Pelvic Trauma: Bone

  • Michele Galluzzo
  • Francesco Gaudino
  • Gloria Addeo
  • Grazia Loretta Buquicchio
  • Ginevra Danti
  • Margherita Trinci
  • Vittorio Miele


Pelvic ring fractures are a common consequence of high-energy blunt trauma, as may result from motor vehicle collisions and work-related falls from great height or crushing, and occur in younger adults. A constantly rising number of pelvic fractures have also been observed. The seriousness of pelvic fractures lies in the high rates of morbidity and mortality due to accompanying injuries associated with other organ systems, particularly vascular and visceral structures. Improvements in outcome depend on management of patients with pelvic ring fractures: the appropriate treatment depends upon a thorough knowledge of pelvic anatomy and biomechanics and understanding of the various types of lesions. Use of a classification system of pelvic fractures based on force vectors provides a logical approach to the multidisciplinary management of pelvic ring disruption (PRD) and allows early and aggressive treatment. Advantages of a “restitutio ad integrum” of normal pelvic anatomy, in a young population, offer a fast operative recovery that avoids probable complication due to a long period in bed. Diagnostic imaging should be considered the key to understand the mechanism of injury. Computed tomography (CT) is the technique of choice in the management of polytraumatized patients. Multi-planar reconstruction (MPR) and volume-rendering (VR) three-dimensional (3D) reconstruction views, reproducing radiological standard representations and oblique projections, are powerful modalities in classifying the various types of fractures and the mechanism and severity of injury. The pelvic bone is an anatomically complex tridimensional, ringlike structure, and for this reason, the integration of the information amongst axial, bi-, and three-dimensional images appears to be fundamental and eliminates any interpretive problems to understand the anatomy of the pelvis in all its aspects, and exactly detect the fracture sites, especially in complex cases. Three-dimensional reconstruction views are a kind of ideal conjunction between the traditional information gained from the radiographic images and axial CT scans.

The analysis of fracture morphology necessary for understanding the failure mechanisms is a very useful tool also for assessing the possible presence of vascular, visceral, or nervous complications and for emphasizing the key role of the radiologist in the management of polytrauma patient.Understanding of underlying injury mechanisms and treatment concepts of pelvic ring injuries represents the ‘key’ to successful management strategies for high-energy pelvic injuries.


Pelvis Pelvic ring fractures Trauma Traumatic injuries X-rays Computed tomography (CT) Magnetic resonance imaging (MRI) 


  1. 1.
    Flint L, Cryer HG. Pelvic fracture, the last 50 years. J Trauma. 2010;69:483–8.CrossRefGoogle Scholar
  2. 2.
    Leone A, Galluzzo M, Miele V. Traumi del bacino. In: Miele V, Scaglione M, Grassi R, Rotondo A, editors. Diagnostica per Immagini nel trauma maggiore. Milano: Elsevier Editore; 2010. p. 231–40.Google Scholar
  3. 3.
    Galluzzo M, Buquicchio GL, Gaudino F, et al. Traumi del cingolo pelvico: pictorial essay. Il Giornale Italiano di. Radiol Med. 2016;3:46–57. doi: 10.17376/girm_3-1-01022016-7.CrossRefGoogle Scholar
  4. 4.
    Trainham L, Rizzolo D, Diwan A, Lucas T. Emergency management of high-energy pelvic trauma. JAAPA. 2015;28:28–33.PubMedGoogle Scholar
  5. 5.
    McCormak R, Strauss EJ, Alwatter BJ, Tejwani NC. Diagnosis and management of pelvic fractures. Bull NYU Hosp Jt Dis. 2010;68:281–91.Google Scholar
  6. 6.
    Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990;30:848–56.CrossRefGoogle Scholar
  7. 7.
    Hak DJ, Smith WR, Suzuki T. Management of hemorrhage in life threatening pelvic fracture. J Am Acad Orthop Surg. 2009;17:447–57.CrossRefGoogle Scholar
  8. 8.
    Tile M. Acute pelvis fractures – I. Causation and classification. J Am Acad Orthop Surg. 1996;4:143–51.CrossRefGoogle Scholar
  9. 9.
    Pennal GF, Tile M, Waddell JP, et al. Pelvic disruption: assessment and classification. Clin Orthop Relat Res. 1980;(151):12–21.Google Scholar
  10. 10.
    Riemer BL, Butterfield SL, Diamond DL, et al. Acute mortality associated with injuries to the pelvic ring: the role of early mobilization and external fixation. J Trauma. 1993;35:671–5.CrossRefGoogle Scholar
  11. 11.
    McMurtry R, Walton D, Dickinson D, et al. Pelvic disruption in the polytraumatized patient: a management protocol. Clin Orthop. 1980;151:22–30.Google Scholar
  12. 12.
    Ward RE, Clark DG. Management of pelvic fractures. Radiol Clin North Am. 1981;19:167–70.PubMedGoogle Scholar
  13. 13.
    Agnew SG. Hemodynamically unstable pelvic fractures. Orthop Clin North Am. 1994;25:715–21.PubMedGoogle Scholar
  14. 14.
    Tile M. Pelvic fractures: operative versus nonoperative treatment. Orthop Clin North Am. 1980;11:423–64.PubMedGoogle Scholar
  15. 15.
    Stephen DJG. Understanding high-energy pelvis fractures. Can J CME. 2004;75–8.Google Scholar
  16. 16.
    McCort JJ, Mindelzum RE. Bladder injury and pelvic fractures. Emerg Radiol. 1994;11:47–51.CrossRefGoogle Scholar
  17. 17.
    Rothenberger DA, Fischer RP, Strare R, et al. The mortality associated with pelvic fractures. Surgery. 1978;84:356–61.PubMedGoogle Scholar
  18. 18.
    Khurana B, Sheehan SE, Sodickson AD, Weaver MJ. Pelvic ring fractures – what the orthopaedic surgon wants to know. Radiographics. 2014;34:1317–33.CrossRefGoogle Scholar
  19. 19.
    Woodley SJ, Kennedy E, Mercer SR. Anatomy in practice: the sacrotuberous ligament. N Z J Physiother. 2005;33:91–4.Google Scholar
  20. 20.
    van Wingerden J-P, Vleeming A, Snijders CJ, Stoeckart R. A functional-anatomical approach to the spine-pelvis mechanism: interaction between the biceps femoris muscle and the sacrotuberous ligament. Eur Spine J. 1993;2:140–4.CrossRefGoogle Scholar
  21. 21.
    Pool-Goudzwaard AL, Kleinrensink GJ, Snijders CJ, et al. The sacroiliac part of the iliolumbar ligament. J Anat. 2001;199:457–63.CrossRefGoogle Scholar
  22. 22.
    Gamble JG, Simmons SC, Freedman M. The symphysis pubis. Anatomic and pathologic considerations. Clin Orthop Relat Res. 1986;203:261–72.Google Scholar
  23. 23.
    Salari P, Moed BR, et al. Supplemental S1 fixation for type C pelvic ring injuries: biomechanical study of a long iliosacral versus a transsacral screw. J Orthop Traumatol. 2015;16:293–300.CrossRefGoogle Scholar
  24. 24.
    Chenoweth DR, Cruickshank B, Gertzbein SD, et al. A clinical and experimental investigation of occult injuries of the pelvic ring. Injury. 1980;12:59–65.CrossRefGoogle Scholar
  25. 25.
    Gertzbein SD, Chenoweth DR. Occult injuries of the pelvic ring. Clin Orthop Relat Res. 1977;128:202–7.Google Scholar
  26. 26.
    Stahel PF, Hammerberg EM. History of pelvic fracture management – a review. World J Emerg Surg. 2016;11:18.CrossRefGoogle Scholar
  27. 27.
    Sarin EL, Moore JB, Moore EE, et al. Pelvic fracture pattern does not always predict the need for urgent embolization. J Trauma. 2005;58:973–7.CrossRefGoogle Scholar
  28. 28.
    Ben-Menachem Y, Coldwell DM, Young JW, Burgess AR. Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management. AJR Am J Roentgenol. 1991;157:1005–14.CrossRefGoogle Scholar
  29. 29.
    Bucholz RW. The pathological anatomy of Malgaigne fracture-dislocations of the pelvis. J Bone Joint Surg Am. 1981;63:400–4.CrossRefGoogle Scholar
  30. 30.
    Gorczyca JT, Powell JN, Tile M. Lateral extension of the ilioinguinal incision in the operative treatment of acetabulum fractures. Injury. 1995;26:207–12.CrossRefGoogle Scholar
  31. 31.
    Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures, Part 1 – evaluation, classification and resuscitation. J Am Acad Orthop Surg. 2013;21:448–57.CrossRefGoogle Scholar
  32. 32.
    Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology. 1986;160:445–51.CrossRefGoogle Scholar
  33. 33.
    Young JWR, Resnik CR. Fractures of the pelvis: current concepts of classification. AJR. 1990;155:1169–75.CrossRefGoogle Scholar
  34. 34.
    Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 2. Contemporary indications and techniques for definitive surgical management. J Am Acad Orthop Surg. 2013;21:458–68.CrossRefGoogle Scholar
  35. 35.
    Huitten VM, Slatis P. Fractures of the pelvis: trauma mechanism, types of injury and principles of treatment. Acta Chir Scand. 1972;138:563–9.Google Scholar
  36. 36.
    Basta AM, Blackmore CC, Wessells H. Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma. J Urol. 2007;177:571–5.CrossRefGoogle Scholar
  37. 37.
    Beckmann N, Cai C. CT characteristics of traumatic sacral fractures in association with pelvic ring injuries: correlation using the Young-Burgess classification system. Emerg Radiol. 2016;24:255–62.CrossRefGoogle Scholar
  38. 38.
    Daffner RH, Sciulli RL. CT-guided iliosacral screw placement. Semin Musculoskelet Radiol. 2013;17:407–15.CrossRefGoogle Scholar
  39. 39.
    Hakim RM, Gruen GS, Delitto A. Outcomes of patients with pelvic-ring fractures managed by open reduction internal fixation. Phys Ther. 1996;76:286–95.CrossRefGoogle Scholar
  40. 40.
    Hunter JC, Brandser EA, Trank KA. Pelvic and acetabular trauma. Radiol Clin North Am. 1997;35(3):559–90.PubMedGoogle Scholar
  41. 41.
    Resnik CS, Stackhouse DJ, Shanmuganathan K, et al. Diagnosis of pelvic fractures in patients with acute pelvic trauma: efficacy of plain radiographs. AJR Am J Roentgenol. 1992;158:109–12.CrossRefGoogle Scholar
  42. 42.
    Mears DC, Ward AJ, Wright MS. The radiological assessment of pelvic and acetabular fractures using three-dimensional computed tomography. Int J Orthop Trauma. 1992;2:196–209.Google Scholar
  43. 43.
    Tile M. Acute pelvic fractures – II. Principles of management. J Am Acad Orthop Surg. 1996;4:152–61.CrossRefGoogle Scholar
  44. 44.
    Chaumòitre K, Portier F, Petit P, et al. CT imaging of pelvic injuries in polytrauma patients. J Radiol. 2000;81:111–22.PubMedGoogle Scholar
  45. 45.
    Gill R, Bucholz RW. The role of computerized tomographic scanning in the evaluation of major pelvic fractures. J Bone Joint Surg. 1984;66:34–9.CrossRefGoogle Scholar
  46. 46.
    Pretorius ES, Fishman EK. Volume-rendered three-dimensional spiral CT: musculoskeletal applications. Radiographics. 1999;19:1143–60.CrossRefGoogle Scholar
  47. 47.
    Rafii M, Firooznia H, Golimbu C, et al. The impact of CT in clinical management of pelvic and acetabular fractures. Clin Orthop. 1983;178:228–35.Google Scholar
  48. 48.
    Rommens P, Hartvig T, Wissing H, et al. Diagnosis and treatment of unstable fractures of the pelvic ring. Acta Chir Belg. 1986;6:352–9.Google Scholar
  49. 49.
    Yoon W, Kim JK, Jeong YY, et al. Pelvic arterial hemorrhage in patients with pelvic fractures: detection with contrast-enhanced CT. Radiographics. 2004;24:1591–605.CrossRefGoogle Scholar
  50. 50.
    Dunn EL, Berry PH, Connoly PJ. Computed tomography of the pelvis in patients with multiple injuries. J Trauma. 1983;23:378–83.CrossRefGoogle Scholar
  51. 51.
    Benedetti PF. MR imaging in emergency medicine. Radiographics. 1996;16:953–62.CrossRefGoogle Scholar
  52. 52.
    Eustace S, Adams J, Assaf A. Emergency MR imaging of orthopedic trauma. Current and future directions. Radiol Clin North Am. 1999;37:975–94.CrossRefGoogle Scholar
  53. 53.
    Elsayes KM, Lammle M, Shariff A, et al. Value of magnetic resonance imaging in muscle trauma. Curr Probl Diagn Radiol. 2006;35:206–12.CrossRefGoogle Scholar
  54. 54.
    Piccolo C, Galluzzo M, Ianniello S, et al. Pediatric musculoskeletal injuries: role of ultrasound and magnetic resonance imaging. Musculoskelet Surg. 2017;101(Suppl 1):85–102.CrossRefGoogle Scholar
  55. 55.
    Piccolo CL, Galluzzo M, Trinci M, et al. Upper limbs trauma in pediatrics. Semin Musculoskelet Radiol. 2017;21:167–74. doi: 10.1055/s-0037-1602416.CrossRefPubMedGoogle Scholar
  56. 56.
    Piccolo CL, Galluzzo M, Trinci M, et al. Lower limbs trauma in pediatrics. Semin Musculoskelet Radiol. 2017;21:175–83. doi: 10.1055/s-0037-1602417.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Michele Galluzzo
    • 1
  • Francesco Gaudino
    • 1
  • Gloria Addeo
    • 2
  • Grazia Loretta Buquicchio
    • 1
  • Ginevra Danti
    • 2
  • Margherita Trinci
    • 1
  • Vittorio Miele
    • 2
  1. 1.Department of Emergency RadiologyS. Camillo HospitalRomeItaly
  2. 2.Department of RadiologyCareggi University HospitalFlorenceItaly

Personalised recommendations