Essr2017 P-0234 PDF

Traumatic pelvic fractures: How to identify and classify an
important sequelae of trauma
Poster No.: P-0234

Congress: ESSR 2017
Type: Educational Poster
Authors: S. Leach, V. T. Skiadas, C. Lord, N. Purohit; Southampton/UK
Keywords: Trauma, Safety, Diagnostic procedure, Plain radiographic studies,
CT, Musculoskeletal system, Musculoskeletal bone
DOI: 10.1594/essr2017/P-0234
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Page 1 of 39
Learning objectives
In this educational poster we will demonstrate the appearances of pelvic fractures on

Trauma CTs by mechanism of fracture in the Young and Burgess classification system.
This will allow the reader to identify acute fractures of the pelvic ring and characterise
them by mechanism in order to identify more subtle associated or higher grade injury.
The reader will then be able to assess trauma scans more effectively for pelvic fracture
and comment on fracture stability.
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Background
A large scale study covering 21 years of trauma in the UK has demonstrated that pelvic
fractures are a common sequela of trauma, affecting 8% of trauma patients [Giannoudis
et al, 2007]. There is also an increased risk of mortality in patients with pelvic trauma
(14.2%) versus those without (5.6%) at 3 months after injury. Some studies have also
demonstrated an increased mortality rate with certain fracture features such as fractures
of the obturator ring and pubic symphsis diastasis [Blackmore et al, 2006]. It is therefore
crucial that radiologists who report trauma, including general radiologists as well as
dedicated Musculoskeletal radiologists, are able to quickly and confidently identify and
characterise pelvic fractures in trauma patients.
Due to the importance of being able to quickly assess trauma scans for pelvic fractures
several classification systems have arisen, the most commonly used of which is the
Young and Burgess system, recommended by the British Society of Joint and Bone
Surgery [Guthrie et al, 2010]. The Young and Burgess system is based on classification
by mechanism of trauma, improving the ability of radiologists to identify more subtle injury
based on the expected fracture pattern, as well as to guide further management of the
patient based upon an estimate of instability [Burgess et al, 1990].
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Imaging findings OR Procedure Details
Young and Burgess Classification
The Young and Burgess classification of pelvic fractures is divided into 3 distinct
mechanisms of injury: anteroposterior compression, lateral compression and vertical
shear, with a further 4th classification of combined mechanism. Anteroposterior and
lateral compression injuries are divided into 3 grades of severity. The lower grades reflect
injury to only the anterior pelvic ring with the higher grades reflecting injury to the posterior
pelvis with consequent loss of stability [Burgess et al, 1990].
Injuries to the anterior part of the pelvic ring can be indicated by symphysis pubis
disruption or diastasis, or pubic rami fractures. The posterior pelvic fractures can be
fractures of the iliac bone, the sacrum or a fracture dislocation of the sacroililiac joint,
which is the most common posterior pelvic injury [Tile and Schatzker, 2005].
Anteroposterior compression (APC)
Anteroposterior compression grade 1
This classically refers to diastasis of the pubic symphysis caused by an anteroposterior

compressive force. A study of pelvic binders has shown that their use in pelvic trauma can
reduce pubic symphysis diastasis and open book fractures completely [Simpson et al,
2002]. These images demonstrate the appearances of an anteroposterior compression
grade 1 injury with a pelvic binder, when the injury to the pubic symphysis cannot be
appreciated, and without a binder in the same patient, where there is clear diastasis.
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Fig. 1: Axial Trauma protocol CT of pelvis, level of pubic symphysis. Anteroposterior
compression grade 1 with pelvic binder in situ.
References: Radiology, University Hospitals Southampton, Southampton General
Hospital - Southampton/UK
Page 5 of 39
compression grade 1, without pelvic binder (same patient as in Figure 1).
There is no disruption of the sacroiliac complex, therefore this is a stable fracture,

although the patient may go on to have operative fixation of the diastasis [Guthrie et al,
2010].
Grade 2 anteroposterior compression injury includes widening of the symphysis pubis

with additional widening of the anterior part of the sacroiliac joint. Injury to the ipsilateral
anterior sacroiliac ligaments, sacrotuberous and sacrospinous ligaments occurs with
widening of the sacroiliac joint anteriorly. The stronger posterior sacroiliac ligaments will
remain intact [Tile and Schatzker, 2005]. This fracture pattern is commonly described as
'open book'. As noted for Anteroposterior compression grade 1 injuries the use of pelvic
binders can reduce these fractures and make them more difficult to identify.
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compression grade 2.
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Fig. 4: Axial Trauma protocol CT of pelvis, level of sacroiliac joints. Anteroposterior
These axial CT images show widening and disruption of the pubic symphysis, with
posterior displacement of associated fractures of the pubic rami bilaterally. Comparing
the left sacroiliac joint (arrow) with the right we can see anterior widening of the
sacroiliac joint. These appearances indicate a potentially unstable pelvis. Knowledge of
the expected fracture pattern will allow you to identify this injury, which can be subtle.
Note that the posterior joint margin remains symmetrical with the right, indicating that the
posterior sacroiliac ligaments are intact.
Grade 3 anteroposterior compression fractures of the pelvis will incorporate pubic

symphysis disruption but unlike the grade 2 injury there will be disruption of the entire
left sacroiliac joint. This will mean that there is a 'floating' hemipelvis on the side of injury,
completely separated from the sacrum with complete disruption of the posterior sacroiliac
ligaments. These injuries are often associated with significant vascular injury [Burgess
et al, 1990].
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Page 9 of 39
Fig. 6: Axial Trauma protocol CT of pelvis, level of inferior sacroiliac joints.
Anteroposterior compression grade 3.
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Fig. 7: Axial Trauma protocol CT of pelvis, level of superior sacroiliac joints.
As in grade 2 injury there is diastasis of the pubic symphysis with obvious widening of the
sacroiliac joints anteriorly. However, at the caudal margin of the sacroiliac joints there is
a more subtle area of sacroiliac joint disruption (arrow) at the posterior sacroiliac joint.
Although a subtle injury (with the pelvic binder in situ) the posterior sacroiliac joint cannot
be disrupted without significant injury to the posterior sacroiliac ligaments, therefore this
indicates an unstable grade 3 Anteroposterior compression injury.
Vertical shear (VS)
Vertical shear fractures are not graded, however a vertical shear conforming to the classic
description indicates an unstable fracture in itself as there will be vertical displacement
of the ipsilateral hemipelvis relative to the sacrum and contralateral hemipelvis, with both
anterior and posterior diastasis. The anterior injury can be at the pubic symphysis or
pubic rami but vertical displacement will help separate from APC or LC type injury. This
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is often more easily appreciated on coronal or 3D reconstruction. The posterior injury will
often be though the sacroiliac joint but can also be through the sacrum or iliac.
Fig. 8: Axial Trauma protocol CT of pelvis, level of sacroiliac joints. Vertical shear.
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Fig. 9: Coronal reconstruction of trauma CT in patient with Vertical shear injury.
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Fig. 10: 3D reconstruction of trauma CT in patient with Vertical shear injury.
This case demonstrates fractures passing through the right sacral ala, with vertical
displacement of the fracture on coronal reconstruction. Note also the fracture of the right
L5 transverse process, onto which the iliolumbar ligament attaches, another key stabiliser
of the pelvis [Guthrie et al, 2010]. The 3D reconstruction also demonstrates clearly the
vertical disruption of the pubic symphysis. Although the right sacroiliac joint is intact the
vertical disruption of the sacral fracture indicates complete disruption of the posterior part
of the pelvic ring.
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Fig. 11: AP plain radiograph of Vertical shear injury after fixation.
Post operative plain radiograph demonstrates cannulated screw fixation across the righ
sacral alar fracture. There is also anterior fixation of the pubic symphysis.
Lateral compression (LC)
Lateral compression grade 1
In fractures due to lateral compression the impacted hemipelvis will rotate medially. In
a grade 1 injury this will cause transverse fractures of the pubic rami, with a lateral
compression fracture of the sacrum. There is no posterior ligamentous injury or inherent
instability to this fracture pattern.
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Fig. 12: Axial Trauma protocol CT of pelvis, level of inferior pubic rami. Lateral
Page 16 of 39
Fig. 13: Axial Trauma protocol CT of pelvis, level of sacroiliac joints. Lateral
These images show the transverse fracture of the right inferior pubic ramus, with
consequent minor medial displacment of the medial fracture fragment. Fracture of the
right superior pubic ramus was visible on other slices of the trauma scan. The 2nd image
is from a different patient and demonstrates the classic sacral compression fracture,
indicating a lateral compression injury.
This plain radiograph demonstrates the appearances of a lateral compression grade 1

injury. The right-sided pubic rami fractures are visible on the plain pelvic radiograph. The
associated sacral injury cannot be definitively identified on radiograph.
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Fig. 14: AP Plain radiograph of pelvis in patient with Lateral Compression grade 1
injury.
On axial STIR (Short Tau Inversion Recovery) MRI we can see that there is also a fracture
of the right sacral alar consistent with a grade 1 lateral compression injury. In addition
there is bone marrow oedema in the posterior iliac bone, consistent with bone contusion,
although no displaced fracture to indicate a higher grade lateral compression injury.
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Fig. 15: Axial STIR sequence MRI of pelvis at level of sacroiliac joint in patient with
Lateral Compression grade 1 injury.
Lateral compression grade 2 injury
In a grade 2 injury there will be the same fractures seen in a grade 1 lateral compression
injury, with the addition of a fracture of the ipsilateral iliac wing. The fracture of the
iliac wing tends to occur just anterior to the sacroiliac joint, as the strong posterior
sacroiliac joints will usually keep the iliac in situ at the sacroiliac joint, forming a crescent
fracture [Burgess et al, 1990]. As these fractures involve an iliac wing fracture through
the posterior ring they will usually be fixed in order to stabilise the pelvis.
Page 19 of 39
Fig. 16: Axial Trauma protocol CT of pelvis, level of inferior pubic rami. Lateral
Page 20 of 39
Page 21 of 39
Fig. 18: AP Plain radiograph of Lateral compression grade 2 injury.
This case demonstrates the right sided pubic rami fractures and characteristic right iliac
crescent fracture. Note that on the plain radiograph of the same patient the pubic rami
fractures are obvious, but the iliac fracture is much more difficult to define.
Lateral compression grade 3
In high impact injury the internal rotation of the ipsilateral hemipelvis will continue, causing
forced external rotation of the contralateral pelvis. This is known as a 'windswept pelvis'.
There will be disruption to the pelvic ring in both hemipelvises, causing bilateral instability.
The LC grade 3 description does not necessarily indicate disruption and displacement of
the posterior ring and therefore these injuries may be desribed as 'partially stable' rather
Page 22 of 39
than 'completely unstable' if the posterior sacroiliac ligaments are still intact [Tile and
Schatzker, 2005].
Fig. 19: Axial Trauma protocol CT of pelvis, level of sacroiliac joints.Lateral

Page 23 of 39
Fig. 20: Coronal reconstruction of Trauma protocol CT of pelvis, level of superior pubic
rami. Lateral compression grade 3.
In this severe grade 3 LC injury we can see that there is internal rotation of the left
hemipelvis with external rotation of the right hemipelvis and widening of the right anterior
sacroiliac joint. The sagittal reconstruction demonstrates associated overriding of the
pubic rami at the pubic symphysis. However, there is also a comminuted fracture-
dislocation at the left sacroiliac joint indicating complete instability of the left sacroiliac
joint and a floating hemiplevis on the left.
Page 24 of 39
Fig. 21: AP plain radiograph of Lateral compression grade 3 injury after operative
fixation.
On the post operative radiograph we can see there has been fixation of both sacroiliac
joints, with a cannulated screw spanning both joints. In addition there has been fixation
of the left iliac fracture and across the pubic symphysis.
Combined mechanism (CM)
In combined mechanism there will be a combination of at least 2 of the other injury

patterns. The combined mechanism classification by itself iwll not imply instability.
Therefore it is important to study which injury patterns are present and then determine
where related fractures or displacement will cause instability.
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Fig. 22: Axial Trauma protocol CT of pelvis, level of acetabula. Combined mechanism.
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Fig. 23: Axial Trauma protocol CT of pelvis, level of sacroiliac joints. Combined
mechanism.
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Fig. 24: Coronal reconstruction of Trauma protocol CT of pelvis, level of superior pubic
rami. Combined mechanism.
The axial images shows comminuted fractures of the left pubic ramus and left iliac bone,
with internal rotation of the left hemipelvis, consistent with a grade 2 lateral compression
injury. On coronal reconstruction however there is also vertical displacement of the
superior pubic rami at the pubic symphsis. In addition there are superiorly avulsed
fragments of bone visible on the left with considerable soft tissue disruption and
subcutaneous air. The appearances are consistent with an open fracture due to combined
mechanism of lateral compression and vertical shear.
This MRI demonstrates a further case of combined mechanism injury. On the axial STIR
sequence there can be seen bilateral superior pubic rami fractures, which would be
consistent with an AP compression injury. On the coronal STIR sequence we can see
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a vertical fracture through the sacrum. This is not vertically displaced and is consistent
with a lateral compression injury.
Fig. 25: Axial STIR sequence MRI of Combined Mechanism injury at level of superior
pubic rami.
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Fig. 26: Coronal STIR sequence MRI of Combined Mechanism injury at level of
superior sacroiliac joints.
Associated injuries with pelvic fractures
In this combined mechanism injury the coronal CT reconstruction of the pubic symphysis
indicates vertical displacement through the symphysis consistent with vertical shear
mechanism. The axial images of the sacroiliac joint demonstrate a comminuted,
posteriorly displaced fracture of the left iliac wing extending into the sacroiliac joint. This
is consistent with anteroposterior compression mechanism.
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Fig. 27: Coronal reconstruction of Trauma protocol CT of pelvis, level of pubic
symphysis. Combined Mechanism.
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Fig. 28: Axial Trauma protocol CT of pelvis, level of sacroiliac joints. Combined
mechanism.
Axial CT on soft tissue windows clearly delineates gross soft tissue swelling and
haematoma anteriorly to the left sacroiliac joint. Internally there are several blushes of
contrast indicating active extravasation. While contrast can be seen in the right internal
and external iliac vessels these structures cannot be defined on the left and this patient
had significant vascular injury at surgery.
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Fig. 29: Axial Trauma protocol CT of pelvis, soft tissue reconstruction, level of iliac
bones. Combined mechanism.
On this axial CT on bone reconstruction there is a lateral compression grade 3 injury

of the pelvis. Axial CT of the pubic symphysis shows overriding of the symphysis, while
there is a subtly displaced fracture traversing the body of the sacrum.
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Fig. 30: Axial Trauma protocol CT of pelvis, level of pubic symphysis. Lateral
Page 34 of 39
Compression grade 3.
On the soft tissue windows of the same patient, slightly superiorly to the pelvis, there
is haematoma in the right paracolic gutter. There are blushes of contrast within this
haematoma, as well as adjacent to the mesenteric vessels. The right sided bowel is hypo-
enhancing relative to the left sided bowel and these appearances are consistent with
significant mesentery and bowel injury, confirmed at surgery. There is also a traumatic
tear of the right sided abdominal muscles with herniation of intra-abodminal fat. The
pattern of these right sided abdominal injuries is consistent with the lateral compression
injury indicated by the pattern of bone injury.
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Fig. 32: Axial Trauma protocol CT of pelvis, soft tissue reconstruction, level of L5.
Lateral compression grade 3.
Page 36 of 39
Conclusion
After reading this poster the radiologist will be familiar with classification of pelvic fractures
by mechanism. This will allow you to assess trauma and pelvic CT for subtle signs of
instability, in order to grade pelvic injury and help guide acute management and future
fixation.
Page 37 of 39
References
1. Giannoudis PV, Grotz MRW, Tzioupis C, Dinopoulos H, Prevalence of Pelvic

Fractures, Associated Injuries and Mortality: The United Kingdom Perspective. J Trauma
2007, 63: 875-883
2. Blackmore CC, Cummings P, Jurkovich GJ, Linnau KF, Predicting Major Haemorrhage
in Patients with Pelvic Fracture. J Trauma 2006; 61: 346-352
3. Guthrie HC, Owens R, Bircher MD, Focus on Pelvic Fractures. J Bone

Joint Surg,2010,http://www.boneandjoint.org.uk/sites/default/files/FocusOn_jun10.pdf
Accessed 14/04/2017
4. Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective
classification system and treatment protocols. J Trauma 1990;30:848-56
rd
5. Schatzker J, Tile M, Axelrod TS, The Rationale of Operative Fracture Care, 3 Ed,
Springer, 2005
6. Simpson T, Krieg JC, Heuer F, Bottlang M. Stabilization of pelvic ring disruptions with
a circumferencial sheet. J Trauma 2002;52:158-61.
Page 38 of 39
Personal Information
Radiology Department, University Hospital Southampton, UK
Page 39 of 39

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Traumatic pelvic fractures: How to identify and classify an

important sequelae of trauma

Poster No.: P-0234

In this educational poster we will demonstrate the appearances of pelvic fractures on

Young and Burgess Classification

Anteroposterior compression (APC)

Anteroposterior compression grade 1

This classically refers to diastasis of the pubic symphysis caused by an anteroposterior

There is no disruption of the sacroiliac complex, therefore this is a stable fracture,

Anteroposterior compression grade 2

Grade 2 anteroposterior compression injury includes widening of the symphysis pubis

Anteroposterior compression grade 3

Grade 3 anteroposterior compression fractures of the pelvis will incorporate pubic

Vertical shear (VS)

Lateral compression (LC)

Lateral compression grade 1

This plain radiograph demonstrates the appearances of a lateral compression grade 1

Lateral compression grade 2 injury

Lateral compression grade 3

Fig. 19: Axial Trauma protocol CT of pelvis, level of sacroiliac joints.Lateral

Combined mechanism (CM)

In combined mechanism there will be a combination of at least 2 of the other injury

Associated injuries with pelvic fractures

On this axial CT on bone reconstruction there is a lateral compression grade 3 injury

1. Giannoudis PV, Grotz MRW, Tzioupis C, Dinopoulos H, Prevalence of Pelvic

3. Guthrie HC, Owens R, Bircher MD, Focus on Pelvic Fractures. J Bone

Radiology Department, University Hospital Southampton, UK

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