What is the diagnosis?

Bilateral pubic rami fracture with urethral injury seen on the retrograde urethrogram.

• Pearl: Pelvic fractures have a mortality of 10-13%, and up to 50% if unstable [1]. Pelvic ring fractures are often associated with venous plexus or arterial injury [2].

• Pearl: The Young-Burgess classification system differentiates pelvic ring fractures into three patterns based on the primary mechanism as well as the extent of injury and instability: Lateral Compression (LC), Anterior-Posterior Compression (APC), and Vertical Shear (VS) [1].

What is the mechanism of injury?

Pelvic fractures are seen in a bimodal distribution, with young men more likely to suffer from high energy trauma such as motor vehicle collisions and elderly females predisposed to osteoporosis more likely to suffer pelvic fractures after a low energy mechanism such as fall from standing [3].

• Pearl: AP and lateral compression fractures are commonly seen in roll-over MVCs or pedestrian-struck by motor vehicle. Vertical shear is more common with MVCs or falls from height where a significant force is transmitted upward through the lower extremities to the pelvis [4].

What physical exam findings are expected?

Expect tenderness to palpation of the pelvis and hips. Evaluate for pelvic stability with manual compression to bilateral iliac crests. Examine the abdomen and perineum for ecchymosis and associated injuries. The rectal exam is important to check for gross blood, tone and sensation to assess for visceral and neurological injury. Thoroughly evaluate the lower extremities to identify other fractures or neurovascular injuries [5].

Which imaging modalities can be used?

A portable AP pelvic x-ray should be obtained for a critical trauma patient and it can reveal 90% of pelvic injuries [5]. Look for any discontinuity in the “rings and lines” to assess for fractures. Other views can be used to isolate different parts of the bony pelvis including inlet, outlet, and Judet views [2]. 

CT is often preferred over multiple x-rays to better identify bony injuries and to aid in operative planning. CT can also be used to evaluate for associated injuries like retroperitoneal and intraperitoneal injuries [5].

What is the management in the ED?

Start with ATLS and remember that pelvic fractures are indicative of a high energy mechanism and you should systematically check for other injuries. A pelvic binder should be placed at the level of the greater trochanters for hypotensive pelvic fractures, particularly APC injuries. LC injuries have the potential to be exaggerated if a pelvic binder is placed too tightly [2,7]. VS injuries can be stabilized with skeletal traction [5]. Many of these patients will require resuscitation with blood products, angiography and embolization with Interventional Radiology, or external fixation [2,5].

What is definitive management?

Stable fractures including pubic rami fractures, APC I and LC I injuries may be treated nonoperatively with outpatient follow up, protected weight bearing and physical therapy. Unstable fracture patterns such as APC II/III, LC II/III, and Vertical Shear should be treated operatively with emergent orthopedic consultation and open reduction and internal fixation [2].

Addendum: Additional information about urethral injury and work-up

Retrograde urethrogram should be performed in male patients with pelvic trauma and blood at the urethral meatus, gross hematuria, difficulty voiding, perineal bruising, or a boggy prostate. A cystogram should be performed after ruling out urethral injury. Extravasation of contrast during these studies is suggestive of urethral or bladder injury, and Urology should be consulted [6].

Figure 2. Retrograde Urethrogram without extravasation. Case courtesy of Dr. Matt A. Morgan, Radiopaedia.org, rID: 40478.