams.

📚 References

ATLS®: Advanced Trauma Life Support, 10th edition.
BOAST Guidelines: Management of Pelvic Fractures.
Rockwood & Green’s Fractures in Adults, 9th edition.

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Pelvic fractures