Pelvic Fracture Classification and Management : Simplified

Before proceeding to this topic, it would be wise to go through the topics listed below:

  1. Pelvis X-ray : Simplified Approach | Epomedicine
  2. Ligaments of Pelvis | Epomedicine

Tile/AO Classification

Tile classification divides pelvic fractures into three basic types according to stability based on the integrity of the posterior sacroiliac complex. Here is a mnemonic that can be used to remember tile classification.

tile classification
Tile M. Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg 1996; 4 (3): 143-51.). Available via license: CC BY-NC-ND 4.0

Tile A: Anterior arch only (Posterior arch intact)

  1. Avulsion injury (3 spines – ASIS, AIIS or pubic spine)
  2. Anterior arch or Ala of ilium (Iliac wing)
  3. Across (transverse fracture) the Ala of sacrum or coccyx

Tile B: Borderline stable (Posterior arch – incomplete disruption)

  1. Book (Open): External rotation – Pubic diastasis > 2.5 cm +/- SI joint widening
  2. Book (Closed): Internal rotation – Lateral compression injury
  3. Book – Bilateral B injuries

Type C: Completely unstable (Complete disruption of posterior arch)

  1. One side C
  2. One side B, One side C
  3. Both side C

Young Burgess Classification

It is based on injury mechanism.

young burgess classification
Ahn, J. M., & Suh, J. T. (2013). Anatomy, Classification and Radiology of the Pelvic Fracture. Journal of the Korean Fracture Society, 26(3), 221. doi:10.12671/jkfs.2013.26.3.221. Available via license: CC BY-NC 3.0
TypeFracture characteristicsLigaments disruptedTreatmentKey concepts
Anterior-Posterior Compression (APC)
APC1Pubic diastasis <2.5 cmStretched anterior SI, sacrospinous, sacrotuberous ligamentsNonsurgical
Protected WB
Tile A
APC2Pubic diastasis >2.5 cm with widening of anterior SI jointDisrupted anterior SI, sacrospinous, sacrotuberous ligamentsORIF anterior pelvis (symphyseal plate)Tile B
APC3Pubic diastasis with widening of both anterior and posterior SI joint+ Posterior SI ligament disruptionUrgent pelvic sheet or binder to stabilize the pelvis
ORIF of anterior pelvis with posterior fixation (SI screws or plate/screws)
Tile C
Highest rate of blood loss and GU injury
Lateral compression (LC)
LC1Transverse pubic rami fractures
Sacral impaction fracture on side of impact
Proteced WB (Complete, comminuted sacral component)
WBAT (Simple, incomplete sacral fractures)
Tile A
LC2Transverse public rami fractures
Crescent fracture of ilium on side of impact
Variable disruption of posterior ligamentous structuresORIF of iliumTile B
LC3LC1/2 + APC on other side (Windswept pelvis)ORIF anterior and posterior pelvisTile C
Windswept pelvis
Associated with head, chest and abdominal trauma
Most common cause of death is closed head injury
Vertical Shear (VS)
VSVertical displacement of hemipelvis (malgaigne fracture)SI ligaments, sacrotuberous ligament, sacrospinous ligaments, symphyseal ligamentTraction initially

ORIF anterior and posterior pelvis
Tile C
Associated with intrapelvic hemorrhage and neurologic injury
WBAT: Weight bearing as tolerate; NWB: Non-weight bearing; GU: Genito-urinary

WSES (World Society of Emergency Surgery) Classification

It uses Young-Burgess classification and hemodynamic stability to classify and guide pelvic fracture management. Hemodynamic stability is the condition in which the patient achieve a constant or an amelioration of blood pressure after fluids with a blood pressure >90 mmHg and heart rate <100 bpm.

Hemodynamic instability:

  • Admission systolic blood pressure <90 mmHg, or > 90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs OR
  • Admission base deficit (BD) >6 mmol/l OR
  • Shock index (Pulse rate/Systolic BP) > 1 OR
  • Transfusion requirement of at least 4–6 Units of packed red blood cells within the first 24 h
WSES gradeYoung-Burgess classificationHemodynamicMechanicCT-scanFirst-line Treatment
MINORIAPC I – LC IStableStableYesConservative
StableUnstableYesPelvic Binder in the field
± Angioembolization (if blush at CT-scan)
Operative – Anterior External Fixation
IIIVS – CMStableUnstableYesPelvic Binder in the field
± Angioembolization (if blush at CT-scan)
Operative – C-Clamp
SEVEREIVAnyUnstableAnyNoPelvic Binder in the field
Preperitoneal Pelvic Packing
± Mechanical fixation
± REBOA (Resuscitative Endo-aortic balloon)
± Angioembolization

Further reading: Coccolini, F., Stahel, P.F., Montori, G. et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg 12, 5 (2017).

Denis classification for Sacral fractures

Denis typeFracture descriptionNeurologic injuryRemarks
Zone 1Lateral to foramina (Alar)L5 root; 5%Commonest (50%)
Zone 2Through foramina (Transforaminal)L5/S1/S2 root; 30%Stable vs Unstable
Zone 3Medial to foramina (Spinal canal)60%Bowel, bladder & sexual dysfunction
Includes “H” or “U” type fractures
Indications for surgical fixation are: >1 cm displacement, neurologic deficits and failure of non-operative management

Letournel Judet classification for Acetabulum fractures

Simple/Elementary patterns: Posterior wall, Posterior column, Anterior wall, Anterior column and Transverse

Associated patterns: Posterior column/posterior wall, Transverse with posterior wall, T type, Anterior column/posterior hemitransverse, Both column

Indications for surgery:

  1. >2 mm displacement
  2. Posterior wall fracture >/= 20% of wall (20-40% and unstable under stress EUA)
  3. Roof arc angle <45 degrees
  4. Incongruity of hip joint (absence of secondary congruence)
  5. Incarcerated fragments/loose bodies
  6. Marginal impaction
  7. Irreducible fracture-dislocations

Roof arc angle of Matta: It is the estimation of amount of weight bearing dome (WBD) involved. It is the angle measured between a line from dome to geometric center of femoral head and another line from fracture to the geometric center in following 3 views:
a. AP view: Medial roof arc angle
b. Obturator oblique view: Anterior roof arc angle
c. Iliac oblique view: Posterior roof arc angle

Roof arc angle <45 degrees in any view (Matta signifies unstable fracture requiring fixation.
Roof arc angle <45 degrees in AP, <25 degrees in obturator oblique and <70 degrees in iliac oblique view (Varhas signifies unstable fracture requiring fixation.

It is not applicable to isolated posterior wall fracture and both column fractures.

Important points on management of pelvic ring fractures

1. Pelvic binder/sheet: Applied at the level of greater trochanter (GT)

2. Anterior stabilization with external fixator (Ganz): Decreases pelvic volume; Consider partial closed reduction 1st

  • High route: Iliac crest (3-5 cm posterior to ASIS); Place atleast 2 pins on each side
    • Place at junction of lateral 2/3rd and medial 1/3rd of iliac crest
    • Aim: 30-45 degrees from lateral to medial (towards the hip joint)
    • Fluoroscopy: Outlet-oblique view
  • Low route: Supra-acetabular (AIIS); Single pin
    • Fluoroscopy:
      • 30/30 outlet/obturator oblique view (to confirm entry location and direction)
      • Iliac oblique (to confirm location above sciatic notch)
      • Inlet/obturator oblique (to confirm depth)
    • Direction: 30 degrees cephalad (towards SIJ) to avoid greater sciatic notch
    • Provides better stabilization than high route
    • Risk: lateral femoral cutaneous nerve

3. Posterior stabilization with C-clamp:

  • Entry point: Intersection of femoral axis line and a perpendicular line dropped from ASIS to bed

4. Pre-peritoneal pelvic packing:

  • 6-8 cm midline longitudinal incision from pubic symphysis
  • Divide midline fascia, leave peritoneum intact
  • Retract bladder
  • Place 3 lap pads on each side of bladder, into true pelvis below the pelvic brim
  • Close fascia and skin
  • Pack removal 24-48 hours later

5. Traction for vertical shear fractures:

  • Bilateral upper tibial skeletal traction
  • A heavy weight (upto 20 kg) may be required to achieve reduction
  • After 3 weeks, weight is reduced to 10 kg
  • Traction is removed after 6-8 weeks

6. Percutaneous ilio-sacral screws:

  • Safe zone: S1 vertebral body
  • Inlet view: guides antero-posterior screw placement
  • Outlet view: guides superior-inferior screw placement
  • Complication: L5 nerve root injury

7. Surgical approaches:

ApproachIntervalAccessAcetabular fracture indicationsRisks
Ilioinguinal1. Medial window: Medial to external iliac vessels

2. Middle window: Between external iliac vessels and iliopsoas muscle

3. Lateral window: Lateral to iliopsoas muscle
1. Pubic rami, iliac fossa, anterior SIJ

2. Pelvic brim, quadrilateral plate

3. Quadrilateral plate, SIJ, Iliac wing
Both column
Anterior wall
Anterior column
Anterior column-posterior hemi transverse
Some T-type and transverse types
Obturator artery/nerve

Corona mortis

Femoral nerve/vessels

Lateral femoral cutaneous nerve

Spermatic cord, round ligament
Kocher-LangenbeckSplit gluteus maximus; detach short external rotators 1 cm from insertion
Quadratus femoris left intact to protect femoral head blood supply
Outer table of ilium
Sciatic notch
Posterior wall
Posterior wall
Posterior column
Sciatic nerve
Superior gluteal artery
Medial femoral circumflex artery
Heterotopic ossification
IliofemoralExtensile approachPosterior and anterior acetabulum
Inner and outer table of ilium
High anterior column
Both column
Fractures >3 weeks old
Heterotopic ossification
High complication rates
StoppaBehind iliopectineal fascia to enter true pelvis
Can use “lateral” window of ilioinguinal approach
Pubic symphysis
Pelvic brim
Quadrilateral plate
Anterior column
Anterior wall
Both column
Anterior column-posterior hemitransverse
Corona mortis
Obturator nerve

Cause of hemorrhage:

  1. Stable pelvic fractures: ~70% due to associated injuries and 30% due to pelvic fracture
  2. Unstable pelvic fracture: ~70% due to pelvic fractures and 30% due to associated injuries

Superior gluteal artery is the most common artery to be damaged. Internal pudendal artery yields the most symptomatic bleeds.

Further reading: Montmany S, Rebasa P, Luna A, Hidalgo JM, Cánovas G, Navarro S. Source of bleeding in trauma patients with pelvic fracture and haemodynamic instability. Cir Esp. 2015 Aug-Sep;93(7):450-4. English, Spanish. doi: 10.1016/j.ciresp.2015.01.011. Epub 2015 Mar 21. PMID: 25804517.

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