Pelvic fractures include disruption of the superior and inferior pubic rami, the acetabulum (hip socket), the iliac wing, and the sacrum. It is also possible to have a serious pelvic injury without fractured bone, as might be seen with a rupture of the ligaments that connect the two pubic rami or the ligaments stabilizing the sacroiliac joint.
Fractures of the pelvis can be caused by high-energy trauma, such as a motor vehicle collision, or in the setting of frailty, a simple fall may be responsible. When a fracture is due to a high-energy mechanism, damage to the internal organs and major blood vessels is common and must be addressed first. The focus of treatment is “life before limb,” using the approach of Advanced Trauma Life Support (ATLS) guidelines. Thereafter, surgical reduction and fixation is often needed. Notably, the initial medical response to hemorrhagic shock in patients with pelvic fractures can include musculoskeletal treatments: emergency pelvic stabilization can compress damaged vessels and stem the bleeding, for example.
Even in the absence of pelvic instability, high energy pelvic fractures can be lethal. Death may result from associated injuries or from internal hemorrhage. Morbidity among survivors is also high as residual pain, neurological loss, and functional disabilities are commonly seen. Fractures of the acetabulum pose a specific risk for hip arthritis.
Low energy fractures, typically involving the pubic rami or sacrum, are usually seen in older or frail patients who fall. Most low energy fractures are stable injuries and can be managed with pain medication and early physical therapy. Particular attention to geriatric management is needed to prevent delirium in the short term and to prevent further falls and fragility fractures after initial recovery.
Last, the pelvis is susceptible to avulsion fractures. Sudden and forcible movements – usually in sports activities – can pull off, or “avulse,” small fragments of bone at the point of ligament and tendon attachments. These injuries often, but not always, need no treatment beyond supportive care.
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