J Forensic Sci, 2014

doi: 10.1111/1556-4029.12613
TECHNICAL NOTE Available online at: onlinelibrary.wiley.com

ANTHROPOLOGY

Socorro Baez-Molgado,1,2 Ph.D.; Eric J. Bartelink,3 Ph.D.; Lyman M. Jellema,4 Ph.D.; Linda Spurlock,5
Ph.D.; and Sabrina B. Sholts,6 Ph.D.

Classification of Pelvic Ring Fractures in

Skeletonized Human Remains

ABSTRACT: Pelvic ring fractures are associated with high rates of mortality and thus can provide key information about circumstances sur-
rounding death. These injuries can be particularly informative in skeletonized remains, yet difficult to diagnose and interpret. This study
adapted a clinical system of classifying pelvic ring fractures according to their resultant degree of pelvic stability for application to gross human
skeletal remains. The modified Tile criteria were applied to the skeletal remains of 22 individuals from the Cleveland Museum of Natural His-
tory and Universidad Nacional Aut
onoma de M
exico that displayed evidence of pelvic injury. Because these categories are tied directly to clini-
cal assessments concerning the severity and treatment of injuries, this approach can aid in the identification of manner and cause of death, as
well as interpretations of possible mechanisms of injury, such as those typical in car-to-pedestrian and motor vehicle accidents.

KEYWORDS: forensic science, forensic anthropology, pelvic ring fracture, motor vehicle accident, skeletal remains, trauma analysis

The pelvis is a crucial structure connecting the thorax to the
lower limbs of the body, forming a bony ring through which
weight-bearing forces are transmitted and major anatomical
structures of various body systems pass. Disruption or destabili-
zation of the pelvic ring results from fractures to one or more of
its constituent elements. Such injuries are associated with high
rates of morbidity and mortality (1–4), often due to significant
loss of blood and disruption of the genitourinary system, the
gastrointestinal system, and the lumbosacral plexus (5). Most
pelvic fractures in the United States result from motor vehicle
accidents or falls (6).
In a clinical setting, the assessment of pelvic fractures is often
straightforward, with diagnoses made most commonly through
physical examination and radiography (7,8). Radiographic diag-
noses have been greatly simplified by classification systems that
differentiate the severity of injuries by the pattern and extent of
disruptions to the sacroiliac complex (9). Classificatory
approaches to pelvic fractures have shown moderate to high lev-
els of intraobserver reliability and interobserver agreement across
medical specializations (9) and are widely used by clinicians for
accurate and prompt evaluation of these injuries.
Based on the strong association between pelvic injuries and
mortality, fractures of the pelvic ring may provide important
1 descriptions and examples of pelvic fracture patterns in skele-
Department of Anthropology, Texas State University, San Marcos, TX.
2
Instituto de Investigaciones Antropol
ogicas, Universidad Nacional Aut
onoma
de M
exico, Mexico City, Mexico.
3
Department of Anthropology, California State University, Chico, CA.
4
Department of Anthropology, Kent State University, Kent, OH.
5
Department of Physical Anthropology, Cleveland Museum of Natural
History, Cleveland, OH.
6
Department of Anthropology, National Museum of Natural History,
Smithsonian Institution, Washington DC.
Received 10 Jan. 2013; and in revised form 8 Jan. 2014; accepted 20 Jan.
2014.
information about the death of an individual in the absence of
the soft tissues and other contextual evidence. For example, in
cases where the victim is thrown off the road or the body is
moved after a motor vehicle or car-to-pedestrian accident, frac-
tures in the pelvic bones can often indicate the mechanism,
force, and direction of impact, even if the remains are skeleton-
ized (10). However, in order to fully and accurately assess these
injuries, an in-depth understanding of the biomechanics of the
pelvic girdle and bony responses to trauma is needed. Clinical
classification systems could facilitate and standardize analyses of
pelvic fractures by forensic anthropologists and osteologists and
thus help with determinations of manner and cause of death
(MOD and COD). Unfortunately, criteria for clinical classifica-
tions are often missing or unclear in skeletonized remains and
thus prevent the direct application of this method in forensic
contexts.
To address this problem, this study presents a classification
system that has been developed specifically for pelvic fractures
in gross human skeletal remains. A modification of Tile’s sys-
tem was chosen for this study because it is most easily
adapted to skeletal analyses (11), unlike other systems which
necessitate evaluation of soft tissue structures (12). Pelvic frac-
tures in 22 individuals from two osteological collections in the
United States and Mexico were classified into one of three
categories of pelvic ring instability, using corresponding
tonized remains.
Biomechanics and Patterns of Pelvic Ring Fracture
Fracture Mechanics
The three bones of the pelvic ring — the sacrum and the right
and left ossa coxae — are connected by three joints and numer-
ous ligamentous structures. The strong posterior sacroiliac

© 2014 American Academy of Forensic Sciences 1

2 JOURNAL OF FORENSIC SCIENCES
ligaments of the pelvic ring are especially important for main-
taining its stability. Two primary modes of pelvic instability are
defined by rotational and vertical displacement of the pelvic
ring. The rotationally unstable pelvis is produced by forces that
open and externally rotate, or compress and internally rotate, the
hemipelvis, whereas vertical instability indicates a complete dis-
ruption of the posterior osseous ligamentous structures (5).
Specific biomechanical forces of various direction and magni-
tude have been suggested to cause pelvic disruption (e.g., ante-
rior–posterior force, lateral compression, external rotation,
abduction, and shear force) (5). Fractures of the pelvic ring
occur when forces, such as compression and shearing, compress
tissues and slide them across one another, resulting in deforma-
tion and bone failure (13).
In an anthropological analysis of skeletal trauma, fractures are
generally classified according to the pattern and severity of the
injury (14). Incomplete fractures retain some continuity between
portions of the fractured bone, whereas complete fractures show
evidence of comminution (13). In the pelvic girdle, fractures can
occur in isolated or multiple locations (15), representing a broad
spectrum of low- to high-energy injuries that range from benign to
life-threatening (2,8,16). In addition to the different biomechanical
forces, mechanisms of fracture are dependent on the relationship
between bone strength and ligamentous structures, as bone is
weaker than the ligaments in osteoporotic or elderly individuals
and thus is more likely to fail first (5). Fracture properties also vary
according to the viscoelasticity of the associated bones, which
changes with age, and whether bone is fractured in a fresh (ante-
mortem or perimortem) or dry (postmortem) state (16–19). These
factors are important considerations for any forensic assessment of
pelvic ring fractures and particularly in cases where only skeletal
remains are available.
Tile’s Classification System
The following type descriptions are summarized from Tile
(11) and are typically applied to pelvic radiographic images by
clinicians, whose prognoses are facilitated by the assessment of
pelvic ring stability and its implications about the direction,
force, and morbidity of the injury.
Type A fractures are defined by a stable ring with minimal dis-
placement. This category includes fractures that do not involve the
actual pelvic ring, such as avulsion fractures of the ischial spines,
the ischial tuberosity, and isolated fractures of the iliac wing (Type
A1). Although Type A2 may involve the pelvic ring, no elements
are displaced, and the pelvis maintains its stability.
Type B fractures are defined as vertically stable but unstable
in external or internal rotation. Unstable external rotation (Type
B1) is caused by external rotator forces resulting in disruption at
the pubic symphysis. This may include a separation of <2.5 cm
but without a posterior lesion (Stage 1), a greater separation on
one side (Stage 2), or a greater separation on both sides (Stage
3), which implies disruption of the sacrospinous and anterior
sacroiliac ligaments. Unstable internal rotation from lateral com-
pression is dependent on the location of anterior and posterior
lesions. Ipsilateral compression (Type B2) can occur as the result
of anterior fracture of the rami and a crushed posterior complex,
an overlapped pubic symphysis, or a fractured superior ramus
rotated around a disrupted symphysis. Contralateral compression
(Type B3) is usually caused by a direct blow to the iliac crest
and results in a posterior fracture that is located on the side
opposite a major anterior fracture (e.g., all four rami fractured
anteriorly).
Type C fractures are defined as vertically and rotationally
unstable, resulting from a rupture of the pelvic floor. The injury
can occur unilaterally (Type C1) or bilaterally (C2) and include
the posterior sacroiliac complex and the sacrospinous and sa-
crotuberous ligaments. Instability may be identified radiographi-
cally by posterior displacement of the hemipelvis of more than
1.0 cm, avulsion of the transverse process of the fifth lumbar
vertebra, and detachment of the insertion of the sacrospinous lig-
ament from either the sacrum or the ischial spine. Associated
acetabular fractures (Type C3) also may be evident.
Materials and Methods
Skeletal criteria for classifying pelvic stability versus instability
were developed from two modern human osteological collections
from North America. At the Physical Anthropology Laboratory in
the Anatomy Department of the Faculty of Medicine at the Univers-
idad Nacional Aut
onoma de M
exico (UNAM), pelvic ring fractures
were identified in 13 of 172 individuals. For all 13 individuals,
MOD was not recorded, although some individuals had COD infor-
mation consistent with MVAs. The unclaimed bodies received by
the Faculty of Medicine are from individuals who may have been
indigent or died in hospitals, whereas bodies of victims of inten-
tional violence are received elsewhere (Servicio M
edico Forense).
At the Cleveland Museum of Natural History (CMNH), nine indi-
viduals with pelvic ring fractures and documented MODs related to
MVA were identified among the skeletal remains of 3100 individu-
als in the Hamann-Todd Osteological Collection. For these nine
individuals, associated museum records indicated that the MOD
was due to a MVA. Both collections are drawn from urban popula-
tions, consisting primarily of donated or unclaimed bodies from
morgues and public hospitals. For all individuals in both collections,
information about age and sex was known or estimated, and pro-
vided in the associated documentation. All trauma assessments in
both samples were made independently by author SBM.
Differential Diagnosis of Fresh Bone Fractures
Distinguishing characteristics of fresh and dry bone fracture is
necessary for understanding whether or not a fracture could be
related to the death event. Fresh bone has high moisture content
due to fluid-filled vessels, fat, and collagen fibers, which
increase its ability to absorb stress (17–19). Because of its elas-
ticity and plasticity, fresh bone can withstand high amounts of
strain and deformation before failure (18). Dry bone is stiffer
and more brittle due to low moisture content and thus requires
much less energy to fracture (18). Because fresh bone responds
to loading differently than dry bone, fractures made in fresh
bone are identifiable by a variety of characteristics (17–22).
However, forensic assessment of fracture patterns can be compli-
cated by taphonomic factors that can mimic and obscure fresh
bone characteristics (23).
In this study, the differential diagnosis of fresh bone fracture
in the pelvic ring relied on the presence of any of following five
criteria: (i) plastic deformation (19,23); (ii) radiating fracture
lines (24); (iii) splintering (17,19); (iv) irregular fracture margins
(17,19); and (v) hinging (25).
Tile Classifications of Pelvic Instability
To classify pelvic girdle fractures in gross human skeletal
remains according to Tile’s categories of pelvic ring instability,
the following category descriptions were utilized (Fig. 1):


BAEZ-MOLGADO ET AL.
FIG. 1––Tile’s classification system of progressive instability of pelvic fracture, illustrated by examples from the study sample (top row) and CT reconstruc-
tions (bottom row). Type A fractures are stable (left column), Type B fractures are partially unstable (middle column), and Type C fractures are completely
unstable (right column).
FIG. 2––Cases of Type A fractures observed in the study sample: (i) right iliac crest, Case 1-A; (ii) right ischiopubic ramus, Case 2-A; and (iii) right ischiop-
ubic ramus, Case 3-A.
• Type A fractures do not produce instability in the pelvic ring.
They are identified by lesions in only one of these anatomical
regions: the iliac wing, the ischiopubic or iliopubic ramus, or
the sacrum (e.g., transverse or crush fracture without dis-
placement). These fractures are usually not life-threatening.
Type A fractures are illustrated by three cases shown in
Fig. 2. In all cases, only one of the three skeletal elements of
the pelvic girdle is affected. These fractures did not disrupt
the stability of the pelvic ring and are well-healed, consistent
with antemortem trauma. Case 1-A shows evidence of a pos-
sible impact to the posterior right iliac crest, resulting in a
fractured ilium. Case 2-A and Case 3-A are possible impacts
to the inguinal region that fractured the right ischiopubic
ramus.
• Type B fractures produce rotational, but not vertical, instabil-
ity in the pelvic ring. They are identified by a complete frac-
ture of the anterior ring and an incomplete fracture of the
posterior ring (either on the sacrum or the sacroiliac articula-
tion). Type B fractures are illustrated by four cases in Fig. 3.
Case 4-B and Case 5-B show very similar fracture patterns
consistent with vertical stability and rotational instability,
which are in accordance with Tile’s B2 classification. Incom-
plete vertical fractures of the sacrum affect only the first and
second sacral foramina and suggest that the posterior part of
the pelvic ring could maintain vertical stability. However,
complete ischiopubic and iliopubic fractures of the left ramus
. FRACTURE CLASSIFICATION OF THE PELVIC RING 3
indicate rotational instability. These injuries may have
occurred through lateral compression. Case 6-B shows a ver-
tical sacral fracture and fractures of the right ischiopubic and
iliopubic rami, indicative of rotational instability. Unlike Case
4-B and Case 5-B, however, Case 6-B shows some indication
of healing of the sacrum. Case 7-B shows a vertical fracture
on the right side of the first sacral vertebra and incomplete
fracture of the ramus on the internal aspect of the left pubis,
with dislocation suggested by evidence of chipping in both
the femur and the posterior wall of the right acetabulum.
• Type C fractures produce both rotational and vertical instabil-
ity in the pelvic ring. They are identified by complete frac-
tures of the anterior and posterior ring (e.g., transverse or
crush fracture of the sacrum). Type C fractures are illustrated
by three cases in Fig. 4. Case 8-C presents a complete frac-
ture on the left sacral ala that suggests vertical instability.
There are fractures of the ischiopubic and iliopubic rami on
both the right and left sides, indicating bilateral rotational
instability. This injury is made more complex by a linear
fracture on the left acetabulum. Case 9-C shows a complete
disruption of the sacrum by a fracture more severe than in
Case 8-C. On the left ilium, there is a posterior fracture that
involves the sacroiliac joint and anteriorly there is a complete
fracture of the pubis. Evidence of surgical intervention to
treat these iliac fractures is present in wires attached to both
bone fracture segments. The overall fracture pattern indicates
4 JOURNAL OF FORENSIC SCIENCES
FIG. 3––Cases of Type B fractures observed in the study sample: (i) sacrum and left ischiopubic and iliopubic rami, Case 4-B; (ii) sacrum and left ischiopubic
and iliopubic rami, Case 5-B; (iii) sacrum and right ischiopubic and iliopubic rami, Case 6-B; and (iv) sacrum, Case 7-B. Case 7-B also has an incomplete fracture
on the left symphysis and a linear fracture between the right ischium and pubis (not observable in photograph); thus, its rotational instability is uncertain.
FIG. 4––Cases of Type C fractures observed in the study sample:
(i) sacrum and right and left ischiopubic and iliopubic rami, Case 8-C;
(ii) sacrum, left ilium, and left ischiopubic and iliopubic rami, Case 9-C;
and (iii) right and left ilia and left ischiopubic and iliopubic rami, Case
10-C.
both vertical and rotational instability. Case 10-C exhibits a
fracture of the right ilium affecting the sacroiliac joint and
comminuted fracture of the left ilium. There are also com-
plete fractures of the pubis that have been reconstructed with
adhesive for collection management purposes. Together these
fractures suggest both vertical and rotational instability.
Results and Discussion
The main challenge in applying Tile’s type descriptions to
skeletal remains is the absence of diagnostic features involving
the ligaments and muscle groups, which has caused ambiguity in
interpreting pelvic-acetabular trauma (9). Furthermore, the entire
pelvic ring may not be available for study, requiring analysts to
reconstruct the trauma patterns and direction of pelvic displace-
ment from incomplete or isolated elements (14).
In our analysis, identifying fractures that did not affect the sta-
bility of the pelvic ring (Type A) was facilitated by evidence of
bone remodeling associated with the injury in some cases (Fig. 2).
The extent of fracture healing indicates that these individuals lived
for some time after sustaining the injuries. As Type A fractures
show the lowest mortality rates among Tile’s three categories of
pelvic instability in clinical cases, it was expected that these
lesions would be more likely observed in a healed state (26–28).
In contrast, classifying fractures as Type B or C was more ambig-
uous. These categories are defined by the anterior and posterior
stability of the pelvic ring, which was difficult to assess without
the presence of soft tissues. Nonetheless, Type B and C classifica-
tions were identified by the presence of anterior and posterior frac-
tures and distinguished mainly on the basis of presence of either
incomplete (Type B) or complete (Type C) fractures in the poster-
ior region. In this study, ten percent of pelvic injuries (2 out of 22)
could not be classified based on ambiguous fracture patterns. In
both cases, the pelvic ring did not exhibit the level of instability
associated with the Type C category, although a linear fracture
was observed through the auricular surface that could be related to
disruption of the pelvic floor. These cases illustrate the limitations
of fracture analysis in skeletal remains, where the full extent of the
injury often cannot be known.


BAEZ-MOLGADO ET AL.
Assessment of fresh bone fracture characteristics is an
important part of understanding skeletal trauma in relation to the
death event. Although there are many characteristics that can
distinguish fresh bone fractures from postmortem damage, many
of them are found typically in compact tubular bones (e.g., long
bones). The fresh fracture characteristics used for diagnoses in
this study are those most likely to be found in the complex, tra-
becular structures of the bony pelvic ring and can serve as a use-
ful procedure for trauma analysis affecting these elements. In
addition to the general challenges of differentiating fractures
caused before and after death (29), certain characteristics of fresh
bone fracture can be easily misdiagnosed or misinterpreted in
classifications of pelvic instability from skeletal remains. For
instance, the pelvic floor is partially formed by the sacrotuberous
and sacrospinous ligaments, the latter of which is inserted into
the lateral border of the sacrum and attaches to the ischial spine
of the ischium. Ischial fracture may occur with avulsion fractures
of the sacrospinous ligament, which can disrupt the pelvic floor
and cause Type C instability of the pelvic ring. However, in ana-
lyzing and interpreting skeletal remains, it should be noted that
postmortem fractures in the ischial spine may occur during skel-
etal processing or handling, due to the fragile nature of this
feature.
Although the COD for the majority of Type B and C fractures
in the CMNH collection was most consistent with MVAs, there
are substantial differences in severity and distribution of MVA
injuries depending on variables related to how and when the acci-
dent occurred. Determining whether or not MVA victims were
“protected” (i.e., vehicle occupants) or “unprotected” (i.e., pedes-
trians or bicyclists) (30) can be difficult when based solely on
skeletal analysis, where important forensic evidence such as tire
marks and car paint, imprint injuries, and skin excoriations are not
available (31). However, the occurrence of fractures in skeletal
elements in addition to the pelvic bones, such as one individual in
the study sample (CMNH-HTH-0251) with fractures in nine dif-
ferent elements, can provide further evidence of MVA-related
trauma and circumstances. Comparative studies of MVA injury
patterns have shown higher injury rates in the head and lower
extremities of unprotected victims, as well as a shorter average
period of initial survival (e.g., 4.8 days vs. 10.8 days for protected
victims) (30). Among pedestrians, there is a much higher inci-
dence of spinal fracture and sacroiliac dislocation in those who
were in an erect position at the time of primary collision, and
subsequently run over (32). During the first decades of the 20th
century, when the individuals in the CMNH sample lived, the
majority of fatalities from MVAs occurred to unprotected victims
who were also run over following the initial impact (33). How-
ever, the types of injuries sustained by MVA victims changed over
subsequent decades, as the hoods and front bumpers of cars
became lower and pedestrian victims were thrown against the
hood or struck in the lower leg upon collision (33).
Conclusions
Although pelvic ring fractures are often classified according to
Tile’s categories of instability in living individuals and occasion-
ally during postmortem medical examination, this study is among
the first to extend this approach to completely skeletonized human
remains. Given that the bony pelvis has no inherent stability, dif-
ferentiating levels of pelvic ring instability is particularly difficult
in the absence of the ligaments that maintain its integrity. The
descriptions and examples presented in this study can increase
identifications of pelvic fractures in forensic anthropology cases,
. FRACTURE CLASSIFICATION OF THE PELVIC RING 5
where radiographs (34) and decomposed soft tissues (35) can
obscure fractures in the skeleton. Furthermore, as these classifica-
tions are tied directly to clinical assessments concerning the
severity and treatment of pelvic injuries, this approach can aid in
determinations of manner and cause of death, as well as interpreta-
tions of possible mechanisms of injury.
Further studies of pelvic fractures in skeletal remains will
expand upon and improve skeletal trauma analyses and facilitate
future forensic investigations where circumstances of death are
unknown. In cases of MVAs, investigating the relationship
between pelvic ring stability and the speed or direction of the
vehicle could provide additional information to support medicole-
gal determinations of COD and MOD. In future research, evalua-
tion of the association between pelvic fractures (and types) and
fractures in other postcranial elements and the skull would also
provide a more comprehensive approach for trauma interpretation.
Acknowledgments
The authors wish to thank the Department de Anatomy of the
Faculty of Medicine at the Universidad Nacional Aut
onoma de
M
exico for help with access to collections. Author SBM thanks
Abigail Meza-Pe~ naloza, Carlos Serrano- S
anchez and Maria
Villanueva Sagrado for their support of this research, which was
part of her dissertation work. This paper was greatly improved
by the comments of the anonymous reviewers.
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Additional information and reprint requests:
Socorro B
aez-Molgado, Ph.D.
Department of Anthropology
Texas State University
601 University Drive
San Marcos, TX 78666
E-mail: socorro@forost.org