The pelvis' structural and mechanical integrity make it stable. Thus, pelvis fractures are most common in high-impact trauma and often accompany other fractures or injuries [1]. Iliac wing fractures, which do not damage the pelvic ring, can be treated without surgery. In high-energy injuries, hip dislocations and senior falls, acetabulum fractures are common and examined by fracture anatomy.

The Young-Burgess classification system for pelvic ring injuries is detailed below. Trauma surgeons and emergency physicians can treat the pelvic ring injury and advise the orthopaedic surgeon about the patient's anatomy by accurately recognising it.

For clinicians to use the Young-Burgess classification of pelvic ring injuries, they must know how pelvic ligaments work. The symphyseal ligaments between the right and left pubic symphyses on the anterior pelvic ring stop the sacroiliac joints from turning outwards through the back. The posterior sacroiliac complex and pelvic floor ligaments stabilize the pelvic ring. The sacrospinous and sacrotuberous ligaments of the pelvic floor are in front of the sacroiliac joint and stop the joint from being pulled apart and turned outward. The posterior sacroiliac complex stabilizes the pelvic ring. One of the strongest ligaments in the body, the posterior sacroiliac complex, is injured by a high-energy mechanism.

Due to the movement of soft tissues, pelvic ring injuries often cause damage to the blood vessels, nerves and organs. The posterior pelvic venous plexus causes most pelvic ring injury bleeding. The obturator artery is a branch of the internal iliac artery. The corona mortis connects the obturator artery to the external iliac. Intraoperative corona damage can cause pelvic blood loss and patient death.

Etiology

Low-impact accidents can cause pelvic fractures. Low-impact injuries are more common in adolescents and the elderly. Athletic injuries in adolescents cause avulsion fractures of superior or inferior iliac spines or apophyseal avulsion fractures of the iliac wing or ischial tuberosity, while falls in the elderly cause pelvic fractures (e.g. stable fractures of the pelvic ring or insufficiency fractures of sacrum and anterior pelvic ring) [2]. High-impact injuries are most common in motor vehicle accidents or falls from great heights.

Pathophysiology

The sacrum and the ilium, ischium and pubis create an anatomical ring. Due to the energy needed to shatter this ring, a pelvic fracture often involves ligaments or structures inside or outside the pelvis [3].

The Young-Burgess classification mechanistically classifies pelvic ring injuries by impact direction, with common fracture patterns [4]. The most widely used classification system for pelvic ring injuries in orthopaedic trauma surgery is this one. It helps guide initial therapy.

The three mechanisms of injury described by the Young-Burgess classification are as follows: Anterior to Posterior Compression Injuries (APC), Lateral Compression Injuries (LC) and Vertical Shear Injuries (VS). 

Anterior to Posterior Compression Injuries (AC)

In anterior to posterior compression type injuries, ligamentous tissues fail from an anterior to posterior direction. First, there is injury to the symphyseal ligaments at the pubic symphysis. This is followed by disruption of the ligaments of the pelvic floor, that is the sacrospinous and sacrotuberous ligaments. And finally, there is dislocation of the posterior sacroiliac complex. APC-type pelvic ring injuries have three progressions:

• APC Type I: APC I injuries are characterised by a disruption of the symphyseal ligaments exclusively and are often caused by isolated disruption of the symphyseal ligaments

• APC Type II: Symphyseal and pelvic floor ligament disruptions are APC II injuries (sacrospinous and sacrotuberous ligaments). On radiographs, this shows as a widening of the symphyseal ligaments by more than 2.5 cm

• APC Type III: APC III injuries are described as the disruption of both the anterior and posterior sacroiliac ligaments, including the posterior sacroiliac complex, the strongest ligaments in the body

APC III injuries have the highest rate of fatality, blood loss and need for transfusion of all pelvic ring injuries [5]. 

Lateral Compression (LC) Injuries

Lateral compression injuries are more likely to fracture than anterior-posterior ones. Lateral compression injuries typically have coronal plane rami fractures, while APC injuries have vertical fractures. Rami fractures often involve sacral ala or iliac wing fractures [6]. 

• LC Type I: Rami fractures with ipsilateral sacral ala fractures from lateral pelvic trauma

• LC Type II: More anteriorly directed lateral compression injury than LC I. Usually rami fractures with ipsilateral crescent ilium fracture [7]

• LC Type III: Colloquially described as "windswept pelvis." The greatest energy mechanism of all lateral compression fractures. APC-like ipsilateral disruptive lateral compression type I or II injury with contralateral external rotation. Closed head injury kills most lateral compression fracture patients [8] 

V-Shear (VS)

One hemipelvis axial load causes vertical shear damage. Falls from height or motorbike incidents where one leg is forcefully laden are more prone to cause these injuries. The iliac wing is raised over the sacrum, disrupting the symphyseal ligaments, pelvic floor and strong posterior sacroiliac complex [9]. 

History and Physical Examination

Pelvic injuries are high-energy injuries that require a trauma evaluation. The American College of Surgeons recommends routine assessment, including evaluation for life-threatening injuries, for all patients [10].

Axial or appendicular spine traumas often cause pelvic ring fractures. Therefore, check the spine and extremities for limb length discrepancies and evident angular or rotational abnormalities. Injuries to the pelvis may involve neurovascular networks crossing the pelvis, requiring a complete first neurological assessment for proper care and surveillance.

Even closed pelvic fractures cause blood loss, thus doctors must check their hemodynamic condition. In up to 40% of instances, such injuries cause intra-abdominal, intrathoracic, retroperitoneal, or compartmental haemorrhage. Shearing of the venous plexus causes pelvic bleeding and hematomas up to 4L. Superior gluteal artery injuries from posterior pelvic fractures are surgical emergencies. Soft-tissue injuries may help determine patient impact. Lacerations of the perineum (rectum or vagina) suggest a serious injury and fractures potentially polluted by urine, stool, or other environmental toxins. Pelvic fractures often damage L5 or S1 nerve roots. An S2-S5 sacral nerve root injury from a sacral fracture may cause bowel or bladder incontinence and sexual dysfunction. 

Care

As a pelvic fracture requires a lot of force, other life-threatening injuries should be treated in the acute situation. Early stable fixation reduces blood transfusion, systemic problems, hospital stay and mortality in the acute situation. Avoid pelvis movement. As soon as possible, get large-bore intravenous access for analgesics and fluids and monitor vital signs [11].

Mechanical stabilization with an external compression device like a pelvic binder or sheet centred over the greater trochanter can stabilize the pelvic ring and stop internal bleeding from the venous plexus in APC-type pelvic ring injuries but should be avoided in LC-type injuries with internal rotation. Skeletal traction stabilizes vertical shear pelvic ring injuries. Skeletal external fixation of the pelvis is preferable for hemodynamically unstable individuals and can be done with an emergency laparotomy.

Modern pelvic implants, unaesthetic procedures, intraoperative imaging, coordinated poly-trauma treatment and a better understanding of injury patterns have led to the operational management of pelvic fractures that were previously handled non-operatively. Preventing and repairing major pelvic abnormalities and mobilizing patients earlier improves clinical outcomes. Some pelvic ring fractures can be treated non-surgically. APC and LC Type I fractures can be weight-bearing as tolerated. Early mobilization is advised. Minimally displaced pelvic fractures can often be treated non-operatively but must be assessed individually. 

Diagnostics

"Pelvic fractures" include pelvic ring fractures, acetabulum fractures and iliac wing fractures, the latter of which may usually be treated non-operatively.

The Letournel Classification lists 10 classic acetabular fracture types that require their own research. High-risk or minimally displaced acetabulum fractures can be treated non-operatively with protective weight-bearing. Acute acetabulum fractures with major displacement or hip instability require open reduction and internal fixation [12]. 

Prognosis

Even with adequate radiographic recovery, pelvic injury patients report decreased mental and physical quality of life two years following therapy [13]. Pelvic fractures are often accompanied with additional injuries and impairment, making it difficult to link lower quality of life to pelvic ring injuries. Orthopedic injuries worsened disability, psychological, social and vocational effects. 

Complications

Pelvic ring injuries often cause long-term impairments. 56% of women have dyspareunia and symphyseal displacement of 5 mm or greater increases intercourse pain [14]. Pelvic ring injury increases the likelihood of a caesarean section [15]. 61% of men experience sexual dysfunction and 19% erectile dysfunction, with rates up to 90% for APC-type injuries [16]. Fixing unstable pelvis fractures does not reduce trauma-related sexual dysfunction or brain impairment. 

Preventing and Teaching

In the event of concomitant injuries, pelvic ring injury patients should be advised about long-term effects. Permanent impairment affects many individuals financially, mentally and physically. Rehabilitating and managing impairments requires an interdisciplinary team.

Improving Healthcare Team Results

Therapists help patients recover from pelvic ring problems after surgery. Pharmacists should help manage pain. 
 

Urologists for bladder and sexual dysfunction and mental health doctors for major psychosocial difficulties may be needed to treat pelvic fractures.

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