Eur Radiol (2002) 12:13121330

DOI 10.1007/s00330-002-1446-7

N. H. Theumann
J. P. Verdon
E. Mouhsine
A. Denys
P. Schnyder
F. Portier

Published online: 24 April 2002

Springer-Verlag 2002
Categorial Course ECR 2003

N.H. Theumann () J.P. Verdon

A. Denys P. Schnyder F. Portier
Department of Radiology,
CHUV, Rue du Bugnon,
1011 Lausanne, Switzerland
e-mail:
Nicolas.Theumann@chuv.hospvd.ch
Tel.: +41-21-3144584
Fax: +41-21-3144554
E. Mouhsine
Department of Orthopaedic Surgery,
CHUV, Rue du Bugnon,
1011 Lausanne, Switzerland

EMERGENCY RADIOLOGY

Traumatic injuries: imaging of pelvic fractures

Abstract Pelvic trauma includes a

great variety of very polymorphous
lesions, differing from each other by
their anatomical aspect, their context
and therapeutic implication: In order
to be efficient, the radiologist first
has to know diagnostic value of each
radiological technique, in order to
suggest the investigation strategy
appropriate to any clinical situation.
Then, he must be able to accurately
describe fractures and to include
them into a classification in agreement with the clinician. Pelvic fractures form a polymorphous group.
In the isolated acetabular fractures,
function is mainly at stake. Radiological assessment relies upon goodquality plain films completed by CT
imaging in fine slices with multiplanar reconstruction. Letournels classification remains the reference standard. Management consists mainly

Introduction
Pelvic trauma includes a great variety of very polymorphous lesions, differing from each other by their anatomical aspect, context, and therapeutic implications:
1. Isolated bone tear needing no particular treatment
2. Acetabular fractures with major functional prognosis
3. High-energy trauma with pelvic ring disruption, vital
lesions, and hemorrhage implying emergency hemostasis
In order to be efficient, the radiologist first has to know
diagnostic value of each radiological technique, in order
to suggest the investigation strategy appropriate to any

of re-establishing a joint congruence

to prevent early coxarthrosis. Pelvic
fractures often occur in violent trauma and are associated with visceral
lesions, putting vital prognosis at
stake. Radiological assessment must
be included in multidisciplinary
management and CT imaging stands
for the most complete and least timeconsuming device, allowing for investigation of both visceral and osseous lesions. In case of hemodynamic
shock, external fracture stabilization
and embolization of pelvic bleeding
are preponderant. Tile/Association
for Osteosynthesis classification is
the most used presently. It allows
good description of mechanisms
and lesions and more adapted management.
Keywords Trauma Pelvic fractures
Fractures

clinical situation. Then, he must be able to accurately describe fractures and to include them into a classification
in agreement with the clinician.

Incidence
Pelvic ring fractures amount to 1.5% of all joint fractures
[1, 2]. Simple fractures without great displacement mainly affect elderly female patients with low-energy trauma.
Severe displaced lesions affect younger, essentially male
patients in a context of high-energy trauma, resulting in
multiple trauma (polytrauma) in 75% of cases [3, 4, 5].
Melton et al. [1] reported 175 pelvic fractures over

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10 years, including 84 fragmented and isolated lesions,

71 simple pelvic ring ruptures, and 20 severe fractures;
among the latter, 48% were provoked by high-energy
trauma and 2% by simple falls. The average age of the
first group was approximately 33 years, whereas in the
second, it was approximately 69 years. Low-energy trauma provoked fragmented or simple lesions in 95% of
cases. Gender ratio was 2 women for 1 man. Pohleman
et al. [6] report 200 serious fractures (10.5%) out of a series of 1409 cases within 20 years. The most frequent
causes of pelvic trauma relate to car accidents (5060%)
and carpedestrian crash (1418%) [7, 8, 9, 10, 11]. In a
recent review of traffic accidents, 4.1% of cases presented pelvic ring lesions; among these, 47% of cases were
car passengers, 31% pedestrians, 12% motorcyclists, and
10% cyclists [12]. In the same group, only those belt-fastened patients, for whom the speed gradient exceeded
30 km/h, suffered pelvic ring lesions, whereas the unbelted ones suffered lesions with lower speed gradients.

Anatomy and biomechanics

Pelvic ring
The pelvis is a ring composed of three bones: the sacrum
dorsally, and two innominate bones frontal medially. The
sacrum joins to the innominate bone by the sacroiliac
(SI) joints. The two innominate bones join frontally by
the symphysis pubis. The innominate bone includes three
separate ossifications: the ilium; the ischium; and the pubis (Fig. 1). The posterior stability of the ring is assumed
by the posterior tension band, which includes the posterior and interosseous sacroiliac ligaments. This ligamentous complex and the sacrotuberous ligaments resist vertical translation between the ilia and the sacrum. The anterior sacroiliac, symphyseal, and sacrospinous ligaments are transversely oriented and resist rotation of the
pelvis (Fig. 1) [13, 14]. For the pelvis, the instability is
defined by two displacements: rotational and vertical.
The forces, caused by rotational displacements, tend either to open and externally rotate the pelvis, or to close
and internally rotate it. Vertical instability indicates disruption of the posterior tension band and implies craniocaudal, rotational and antero-posterior displacement
[13].
Three basic mechanisms lead to pelvic ring disruptions [15, 16, 17]. They are based on the direction of the
force imparted to the pelvis at the time of injury:
Antero-posterior compression
The antero-posterior (AP) compression injury pattern
(Fig. 2)is due to a force directly applied to the pubis or to
the posterior pelvis and results in iliac external rotation

Fig. 1a, b Normal pelvic ligaments. a Anterior view; b posterior

view. 1 Interosseous sacroiliac ligament; 2 anterior sacroiliac ligaments; 3 sacrospinous ligaments; 4 sacrotuberous ligaments;
5 symphysis pubis; 6 posterior sacroiliac ligaments

deformity. The symphyseal separation suggests damage

to the ligamentous structures and possible instability.
The presence of a vertical obturator ring fracture, a diastasis of both the symphysis pubis and the sacroiliac
joint are important points of this pattern and serve as stability hallmarks [13, 14, 16, 18].
Lateral compression
The lateral compression injury pattern (Fig. 3) or iliac
internal rotation injury is the result of a lateral blow to
the side of the pelvis. This fracture affects either one or
both sides of the pelvis ring. Anteriorly, the fracture
fragments frequently override the adjacent fragments.
Posteriorly, the fracture fragments are impacted (mainly

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Fig. 3 Lateral compression. 1 Impacted fractures of the sacrum;

2 horizontal overlapping ring fracture; 3 internal rotation of the
left hemi-pelvis

Fig. 2a, b Antero-posterior (AP) compression. a Low energy;

b high energy. 1 Symphysis diastasis; 2 sacrospinous and sacrotuberous ligament disruption; 3 anterior sacroiliac ligament disruption; 4 posterior sacroiliac ligament disruption

in elderly patients), or there is a diastasis of the sacroiliac joint (mainly in the younger patients, sometimes associated with ligamentous disruption) [13, 16, 18, 19].
Vertical shear
The vertical shear pattern (Fig. 4) is often an unstable
state, when it appears after a vertical axial fall, with presence of anterior and posterior fractures of the pubic rami,
fractures of the sacrum, sacroiliac diastasis, or iliac wing
fracture. A typical finding is always present as a superior
and usually asymmetric displacement of the involved
hemi-pelvis secondary to the vertical axial fall [17].

Fig. 4 Vertical shear pattern. 1 Note both anterior and posterior

ligamentous disruption; 2 obturator ring fractures

The acetabulum
The acetabulum is composed of two columns: the large
anterior one and the small posterior one. An inverted
Y is formed by these two columns which support the
hip (Fig. 5) [20, 21, 22, 23]. The anterior column begins
at the inferior pubic ramus and extends above the acetabulum into the iliac wing. The posterior column is shaped
by the ischium and extends to the greater sciatic notch
and the sacroiliac. The inferior junction of the two columns forms the ischio-pubic junction. The quadrilateral
plate shapes the medial wall of the acetabulum. It is a
thin layer of bone between the hip joint and the pelvis. In
addition to the two columns, the bone stability of the hip

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Fig. 6 Normal anatomy, AP view. 1 Anterior lip; 2 posterior lip;

3 roof; 4 ilio-ischial line; 5 iliopectineal line; 6 teardrop; 8 arcuate
line

Fig. 5 Normal acetabular anatomy. 1 Inverted Y; 2 iliopectineal

line; 3 anterior wall; 4 ischial tuberosity; 5 posterior wall; 6 sciatic
notch

is increased by the presence of an anterior and a posterior wall, the latter being larger than the former.
Basic fracture mechanisms are developed with the
classifications given later.

Imaging
Plain films
Antero-posterior view of the pelvis is the basic incidence
for pelvic trauma. It allows identification of ischio-ilial
line, iliopectineal line (iliopubic line), as well as anterior
and posterior acetabular walls (Fig. 6). The iliopectineal
line is formed by the anterior structure of acetabulum.
The ilio-ischial line is formed by posterior structures of
the acetabulum [24].
More specifically to each type of fracture, numerous
incidences have been evaluated among which Pennals
are mostly used in pelvic ring investigations and Judets
in acetabulum investigations.

Fig. 7 Inlet view. 1 Anterior lip; 2 posterior lip; 3 roof; 4 iliopectineal line; 5 anterior border of the sacral body

Pelvic ring investigation

Pelvic inlet (tube angled 45 caudad; Fig. 7) and outlet
(tube angled 45 cephalad; Fig. 8) views may be added
to AP view when pelvic fracture is suspected [13, 16, 19,
23, 25]. They are known as Pennals incidences. Inlet
view is best to display AP displacement of hemi-pelvis
as well as horizontal rotation, whereas outlet view allows

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Fig. 8 Normal anatomy, outlet view. 1 Anterior lip; 2 posterior

lip; 3 roof; 4 iliopectineal line

to identify vertical displacement, superior displacement

of hemi-pelvis thus being evaluated in comparison with
the levels of posterior elements. Anteriorly, symphysis
pubis and pubis rami are inspected, whereas posteriorly
iliac crests, sacrum, sacral foramina, sacroiliac joints,
and L5 transverse processes are evaluated to rule out
possible injuries. Particular attention is paid to the sacrogluteal line, which corresponds to the continuation of the
iliopectineal line around the greater sciatic notch and onto the body of the sacrum. This hallmark is useful to
identify posterior fractures. The arcuate lines of the sacrum representing the dense cortical bone between the
sacral foramina should also be examined. A distortion or
break of it highlights a lesion [26].
Acetabular investigation
If an acetabular fracture is suspected, three more incidence are mandatory in addition to AP view: an AP view
centered on the injured hip and two Judets oblique
views obtained with patient rotated 45 right posterior
oblique (iliac oblique view; Fig. 9) and left posterior
oblique (obturator oblique view; Fig. 10), in the supine
position [27]. In majority of cases, these four incidences
are sufficient to classify these fractures and to propose
therapeutic strategy.
The two oblique views and the classical AP view of
the hip allow to identify the six fundamental landmarks:
the acetabular roof; the acetabular anterior lip; the acetabular posterior lip; the ilioischial line; the iliopectineal
(iliopubic) line; and the tear drop. The ilioischial line is
shaped by posterior parts. The iliopectineal line is

Fig. 9 Normal anatomy, iliac oblique view. 1 Anterior lip; 2 posterior lip; 3 roof; 4 greater sciatic notch

shaped by anterior parts of the acetabulum. If disruption

of the landmarks are noted on plain films, the fracture
can often be classified properly. The iliac oblique view
shows the iliac wing, useful to display a fracture that extends above the acetabulum into the iliac wing. The obturator oblique view shows fractures of the obturator
ring, of the posterior wall of the acetabulum, and of the
greater sciatic notch [28].
Computed tomography
Diagnostic value
Computed tomography has become an outstanding tool
in pelvis imaging [29]. Its technological improvements
(helicodal and Multidetector technologies) have recently
increased its potentialities. In some cases its performanc-

1317

Moreover, CT allows complete investigation of visceral pelvic lesions and of associated thoracic, abdominal, and even brain lesions [36, 37].
Indications
Because of its performances, CT indications tend to increase. For Hunter et al. [17], they are detailed as follows:
1.
2.
3.
4.
5.

Acetabular fractures
Dislocations of the hip
All potential or recognized sacral fractures
All potential or recognized sacroiliac injuries
Any question of stability in pelvic fractures

Technical considerations
Several protocols can be taken into consideration according to the context:

Fig. 10 Normal anatomy, obturator oblique view. 1 Anterior lip;

2 posterior lip; 3 roof; 4 pelvic brim

es have proved to be superior to plain films. Approximately 30% of pelvic fractures detected by CT are
missed by plain films [19, 30]. In sacral trauma, plain
films missed 29% of sacroiliac diastasis, 57% of acetabular rim fractures and 34% of vertical shearing fractures
[31]. Plain films also missed up to 40% of intra-articular
fragments and 50% of femoral head fractures visualized
with CT [21, 32]. It must be mentioned that detection of
additional fractures will change patient management [32,
33]. Computed tomography has some limitations. Some
authors relate false negatives [34], but confrontation
with new-generation CT device might show better results; however, plain films should never be overlooked,
mainly in the initial evaluation. In acetabular fractures,
for instance, CT remains insufficient in the characterization of certain fractures, whereas plain films allow better
understanding of its findings [23, 35].

1. In case of pelvic trauma, complete pelvis investigation may be performed with 5-mm slices every 5 mm
allowing for a wide area of investigation, from above
the iliac crests down to the ischia, with a sufficient investigation quality. Depending the context, an intravenous contrast agent injection is useful to investigate
visceral lesions in one action. Associated examination
of the abdomen seems mandatory as abdomen and
pelvis remain the same traumatic entity [36, 38].
Computed tomography acquisition should occur at
least 60 s after injection of contrast agent to make
sure of a good visceral impregnation and mainly to allow for the detection of an active hemorrhage (contrast agent leak). Such a protocol allows appreciation
of both osseous and visceral lesions.
2. If an acetabular lesion is suspected from the clinical
examination and plain films or during detection CT imaging, thinner slices, ranging between 1 and 3 mm,
joint or overlapping, are mandatory. They allow better
analysis of the lesions and good-quality multiplanar reconstructions. If not performed before, a systematic investigation of all the pelvis with 5-mm slice thickness
is recommended to complete acetabular examination
3. Multiplanar reconstructions are useful to the interpretation of complex fractures, mainly for the acetabulum. They often need thinner acquisition (3 mm slices
or less) and overlapping reconstruction to improve
imaging quality; however, even with 5-mm thickness
slices acquisitions, multiplanar reconstructions may
be of interest. In this latter case quality may be improved by overlapping of axial slices. Reconstruction
in anatomical planes may be added to the classic sagittal and frontal reconstruction planes (e.g., sacrum
plane, iliac wing plane)

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4. A 3D reconstruction is favored by surgeons but

should only be used as a tool to the understanding of
complex fractures, in particular for the acetabular
fractures or important displacements of the fragments.
Their reading should always be achieved with axial
and/or multiplanar reconstructions, which remain the
best analysis tools.
5. In case of doubt about sacral lesions, acquisitions in
the oblique coronal plane, inclining the gantry according to the great sacral axis, often improve imaging
quality. But, in most cases, multiplanar reconstructions are sufficient.
Multislice CT and pelvic trauma
Multidetector technology allows extended possibilities in
trauma investigation: large area of exploration; faster acquisition; thinner thickness of slices; and easy reformation in the appropriate plane. At our institution, pelvic
investigation of multiple-trauma patients is systematically included in a complete thoracic, abdominal, and pelvic
examination realized with multislice CT (5-mm slices
every 5 mm after contrast agent intravenous injection).
Slices may be secondarily reconstructed in 2.5-mm
thickness in case of suspected lesions. This protocol is
used in our hospital for more than 1 year (approximately
300 patients explored). It allows faster and accurate detection of visceral and osseous lesions in one action.
Secondary multiplanar and 3D reconstructions with
2.5-mm slice thickness are of great quality even for acetabular fractures. If needed, better quality can be obtained with 1.25- or 1-mm slice thickness in addition to
initial exploration.
Magnetic resonance imaging
Some studies have shown the superiority of MR imaging
under particular circumstances such as the detection of
intra-articular splinters, appreciation of the femoral head,
and detection of hidden fractures mainly in the elderly
[39]; however, its use remains minor with pelvic trauma
in the acute phase.

several fracture categories according to the mechanism

of lesion: AP or lateral compression or vertical shearing.
Thus are set the bases of most of the classifications established so far. In 1981, Bucholz [40] gave a clear definition of the anterior and posterior pelvic ring and insisted on the frequent occurrence of unknown lesions of the
posterior ring. They suggested an anatomical classification based on the importance of these lesions of the posterior ring.
In the late 1980s, Tile and Young developed two classifications which have been the most used in past years.
Tile [14, 41, 42, 43] modified Pennals classification. He
introduced the idea that management of these fractures
was directly related to the importance and direction of
instability. So, he insists on the importance of the appreciation of the stability. But the classification did not include description of complex fractures. Fractures are
classified using their principal elementary lesion. At the
same time, Young et al. developed a classification
(Young and Burgess classification), including mechanism of the lesion and radiographic (AP plain film) grading of severity. This classification emphasizes the level
of energy imparted [7, 34]. They also noted that the
mechanism may not always be identified and therefore
introduced the category called combined mechanical injury. Later, Dalal et al. [9] demonstrated that YoungBurgess classification could be of value in predicting associated injuries and in prioritizing the work-up during
resuscitation of acutely ill patients.
However, all these classifications still remain difficult
to apply. On one hand, the link between trauma mechanism and anatomical lesions can be difficult to define.
On the other hand, the appreciation of lesion stability remains ill-defined in emergency cases as it often relies on
incompletely validated radiological criteria. Tile, in association with the thoughts of a working group of the
Association for Osteosynthesis (AO), suggested an alphanumerical classification in order to harmonize the
therapeutic management and the prognostic evaluation
(Table 1) [14, 44]. This Tile/AO classification seems to
be the most frequently used presently. It is our reference
classification. It allows to describe the mechanisms involved, the elementary lesions, and the therapeutic consequences implied.
Tile/AOs classification suggests three subdivided
main categories (A, B, C; Fig. 11).

Classifications
Pelvic ring fractures

Type-A fracture

One of the first descriptions of pelvic fracture (iliac wing

fracture) was reported by Duverney in 1751 [26]. Until
the 1950s, classifications of pelvic ring fractures were
only based on anatomical descriptions of the lesions.
Pennal and Sutherland [15] suggested the first mechanistic classification of these fractures. They distinguished

Type-A fracture is an incomplete fracture with neither

disruption of the pelvic ring nor lesion of the posterior
band (Fig. 11a).
Type A1 corresponds to an avulsion fracture of the
pelvic ring. It usually concerns teenagers at the end of
their growth and may involve the anteriorsuperior, ante-

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Table 1 Tile/AO classification of pelvic fractures

Mechanism

Anterior
compression

Classification

Features

Stability

Type A

A1: apophyseal avulsions

A2: stable iliac wing fracture or stable minimally
displaced ring fracture
A3: sacro-coccygeal fractures

Stable

Type B1

External rotation or open-book injuries

Partially stable (complete rupture of anterior arch,

incomplete rupture of posterior arch)

B1.1: unilateral antero or sacro-iliac disruption

B1.2: sacral fracture
Lateral
compression

Type B2

Internal rotation injuries

Partially stable (complete rupture of anterior arch,

incomplete rupture of posterior arch)

B2.1: anterior compression fracture of the sacrum

B2.2: partial sacroiliac joint fracture
B2.3: incomplete posterior iliac wing fracture
Anterior
compression

Type B3

Bilateral external rotation (bilateral open book)

Partially stable (complete rupture of anterior arch,

incomplete rupture of posterior arch)

B3.1: bilateral B1
B3.2: B1 and B2
B3.3: bilateral B2
Vertical
rshea

Type C

C1: complete unilateral rupture

Unstable (complete rupture of both anterior

and posterior arches)

C1.1: iliac fracture

C1.2: sacroiliac dislocation
C1.3: sacral fracture
C2: bilateral injury (B+C types)
C3: bilateral complete rupture

riorinferior, or ischial spine. The avulsion of the anteriorsuperior spine is caused by the sudden contraction of
the sartoris, whereas that of the anteriorinferior spine is
caused by the contraction of the rectus femoris. The
avulsion of the pubic tubercle is caused by the contraction of the pectineus (Fig. 12).
Type A2.1 corresponds to a stable iliac wing fracture
caused by direct blow on the ilium and does not involve
pelvic ring which remains stable (Fig. 13).
Type A2.2 relates to a stable, minimally, or undisplaced fracture of the pelvic ring and usually affects elderly women with osteoporosis after a fall. The mechanism corresponds to a lateral compression, cracking the
pubic rami. (Fig. 14).
Type A2.3 relates to anterior ring fractures or four pillar fractures and involves the four pubic rami frontally,
without posterior injury. These fractures are caused by a
direct blow or by a high-energy trauma of shearing or
lateral compression (Fig. 15).
Type A3 are sacral or coccygeal fractures.
Type A3.1 implies fractures of the coccyx or sacrococcygeal dislocation which are common after a sitting
fall and may be the source of prolonged pain, but no neurological disability is observed. The transverse fractures
of the sacrum distal to the gluteal line do not involve the
pelvic ring.
Type A3.2 relates to undisplaced fractures and rarely
causes neurological deficit.

Type A3.3 corresponds to displaced and translated

fractures with injury to the sacral nerve roots.
Type-B fracture
Type-B fracture relates to disruption (or fracture) of the
symphysis pubis, associated with anterior sacroiliac joint
disruption (unilateral or bilateral) (Fig. 11b). The posterior sacroiliac ligaments, responsible for the vertical stability, remain untouched. The typical lesion is caused by
an AP compression applied to the anteriorsuperior iliac
spines of the fixed pelvis. A posterior blow against the
posteriorsuperior iliac spines may produce a similar
fracture. Displacement of the symphysis pubis is an important feature of this type. If the splitting of the symphysis pubis is smaller than 2.5 cm, it cannot be associated with a disruption of either the pelvic floor or the
sacro-spinous ligament. But if it is wider than 2.5 cm,
then it is often associated with a disruption of either the
pelvic floor or the sacro-spinous ligament. In the latter
case, a much higher occurrence of visceral injury is observed.
Type B1 relates to a unilateral open-book injury
usually caused by a violent external rotation of one femur. The typical situation is that of the motorcyclist who
puts out a leg for balance and gets caught by a stationary
object such as a road panel or a tree. The external rota-

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Fig. 12 Type-A1 fracture, AP view. Fracture avulsion of the right

antero-inferior iliac spine

Fig. 11ac Tile classification. Black areas represent fractures

zones. a Lesion sparing or with no displacement of posterior
arch. b Incomplete disruption of posterior arch, partially stable.
c Complete disruption of posterior arch, unstable

tion force usually disrupts the symphysis pubis first, and

as the external rotation goes on, a disruption of the pelvic floor, of the fascia, of the sacrospinous, and of anterior sacroiliac ligaments follows.
The variants include B1.1 (sacroiliac joint anterior
disruption) and B1.2 (sacral fractures; Fig. 16).
Type B2 relates to lateral compression injuries characterized by unilateral partial disruption of the posterior
arch maintaining the vertical or posterior stability (internal rotation). A lateral compressive force directed at the
pelvic ring may cause two types of injury, the first in
which the anterior and posterior lesions occurs on the
same side of the pelvis, and the second in which the displacement is shown on the opposite side. In the latter
case, the relative stability is maintained by the osseous

Fig. 13 Type-A2.1 fracture. Isolated right iliac wing fracture

impaction (no muscle or ligament tears). Variants include

B2.1 (anterior crush fracture of the sacrum), B2.2 (partial sacroiliac joint fracture/subluxation), and B2.3 (incomplete iliac fracture; Figs. 17, 18).
Type B3 stands for the classical, bilateral openbook injury. Despite the relative stability of the pelvic
ring, maintained by the posterior sacroiliac ligaments,
the pelvic floor disruption causes visceral injuries. Variants include B3.1 (bilateral B1), B3.2 (B1 on one side
and B2 on the other side), and B3.3 (bilateral B2;
Fig. 19).

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Fig. 14 Type-A2.2 fracture, AP view. Left unilateral pubic rami

fractures

Fig. 16 Type-B1.1 fracture. Unilateral open-book injury. A 3D

CT scan. Symphyseal disjunction and anterior sacroiliac disruption

Fig. 15 Type-A2.3 fracture, AP view. Bilateral pubic rami fractures

Type-C fracture
Type-C fracture relates to unstable injuries with complete
disruption of the posteriorsacroiliac complex, involving
vertical shearing forces (FIGURE). These unilateral or bilateral fractures are almost always caused by severe trauma such as falls from heights, crushing injuries, or motor
vehicle accidents. They cause massive disruption of both
the pelvic ring and the surrounding soft tissues.
Type C1 corresponds to unilateral injuries of the
hemi-pelvis.
Type C1.1 relates to sheer fractures of the ilium,
which begin at the inferior part of the sacroiliac joint and
run to the iliac crest at the rear.
Type C1.2 stands for sacroiliac dislocations. These
fractures can only be associated with extreme violence,

Fig. 17a, b Type-B2.1 fracture. Lateral compression, stable

fracture. a An AP view. Left pubic rami fracture. b A CT
scan. Anterior compression fracture of right superior sacroiliac
joint

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Fig. 19a, b Type-B3 fracture. a An AP view. Open-book lesion

with symphyseal diastasis and bilateral sacroiliac disruption. b An
AP view. Same patient after external fixation and reduction of diastasis

as the sacroiliac ligaments are the strongest in the human

body (Fig. 20)
Type C1.3 deals with fractures of the sacrum caused
by high-energy shearing forces.
Type C2 stands for bilateral injuries of the pelvis ring
in which one side remains partially stable and thus corresponds to a type-B injury, e.g., in sacral fractures, whereas the opposite relates to an unstable type-C injury such
as an iliac fracture (Fig. 21).
Type C3 deals with bilateral injuries in which both
hemi-pelves are unstable (Fig. 22).
Fig. 18ac Type-B2.3 fracture. Lateral compression. Partially stable fracture. a A CT scan. Partial left iliac wing fracture. b A CT
scan. Internal symphyseal displacement. c A 3D CT scan. Left iliac wing fracture, internal rotation of left hemi-pelvis

Incidence
Type-A lesions represent up to 52%, type B up to 27%,
and type C up to 21% of all cases [12]. Type-B and typeC lesion percentage grows with the speed implied in the
trauma.

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Fig. 20ae Type-C1.2 fracture. Major trauma, unstable fracture of

pelvic ring. a An AP view. Symphyseal diastasis, left sacroiliac
disruption and iliac wing fracture. b Outlet view. Note the ascension of the left hemi-pelvis related to complete posterior ligaments
disruption. c The inlet view confirms the posterior displacement of
the left iliac wing. d Same patient after temporary external fixation. e Same patient after internal fixation

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Fig. 22 Type-C3 fracture. Bilateral instability. An AP view. Bilateral iliac wings fractures, symphyseal disjunction

Fig. 21a, b Type-C2 fracture. Bilateral sacral fracture complete

on the right (unstable) and incomplete on the left side (stable).
a An AP view. Bilateral pubic rami fractures and right sacral fracture. Note the rupture of right arcuate lines. b Axial CT scan

Fig. 23a, b Acetabular fractures. Letournel and Judets classification. a Elementary fractures. 1 Posterior wall fracture; 2 posterior
column fracture; 3 anterior wall fracture; 4 anterior column fracture; 5 transverse fracture. b Associated fractures. 1 Two-column
fracture; 2 transverseposterior wall fracture; 3 T-type fracture;
4 anterior wall posterior hemi-transverse fracture; 5 posterior column posterior wall fracture

Classification of acetabular fractures

1.
a.
b.
c.
d.
e.

Elementary fractures
Anterior wall fractures
Anterior column fractures
Posterior wall fractures
Posterior column fractures
Transverse fractures

2.
a.
b.
c.
d.
e.

Associated fractures
T-shaped fractures
Complete two-column fractures
Transverse and posterior wall fractures
Posterior column and posterior wall fractures
Anterior column posterior hemi-transverse fractures
(uncommon)

The study of acetabular trauma is closely connected to

Letournel and Judets works. After establishing the bases
of standard radiography from outstanding anatomical
studies which allowed them to introduce the concept of
the two columns of the hip bone, they developed a classification of acetabular fractures still in use presently
[27, 45].
This classification is divided into ten patterns, consisting of five elementary and five associated patterns
(Fig. 23). Elementary fractures run in a single plane,
whereas associated fractures are combinations of elementary patterns.

1325

Fig. 24ac representation Axial plane representation of main

fracture orientation depending on fracture type. (Level: roof of the
acetabulum). a Wall fracture. b Column fracture. c Transverse
fracture

Acetabular fractures are uncommon, and thus this classification remains difficult to remember; however, among
these ten fracture types, five of them are very common:
complete two-column, transverse, T-shaped, transverse
with posterior wall and posterior wall fractures constitute
approximately 90% of acetabular fractures; thus, knowledge of these five types allows correct assessment of
90% of all acetabular fractures [35]. Grouping the different categories could be another way to simplify this classification. Brandser et al. [35] suggest three major categories: transverse-type fractures; column-type fractures;
and wall-type fractures. Computed tomography is helpful in recognizing these three categories by identifying
main orientation fracture on a slice through the roof of
the acetabulum (Fig. 24) [17, 46].
We prefer Tiles grouping [14] in anterior, posterior,
and transverse fractures. In our experience, these groups
are easier both to memorize and to identify from radiological data (Figs. 25, 26, 27, 28).
Anterior fractures
Anterior fractures include the anterior wall and the anterior column fractures. They are often associated with a
pelvic fracture, and, as such, are considered as pelvic
ring rather than acetabulum fractures. These injuries are
caused by a lateral blow to the greater trochanter when
the leg is externally rotated. An anterior hip dislocation
is rarely associated, when compared with posterior fracture types, and is almost always associated with posterior
hip dislocation. With anterior injury, the complications
are less frequent and the overall prognosis remains better
than in other types [14]. The anterior wall fracture usually begins at the anteriorinferior iliac spine and passes

Fig. 25ac Posterior wall fracture. a An AP view. b Axial CT

scan. c A CT sagittal reconstruction confirms posterior wall fracture and suggests potential posterior instability

1326

Fig. 27 Transverse posterior wall fracture. Axial CT scan. Note

the sagittal fracture line and the arrachment of the posterior wall
associated with posterior luxation of the femoral head

Fig. 26a, b Two-column fracture of the acetabulum. a Axial CT

scan at the level of the roof of the acetabulum. b Axial CT scan.
Extension of the fracture into the iliac wing

below through the cotyloid fossa up to the junction of

the articular dome and the superior ramus. The anterior
column fracture is characterized by a fracture line that
extends from the middle of the pubic ramus to any point
above the anterior segment of the iliac crest [28].
Posterior fracture
Posterior fractures include the posterior wall and the
posterior column fractures. Posterior fractures are usually caused by a blow to the flexed knee (also called dashboard injury), and therefore, associated knee injuries are
common. Posterior dislocation of the hip is frequent and
almost always presents when the posterior wall is fractured. This complication affects the prognosis, since the
prevalence of vascular necrosis and sciatic nerve lesions

Fig. 28a, b Anterior column fracture in a 3D CT scan. a Anterior

view illustrates the orientation of the fracture. b Posterior view
demonstrates integrity of posterior column

is markedly increased [14]. The posterior wall fracture is

identified by a disruption of the posterior border, best
seen on the obturator oblique view. The posterior column
fracture is completely detached, because it usually originates in the greater sciatic notch, and then crosses the

1327

weight-bearing dome and the obturator foramen. Plain

films show medial displacement of the femoral head
[28].
Transverse and T-type fractures
Transverse and T-type fractures are commonly caused by
high-energy shearing forces. They appear simple but often have the worst prognosis. In a pure transverse fracture, the fracture line extends transversely from the anterior to the posterior column. So the weight-bearing dome
portion remains attached to the ilium. This type of fracture presents three subdivisions:
1. The transtectal transverse fracture which goes through
the weight-bearing dome
2. The juxtatectal transverse fracture which occurs just
above the cotyloid fossa
3. The infratectal transverse fracture which affects the
whole weight-bearing dome
The T-type essentially consists of a transverse fracture
with a vertical component, splitting the cotyloid fossa.
The posterior column thus becomes a loose fragment [28].

Pelvic trauma management

Clinical evaluation
Cross questioning and anamnesis should define the type
and mechanism of trauma. A high-energy mechanism relates to crush lesions, traffic accidents, and defenestration, whereas a low-energy mechanism relates to being
dumbfounded or to muscular contractions. Defining the
initial shock spot leads to a particular mechanism and a
certain type of lesion: AP compression relates to openbook lesions; lateral impact on the great trochanter or
iliac wing is associated with rotation lesions, and shearing strain in axial trauma on one or both members (defenestration, dashboard syndrome) connects with unstable lesions of the posterior ring. Investigation should
look for impact lesions or graze on the pelvis, whereas
clinical check-up should look for pain at palpation or
pelvic manipulation. The value of this clinical investigation varies according to the patients state:
1. In a patient without spinal column lesion, a normal
clinical status of the pelvis rules out pelvic ring fracture and thus radiological investigation need not be
performed [47, 48].
2. On the other hand, if pain occurs at palpation or manipulation, or if the clinical findings cannot be trusted
for sure (unconscious or intoxicated patient, spinal
column lesion), radiological investigation is mandatory; however, one must be careful in pelvic clinical

evaluation which may lead to aggravation of fracture

displacement or hemorrhage
Imaging strategies
Regarding imaging stategies, initial clinical evaluation
leads to different situations.
Minor trauma limited to the hip
Radiological appraisal must include four basic incidences: AP pelvic view; front-hip view; and oblique
views. Normal views of good quality can rule out fractures. In case of doubt or recognized lesion, further exploration with CT is highly advisable. This allows to
confirm fracture, to define its characteristics, to look for
associated lesions, and to plan surgical management.
Major trauma
It should be carefully analyzed (see Table 2) whether or
not a trauma is predominantly pelvic or complex in a
conscious or unconscious patient. In any case, the patient
must be considered as polytraumatized with possible
hidden visceral or osseous lesions. Radiological assessment must be included in a multi-disciplinary approach
and correspond to pre-established protocols in order to
optimize management:
1. First, AP pelvic view as well as AP thoracic and profile cervical spine views should be performed in any
patient. Inlet and outlet views may complete assessment, systematically or on request.
2. Patients hemodynamic state will then lay down further proceeding:
a. If patients hemodynamic state is unstable, treatment
of hemorrhage is the priority. Bedside US abdominal
screening must be performed.
b. In case of abnormal US or thoracic views, hemorrhage management is suggested first.
c. In case of isolated pelvic fracture with normal US and
thoracic views, indication for angiography with possible hemostatic embolization must be determined (after external pelvic fixation).
3. In case of stable hemodynamics, complete body lesion (visceral and osseous) assessment should be performed. Thoracic, abdominal, and pelvic investigation
is advisable in the same examination with whole-body
CT (as described above). It leads to the more specific
and least time-consuming assessment and allows better therapeutic management.

1328

Table 2 Young-Burgess classification of pelvic fractures.

SP symphysis pubis; ST sacrotuberous ligament; SS sacrospinous

ligament; ASI, PSI anterior and posterior sacroiliac ligaments,

respectively; R rotationally; V vertically; P posteriorly

Fracture type

Classification

Features

Stability

Anterior
compression

Antero-posterior
compression:
Types IIII

External rotation or open-book injuries

Type I: SP disrupted ST, SS, ASI, and PSI spared
Type II: SP, ST, SS, and ASI disrupted PSI spared
Type III: SP, ST, SS, ASI, and PSI disrupted

Type I: stable
Type II: R unstable, V, and P stable
Type III: R, V, and P unstable
Type I: stable
Type II: R unstable, V stable
Type III: R unstable, V stable

Lateral
compression

Lateral compression:
Types IIII

Internal rotation injuries

Type I: ipsilateral sacral compression
Type II: type I with associated iliac wing fracture
Type III: types I or II with contralateral open-book
injury (windswept pelvis)

Vertical shear

Vertical shear

Disruption of SP, ST, SS, ASI, and PSI

Vertical displacement of one hemi-pelvis
Posterior disruption may include sacral or iliac
fractures with sparing of ASI and PSI

R, V, and P unstable

Complex

Complex

Variable

Variable

Treatment
The great variety of clinical situations explains the diversity of possible treatments. Some principles can be established, keeping in mind that therapeutic indications rely
on precise lesion assessment [42, 49].
In case of pelvic ring lesions, stabilization of patients hemodynamics must first be achieved. This may
consist of external fracture stabilization, in surgical hemostatic treatment or in hemostatic embolization. The
radiologist has to know the importance of angiography
in the management of hemorrhagic blows in pelvic trauma. The external fixation of fracture is essential for hemodynamic stabilization, contributing to hemostasis
[50, 51]. A 2-cm symphyseal diastasis can increase pelvic volume in the adult from a normal of 1.5 l to as
much as 5 l [17].
After completing hemostasis, the choice of orthopedic
management will rely on the associated visceral (neurological, thoracic, or abdomino-pelvic) or osseous (femoral or acetabular) lesions. Type-A lesions rarely lead to
surgical fixing. Type-B or type-C lesions usually need
osteosynthesis; because of the latters complexity, a clear
evaluation of the real profit implied by surgical fixing
must be made. It should consider neurological complications, skin necrosis, and sepsis. If surgery is required, it
must be completed within the first 3 weeks after trauma
to prevent lesions from becoming fixed or irreducible. If
performed, internal fixation allows easier reduction and
stabilization of fracture and facilitates patient mobilization.
For the acetabulum, emergencies consist of the associated displacement of the femoral head, which must be
reduced immediately. A suspected injury of the gluteal
artery with a sciatic notch fracture is also an emergency

and has to lead to angiography with possible embolization in mind. In other cases, reduction of an acetabular
fracture is not an emergency and best recovers when
treated within the third to seventh day after trauma.
In all cases, the main preoccupation must be the restoration of the articular congruence in order to prevent
early coxarthrosis; however, the indications are often
difficult to come to terms with, due to, for example,
fracture complexity, age, osseous potential, associated
lesions.
In cases of association of pelvic ring and acetabular
fractures, priority is given to pelvic ring fracture management.

Complications
Death rate
Death rate in pelvic trauma ranges between 5 and 15%,
but may reach 50% of cases [2, 6, 7, 8, 9, 19, 52, 53].
The cause of death relates directly to pelvic trauma in
12% of cases [2]. This rate is closely connected to the
associated lesions, to the importance of trauma, and to
the patients age [25, 54]. The Injury Severity Score
(ISS) and patients hemodynamic state seem to be the
best prognostic indicators. The value of the fracture
type as a prognostic tool has also been evoked. In
Pohlemanns series, death rate amounts to 11.7% in the
A, 14.9% in the B, and 23% in the C types [3]. The best
prognostic improvement factors are multidisciplinary
management and early fracture fixing [55, 56, 57]. For a
same ISS and comparable age group, the death rate can
be reduced threefold in case of early fracture management [58].

1329

In pelvic fractures with intense bleeding, mainly in

case of pelvic ring disruption, transfusion is mandatory
in nearly 50% of cases [8]. These hemorrhages cause
half of the fatalities [59] and may sometimes occur in
isolated acetabular lesions.
Associated lesions
Associated vascular and visceral lesions are frequent. In
brief, brain lesions occur in 2655% and abdominal lesions in 1626% of cases [19, 60, 61]. Pulmonary lesions
are frequent, with aortic isthmus rupture occurrences increased six times when attributed to pelvis fractures [62,
63, 64]. Lower urinary track lesions are found in 417%
of cases in the urethra and 525% of cases in the bladder
[19, 65, 66, 67, 68]. Ano-rectal or gynecological lesions
are rare and most often secondary to open trauma. Peripheral nerve lesions represent 10% of cases, mainly
complicating sacrum fractures (40% of cases) [69]. Posterior femoral head dislocation goes along with sciatic
lesions in 20% of cases [45].

Conclusion
Pelvic fractures form a polymorphous group:
1. In the isolated acetabular fractures, function is mainly
at stake. Radiological assessment relies on good-quality plain films completed by CT imaging in fine slices
with multiplanar reconstruction. Letournels classification remains the reference standard. Management
consists mainly of re-establishing a joint congruence
to prevent early coxarthrosis.
2. Pelvic fractures often occur in violent trauma and are
associated with visceral lesions, putting vital prognosis
at stake. Radiological assessment must be included in
multidisciplinary management and CT imaging stands
for the most complete and least time-consuming device,
allowing for investigation of both visceral and osseous
lesions. In case of hemodynamic shock, external fracture stabilization and embolization of pelvic bleeding
are preponderant. Tile/AOs classification is the most
used presently. It allows good description of mechanisms and lesions and more adapted management.

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