Pelvic Ring Injuries
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Direct answer
Pelvic ring injuries are disruptions of the sacroiliac and pubic complex, which the Young-Burgess classification sorts by injury mechanism and the Tile classification by stability. Haemorrhage is the main early threat, so a pelvic binder is applied over the greater trochanters on suspicion, with external fixation or angioembolisation used if bleeding persists.
What you must remember
- Young-Burgess mechanisms: lateral compression, anteroposterior compression, vertical shear and combined mechanism, each with a typical pattern of injury.
- Tile classification: type A is stable, type B is rotationally unstable but vertically stable, and type C is both rotationally and vertically unstable.
- Lateral compression: the commonest mechanism, often with an ipsilateral sacral compression injury and pubic rami fractures.
- Vertical shear: a vertical displacement through the sacroiliac complex, a highly unstable pattern with greater haemorrhage and neurological risk.
- Pelvic binder: placed over the greater trochanters, not at the iliac crest, because the trochanters are the correct level to reduce pelvic volume.
- Haemorrhage control: binder, external fixation and pelvic packing in damage control, with angioembolisation for arterial bleeding.
- Associated injuries: urethral injury in a man with blood at the external meatus, bladder rupture and lumbosacral nerve injury must be sought.
A stepwise plan for the unstable pelvis
A 35-year-old man is struck by a truck and arrives tachycardic and hypotensive, with a widened symphysis on the first film. The steps follow the sequence a trauma team uses, with resuscitation and bleeding control running ahead of definitive fixation.
- Apply a binder. Place a pelvic binder over the greater trochanters on suspicion of pelvic ring disruption, and avoid placing it too high at the iliac crest.
- Resuscitate and examine. Give blood products according to the trauma protocol, and check for a urethral injury before any urethral catheter is passed.
- Image the pelvis. Obtain an AP pelvis with inlet and outlet views, and add CT once the patient is stable enough to travel safely.
- Classify the injury. Name the Young-Burgess mechanism and the Tile type, which together estimate stability and the likely bleeding risk.
- Control the bleeding. Use external fixation or pelvic packing for ongoing haemorrhage, and angioembolisation if arterial bleeding continues.
- Plan definitive fixation. Fix the posterior sacroiliac complex and the anterior symphysis once the patient is physiologically stable, with the construct chosen by the Tile type.
Where the exam tries to catch you
Pelvic ring questions usually test the bleeding priority and the stability grade.
- Trap: placing the binder at the iliac crest. Correct: the greater trochanters are the right level, because the crest is too high to close the pelvic volume effectively.
- Trap: catheterising a man with blood at the meatus. Correct: a urethral injury is suspected first, and urological advice is sought before any catheter is passed.
- Trap: treating a Tile B pattern as stable. Correct: it is rotationally unstable, so it needs fixation with a posterior or anterior construct according to the pattern.
Frequently asked questions
Which classification grades pelvic ring injuries by stability?
The Tile classification grades pelvic ring injuries by stability, with type A stable, type B rotationally unstable and type C rotationally and vertically unstable. The Young-Burgess classification complements it by describing the mechanism of injury.
Where should a pelvic binder be placed in a patient with pelvic fracture?
A pelvic binder should be placed over the greater trochanters, not at the iliac crest, to reduce pelvic volume effectively. It is applied on suspicion of pelvic ring disruption and tightened to control bleeding while definitive care is planned.
Which mechanism is the commonest in pelvic ring injury?
Lateral compression is the commonest mechanism of pelvic ring injury in the Young-Burgess scheme. Vertical shear is less common, but it is associated with greater instability and morbidity.
Which injury must be excluded before catheterising a man with a pelvic fracture?
A urethral injury must be excluded before catheterisation in a man with a pelvic fracture, especially if there is blood at the external meatus or a high-riding prostate. Urological advice should be sought before any urethral catheter is passed.