Chapter 32

Pelvis and Acetabulum: Trauma

Mark C. Reilly, MD

Pelvic Fractures The trauma AP pelvis radiograph is recommended

Evaluation as an Advanced Trauma Life Support diagnostic adjunct
Fractures of the pelvic ring frequently result from high- for use in the resuscitation of blunt trauma patients and
energy injuries. The orthopaedic surgeon should be in- provides information about the mechanism of injury
volved early in the treatment process. Patient evaluation that may contribute to the initial treatment protocol.
should begin with information from the injury scene, However, because most blunt trauma patients also will
and the patient’s hemodynamic stability assessed while undergo a CT scan, the utility and cost effectiveness of
en route to the emergency department. A physical ex- the trauma AP radiograph as a resuscitative adjunct has
amination should identify associated integument, neuro- been questioned. In one study of awake, alert trauma
logic, urologic, and skeletal injuries. A careful evaluation patients, physical examination was found to be as sensi-
of the soft tissues surrounding the pelvis should include tive as the AP radiograph of the pelvis in identifying un-
an evaluation of the perineum for evidence of swelling, stable pelvic injuries. Another large study found that
laceration, or deformity. The patient should be log rolled physical examination alone would not have identified a
to allow for examination of possible open wounds or significant number of unstable pelvic ring injuries.
subcutaneous degloving injuries. Rectal and vaginal ex- Definitive radiographic evaluation of a patient with
aminations are mandatory and may identify lacerations a pelvic ring injury should include the AP radiograph of
in connection with the pelvic ring injury. the pelvis and the 40° caudad (inlet) and 40° cephalad
Concomitant urologic injuries are present in approx- (outlet) projections. The CT scan of the pelvis, usually
imately 15% of patients with pelvic fractures and are obtained in conjunction with the trauma abdominal CT
most commonly urinary tract injuries. Physical findings scan, should include cuts of 5 mm or less through the
often associated with urethral injury in men are blood at posterior pelvic ring. Results from the CT scan will help
the meatus and a high-riding or excessively mobile pros- determine the location and type of posterior pelvic ring
tate. Female patients should be examined for vaginal injury, identify compression of neurologic elements, and
wall, urethral, or labial lacerations. Hematuria, when highlight subtle ligamentous or bony injuries that may
present, is an accurate indicator of urologic injury (par- alter the treatment plan. The lower lumbar spine can be
ticularly bladder injuries). A retrograde cystourethro- seen and concurrent injuries may be identified.
gram should be done on hemodynamically stable male
patients with displaced anterior pelvic ring injuries be-
fore Foley catheter placement. In female patients, cathe- Classification
ter placement may be performed without a urethrogram Systems based on the anatomic location of the injury,
because the urethra is short and is not often injured. mechanism of injury, or stability of the pelvic ring are
Retroperitoneal bladder ruptures are generally repaired used to classify pelvic ring injuries. These classification
at the time of anterior pelvic ring fixation. If no anterior systems are usually used together. The anatomic classifi-
pelvic ring surgery is performed, these ruptures may be cation system helps to identify all of the injured bony
treated nonsurgically. Although controversy exists con- and ligamentous structures. The mechanism of injury
cerning the treatment of urethral injuries, multiple stud- system aids in fracture pattern recognition and assists in
ies have shown that early endoscopic primary realign- the early resuscitation and treatment of the patient (Fig-
ment is associated with an acceptably low rate of ure 1). Determining the stability of the pelvic ring can
intraoperative morbidity, stricture formation, impotence, help in the selection of the most appropriate definitive
and incontinence. fixation for the injury.

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Figure 1 Young-Burgess classification of mechanism of injury. A, Lateral compression, grade I. B, Lateral compression, grade II. C, Lateral compression, grade III. D, Anterior-
posterior compression, grade I. E, Anterior-posterior compression, grade II. F, Anterior-posterior compression, grade III. G, Vertical shear. (Reproduced from Tornetta P III: Pelvis
and acetabulum: Trauma, in Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 427-439.)

Initial Treatment ually to avoid a sudden expansion in intravascular vol-

Resuscitation ume and subsequent hypotension.
Pelvic ring injuries may be associated with significant In the emergency department, external stabilization
hemorrhage. The patient’s response to resuscitation, may be an important factor in patient resuscitation. Cir-
which begins during the initial trauma evaluation, will cumferential pelvic antishock sheeting or the placement
guide the overall treatment plan. Patients with pelvic of a pelvic binder is a noninvasive and rapid means for
fractures often will require blood replacement in addi- obtaining pelvic stability and has been shown to achieve
tion to receiving fluid and crystalloid. Patients present- reduction and stabilization of external rotation-type pel-
ing in shock (systolic blood pressure less than 90 mm vic fractures. Pelvic sheeting has replaced the applica-
tion of a resuscitative external fixator in many treat-
Hg) have mortality rates of up to 10 times of those
ment centers because it avoids the delay required to
found in normotensive patients. In one study, the pres-
apply the frame and may be applied earlier in the
ence of shock on arrival in the emergency department
course of treatment to prevent ongoing hemorrhage.
and revised trauma score were determined to be the
The trauma AP radiograph of the pelvis should be re-
most useful predictors of mortality and transfusion re-
viewed to determine the fracture pattern (before appli-
quirement. The most common direct causes for mortal- cation of the sheet) to ensure that the injury is not a lat-
ity in patients with pelvic fractures are head and thorax eral compression injury, which could be further
injuries; however, hemorrhage from pelvic fractures may displaced by such treatment. When used, external fixa-
be a significant contributing factor to mortality. Hypo- tion pins may be inserted into the medius tubercle por-
thermia and coagulopathy frequently contribute to on- tion of the iliac crest or just above the anterior inferior
going blood loss and should be treated aggressively if iliac spine. Skeletal traction also may be indicated as an
present. Most pelvic bleeding is venous and can be con- additional method for temporary stabilization, particu-
trolled with mechanical stabilization, prevention of clot larly for fractures with cranial displacement.
disruption, and treatment of coagulopathy.
Angiography
External Stabilization Angiography with selected embolization is useful for pa-
If the pelvic ring is mechanically unstable, external im- tients who are not responding to fluid and blood resusci-
mobilization may be indicated. Initial stabilization for tation. In one study, it was found that hemorrhage in pa-
transport from the injury site may consist of sandbags, tients with unstable pelvic fractures usually originated
beanbags, or military antishock trousers (MAST). All from pelvic sources and was often treatable with embo-
devices must be removed for the evaluation of the lization. In patients with both pelvic and abdominal
trauma patient. The MAST suit should be deflated grad- sources of bleeding, mortality was lower in the group of

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Orthopaedic Knowledge Update 8 Chapter 32 Pelvis and Acetabulum: Trauma

patients treated with angiography followed by laparotomy complicated by neurologic or vascular injury, infection,
compared with a group first treated with laparotomy. wound complications, and nonunion or malunion of the
Stable fracture patterns also may be complicated by pelvic ring, and loss of reduction.
arterial bleeding and may be appropriate for treatment
by selective embolization. Arterial bleeding can occur in Anterior Pelvic Ring Injuries
up to 18% of patients with mechanically stable pelvic Injuries to the anterior pelvic ring include symphysis
fractures. In one study however, an intra-abdominal dislocations, pubic body fractures, and pubic rami frac-
source of bleeding was found in 85% of patients who tures. These injuries may occur alone, in combination, or
were hemodynamically unstable but had mechanically in association with a posterior pelvic ring injury. All
stable pelvic fractures. complete dislocations of the symphysis pubis should be
stabilized. Displacements of less than 2.5 cm in conjunc-
Definitive Treatment tion with an intact posterior pelvic ring are incomplete
Most pelvic fractures are mechanically stable injuries injuries and can be considered for nonsurgical treat-
and are often caused by a lateral compression mecha- ment. Because radiographs of the injury may not reflect
nism resulting in an anterior impaction fracture of the the magnitude of the initial displacement, close
sacrum and pubic rami fractures. If there is less than follow-up is warranted if nonsurgical treatment is se-
1 cm of posterior pelvic ring displacement and no neu- lected. The symphysis dislocation is most effectively and
rologic deficit, these injuries are appropriate for nonsur- efficiently treated with a single plate applied superiorly
gical treatment with progressive mobilization. Repeat through a rectus-splitting Pfannenstiel approach. This
radiographs should be obtained after mobilization to procedure may be done in conjunction with an emer-
ensure that there has been no further displacement. gent laparotomy or urologic surgery and adds the least
Fractures of the processes of the pelvis, such as anterior amount of additional soft-tissue disruption.
superior iliac spine avulsion fractures, do not disrupt the Fractures of the superior pubic ramus rarely require
stability of the pelvic ring and are usually treated non- stabilization; even those that occur in association with
surgically unless significant displacement is present. symphyseal dislocations are usually treated nonsurgi-
cally. Poupart’s, Cooper’s, and the inguinal ligaments
External Fixation combine with the periosteum of the ramus to provide
External fixation as definitive treatment is generally only stability for these injuries. It is believed that more than
appropriate for rotationally unstable injuries. The most 2 cm of residual distraction or fracture gap of the ramus
common scenario involves an AP compression injury, after treatment of the posterior pelvic injury implies dis-
which results in an external rotation of one or both hemi- ruption of these soft tissues and fixation may be needed.
pelves. The anterior ring usually fails as a symphysis dis- Fixation may be achieved with open reduction and plate
location or less commonly as fractures of the pubic rami. osteosynthesis; intramedullary screw fixation or external
The posterior ring injury is incomplete. In this situation, fixation also has been used. If the fracture involves the
the external fixator may provide enough anterior stability body of the pubis (medial to the pubic tubercle), the
to allow the anterior injury to heal. In a lateral compres- supporting tissues mentioned above are all lateral to the
sion injury, distraction external fixation with external ro- site of injury and cannot contribute to stability. Pubic
tation of the injured hemipelvis has been used with suc- body fractures are generally treated as symphysis dislo-
cess; this treatment is only required if there is neurologic cations and require reduction and plate fixation.
compression or unacceptable deformity. Although it may
be used in association with internal fixation for some in- Posterior Pelvic Ring Injuries
juries, external fixation alone is not appropriate for the The posterior pelvic ring is the most important compo-
treatment of unstable posterior pelvic ring injuries. The nent in overall stability and function of the pelvis. The
posterior pelvic ring injury may ultimately heal; however, anatomic site of injury will determine the surgical ap-
it will heal in a displaced position and may lead to pelvic proach and the type of fixation used. Unstable posterior
obliquity, pain, and long-term disability. pelvic ring injuries are ilium fractures, sacroiliac (SI)
joint dislocations, sacral fractures, or SI joint fracture-
Internal Fixation dislocations. It is usually best to reduce the posterior
Internal fixation is the most biomechanically stable fixa- pelvic ring injury first, building to the intact portion of
tion for the pelvic ring. The implants are situated closer the pelvis. This is particularly crucial if there are many
to the site of injury than in external fixation and may be sites of pelvic displacement. If there are only two sites
optimally located to resist the forces applied to the pel- of injury within the pelvic ring, reduction of the anterior
vic ring. Achieving an accurate reduction of the pelvic ring may facilitate reduction of the posterior pelvis in
ring may be a prerequisite to achieving stable fixation. some circumstances; however, beginning treatment with
Placement of internal fixation for the pelvis may be the posterior injury is still recommended.

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Figure 2 A, Radiograph showing dislocation of the symphysis pubis and incomplete injuries to both SI joints. B, Radiograph at 2 years shows maintenance of the reduction of
the pelvic ring without evidence of SI joint arthrosis.

Ilium Fractures visualization of the cranial aspect of the joint to the pel-
Ilium fractures typically propagate from the iliac crest vic brim, and the ilium can be manipulated through the
to the greater sciatic notch and are unstable injuries. Al- placement of clamps on the crest or through the inter-
though nondisplaced fractures may be treated nonsurgi- spinous notch. Excessive retraction or retractors placed
cally, displaced fractures require reduction and fixation. too medially on the sacrum may cause injury to the L5
A posterior pelvic approach is useful, although some nerve root. Fixation is achieved through the use of
fracture patterns may be treated through the lateral plates applied with a single screw in the sacrum and
window of the ilioinguinal approach. Fractures that in- with one or two screws placed into the ilium. The use of
volve only the iliac wing are stable injuries, are often two plates, oriented at 90° to each other, is recom-
minimally displaced, and can be treated nonsurgically. If mended. In the obese patient, reduction and fixation
significant displacement is present, open reduction and through the anterior approach can be very difficult be-
internal fixation may be indicated. These fractures are cause of the inability to retract the abdominal contents.
generally reduced and fixed through the lateral window Fixation also may be compromised if there is a marginal
of the ilioinguinal approach. Iliac wing fractures have a fracture of the sacral lip of the SI joint. This fracture can
high incidence of local arterial injuries, bowel injury, and be identified on the CT scan preoperatively and may
soft-tissue degloving. Plate or screw fixation between preclude stable plate fixation from the anterior ap-
the tables of the ilium can be useful. proach. Fixation also can be achieved through iliosacral
screws placed percutaneously while the patient is supine
Sacroiliac Joint Dislocations and while the reduction is assessed and held from the
A complete radiographic evaluation including CT scan anterior approach.
is often required to differentiate between incomplete SI Reduction and fixation is facilitated by the use of an
joint injuries and complete SI dislocations. The anterior open reduction done through the posterior pelvic ap-
pelvic ring and anterior SI ligaments may be signifi- proach with the patient prone. The posterior-inferior SI
cantly disrupted, whereas the posterior SI ligaments re- joint is visualized while the anterior joint is palpated
main intact. These injuries are only rotationally unstable through the greater sciatic notch. Reduction is per-
and usually require treatment of only the anterior ring formed with a combination of clamps placed between
injury (Figure 2). The posterior ring injury will reduce the ilium and sacrum. Fixation is achieved with the fluo-
indirectly and be stabilized by the anterior ring fixation. roscopically guided placement of iliosacral lag screws.
Complete dislocations of the SI joint are vertically un- The iliosacral screws are inserted through a separate in-
stable injuries and require posterior pelvic ring fixation cision with a percutaneous technique; it is rarely possi-
in addition to anterior ring fixation (Figure 3). ble to insert the screws through the posterior approach
Reduction and fixation of the SI joint may be done incision. If the reduction of the SI joint can be achieved
either open (through an anterior or posterior approach) with closed manipulation and traction, the joint may be
or through closed manipulation with percutaneous fixa- similarly stabilized with iliosacral lag screws placed with
tion. The anterior approach to the SI joint allows direct the patient either prone or supine.

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 Orthopaedic Knowledge Update 8 Chapter 32 Pelvis and Acetabulum: Trauma

Figure 3 A, Patient with dislocation of the symphysis pubis, incomplete injury to the right SI joint, and complete dislocation of the left SI joint. Note the cranial displacement of
the left hemipelvis. B, Open reduction of the SI joint was performed through a posterior pelvic approach and the joint stabilized with iliosacral screw fixation. Open reduction and
internal fixation of the symphysis pubis followed.

Sacroiliac Fracture-Dislocations Open accurate reduction and internal fixation is recom-

SI fracture-dislocations are a combination of an iliac mended, but closed reduction and percutaneous fixation
fracture and an SI dislocation. The posterior superior also has been advocated. Open reduction through a pos-
spine and often the posterior iliac crest remain attached terior pelvic approach allows direct visualization of the
to the sacrum by the posterior SI ligaments. The remain- fracture site and sacral nerve roots. This approach al-
ing portion of the ilium dislocates from the sacrum as lows for direct decompression of the nerve roots and vi-
the anterior SI ligaments rupture. Fracture-dislocations, sualization of the fracture during fixation to ensure that
which leave only a small intact iliac fragment, resemble the fracture is reduced and not overcompressed. Closed
pure SI dislocations and are treated similarly. Fracture- manipulation and percutaneous fixation may increase
dislocations with a large intact iliac fragment have been the risk for iatrogenic nerve injury if the fracture is not
termed crescent fractures and may be large enough to aligned and is overcompressed. The space available for
maintain the integrity of the posterior SI ligaments. In safe placement of iliosacral screw fixation is increasingly
this situation, interfragmentary fixation of the ilium will compromised with the increasing magnitude of malre-
restore skeletal stability and the posterior SI ligaments duction. In either open or closed reduction, it is impera-
will maintain the reduction of the SI joint. If the frag- tive to obtain an accurate reduction to ensure safe
ment is small or the integrity of the posterior SI liga- fixation.
ments cannot be ensured, interfragmentary fixation A subgroup of sacral fractures is the U-shaped frac-
must be augmented with SI joint fixation. Generally, tures in which bilateral transforaminal sacral fractures
rami fractures are the type of anterior ring injury seen are connected by a transverse fracture, usually between
in association with the SI fracture-dislocation; this injury the second and third sacral segments. This condition
may be treated nonsurgically if secure posterior fixation represents a complete spinopelvic dissociation and often
is achieved. Closed reduction and percutaneous fixation occurs with a sacral kyphosis and disruption of the
of SI fracture-dislocations has been reported but has cauda equina at the level of the transverse sacral frac-
been associated with a significant incidence of fixation ture. Percutaneous screw fixation has been used without
failure. Outcome, as measured by patient satisfaction, reduction of the kyphotic deformity; however, reduction
was acceptable. of the deformity and fixation with spinopelvic instru-
mentation is recommended. Late decompression is re-
Sacral Fractures served for patients with neurologic deficits and no evi-
Most fractures of the sacrum are minimally displaced dence of spontaneous recovery. Midline sagittal sacral
and stable. Those associated with lateral compression- fractures also have been reported. These fractures are
type injuries are often impacted and have a negligible generally vertically stable injuries and are treated with
incidence of subsequent displacement. Displaced and fixation of the anterior ring injury alone and indirect re-
unstable sacral fractures require reduction and fixation. duction of the sacral fracture.

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Open Versus Closed Reduction Outcome

Although percutaneous fixation of the pelvic ring has Outcome after pelvic fracture is more a function of the
been proposed, the most important factor in the treat- effects of associated injuries than of the pelvic ring in-
ment of pelvic ring fractures remains the reduction. The jury itself. At long-term follow-up after pelvic fracture,
stability of the fracture fixation and the safety of fixa- patients reported decreased satisfaction in most of the
tion placement has been shown to be compromised with categories measured by the Medical Outcomes Study
fracture malreduction. In one study, 20% of patients Short Form-36. Pain, general health, and physical func-
with sacral fractures who were treated with closed re- tioning are typically affected. Clinical results appear to
duction and percutaneous iliosacral screws had fixation decline with the increasing level of instability caused by
failures and displacement, and 13% required revision the initial injury. In one study, functional and radio-
surgery. CT-guided, computer-, fluoroscopic-, and graphic results were worse and mortality was higher in
endoscopic-assisted insertion techniques for internal fix- patients with more unstable fracture patterns. Good and
ation have all been described but only a few of these excellent outcomes after rotationally unstable fractures
have been reported in up to 96% of patients, whereas
techniques review the reduction obtained. In one study
up to 70% of patients with vertically unstable fractures
of closed reductions, 92% of iliac wing and SI
reported acceptable results.
fracture-dislocations were reduced to within 1 cm of re-
Associated neurologic, urologic, and lower extremity
sidual displacement. Fractures may be treated with in-
injuries are the most common causes of long-term dis-
ternal fixation using many different techniques, but suc-
ability, pain, and impaired function. Resolution of neu-
cessful closed reduction of the pelvic ring remains a rologic dysfunction has been seen in up to 50% of pa-
challenge. tients at long-term follow-up, with the L5 nerve root
Closed reduction of the pelvic ring is most successful being the least likely to regain normal function.
when applied early in the postinjury period. Open re- Sexual dysfunction after pelvic fracture has been
duction of posterior pelvic ring injuries has been shown noted in women. Dyspareunia was reported in 43% of
to result in accurate reductions but increases the risk of female patients who had more than 5 mm of residual
posterior wound complications. Infection rates after displacement. In another study of functional outcomes
open reduction and internal fixation of the posterior after pelvic fracture, 44% of patients reported signifi-
pelvic ring are reported to be 4%. Significant pos- cant sexual dysfunction after unstable pelvic injuries. A
terior soft-tissue injury should be considered a relative study of erectile dysfunction after pelvic fracture found
contraindication to a formal, open posterior approach. that 30% of male patients who were sexually active af-
ter pelvic fracture reported some degree of erectile dys-
function; those patients sustaining symphyseal disrup-
Iliosacral Screw Fixation
tions reported the greatest dissatisfaction. Disruption of
Iliosacral screws are used in the internal fixation of SI
the cavernosal nerves has been implicated in this com-
dislocations, fracture-dislocations, and sacral fractures.
plication.
The placement of these screws is technically demanding Urologic injury may result in a significant compro-
and requires a thorough knowledge of the three- mise in patient outcome after pelvic fracture. Urethral
dimensional anatomy of the posterior pelvic ring. Com- stricture, incontinence, and erectile dysfunction may
mon bony anatomic variants such as transitional verte- complicate the treatment of urethral injuries, particu-
brae and hypoplastic first sacral segments may larly delayed perineal reconstruction. Patients who un-
complicate or preclude the safe placement of iliosacral dergo early endoscopic primary realignment have been
screws. Screw malposition has been reported to be as shown to have a lower rate of incontinence and impo-
high as 13% and may be associated with serious compli- tence when compared with patients who have delayed
cations. In one study, 8% of patients treated with iliosac- open repair. Management of concurrent urologic
ral screw fixation had errant screws and neurologic trauma may impact the treatment of the patient’s skele-
complications. These findings highlight the need for tal injury. In up to 35% of patients, orthopaedic treat-
careful screw placement, adequate imaging, fracture re- ment was altered because of urologic intervention.
duction, and surgeon familiarity with the procedure. It
has been suggested that the increased proprioceptive Acetabular Fractures
feedback that is obtained by using an oscillating drill Acetabular fractures are usually the result of high-energy
rather than a threaded guide-wire may allow for safer injuries and are frequently associated with other skeletal,
and more accurate screw insertion. Some surgeons rec- visceral, or abdominal injuries. The position of the hip at
ommend the use of electromyogram monitoring during the time of injury and the direction of impact will deter-
screw insertion. If this device is used, the anode must be mine the fracture pattern. A detailed patient evaluation is
located at or beyond the patient’s midline. mandatory to identify life-threatening associated injuries,

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Figure 4 The classification system of Letournel and Judet.

complications associated with the acetabular fracture, and and may be later recognized by the presence of a fluctu-
other skeletal injuries requiring treatment.Approximately ant circumscribed area of cutaneous anesthesia and ec-
one half of patients with an acetabular fracture will have chymosis. These injuries should be treated with débride-
an injury to another organ system. ment and delayed acetabular fixation because of the
Although hemodynamic instability occurs infre- significant incidence of positive bacterial culture from
quently with isolated fractures of the acetabulum, per- these lesions.
sistent unexplained blood loss despite resuscitation may
be caused by vascular injury. Fractures involving the Diagnosis and Classification
greater sciatic notch may injure the superior gluteal ar- The diagnosis of acetabular fractures begins with appro-
tery, requiring angiography and selective embolization. priately positioned, well-penetrated, plain radiographs.
Neurologic injury is frequently associated with fractures The AP pelvis radiograph and the Judet views (45° ob-
of the acetabulum and may be present in up to 20% of turator and iliac oblique) are needed for accurate inter-
patients. The peroneal division of the sciatic nerve is the pretation and fracture classification. A CT scan can bet-
most frequently injured. Closed reduction of associated ter define rotational displacements, intra-articular
hip dislocations should be performed as quickly as pos- fragments, marginal articular impactions, and associated
sible to reduce the risk of osteonecrosis of the femoral femoral head injuries. A three-dimensional CT recon-
head. Persistent subluxation of the hip may be caused struction may be helpful in understanding the relation-
by either the fracture displacement or from intra- ships between multiple sites of injury, but is not a re-
articular fracture fragments and should be treated with placement for plain radiographs. The classification
urgent skeletal traction to prevent the head from wear- system of Letournel and Judet, which groups acetabular
ing against the fracture edge or incarcerated fragment. fractures into five elementary and five associated frac-
Soft-tissue degloving injuries (Morel-Lavallé lesions) ture patterns, is used to classify the fractures (Figure 4).
may be initially recognized by a fluid wave on palpation The interobserver and intraobserver reliability of the

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able. Secondary congruence alone, therefore, is neces-

sary but not a sufficient criterion for nonsurgical treat-
ment. The criteria also do not apply to fractures of the
posterior wall. It is believed that at least 50% to 60% of
the width of the posterior wall on the CT scan must be
intact for satisfactory clinical outcome after nonsurgical
treatment. Smaller fractures of the posterior wall may
allow hip subluxation; stress radiographs taken while
the patient is under anesthesia may be useful in deter-
mining whether surgical intervention is required.
Nonsurgical treatment is also appropriate for non-
displaced acetabulum fractures. Although it has been
suggested that percutaneous fixation of nondisplaced
fractures allows earlier mobilization of multiply injured
patients, some physicians believe that nondisplaced frac-
tures are unlikely to displace even with early mobiliza-
tion. CT or fluoroscopic-guided percutaneous fixation
remains investigational in the treatment of acetabular
Figure 5 Measurement of the posterior and medial roof arcs as measured on the
iliac oblique (A) and the AP (B) radiographs. fractures.
In addition to fracture location and displacement,
patient-related factors such as age, preinjury activity
classification has been found to be excellent on the basis level, functional demands, and medical comorbidities
of plain radiographs alone; the CT scan did not improve must be considered when determining whether a patient
reliability. However, CT has been reported to be more is best served by surgical or nonsurgical treatment. Non-
accurate than plain radiographs in measuring the true surgical treatment of elderly or infirm patients, with
magnitude of articular displacement. planned subsequent arthroplasty if symptomatic arthri-
tis develops, may be appropriate—particularly if the
Nonsurgical Treatment fracture displacement is minimal.
Fracture displacements of greater than 3 mm are gener-
ally treated surgically. Certain fractures, however, may Surgical Treatment
be amenable to nonsurgical treatment. Roof arc mea- Open anatomic reduction and internal fixation is the
surements are a means of determining fractures with an treatment of choice for displaced fractures of the ace-
intact weight-bearing dome, which is defined as having tabulum. The goal of surgical treatment is to obtain an
medial, anterior, and posterior roof arcs of greater than anatomic reduction of the articular surface while avoid-
45° as measured on the AP, obturator, and iliac oblique ing complications. This treatment restores the contact
radiographs. Geometric analysis has shown that the cra- area between the femoral head and the acetabulum,
nial 10 mm of the acetabulum on the CT scan corre- produces a stable painless joint, and maximizes the po-
sponds to the area defined as the weight-bearing dome tential for long-term survival of the hip (Figure 6). Clin-
by roof arcs (Figure 5). It has been postulated that frac- ical outcome is correlated with the quality of the articu-
tures that do not involve this dome are unlikely to lead lar reduction. The results of perfect reductions (less than
to posttraumatic arthrosis and are candidates for non- 1 mm of residual displacement) are superior to those of
surgical treatment. Prerequisites for nonsurgical treat- imperfect (1 to 3 mm) and poor (greater than 3 mm) re-
ment of associated acetabulum fractures include both ductions at long-term follow-up. Other factors associ-
intact roof arc measurements and congruence of the ated with poor outcomes are femoral head injuries and
femoral head to the intact acetabulum on nontraction postoperative complications.
AP and Judet radiographs. Roof arc measurements are
not applicable to associated both-column fractures be- Surgical Approach
cause there is no intact portion of the acetabulum to The choice of surgical approach is determined by the frac-
measure. Instead, perfect secondary congruence of an ture pattern. A single surgical approach is generally se-
associated both-column fracture on all three standard lected with the expectation that the fracture reduction and
radiographs, taken when the patient is out of traction, is fixation can be completely performed though the one ap-
necessary for nonsurgical treatment. Although a frac- proach.The most commonly used surgical approaches are
ture healed with secondary congruence may have an ad- the Kocher-Langenbeck and the ilioinguinal approaches.
equate articular surface, the resultant shortening of the The extended iliofemoral approach is an extensile ap-
limb and medialization of the hip may not be accept- proach developed to allow maximal simultaneous access

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Figure 6 A, Associated transtectal transverse plus posterior wall acetabular fracture in an 18-year-old woman. B, AP and Judet radiographs at 3 years after injury. The patient’s
hip is rated 6,6,6 on the modified D’Aubigne and Postel scale.

to both columns of the acetabulum. It is most often used Complications

in associated fracture patterns that are surgically treated The primary complication after fracture of the acetabu-
more than 21 days after injury or on certain transverse or lum is posttraumatic arthrosis. Although symptomatic
both-column pattern fractures with complicating features arthritis after acetabular fracture is generally treated
that are not amenable to treatment by either of the two with arthroplasty, arthrodesis and osteotomy remain via-
more limited approaches. Modifications of all three ap- ble treatment options. Posttraumatic arthritis is more
proaches have been described; however, long-term clini- common after poor articular reductions than after a per-
cal outcomes of large numbers of patients are not avail- fect reduction. Evidence shows that, if arthritis develops
able for comparison. after a perfect reduction, the onset is later and the pro-
Closed reduction and percutaneous screw fixation of gression slower than arthritis that develops after a poor
acetabular fractures has not been shown to achieve reduction.
comparable articular reductions when compared with
Heterotopic ossification is related to the degree of
traditional surgery. Because there is a strong correlation
soft-tissue disruption, from either the injury or the sur-
between accuracy of reduction and clinical outcome,
gical approach. Other factors associated with the forma-
such techniques should be considered investigational
tion of heterotopic ossification include head injury, pro-
until appropriate results and long-term outcome data
longed mechanical ventilation, and male gender. Use of
are available.
an extensile approach also contributes to the formation
of heterotopic ossification and is probably caused by the
Posterior Wall Fractures
amount of muscle dissection and elevation from the il-
Posterior wall fractures are the most common type of ac-
ium. Most patients who develop heterotopic ossification
etabular fracture. Although they account for nearly one
after acetabular fracture do not have functional restric-
third of all acetabular fractures, patients with this type of
tions of their hip motion. Prophylactic treatments for
fracture have a disproportionate number of poor out-
heterotopic ossification include 6 weeks of indometha-
comes. Suboptimal outcomes have been reported in up to
cin use, single-dose external beam radiotherapy, or a
32% of patients with these injuries despite perfect reduc-
tions in 92% to 100% of the fractures. Risk factors for combination of both treatments. In a direct comparison
poor outcome are delay in reduction of associated hip dis- of irradiation with indomethacin use, no difference was
location, age older than 55 years at the time of injury, shown in the development of heterotopic bone. In the
intra-articular comminution, and osteonecrosis. When same study, 38% of the patients who were not treated
postoperative CT is added to the routine evaluation of the with prophylaxis developed clinically significant hetero-
posterior wall fracture, however, the association between topic ossification when compared with 7% in those pa-
fracture reduction and clinical outcome is reinforced. The tients who received some form of prophylaxis. Other
CT scan may be more accurate (particularly in the eval- prospective randomized studies have failed to confirm
uation of multifragmentary posterior wall fractures) in de- the efficacy of indomethacin use compared with no pro-
termining true residual fracture displacement and identi- phylaxis. Because of concerns about the use of irradia-
fying small articular malreductions.Articular reduction of tion in young adults, prophylaxis with indomethacin is
the posterior wall fracture as measured by CT was found preferred by many physicians. One study, however,
to strongly correlate with long-term outcome. showed an increased incidence of long bone nonunion

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Pelvis and Acetabulum: Trauma Orthopaedic Knowledge Update 8

in patients treated with indomethacin for concurrent ac- the AP pelvic radiograph at identifying pelvic fracture in the
etabular or pelvic fractures. awake, alert trauma patient.
Deep venous thrombosis and pulmonary embolism
are common complications after pelvic or acetabular Griffin DR, Starr AJ, Reinert CM, Jones AL, Whitlock
fractures treated without prophylaxis. Chemoprophy- S: Vertically unstable pelvic fractures fixed with percuta-
laxis with low molecular weight heparin or warfarin so- neous iliosacral screws: Does posterior injury pattern
dium may reduce the incidence of thromboembolic dis- predict fixation failure? J Orthop Trauma 2003;17:399-
ease, particularly in association with mechanical 405.
prophylaxis. Duplex ultrasound is typically used preop- Sixty-two patients were treated with closed reduction and
eratively to identify patients with venous thrombosis, percutaneous iliosacral screw fixation for posterior pelvic ring
however, it is limited in its ability to detect proximal injuries. Results show that sacral fractures were significantly
thrombi. Despite earlier studies that suggested that more likely to displace than other posterior lesions. Twenty
magnetic resonance venography was more sensitive percent (6 of 30) of sacral fractures displaced and 67% of
than ultrasound at detecting proximal thrombi, an eval- those required revision fixation surgery.
uation of contrast CT and magnetic resonance venogra-
phy showed a significant false positive rate in both stud-
Kabak S, Halicik M: Tuncel M Avsarogullari L, Baktir
ies. This finding was confirmed by invasive contrast
A, Bastruk M: Functional outcome of open reduction
venography. If thrombi are present, the placement of an
and internal fixation for completely unstable pelvic ring
inferior vena caval filter is recommended before frac-
fractures (type C): A report of 40 cases. J Orthop
ture surgery.
Trauma 2003;17:555-562.
Iatrogenic neurologic injury has been reported in
This study involved 40 patients with type C pelvic frac-
2% to 15% of patients who were surgically treated for
tures. At 1-year follow-up, sexual dysfunction was found in
acetabular fractures. Intraoperative neurologic monitor-
44% of patients and correlated with anxiety disorder and ma-
ing has been recommended but there is no evidence jor or moderate depression. Seventy-two percent of patients
that the routine use of monitoring lowers the incidence had returned to work at their original jobs, and of those who
of iatrogenic injury. A direct comparison of monitored did not, an increased incidence of depression was found. Per-
and nonmonitored acetabular fracture surgeries used sistent pelvic pain was reported by 25% of patients.
both sensory and motor pathway monitoring but failed
to show a difference in the incidence of iatrogenic nerve
injury. Most orthopaedic trauma surgeons use prophy- Mayher BE, Guyton JL, Gingrich JR: Impact of urethral
laxis to help prevent heterotopic ossification and deep injury management on the treatment and outcome of
venous thrombosis; however, nerve monitoring is not concurrent pelvic fractures. Urology 2001;57:439-442.
In 61 patients with combined pelvic and lower urinary
routinely used.
tract injuries, urologic treatment affected the orthopaedic
treatment choices in 35% of patients. Long-term suprapubic
Annotated Bibliography catheterization precluded surgical treatment in four patients;
Pelvic Fractures three had poor results. The authors recommend early endo-
Eastridge BJ, Starr A, Minei JP, O’Keefe GE, Scalea scopic realignment for urethral injuries and improved commu-
TM: The importance of fracture pattern in giving thera- nication and cooperation between subspecialty groups.
peutic decision-making in patients with hemorrhagic
shock and pelvic ring disruptions. J Trauma 2002;53:446-
Miller MT, Pasquale MD, Bromberg WJ, Wasser TE,
451.
Cox J: Not so FAST. J Trauma 2003;54:52-59.
In 86 patients with pelvic fracture with persistent hemody-
In this study, 359 patients with blunt abdominal injury
namic instability, abdominal hemorrhage was responsible for
were evaluated with focused assessment with sonography for
hypotension in 85% of stable pelvic fractures. Hemorrhage
trauma (FAST) and contrast CT of the abdomen and pelvis.
was from pelvic sources in 59% of patients with unstable frac-
ture patterns. Patients with unstable fracture patterns had a FAST resulted in an underdiagnosis of intra-abdominal injury
higher mortality (60%) when celiotomy was performed before with a false negative rate of 6% (27% of the false negatives
angiography when compared with patients in which angiogra- required laparotomy). The authors recommended that CT
phy was performed first (25% mortality). with contrast remain the gold standard for the evaluation of
patients with suspected blunt abdominal injury.

Gonzalez RP, Fried PQ, Bukhalo M: The utility of clini-

cal examination in screening for pelvic fractures in blunt Moudouni S, Tazi K, Koutani A, Ibn Attya A, Hachimi
trauma. J Am Coll Surg 2002;194:121-125. M, Lakrissa A: Comparative results of the treatment of
In this study, 2,176 trauma patients were evaluated. post-traumatic rupture of the membranous urethra with
Ninety-seven patients (4.5%) were diagnosed with a pelvic endoscopic realignment and surgery. Prog Urol 2001;11:
fracture. Clinical examination was found to be as sensitive as 56-61.

396 American Academy of Orthopaedic Surgeons

 Orthopaedic Knowledge Update 8 Chapter 32 Pelvis and Acetabulum: Trauma

In this study, 29 men with urethral injuries had primary en- and intraobserver reliability. J Bone Joint Surg Am 2003;
doscopic urethral realignment. At an average follow-up of 5.6 85-A:1704-1709.
years, improved rates of continence, potency, and stricture for- The intraobserver and interobserver reliability of the
mation were found when compared with rates for patients Letournel-Judet classification system for acetabular fractures
who had delayed open urethroplasty. The authors recom- was assessed by surgeons who studied with Letournel, sur-
mended early realignment as an effective and safe technique. geons who specialize in acetabular fracture surgery, and gen-
eral orthopaedic trauma surgeons. The reliability of the classi-
fication was excellent in the first two groups. Use of the CT
Pehle B, Nast-Kolb D, Oberbeck R, Waydhas C, Ruch-
scan in addition to the plain radiographs did not increase the
holtz S: Significance of physical examination and radiog-
reliability of the classification system.
raphy of the pelvis during treatment in the shock emer-
gency room. Unfallchirurg 2003;106:642-648.
In this study, 979 blunt trauma patients were evaluated for Burd TA, Hughes MS, Anglen JO: Heterotopic ossifica-
pelvic instability. Physical examination alone had a sensitivity tion prophylaxis with indomethacin increase the risk of
of 44% and a specificity of 99% for detecting pelvic fracture. long-bone nonunion. J Bone Joint Surg Br 2003;85:700-
Surgically significant pelvic injury could not be reliably ruled 705.
out by examination alone. Patients receiving indomethacin for heterotopic ossifica-
tion prophylaxis were compared with those receiving external
radiation therapy. The 38 patients receiving indomethacin had
Reilly MC, Bono CM, Litkouhi B, Sirkin M, Behrens a statistically significant increase in the incidence of long bone
FF: The effect of sacral fracture malreduction on the fracture nonunion compared with the 38 patients receiving ex-
safe placement of iliosacral screws. J Orthop Trauma ternal radiation therapy (26% versus 7%). No difference in
2003;17:88-94. the efficacy of both methods of prophylaxis was found in the
In a cadaveric model of a zone 2 sacral fracture, increasing authors’ previous study.
cranial displacement of the hemipelvis was found to correlate
with a decrease in the space available for the safe placement
of iliosacral screws. Space available for safe screw placement Burd TA, Lowry KJ, Anglen JO: Indomethacin com-
was insufficient at displacements greater than 1 cm. pared with localized irradiation for the prevention of
heterotopic ossification following surgical treatment of
acetabular fractures. J Bone Joint Surg Am 2001;83:
Rommens PM, Hessmann MH: Staged reconstruction of 1783-1788.
pelvic ring disruption: Differences in morbidity, mortal- In this study, 166 patients were treated surgically for a
ity, radiologic results, and functional outcome between fracture of the acetabulum. Seventy-eight patients received ex-
B1, B2/B3, and C-type lesions. J Orthop Trauma 2002;16: ternal beam radiotherapy, 72 received 6 weeks of indometha-
92-98. cin, and 16 patients received no prophylaxis. Grade 3 or 4 het-
A review of functional outcome of 122 patients with surgi- erotopic ossification developed in 7% of the treated groups
cally treated pelvic ring injuries was done. Mortality was higher and 38% of the untreated group. No difference between the
in patients with type C injuries than in those with type B two treated groups was identified.
(15% versus 5%). Higher rates of anatomic reductions were
found in B1 (open-book) injuries than in lateral compression
injuries (B2, B3) or C-type injuries. Good or excellent out-
Haidukewych GJ, Scaduto J, Herscovici D Jr, Sanders
RW, DiPasquale T: Iatrogenic nerve injury in acetabular
comes were obtained in 74% of patients with B1 injuries, 92%
fracture surgery: a comparison of monitored and un-
with B2/B3 injuries, and 71% of those with C injuries.
monitored procedures. J Orthop Trauma 2002;16:297-
301.
Starr AJ, Griffin DR, Reinert CM, et al: Pelvic ring dis- This article is a retrospective review of acetabular fracture
ruptions: Prediction of associated injuries, transfusion surgery performed with and without somatosensory evoked
requirement, pelvic arteriography, complications, and potential or electromyography nerve monitoring. The use of
mortality. J Orthop Trauma 2002;16:553-561. intraoperative nerve monitoring did not decrease the rate of
In a review of 325 trauma patients with pelvic ring injury, iatrogenic nerve palsy. Seven of 10 iatrogenic nerve injuries in
the presence of shock on arrival in the emergency department the monitored group had previously had normal intraopera-
was associated with increased mortality, transfusion require- tive monitoring.
ments, and injury severity score. Mortality of patients present-
ing in shock was 57%. The authors were unable to identify an Moed BR, Carr SE, Gruson KI, Watson JT, Craig JG:
association between fracture classification and outcome or Computed tomographic assessment of fractures of the
fracture presence and/or type of associated injuries. posterior wall of the acetabulum after operative treat-
ment. J Bone Joint Surg Am 2003;85-A:512-522.
Acetabular Fractures In this study, 67 patients with surgically treated posterior
Beaule PE, Dorey FJ, Matta JM: Letournel classification wall acetabular fractures were evaluated for radiographic and
for acetabular fractures: assessment of interobserver functional outcome at a mean of 4 years after injury. Use of

American Academy of Orthopaedic Surgeons 397

Pelvis and Acetabulum: Trauma Orthopaedic Knowledge Update 8

postoperative CT scanning to document reduction revealed a ual, and reproductive function. J Orthop Trauma 1997;
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wall fractures was more accurately determined on the CT scan Dalal SA, Burgess AR, Siegal JH, et al: Pelvic fracture
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In the largest published study to date, the authors present
Am 1987;18:25-41.
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A prospective comparison of magnetic resonance venogra-
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either test as the sole means of screening for pelvic deep Routt ML Jr, Simonian PT, Mills WJ: Iliosacral screw
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398 American Academy of Orthopaedic Surgeons