Minimally displaced lateral compression (LC) type pelvic ring injuries are some of the most common pelvic fractures, and nonoperative management remains the standard of care around the world [1, 2]. While many patients will ultimately do well with nonoperative management, there exists a subset of patients who will not [3,4,5]. These patients tend to have pain out of proportion to the displacement seen on pelvis radiographs that can severely limit their ability to mobilize [6, 7].

In 1980, Tile and Pennal [8] wrote, regarding lateral compression injuries, that “the potential instability of an apparently innocent fracture is often unrecognized” and later would describe using “direct manipulation of the pelvis in rotation” to determine if rotational instability was present [9]. Today, direct manipulation, or examination under anesthesia (EUA), is still commonly used to evaluate LC injuries for rotational dynamic instability in an attempt to identify patients whose early recovery will be marred by pain and difficulty mobilizing [2, 10]. This practice is not without its downsides, however. As a surgeon, you have to counsel the patient and operating room (OR) staff that if the EUA were to be positive, surgery would be performed, but if the EUA were to be negative, the patient would be woken up immediately. From a busy trauma practice management standpoint, this strategy can be burdensome and likely one of the reasons that surgeons have resisted adopting it. For these reasons, our group began performing lateral stress radiographs (LSR) to assess for dynamic instability [11]. These AP pelvis radiographs taken in the lateral decubitus position recreate and normalize the deforming forces of the injury mechanism without sedation or OR utilization. While the LSR can be painful, especially to patients with unstable injuries, we would argue that Judet radiographs and skeletal traction are also painful, but are accepted as necessary components of caring for patients with pelvic trauma.

To date, the literature has not demonstrated a clear benefit of surgery in patients with minimally displaced LC injuries, which we believe can be contributed to several limitations [3,4,5]. First, a majority of studies on the subject include multiply injured patients, which confounds outcomes. Second, patients with these injuries are typically comfortable at rest and only have severe pain with attempts at mobilizing. Consequently, pain scores and opioid requirements may not adequately convey a patient’s disability. Third, while mid- to long-term outcomes may be no different between treatment groups, the current literature has failed to capture early outcomes such as hospital length of stay, discharge location, time spent in facilities, length of opioid use, and time spent out-of-work or using assistive devices. Fourth and most importantly, the current literature has not isolated the outcomes of patients with dynamic instability. Considering that a majority of patients are stress-negative and will do predictably well, the average reported outcomes will likely obscure the signal of patients with dynamic instability [6].

An unanticipated effect of utilizing the LSR, versus EUA, is that patients can choose nonoperative management after identification of dynamic instability. Subsequently, we have had the opportunity to observe the outcomes of these patients. For example, a 65-year-old woman recently presented to our hospital with a minimally displaced LC injury that displaced 15 mm on LSR. The patient wished to avoid surgery and was able to get out of bed with assistance and stand using a walker. PT cleared the patient that afternoon, she discharged home, and subsequently no-showed her follow-up appointment. This case could be used as an anecdote for the success of nonoperative management. However, we called the patient 2 weeks after her injury and learned that she had been readmitted to another hospital for difficulty mobilizing secondary to pain shortly after her discharge from our hospital. After spending multiple additional days in that hospital, she was discharged to a rehabilitation facility, where she was currently residing. Four weeks post-injury, she was still in the rehabilitation facility, still unable to put weight on her leg, and still requiring opioids every 6 hours. Eight weeks post-injury, she had returned home and was able to mobilize comfortably without assistive devices, however she was still taking opioids and radiographs demonstrated 1 cm of additional displacement of her pelvis fractures.

Younger patients can struggle with these injuries as well. In another example, a 27-year-old woman, with the same injury managed nonoperatively, was still using a walker, unable to put weight on the extremity, and taking opioids one month post-injury. Were either of these situations considered a win by the patient, the orthopaedic surgeon, or the health care system?

These case examples are just anecdotes and subject to our own biases and experiences. Moving forward, a multi-center prospective trial of isolated LC injuries with dynamic instability that monitors early clinical outcomes is needed to determine if the practice of stress radiographs and operative management is beneficial for this patient population.