Pelvic Fracture: Specialists and Information

Pelvic fractures are classified as injuries to the pelvic ring or to the hip socket (acetabulum). Depending on how stable the pelvic ring is, the fracture is classified as either stable or unstable. Stable means that the bone holds together relatively well on its own. Unstable means that the bone continues to shift without surgery, leading to malunion and associated injuries.

If the accident victim also has injuries to other parts of the body, this is referred to as polytrauma. For example, 4 out of 10 injured individuals also suffer a traumatic brain injury. One in four accident victims with a pelvic fracture also sustains injuries to the abdominal organs.

If the pelvic bone is not completely broken through, it is an incomplete pelvic fracture. Only in rare cases does it break completely through. In such cases, doctors refer to it as a complete pelvic fracture. A complete pelvic fracture is often life-threatening because there are numerous large blood vessels in the abdomen. These can rupture even with slight pelvic movements, causing the patient to die from internal bleeding.

For this reason, pelvic fractures are also classified as stable or unstable. This classification reflects the fact that the pelvic bone encloses the pelvic organs, and in the case of an unstable fracture, there is a risk that these organs could be injured by displaced bone fragments.

What does the classification into types A, B, and C mean?

Stability is the decisive criterion for classifying pelvic fractures into types A, B, and C.

Stable Pelvic Fracture

In a Type A pelvic fracture, the pelvic ring is not damaged. There is no life-threatening risk to the patient, as these fractures involve only the sacrum and coccyx. They are transverse fractures and often heal on their own. This type of fracture can often be treated without surgery using pain medication and physical rest following an initial period of bed rest.

Unstable Pelvic Fracture

In a Type B pelvic fracture, both the anterior and posterior pelvic rings are fractured. The pelvis remains stable only vertically, but not rotationally (all around). This is the case, for example, with a pubic bone fracture. The two halves of the pubic bone—located at the very bottom of the pelvis—are then spread open like a book. Anyone with this “open book” fracture is no longer able to walk. This type of fracture often requires surgical treatment; initially, the pelvic bones can be stabilized using an external fixator to prevent further displacement and thereby minimize the risk of injury to internal organs

Completely unstable pelvic fracture

In a Type C pelvic fracture, the pelvic bones are unstable both vertically and in all directions.

What is an acetabular fracture?

In an acetabular fracture, also known as an acetabulum fracture, the acetabulum is fractured. The acetabulum is the bony socket into which the upper part of the femur fits. The acetabula are located on the right and left sides of the outer pelvis and form the center of the hip joint.

The anatomy of the hip and its bony components © bilderzwerg / Fotolia

A pelvic fracture occurs as a result of force applied to the pelvic bones, for example, due to an accident or a fall. The manner and severity of the injury to the lower abdomen depend on the direction from which the force is applied and the intensity of those forces.

Forces acting laterally on the pelvis cause the pelvic ring to bend. If the force comes from the front, the iliac wings move backward. Force directed from top to bottom shifts the two halves of the pelvis vertically relative to each other.

Older adults with osteoporosis are at increased risk of sustaining a pelvic fracture. The condition most commonly affects women over the age of 60 and is the result of long-term calcium deficiency. This causes the bone tissue to become brittle. In patients with osteoporosis, even a minor fall can cause a complicated pelvic fracture.

A stable pelvic fracture generally causes less severe symptoms than an unstable fracture. The most common symptoms of a pelvic fracture include:

• severe pain in the pelvic area
• Swelling in the hip region
• limited mobility in one leg
• Bruising at the site of the injury
• differences in leg length
• A feeling of instability in the pelvic area
• Malalignment of the pelvic bones
• Bloody urine due to a bladder injury
• Significantly elevated pulse
• Pale face
• Restlessness
• Confusion

A pelvic fracture is diagnosed by a specialist in trauma surgery and orthopedics. When the injured person is brought to a hospital’s emergency room, the first step is to document the circumstances of the accident.

This is followed by an examination of the injured person for physical injuries:

• The trauma surgeon carefully palpates the pelvic bones to check for palpable misalignments.
• Applying light pressure to the iliac crest helps determine whether the pelvic bones are stable or unstable.
• Palpation of the pubic symphysis—located between the two semicircular pubic bones—and an examination of the rectum help determine whether the patient has abdominal bleeding.
• In addition, the examining specialist checks the range of motion and sensation in both legs. This helps determine whether the patient also has nerve damage.
• Checking the pulse provides information on whether the extremities are receiving adequate blood flow.
• A pelvic X-ray can determine whether the pelvic fracture is stable or unstable. If the examiner suspects that the posterior pelvic ring is also fractured, they will order additional oblique X-rays. This allows, for example, the precise localization of displaced pelvic bone fragments.
• Computed tomography (CT), another imaging technique, is also very helpful in this case: It provides information about the severity of the pelvic fracture. Soft tissue injuries and hematomas can also be clearly identified on the CT scan.
• Blood that has leaked into the abdominal cavity can also be clearly seen on the ultrasound image.

Depending on what other injuries the patient with a pelvic fracture may have, further examinations are performed:

• urethrography to diagnose urethral tears,
• Excretory urography to identify injuries to the urinary tract, 
• angiography to locate the source of bleeding.

Treatment for a pelvic fracture depends on

• the severity of the patient’s injuries and
• their overall physical condition.

A Type A pelvic fracture is treated conservatively:

• several days of bed rest,
• administration of pain medication, and
• physical therapy (exercises).

Type B and Type C pelvic fractures require emergency medical care and surgery. Since the patient is suffering from severe blood loss, they must first be stabilized—that is, the bleeding must be stopped. In addition, large amounts of fluid are administered intravenously to prevent circulatory collapse.

Next, the affected pelvis is stabilized using an anterior external fixator. This is a support system consisting of metal parts that is attached to the bone from the outside through the skin and is designed to immobilize the fracture.

Alternatively, a pelvic clamp can be used. This emergency surgical device consists of rods and plates and is always used when there is a risk that the patient could bleed to death. Pelvic clamps are typically used only in specialized hospitals.

Acetabular fractures are always treated surgically to prevent premature wear of the joint. Since the procedure is very difficult, it is preferably performed at a specialized hospital. During the procedure, the trauma surgeon stabilizes the fractured joint using metal plates and screws or an external fixator.

How quickly a pelvic fracture heals depends on various factors, including the type of fracture. Stable pelvic fractures, such as a coccyx fracture, typically heal quickly and without complications within 4 to 8 weeks, leaving no long-term damage.

If treatment of an unstable fracture (Types B and C) is successful and no complications arise, the healing process takes several months. Most patients are then able to resume a normal life. However, in some cases, permanent damage may occur, such as incontinence (involuntary leakage of urine or stool) and male impotence (impaired sexual function).

The duration of recovery naturally also depends on individual factors such as the patient’s age and overall health.