Pelvic fracture !

A pelvic fracture is a break in the ring of hip bones. High-energy breaks can bleed heavily and injure the bladder or urethra.

Updated 2026-11-01

Structures involved

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Why it happens

What it is

Fracture of the bony pelvic ring (hip bones, sacrum, pubic symphysis and sacroiliac joints). Low-energy fractures in older adults are often stable; high-energy fractures can disrupt the ring and cause life-threatening bleeding.

Who gets it

Pelvic fractures are a small share of all fractures but are frequent in polytrauma from motorcycle crashes, pedestrian injuries and falls from height, all common in Colombia. In older adults with osteoporosis they also follow simple falls.

Causes

Motorcycle and car crashes, pedestrians struck
Falls from height
Crush injuries
Low-energy falls in older adults with osteoporosis
Avulsion fractures in adolescent athletes

Risk factors

High-energy mechanism
Osteoporosis and older age
Motorcycle riding
Work at height

Pathophysiology

The pelvis is a ring, so a displaced break usually occurs in two places. Disruption, especially open-book injuries, increases pelvic volume and tears the posterior venous plexus, cancellous bone and sometimes branches of the internal iliac arteries; most bleeding is venous and retroperitoneal. Bone fragments and shearing can injure the bladder, urethra, rectum, vagina and lumbosacral nerves.

Classification

Stable versus unstable ring (mechanically and haemodynamically)
Young–Burgess by mechanism: lateral compression, anteroposterior compression (open book), vertical shear, combined
Tile: A stable, B rotationally unstable, C rotationally and vertically unstable
Open versus closed fracture
Acetabular fractures are classified separately

Symptoms and signs

Pain in the pelvis, groin or lower back that worsens with movement
Inability to walk or bear weight
Bruising or swelling of the perineum, scrotum or flank
Leg-length difference or rotation without a hip fracture
Signs of shock

Diagnosis

Clinical: ATLS primary survey; the pelvis is assessed once and gently, without repeated rocking that can restart bleeding. Look for perineal bruising, urethral blood and leg deformity, and examine the rectum and vagina for open injury.
Tests: Haemoglobin, blood group and crossmatch, lactate and base deficit, coagulation tests and urinalysis for blood.
Imaging: Anteroposterior pelvic X-ray and eFAST in unstable patients. Contrast CT defines the fracture and shows arterial blush in stable patients. Retrograde urethrogram before any bladder catheter when urethral injury is suspected; CT or conventional cystography for bladder injury.

Differential diagnosis

Hip fracture or dislocation
Acetabular fracture
Lumbar spine fracture
Intra-abdominal bleeding as the source of shock

Goal of treatment

Close the pelvic volume and stop bleeding, identify associated urological, rectal and abdominal injuries, then restore a stable ring that allows early mobilisation.

Treatment

Acute: Pelvic binder (or a sheet) centred on the greater trochanters, early balanced blood transfusion and tranexamic acid in bleeding patients.
Procedure: Angioembolisation for arterial bleeding seen on CT, preperitoneal pelvic packing when angiography is not available or bleeding persists, and endovascular aortic balloon occlusion as a bridge in selected centres.
Surgical: Temporary external fixation for unstable rings, later definitive fixation (open reduction and internal fixation) once the patient is physiologically stable.
Conservative: Stable low-energy fractures: pain control, early walking with aids as tolerated and thromboprophylaxis.
Follow-up: Nursing priorities: vital signs and signs of ongoing bleeding, binder position and skin checks, no urethral catheter until urethral injury is excluded, neurovascular checks of the legs and DVT prevention.

Complications

Haemorrhagic shock and death
Urethral stricture, erectile dysfunction and incontinence
Bladder rupture
Deep vein thrombosis and pulmonary embolism
Infection, especially in open fractures
Malunion, nonunion, chronic pain and leg-length discrepancy
Lumbosacral nerve injury

Prognosis

Stable fractures usually heal well. Mortality in unstable high-energy fractures is driven by bleeding and associated injuries; survivors may have long-term pain, gait problems and urological or sexual dysfunction.

Prevention

Road safety and motorcycle protective equipment
Fall prevention and osteoporosis treatment in older adults
Safety measures for work at height

Test yourself

Think of the answer, then tap the question to see it.

What is the first measure to reduce bleeding from an unstable pelvic fracture in the emergency department?

A pelvic binder (or sheet) centred over the greater trochanters to close the pelvic volume, along with blood transfusion.

Where does most bleeding in pelvic fractures come from?

The posterior pelvic venous plexus and the fracture surfaces; only a minority is arterial (branches of the internal iliac artery).

Which signs suggest a urethral injury and what must be avoided?

Blood at the meatus, a high-riding prostate or perineal haematoma; a urethral catheter should not be placed until a retrograde urethrogram excludes injury.

Which pelvic fracture pattern widens the pubic symphysis and is called open book?

Anteroposterior compression injury.

What are the options when a pelvic fracture keeps bleeding despite a binder?

Angioembolisation for arterial bleeding, preperitoneal pelvic packing and external fixation.

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Educational information, not medical advice. For any symptom, see a health professional.

Sources: Pelvic trauma: WSES classification and guidelines (World Journal of Emergency Surgery, 2017); Pelvic Fractures - OrthoInfo - AAOS (American Academy of Orthopaedic Surgeons (OrthoInfo), 2026).

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Representative model, for educational purposes only.

Hip bone highlighted on the Durgical 3D model