History

Basic mechanism of significant blunt trauma should prompt consideration of a pelvic fracture. Helpful historical features include inability to ambulate at the scene, bowel or bladder incontinence, and objective numbness or weakness of lower extremities.

Pelvic apophyseal avulsion fractures generally occur in young athletes, and are commonly associated with sports involving rapid acceleration and deceleration, such as soccer, football, gymnastics, basketball, and baseball.^[21]

Physical

In patients who are awake and alert, the presence of pelvic pain or tenderness to palpation has high sensitivity and specificity for the diagnosis of pelvic fracture: 74% and 97%, respectively. However, in patients who are not awake and alert to express pain and tenderness, physical exam is less useful. Palpation of a pelvic deformity has a sensitivity of 30% for pelvic fractures and 55% for unstable pelvic fractures. Palpating an unstable pelvic ring has a sensitivity of only 8%, but specificity of 99%. Thus, physical exam should not be used to rule out a pelvic fracture in unconscious patients, but it can nearly definitively rule it in.^[10] The clinical exam is useful in patients who are awake and alert, even with elevated ethanol levels, as long as their GCS is 14 or higher.^[11] Finally, extensive manipulation of a fractured pelvis can increase the patient's discomfort and potentially increase bleeding.

Other signs that may suggest a pelvic fracture include hematuria; a hematoma over the ipsilateral flank, inguinal ligament, proximal thigh, or in the perineum; neurovascular deficits in the lower extremities; or rectal bleeding. Digital rectal examination has a very low sensitivity for diagnosing pelvic fractures. In fact, in one study assessing the utility of routine digital rectal examinations to diagnose injury in 1401 trauma patients, the rectal examination missed 100% of the 67 pelvic fractures.^[37]

Vaginal bleeding or palpable fracture line on careful bimanual examination suggests pelvic fracture in females.

Instability on hip adduction and pain on hip motion suggests an acetabular fracture, with or without an associated hip fracture.

The overall incidence of genitourinary injury associated with pelvic fracture is around 4.6% and is overall more common in men. Men with pelvic fractures are 10 times more likely to sustain urethral injuries.^[25]Signs of urethral injury in males may include a scrotal hematoma and blood at the urethral meatus. Assessment for a high-riding or boggy prostate on digital rectal examination has been shown to be unreliable.^[38]

Pelvic apophyseal avulsion fractures generally present with acute onset of localized pain that is exacerbated by passive or active stretching of the involved muscle. Patients will attempt to assume a position that incurs the least tension on the affected muscle.^[21]

Causes

Adults with significant pelvic fracture:

Motor vehicle crash (50-60%)
Motorcycle crash (10-20%)
Pedestrian versus car (10-20%)
Falls (8-10%)
Crush (3-6%)

Children:

Pedestrian versus car (60-80%)
Motor vehicle crash (20-30%)

Complications

Complications of pelvic fracture include the following:

The incidence of deep venous thrombosis is increased.
Continued bleeding from fracture or injury to pelvic vasculature may occur.
GU problems from bladder, urethral, prostate, or vaginal injuries: The incidence of urethral injuries varies by the type of pelvic fracture. Sexual dysfunction may develop.
Infections from disruption of bowel or urinary system may develop.
Chronic pelvic pain, more so if the sacroiliac joints are involved, may occur.^[39]

Differential Diagnoses

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Media Gallery

Anterior-posterior (AP) compression pelvic fracture.
Vertical shear (VS) fracture pattern.
Anteroposterior (AP) compression injury as seen on an AP radiograph of the pelvis. Characteristic features of an AP compression injury include symphyseal and sacroiliac joint diastasis. In this patient, the pubic symphysis and right sacroiliac joint are widened.
Windswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The patient sustained a left lateral compression injury with internal rotation of the left hemipelvis and a characteristic sacral buckle fracture. Note the concomitant left sacroiliac joint diastasis. The lateral force vector continued across the pelvis to produce external rotation of the right hemipelvis and diastasis of the right sacroiliac joint. The combination of injuries resulted in a windswept pelvis.
Pelvic apophyseal avulsion fracture of the ischial tuberosity due to contraction of the hamstring muscles. Courtesy of Wikipedia (https://de.wikipedia.org/wiki/Apophyse).

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Tile Classification System ^[17]

Type A	Sacroiliac complex is intact. Stable fractures of the pelvic ring that can be managed nonoperatively.
Type B	Rotationally unstable, vertically stable. Caused by external or internal rotation forces causing partial disruption of the posterior sacroiliac complex.
Type C	Rotationally and vertically unstable. Complete disruption of the posterior sacroiliac complex.

Young and Burgess Classification System ^[18]

Lateral Compression
Grade I	Sacral compression fracture on side of impact.
Grade II	Sacral compression fracture with associated posterior iliac fracture on side of impact.
Grade III	Type I or II plus associated contralateral sacroiliac joint injury.
Anterior-Posterior Compression
Grade I	Mild widening of the pubic symphysis with intact posterior pelvic ring ligaments and sacroiliac ligaments.
Grade II	Diastasis of pubic symphysis with associated anterior sacroiliac joint widening with intact posterior sacroiliac joint ligaments.
Grade III	Diastasis of pubic symphysis with complete disruption of sacroiliac joint and posterior pelvic ring ligaments.
Vertical Shear	Displacement of the hemipelvis superiorly or posteriorly involving diastasis of the pubic symphysis, rami fractures, displacement of the sacroiliac joint, and/or fractures of the iliac wing or sacrum.
Combined Mechanism	Because of the high-energy nature of these injuries, the mechanisms are often combined and difficult to determine and categorize.

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Author

Nicholas Moore, MD Resident Physician, Department of Emergency Medicine, University of Kentucky-Chandler Medical Center

Nicholas Moore, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, MAAEM, FAAEM, FACEP Tenured Professor of Emergency Medicine, University of Kentucky College of Medicine; Vice Chair of Education, Department of Emergency Medicine, University of Kentucky Chandler Medical Center

Christopher I Doty, MD, MAAEM, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Residency Directors in Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

C Crawford Mechem, MD, MS, FACEP Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Emergency Medical Services Medical Director, Philadelphia Fire Department

C Crawford Mechem, MD, MS, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.