European Journal of Orthopaedic Surgery & Traumatology

https://doi.org/10.1007/s00590-021-02935-z

EXPERT’S OPINION

Lateral compression type 1 (LC1) pelvic ring injuries: a spectrum

of fracture types and treatment algorithms
Kenan Kuršumović1   · Michael Hadeed2 · James Bassett3 · Joshua A. Parry2 · Peter Bates1 · Mehool R. Acharya3

Received: 21 January 2021 / Accepted: 8 March 2021

© The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature 2021

Abstract
Lateral compression type 1 (LC1) fractures are the commonest pelvic ring injury. However, they represent a heterogenous
spectrum of injury mechanisms and fracture patterns, resulting in a lack of strong evidence for a universally agreed treatment
algorithm. Although consensus exists that LC1 fractures have a preserved posterior ligamentous complex and are vertically
stable, controversy persists around defining internal rotational instability. As such, treatment strategies extend from routine
non-operative management through to dynamic imaging such as examination under anaesthetic (EUA) or stress radiographs
to guide fixation algorithm. Multiple protocols sit between these two, all with slightly different thresholds for advocating
surgery or otherwise, exemplifying a broad lack of consensus that is not seen for other, more severe, grades of pelvic ring
injury. In the following review we discuss the evolving concepts of pelvic ring instability and management, starting from
a historical perspective, through to current trends and controversies in LC1 fracture treatment. Emerging directions for
research and emerging pharmacological and surgical treatments/technologies are also considered and expert commentary
from 3 leading centres provided. The distinction is made between LC1 fracture arising from high-energy trauma and those
following low-energy falls from standing height (so-called fragility fractures of the pelvis—FFP), since these two patient
groups have different functional requirements and medical vulnerabilities. Issues pertaining to FFP are considered separately.

Keywords  Lateral compression type 1 · LC1 · Fracture · Pelvic ring

Introduction
Lateral compression type 1 (LC1) fractures make up nearly
2/3 of all pelvic ring injuries [1]. They are more prevalent in
older patients, reportedly making up around 80% of all pel-
vic fractures in patients over 55 years old [2]. LC1 injuries
are usually subdivided by mechanism; those resulting from
high-energy trauma and those arising following a low-energy
fall from standing height. The latter are considered fragility
* Peter Bates
peter.bates2@nhs.net
Kenan Kuršumović
kenankursumovic@doctors.org.uk
1
Department of Trauma and Orthopaedics, Barts Health NHS
Trust, The Royal London Hospital, London, UK
2
Department of Orthopaedic Surgery, Denver Health Medical
Centre, University of Colorado School of Medicine, Denver,
CO, USA
3
Department of Trauma and Orthopaedics, North Bristol NHS
Trust, Southmead Hospital, Bristol, UK
fractures of the pelvis (FFP) and are associated with poor
bone quality in the older population. The overall mortality
during the index hospital admission associated with LC1
fractures ranges from 5.1 to 9.1%, although in the high-
energy setting this probably relates to associated injuries
to the chest, abdomen and head, rather than the LC1 itself
[1, 3]. By contrast, FFP can have devastating sequelae for
patients with pain and associated immobility leading to sec-
ondary complications such as pneumonia, pressure sores and
thrombosis [4]. Mortality for FFP at 1-year has been found
similar to the hip fracture cohort at around 1/3 and many
of those that survive have a decreased level of ambulatory
independence and increased social care requirement [5].
Historical perspective
Pelvic ring injuries as a whole have been recognized for
centuries, but in the past 60 years, the understanding of these
injuries and their management has dramatically evolved [6].
Prior to the development of radiography (~ 1900), these inju-
ries could only be specifically described after autopsies [7].

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The management of these injuries was almost entirely non-
operative, often with prolonged periods of bedrest [7]. With
the advent of radiography, these injuries could be diagnosed
prior to the death of the patient; however, management of
pelvic ring injuries remained largely non-operative [8, 9].
Throughout the 1960–70s, as the understanding of these
injuries improved and operative techniques and instruments
were refined, the indications for operative management
expanded [10]. The modern basis for operative interven-
tion largely depends on the surgeon’s perceived stability of
the injury [11–13]. This trend towards operative manage-
ment of unstable injuries is currently advocated to avoid
prolonged immobilization. Advancements in surgical treat-
ment has also generated controversy, since there continues to
be disagreement and variation in practice worldwide around
defining the term ‘instability’ and thereby having clear-cut
indications for surgical stabilization. Thus the LC1 fracture,
the most common pelvic ring disruption, remains by far the
most controversial in this respect [14, 15].
Understanding the spectrum of injury and classification
In 1932, the largest early series of pelvic ring injuries was
published [8]. This report of 81 cases, discussed pelvic ring
and acetabular fractures together, that were “classified as
fractures of the ilium, fractures of the anterior arch; fracture
involving the acetabulum and double vertical fractures.” [8]
Even with these broad categories, the concept of stability of
the pelvic ring is apparent. In 1948, another large series of
50 cases was reported [9]. In this series, the injuries were
subdivided into two categories: “(1) dislocation of the sac-
roiliac joint; (2) fracture of the ilium or sacrum adjacent
to the sacroiliac joint. In both types there is separation of
the symphysis pubis, or fracture of both pubic rami.” [9]
This report goes on to detail specific non-operative treatment
methods, all including 12-weeks of bedrest [9].
The development of the modern understanding and par-
lance of pelvic ring injuries began with George Pennal in the
1950s [16]. He worked with a radiologist, Dr. Sutherland,
to develop the common series of radiographs obtained to
Fig. 1  Illustration of (a) lateral
compression type 1 and (b)
vertical shear pelvic ring frac-
tures as described by Young and
Burgess [20]
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European Journal of Orthopaedic Surgery & Traumatology
evaluate pelvic ring injuries: the anteroposterior (AP), inlet
and outlet images [16]. He also worked with a biomechani-
cal engineer, Mr. Garside, to define in the laboratory the
various patterns of injury that were observed clinically [16].
This work was the basis of the classification system that
would later become known as the Tile classification [17,
18]. In their landmark paper in 1980, the authors describe
three force directions that lead to pelvic ring injuries: anter-
oposterior compression, lateral compression and vertical
shear [17]. Tile goes on to describe indications for opera-
tive management, which depend on the stability of the pelvic
ring [10]. This understanding of stability, described by Tile
in 1980, would become the basis for the current AO/OTA
classification of pelvic ring injuries [18, 19]. In 1986, the
Young-Burgess classification was derived largely from the
previously described force directions from Pennal’s original
work with added subsets of each force group as well as the
addition of a ‘combined mechanism’ grouping [20].
The LC1 injury was originally described as a unilateral
pelvic ring injury in which there are a disruption to the ante-
rior ring in the form of pubic rami fractures, and a disrup-
tion to the posterior ring in the form of an anterior sacral
compression fracture (Fig. 1a) [20]. Based on the original
description of the Young and Burgess classification system,
a ring injury with anterior rami fractures and a complete
sacral fracture with any vertical displacement would be clas-
sified as a vertical shear injury (Fig. 1b) [20]. They also
created the ‘combined mechanism’ category specifically for
fractures that did not fit into the other categories [20].
Early treatment protocols
Although there were limited case reports of operatively
treated pelvic ring injuries, until the 1960s, most treatment
algorithms included mainly non-operative management with
various reduction, traction and sling techniques combined
with prolonged immobilization [6, 8, 9, 21]. Even into the
1970s, many centres that treated a high number of pelvic
fractures used only non-operative treatments for all pelvic
ring injuries [21]. However, throughout the 1960s and 1970s
European Journal of Orthopaedic Surgery & Traumatology

there were several groups in different countries who were
beginning to use operative reduction and stabilization with
more frequency to treat pelvic ring injuries [10].
In 1980, Tile described treatment options for both stable
and unstable lateral compression type injuries, although he
noted that the “potential instability of an apparently inno-
cent fracture is often unrecognized” due to spontaneous
reduction [10]. He would later describe that “direct manipu-
lation of the pelvis in rotation” could determine if rotational
instability was present, the first description of dynamic
examination and a forerunner of the modern-day examina-
tion under anaesthetic (EUA) [18]. For stable patterns, he
proposed reduction if needed (“if the hemipelvis was grossly
displaced”), and then bedrest until bony healing occurred
[10]. For unstable lateral compression type injuries, three
treatment options were proposed: traction, external skeletal
fixation and open reduction [10]. He stated, “the anterior
pelvic ring can be stabilized with an external fixator. Sta-
bilization across a sacral fracture is difficult and cannot be
recommended at this time. The indications for open reduc-
tion in this injury are not yet clearly defined, and caution
is advised before proceeding with this option.” [10] He did
go on to describe a method of closed reduction and percu-
taneous fixation of superior rami fractures with a threaded
Steinmann pin, yet the patient was to remain on bedrest until
healing occurred [10]. In 1988, Tile had formalized his clas-
sification scheme and for type B2 fractures he stated that
“the elastic recoil of the pelvis restores the anatomy to near
normal, and no formal stabilization is required.” [18]
In 1990, Young, Burgess and colleagues discussed man-
agement strategies used for pelvic ring injuries based on
their classification system [20]. The three general catego-
ries of treatment included external fixation, angiography and
embolization and traction. When discussing indications for
external fixation, they stated “patients with no interruption
of the anterior or posterior ligamentous complexes, i.e.,
LC-I and LC-II, were treated with either bedrest (LC-1) or
bedrest/delayed ORIF (LC-II)” [20]. LC1 injuries, even
those with some component of instability, were treated with
a short period of bedrest and early mobilization, with weight
bearing allowed on the uninjured side [20]. However, they
continued that patients with injuries “that completely inter-
rupted the posterior pelvic ring…were treated with acute
application of external fixation” [20].
Table 1 summarises the evolution of evaluation and treat-
ment of pelvic ring injuries.
Defining an LC1
In a study of 3 dimensional (3D) CT reconstructions of LC1
injuries, Khoury et al. found complex combinations of rota-
tional and translational injuries and suggested that multi-
directional forces acting on the pelvis may be the reason
for our inability to predict clinical outcomes such as late
displacement on static radiographs [26].
Similarly, Lefaivre et al. looked in detail at 100 LC1 frac-
tures and their CT characteristics. They reported a spectrum
of injuries, with complete sacral fractures being predicted
by higher Injury Severity Score (ISS), higher Denis zones
(Table 2) and higher abdominal Abbreviated Injury Scale
(AIS) [27].
Therefore, despite the efforts to effectively classify pel-
vic ring injuries, the LC1 category remains broad with a
heterogenous spectrum of injuries. The rami fractures may
be bilateral or unilateral, ipsi- or contralateral. The sacral
injury may be complete or incomplete, minimally or undis-
placed, simple or comminuted, and involve Denis zones 1,
2 or 3 [26–29]. This creates a diverse group of fractures all
with the same LC1 classification with higher grade injuries
dictated by associated ligamentous disruption. In the classi-
cal LC1, an anterior sacral crush injury leaves the posterior
Table 2  Denis classification of sacral fractures [28]
Zone 1 Fracture line is lateral to the sacral foramen
Zone 2 Fracture line enters the sacral foramen
Zone 3 Fracture line is medial to the sacral foramen

Table 1  Evolution of the evaluation and treatment of pelvic ring injuries

1930-1950s First large case series published detailing analysis of injury patterns, treatment protocols and outcomes
Nearly all pelvic ring injuries are treated non-operatively

1960s-1970s The inlet and outlet radiographic images are described

Operative indications expand for certain fracture patterns (mainly utilizing anterior external fixation)
1980 Major force directions are published including lateral compression (LC), anteroposterior compression
(APC) and vertical shear (VS)
1988 Tile publishes his classification system and treatment protocols based on that system
1990 Young and Burgess publish their classification system and treatment protocols based on that system
1989 Iliosacral lag screws are described by Matta [22]
1998 Anterior column screws are described by Starr [23]
2007–2012 Anterior subcutaneous internal pelvic fixation is described [24, 25]

13

pelvic ligaments intact, along with the sacrospinous and
sacrotuberous, thereby rendering them vertically stable
against displacement. So historically, LC1 fractures have
been considered stable injuries, suitable for non-operative
treatment [30]. The 3D CT inlet reconstructions in Fig. 2 are
two examples of the extremes of pelvic ring injury within
the LC1 category.
Henderson demonstrated that lateral compression (LC)
fractures with more than 1 cm of initial sacral displace-
ment had poorer clinical outcomes when treated non-oper-
atively and so this is typically taken by most authors to be
the threshold at which and LC1 becomes something more
severe and unstable [29–35]. Also, vertical displacement on
post-ambulation X-rays implies occult vertical shear with
significant ligamentous disruption, rather than LC1 [27, 32].
Defining ‘instability’
There remains a lack of consensus around what defines
‘instability’ in the context of an LC1 fracture. Some sur-
geons consider instability to represent the tendency of a
fracture to displace over time, as seen with higher grade
pelvic ring disruptions. Others consider that excessive pain
when attempting to mobilize constitutes instability, regard-
less of the bony position on X-ray; which might be termed
‘functional instability’ [27]. Others use static radiological
parameters [36], while some define fracture stability by its
response to stressing [12, 13, 37, 38]. Therefore, the term
‘instability’ is somewhat unhelpful, since it is used to mean
different things, depending on the perspective taken. These
aspects are considered individually below.
Consensus around fixing LC1 injuries
With percutaneous fixation of pelvic fractures becoming
increasingly routine and perceived to be low-risk, many sur-
geons consider a proportion of LC1 fractures to be unstable
and therefore benefiting from internal fixation, with low
risks of complications [39]. As such, management decisions
Fig. 2  Extremes of LC1 pelvic
ring injury 3D CT inlet recon-
structions of (a) a minimally
displaced incomplete sacral
fracture with unilateral rami and
(b) a displaced complete sacral
fracture with bilateral rami
fractures
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European Journal of Orthopaedic Surgery & Traumatology
are largely based on the treating surgeon’s perception of
fracture stability, but this is not consistent between clinical
groups [14, 15, 26, 29, 40].
In their radiological survey on the management of LC1
fractures, Beckmann et al. [41] found that plain films and
axial CT of 27 pelvic ring injuries presented to 111 OTA
surgeons only yielded agreement (defined as ≥ 90% consen-
sus) on whether surgery was required in 9 (33.3%) cases
with no clear consensus in the remaining 2/3.
Vallier, Tornetta and colleagues [32] ran a 7-year prospec-
tive observational multi-centre cohort study, which demon-
strated surgeons either fixing or not fixing LC1 fractures of
all morphologies, with seemingly no preference for fixation
of configurations more prone to displacement or vice versa.
There appeared to be no pattern to clinical decision-making.
Do LC1 fractures either displace or give inferior
functional outcomes if treated non‑operatively?
Bruce et al. [42] looked retrospectively at 117 high-energy
(non-fragility) LC1 fractures in adults, all treated non-opera-
tively. All were less than 5 mm displaced initially, measured
as posterior step-off of the sacrum on CT. All patients were
mobilized immediately, weight bearing as tolerated. This
was a purely radiological study looking for displacement of
the fractures at bony union. ‘Significant displacement’ was
defined as > 5 mm displacement of the sacrum posteriorly
and more than the width of the ramus anteriorly (adduction
deformity).
Overall, 19% displaced. Of these, only 10% of Denis zone
1 injuries displaced, versus 39% of zone 2 (transforaminal)
fractures. Incomplete sacral fractures showed 2.6% displace-
ment, while complete sacral fractures were 50%. Bilateral
rami fractures were also a risk factor for displacement,
39% versus 8.2% for unilateral. Combining bilateral rami
with complete sacral fractures showed 68% displacement.
Accordingly, incomplete sacral fractures with unilateral (or
no) rami fractures had no displacements [42].
European Journal of Orthopaedic Surgery & Traumatology
Of all that displaced, only two translated in a ‘true orthog-
onal direction’, suggesting these were actually vertical shear
injuries, mis-diagnosed as LC1s. Of the rest, displacement
was internal rotation/adduction of the ramus anteriorly. Cru-
cially though, this purely radiological study doesn’t define
the degree of deformity that might lead to an impaired clini-
cal outcome.
Sembler Soles et al. [30] looked retrospectively at 118
patients with LC fractures with < 10 mm of sacral displace-
ment, all treated initially non-operatively with immediate
weight bearing [30]. All but one went on to uneventful bony
union, with the outlier undergoing sacral translation at the
second X-ray, prompting fixation. Displacement measure-
ments were made on plain X-rays, as with Bruce’s group
[42]. In the remaining 117 patients, the position at bony
union did not differ from that at the time of initial injury.
Because obtaining CT was not their standard protocol at the
time, characterization of the sacral injury was not done [30].
Gaski et al. [34] carried out functional outcomes assess-
ments of 50 patients identified to sit within the most con-
troversial radiological group; those with a complete sacral
fractures. 29 had bilateral rami fractures. All had displace-
ment on CT of < 10 mm on any cut. Primary outcomes were
functional (Majeed and PCS/MCS of SF–12 v2) and second-
ary were radiographic. Functional outcomes overall were
close to population norms and 84% scored good or excellent.
Although 16% were graded functionally fair or poor under
Majeed, 7 out of 9 of these patients had concomitant lower
limb injuries. The presence of lower limb injuries trended
towards lower functional scores vs isolated LC1. Radiologi-
cal follow-up was incomplete, but there were no non-unions,
no pelvic fixations were required and no fractures showed
late displacement > 10 mm, either posteriorly around the
sacrum or rotationally at the rami. The authors were unable
to show a correlation between the extent of anterior pelvic
ring injury (none, unilateral or bilateral) and functional out-
come. Nor did they observe any secondary displacements.
Soni et al. looked at 46 adults with LC1s with incomplete
sacral fractures treated non-operatively, and all had good or
excellent Majeed scores [43].
In summary, only one study has demonstrated a tendency
for LC1s to displace (nearly 20% overall), particularly with
Denis zone 2 sacral fractures, bilateral rami and complete
sacral injuries [42]. However, these late radiological dis-
placements have not been reproduced in other studies and
their clinical relevance is unquantified. Gaski’s findings
suggest that lower limb injuries have a stronger bearing on
functional outcome than a non-operatively treated LC1 frac-
ture [34].
Unfortunately, all these studies are retrospective with con-
siderable limitations and each has slightly different meth-
odology for measuring displacement, none of which are
validated [44]. Bottom line: we do not know what constitutes
functionally meaningful displacement of the anterior ring.
Does EUA or stress radiograph help in defining
an ‘unstable’ fracture?
In a cadaveric study Gardner et al. demonstrated that the
degree of initial displacement and associated soft tissue
injury is underestimated on static radiographs particularly
in LC-type fractures and these may be at risk of displace-
ment with conservative treatment [45].
EUA has been proposed for cases of diagnostic uncer-
tainty to assess LC1 fracture stability, need for operative
intervention [12, 37, 46] and to guide subsequent opera-
tive intervention [38]. Sagi, Mir and colleagues presented a
100% negative predictive value in determining stability and
union of the pelvic ring after non-operative treatment for
LC1, LC2 and APC1 type injuries [47].
Sagi described a comprehensive EUA technique involv-
ing 15 images to assess pelvic ring stability in internal rota-
tion, external rotation and vertical force [12]. Giannoudis
developed a modified version, which focused on stability in
internal rotation of LC1 fractures [37]. Sagi suggested > 1
cm displacement of pubic ramus or symphysis during EUA
as an indication for surgery, while Giannoudis chose ≥ 2cm
as the cut off limit for surgical intervention [12, 37].
More recently Sagi and Mir proposed sequential EUA to
guide fixation of LC type injuries, starting with posterior
ring fixation on positive EUA, repeating the EUA and pro-
ceeding to anterior ring fixation if further instability persists
[38].
In a non-randomized study, Tosonoudis et al. [37] com-
pared operative versus non-operative treatment of 63 LC1
injuries following EUA. All those that displaced at EUA
had complete sacral fractures and none of the incomplete
fractures displaced. Comparing the two groups, they found
that operated patients, despite having objectively worse frac-
tures on CT and EUA, had significantly less pain at 72 h,
mobilized faster and a shorter inpatient stay. They concluded
that surgical fixation of all complete sacral fractures was
indicated and even potentially stable LC1 fractures for pain
tolerance and early mobility. The value of EUA needs to be
considered as a complete sacral fracture recognized pre-op
would have led to the same surgical decision-making.
Critics of EUA and advocates of non-operative manage-
ment cite the arbitrarily chosen measurement thresholds of
displacement to decide between non-operative vs opera-
tive management [15, 32]. There is a lack of clarity around
the force that should be applied, and with the exception of
Tosonoudis et al. [37], articles describing EUA case series
lack control groups against which to compare. EUA also
requires an anaesthetic and occupies operating room time.
13

Also decision-making algorithms do not have broad consen-
sus [12, 37, 38, 48, 49]
Recently, Parry et al. used stress radiographs to overcome
some of the issues with EUA [13]. Taking an anterior–pos-
terior pelvis X-ray in the lateral decubitus position was
reported as being ‘tolerated without sedation’ and was found
to have a 100% correlation with formal EUA, obviating the
need for general anaesthetic or operating room utilization,
while standardizing the force applied to the patient’s own
weight.
Can radiological parameters alone determine
surgical strategy?
Beckmann et al. designed a scoring system seeking to iden-
tify the subgroup of patients with LC1 fractures that may
benefit from operative management or EUA [36]. The scor-
ing system (range 5–14) was based on radiographic mor-
phology of the fracture components to the sacrum, superior
ramus and inferior ramus, validated against the responses
to a survey of 111 OTA members (Table 3) [36, 41]. Their
results demonstrated a strong correlation between increased
operative tendency and sacral displacement of ≥ 2 mm or
three column sacral involvement. They found that scores < 7
and > 9 were highly predictive of recommendation for non-
operative and operative recommendation, respectively by
the survey responders. They propose that scores 7–9 may
identify fracture patterns where little stability/treatment cen-
sus exists warranting further evaluation with EUA or other
Table 3  Beckmann LC1 fracture scoring criteria. Adapted from [36]
Parameter
Posterior sacral displacement
  < 2 mm
  ≥ 2 mm
Dennis classification
 Zone 1
 Zone 2
 Zone 3
Sacral columns
 1 column
 2 columns
 3 columns
Inferior ramus displacement
 Minimal
  > 50%
 Complete
Superior ramus location (Nakatani zone [46])
 Root (zone 1)
 Midramus (zone 2)
 Parasymphyseal (zone 3)
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European Journal of Orthopaedic Surgery & Traumatology
method to determine stability. The authors do recognize,
however, the need for prospective clinical evaluation with
a larger case cohort prior to general use of their scoring
system.
Does surgical fixation of LC1 fractures help reduce
pain and allow earlier mobilization?
A further driver of surgical fixation of undisplaced, poten-
tially unstable LC1 fractures is the argument that it will
decrease visual analogue pain scores (VAS) and narcotic
use and promote early mobilization [11, 37]. As discussed
above, Tosonoudis et al. reported less pain and faster rehab
in the operative group despite them having seemingly worse
injuries at EUA and on CT [37].
In a retrospective study, Hagen et al. found little differ-
ence in narcotic use or pain scores when comparing surgical
and non-surgical groups, although the former did mobilize
earlier [50].
In their multicentre prospective observational study of
unilateral sacral fractures with < 10 mm displacement, Tor-
netta, Vallier and colleagues found that although slightly
higher VAS scores were noted within 24 h after injury in the
non-operative group when compared to the operative group,
more limited difference was seen at 3 months [33]. Although
the difference in VAS scores reached significance in favour
of operative management, these were probably below the
level of clinically important difference [33].
Clear indications for operative stabilization continue to
lack consensus with no level-1 evidence to guide surgeons
on management, potentially due to the heterogeneity of LC1
fractures. The proposed TULIP RCT will aim to improve
Points evidence for one subset of these injuries [51].
Three case studies in Figs. 3, 4 and 5 and accompanying
authors’ comments reflect the current controversies in the
1
management of the spectrum of LC1 injuries, integrating the
2
above discussion.  Figs. 4 and 5 concern two patients that
have sustained LC1 fractures following high-energy trauma,
1
whereas Fig. 3 is an example of an elderly patient sustaining
2
a fragility LC1 injury that we discuss further in the separate
3
section below on these injuries.
1
Fixation concepts/controversies: anterior, posterior,
2
anterior and posterior
3
There is no commonly accepted fixation strategy for verti-
1
cally stable LC type injuries. Historically, anterior fixation
2
was advocated in LC injuries as the posterior pelvic ring is
3
only partially disrupted with additional stability provided by
the posterior sacroiliac ligaments [52]. Matta emphasized
1
primary importance of the posterior ring stabilization due
2
to its the principal role as the weightbearing component of
3
the pelvis, prior to addressing the anterior ring, as Emile
European Journal of Orthopaedic Surgery & Traumatology
Fig. 3  Case example—elderly lady with an LC1 fragility fracture. (a,
b) AP and inlet pelvic radiographs of a 79-year-old woman who sus-
tained a minimally displaced right LC1 fracture following low-energy
fall. (c) Axial computed tomography (CT) image demonstrates a
right-sided incomplete sacral fracture. (d) Stress radiographs with the
patient in the left lateral decubitus position demonstrate greater than
1  cm of displacement making this a LC1b-type (unstable) fracture
as described by Sagi [12]. The patient was offered surgical fixation,
however, she elected for non-operative management. (e, f) 2 months
follow-up radiographs demonstrate a 1  cm of pelvic ring displace-
ment. The patient continued to complain of 7/10 pelvic pain and still
Letournel’s ‘golden rule’ [53]. The current trend is posterior
percutaneous fixation with sacroiliac screws with or without
anterior fixation, but validated treatment algorithms based
on functional outcomes are lacking [54]. Anterior ring
required a walker for ambulation at 2-months, although long-term
clinical outcome is not reported. Authors’ comment: This fracture
demonstrated ‘stress instability’ of the right hemipelvis when lying
on that side, making her potentially amenable to surgery [13]. After
non-operative treatment, X-rays at union showed no further displace-
ment of the pelvis and so radiologically this was a good outcome,
despite the instability. Some authors argue that the analgesic effects
and potential earlier mobilization that might have occurred with inter-
nal fixation, outweighs the relatively minor risks of surgery. However,
there is no level-1 or RCT evidence of this to date
fixation strategies include external fixation or internal fixa-
tion with plating or percutaneous ramus screws (antegrade
or retrograde), or more recently INFIX [55].
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 European Journal of Orthopaedic Surgery & Traumatology

Fig. 4  Case example— a
middle-aged woman with a
high-energy LC1 fracture and
bladder rupture. (a) AP pelvic
radiographs of a 54-year-old
woman with a displaced left
LC1 fracture in a pelvic binder
after a motor vehicle collision.
Patient was found to have blad-
der rupture on CT cystogram.
(b, c) AP and inlet pelvic radio-
graphs after binder removal
showing persistent displace-
ment > 1 cm. (d) Axial CT scan
demonstrated an incomplete
left-sided sacral fracture. (e, f)
Postoperative radiographs after
open bladder repair, distrac-
tion external fixation, and
percutaneous screw fixation
of the posterior ring. Authors’
comments: This patient demon-
strated adduction ‘instability’
of the left hemipelvis in binder.
The bladder injury made pelvic
fixation more compelling but
even without this, multiple
authors would describe this
displacement as an indication
for surgery [12, 13, 37, 38].
Equally, others would argue that
there was no sacral translation
and the minor radiological
adduction deformity on the left
has not been shown to yield
poorer functional outcomes [32,
33]. In the absence of a bladder
injury, many would have treated
this non-operatively

EUA-based fixation strategies for LC1 fractures have
been described by different authors. Starr et al. described
posterior stabilization followed by stress EUA and proceed-
ing to anterior fixation if movement was seen [46]. Sagi et al.
initially described a ramus fracture displacement of > 1 cm
as an indication for anterior fixation alone and > 2 cm for
both anterior and posterior fixation [12].
More recently, however, Sagi and Mir [38] proposed a
fixation algorithm based on sequential intraoperative EUA
starting with the posterior pelvic ring and proceeding ante-
riorly if still unstable.
An international survey by Parry et al. [56] of 19 sen-
ior pelvic trauma surgeons found no or minimal agree-
ment on the use of EUA or stress radiographs, operative or
non-operative management, need for anterior and/or poste-
rior ring fixation, type and number of posterior sacroiliac
screws, anterior fixation method, postoperative weightbear-
ing or timing to weightbearing.
Fragility LC1 fractures in the older population
LC1 pelvic ring injuries in the elderly can occur in the con-
text of high-energy trauma but are more commonly the result
of falls from standing height, so called fragility fractures of
the pelvic ring (FFP) [57].
In contrast to hip fractures, where prompt surgical fixa-
tion or arthroplasty is the emphasis traditionally LC1 FFP
injuries have been treated non-operatively with the goal of

13
European Journal of Orthopaedic Surgery & Traumatology

Fig. 5  Case example— a
young man with a high-energy
LC1 injury with a complete
sacral and bilateral ante-
rior fractures. (a) AP pelvic
radiograph of a 38-year-old man
with a right LC1 fracture with
bilateral pubic rami fractures,
following pedestrian vs car road
traffic collision. (b–d) Axial CT
scans on admission showing a
complete sacral fracture with
posterior cortical displace-
ment of just under 2 mm with
bilateral minimally displaced
parasymphyseal superior rami
fractures and bilateral inferior
rami fractures, of which the
contralateral is displaced by
50% or so. (e, f) AP and inlet
views at two years from injury
show a fully healed pelvic
ring with no late displace-
ment, following non-operative
management. At follow-up,
he was pain-free around his
pelvis and had a full functional
recovery, including cycling.
Authors’ comment: Although
this patient scored highly (10)
on Beckmann’s radiological
criteria in Table 3 [36] and he
would most likely have been
described as ‘unstable’ and
fulfilled criteria for fixation
cited by multiple authors [36,
37, 42], he nonetheless made a
good clinical recovery with no
long-term impairment following
non-operative treatment

care being medical pain relief and early weightbearing as
pain allows. This approach too has been challenged with
regard to the role of surgical intervention, in an attempt to
facilitate pain relief, early mobilization and decrease the risk
of secondary medical complications [54, 57, 58].
Retrospective studies looking at CT scans revealed that
pubic rami injuries have associated posterior injuries as high
as 97% of cases in the context of high-energy trauma [27,
29, 42, 59]. In the case of FFP, rates of posterior ring injury
on advanced imaging (CT or MRI) are ≤ 62% [60–62]. As
such, many of these low-energy injuries consist solely of
isolated pubic rami fractures. Equally though, when there is
a posterior fracture visible, a small proportion will be LC2
types, with crescent fractures or combined sacral and iliac
fractures.
In the fragility, low-energy setting, pelvic ligaments are
largely intact and so vertical sacral instability is usually not
a feature. However, a subset of patients will have horizontal,
internal rotational instability that may prevent early mobili-
zation, thereby exposing them to pain and secondary com-
plications of immobility and opioid analgesia [57].
Arguing that the radiological Tile and Young & Bur-
gess classifications are not granular enough to describe the
spectrum of FFP injuries, Rommens [57] proposed a com-
prehensive CT-based classification system of different frac-
ture patterns and their presumed degree of instability with
implication for treatment. These are types I—IV with further
subdivisions based on the nature and complexity of posterior
ring injury (or its absence in Type I) (Table 4) [57]. Undis-
placed LC1 fractures are represented by Type IIb and IIc
with incomplete and complete sacral fractures, respectively.
Rommens argues that it is the Type II group (the majority
of FFP) that may be amenable to fixation if patients are una-
ble to mobilize within 3–5 days, despite optimal analgesic
regimen, combining concepts of radiographic and functional
stability [57]. This concept of offering surgical fixation to

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 European Journal of Orthopaedic Surgery & Traumatology

Table 4  Rommens classification for fragility fractures of the pelvic ring (FFP) and proposed treatment. Adapted from [57]
Type Characteristics Detailed subdivision Treatment recommendation

Type I Isolated anterior pelvic ring disruption Ia—unilateral Conservative

Type II Non-displaced posterior ring injury
(± anterior ring disruption)
Type III Displaced unilateral posterior ring injury
(+ anterior ring disruption)
Type IV Bilateral or complex posterior ring injury
(+ anterior ring disruption)
Ib—bilateral
IIa—dorsal non-displaced posterior ring Initial conservative trial and percutaneous
injury only fixation when conservative treatment fails
IIb—sacral crush with anterior disruption (i.e., intractable pain or failed mobiliza-
IIc—non-displaced sacral, sacroiliac or iliac tion at 3–5 days)
fracture with anterior disruption
IIIa—displaced unilateral ilium fracture and Posterior and anterior internal fixation
anterior disruption
IIIb—displaced unilateral sacroiliac disrup-
tion and anterior disruption
IIIc—displaced unilateral sacral fracture
together with anterior disruption
IVa—bilateral iliac fractures or bilateral Bilateral posterior and anterior internal
sacroiliac disruptions with anterior fixation, iliolumbar or a combination of
disruption fixation methods depending on complex-
IVb—spinopelvic dissociation with anterior ity of injury
disruption
IVc—combination of different posterior
instabilities together with anterior disrup-
tions

FFP patients who fail early conservative management is a
common practice and is also mentioned by Lefaivre et al.
[27].
Other authors have questioned the benefit of advanced
imaging in managing FFP [60, 61]. Natoli et al. reported on
42 patients with FFP-type fractures, in whom CT or MRI
revealed posterior ring injuries in 26 patients, 3 of which
were complete. All were treated non-operatively with no
radiographic displacement. They argued that CT did not aid
decision-making or outcome, since these were fundamen-
tally a stable group of injuries [61].
Previously, internal surgical fixations used effectively
for the younger patients have presented limitations in the
elderly FFP cohort [58] due to poor hold in osteoporotic
bone [63]. Although small retrospective small studies have
reported pain relief and improved function with surgical
fixation [62, 64], a recent systematic review examining ret-
rospective studies reporting on internal and external fixation
has reported that there is insufficient evidence to support
surgical fixation as an effective treatment for patients that
fail to mobilize after LC1 FFP [58]. Recent development
of the INFIX allows potential for effective stabilization of
LC1 FFP injuries, combing the benefits internal and external
fixation. Two systematic reviews [25, 65] support the use of
INFIX as a good fixation of pelvic injuries in the younger
high-energy pelvic ring fractures in combination with pos-
terior ring fixation or alone. However, the evidence for use
of INFIX for treatment of FFP patients is lacking and is the
subject of the current L1FE trial [66]. INFIX also carries its
own set of unique complications, including lateral cutaneous
nerve injury, heterotropic ossification and more rarely femo-
ral nerve palsy, thought to arise when the connecting rod is
placed too deeply [25, 65].
Medical treatment
Fragility fractures in the elderly are now commonly treated
using primary prevention and secondary prevention with
bisphosphonates. Whilst they reduce fragility fracture risk,
bisphosphonates are also responsible for some atypical
fractures, mainly of the femur [67] but also of the pelvis
in some reported cases [68]. With increased use of antire-
sorptive medications, it is important to be aware of these
atypical fractures which may not behave in the usual pat-
tern influencing management strategies with a multidisci-
plinary approach.
Intermittent use of teriparatide, an anabolic agent similar
to Human parathyroid hormone (PTH), activates osteoblasts
more than osteoclasts leading to overall increase in bone
mass. Although not reproduced in the younger high-energy
cohort, recombinant PTH or teriparatide has been shown in
one fairly small, controlled trial to reduce pain and allow
patients with FFP to mobilize quicker [69]. This makes the
point that medical treatment needs to be fully optimized for
the control group of any trial comparing surgery vs non-
surgery in the FFP setting.
Unfortunately, PTH analogues are expensive and their
non-oral administration makes acceptance/uptake low
in the osteoporotic population [70]. This may make the

13
European Journal of Orthopaedic Surgery & Traumatology
practicality of a large-scale RCT into their use difficult
to realize.
The future
Despite improvements in surgical techniques to treat pelvic
ring injuries, their effectiveness has not yet been proven
in the LC1 group. Hopefully the results of randomized
studies, such as L1FE [66] and TULIP [51], currently in
progress, will help determine if patients sustaining LC1
injuries in the fragility fracture and a subset of non-fragil-
ity fracture population, respectively, benefit from surgical
intervention.
There is still room for further improvement in the diag-
nosis, investigations and management of these common
injuries.
The role of MRI
MRI has yet to be fully investigated to consider its full use
in aiding diagnosis as well as determining management. The
improvements in MRI with the use of dynamic scanning may
help to further assess occult pelvic injuries with associated
ligamentous disruption. Klengel et al. [71] correlated the
initial radiograph of the pubic ramus with the integrity of
the pectineal ligament and found that displacement of the
rami fracture of greater than 3 mm was associated with a
structural lesion of the pectineal ligament on MRI scan (sen-
sitivity 73%, specificity 100%). MRI scans can be used to
visualize specific ligaments around the pelvis including the
sacrospinous, sacrotuberous, anterior and posterior sacro-
iliac ligaments as well as the pelvic floor musculature. Spe-
cific injuries to specific ligamentous structures may be used
to provide further information on the degree of instability
[72]. Unfortunately, the high signal seen on MRI following
injury is difficult to quantify and has not been shown to cor-
relate with instability to date. No authors to date have found
a practical use for MRI in the management of LC1 injuries,
but this is within the scope of future investigation.
Surgical advancements
Less invasive treatments are already described for the treat-
ment of LC1 injuries using percutaneous SI screw fixation
as well as INFIX application [25, 65]. Antegrade and retro-
grade rami screws can be inserted in a percutaneous manner
or through an open approach.
Percutaneous SI screw placement with conventional fluor-
oscopic guidance is technically challenging due to complex
posterior ring anatomy and high incidence of sacral dysmor-
phism with risks of screw malposition of up to > 60% [73]
and neurological injury ranging from 0.5 to 7.7% [74, 75].
Various computer navigation systems have been developed
including CT guided navigation and 2D and 3D fluoroscopy-
based navigation systems for more accurate screw place-
ments. CT navigation may provide the most accurate method
for SI screw placement but is limited in its use in surgical
procedures requiring reduction manoeuvres and additional
fixation [74]. Although a randomized multicentre study indi-
cated a definitive advantage in 3D fluoroscopic navigation
compared to both conventional fluoroscopy guided technique
and 2D navigation [76], other smaller studies have reported
that the  cortical screw perforation rate in 3D navigation
cohorts may still be as high as 31% [73]. Current lack of
clear benefit to patient outcomes from navigation pelvic ring
surgery, persisting margin of error and high set up costs are
[77] are current obstacles to a wider uptake of this technol-
ogy [78].
There have been many advancements in INFIX surgical
technique. Vaidya has already assessed the biomechanics of
using monoaxial vs polyaxial screws used in the INFIX con-
struct and found improved construct stiffness in the monoax-
ial group [79]. These different screw designs, as well as fixed
angle screws, have not been formally assessed clinically to
see if there are improved characteristics for treatment in
more complex or obese patients, or those with osteoporotic
bone. Further advances in pedicle screw technology have
also not been assessed such as the use of dual lead screws
or differential pitch screws. These two new technologies
could also be combined which may offer a suitable option
for improving management of osteoporotic pelvic injuries.
Other novel implant designs such as the Curvafix rod-
screw have been developed with theoretical benefits similar
to an intramedullary device; however, these are not yet avail-
able in routine clinical practice and have therefore not been
formally assessed for use [80].
Summary
LC1 fractures represent a huge spectrum of injury that are
assessed and managed in a very heterogenous manner by
clinicians. There is consensus that LC1 injuries have pre-
served ligaments, making them vertically stable. The con-
troversy sits with horizontal/adduction instability and treat-
ment algorithms including the role of EUA, and subsequent
non-operative or surgical management.
Exclusion of occult vertical shear or combined injury is
an important consideration of those with complete sacral
fractures as this will alter management.
With the heterogeneity in fracture mechanism and pat-
terns of injury, there remains a lack of strong evidence for
management of these injuries or their subsets.
There remain polarized views on treatment, but
many are adopting a pragmatic view of considering
13

surgical management in patients with failed conservative
management.
In FFP, similar controversies exist, the main difference
being the vulnerability of this population to secondary medi-
cal complications, relating to prolonged immobility. Optimal
medical treatment is critical in this patient population and
the use of teriparatide may well become universally first-line
with further evidence to support it. Surgery may have a role
in a subset of these patients, but the risks of general anaes-
thesia and surgical insult should be taken into consideration.
A wide array of treatment protocols span this spectrum,
ultimately leading to a wide variance in practice. Meanwhile,
implant, imaging and navigation technologies are evolving
steadily. There is no doubt that high-quality, robustly con-
trolled RCTs are required, ideally comparing functional out-
comes after non-operative versus operative treatment.
Funding  No funding was received to assist with the preparation of
this manuscript.
Declarations  Jt Surg [Br] 70-B:1–12
Conflicts of interest The authors have no relevant financial or non-
financial interests to disclose.
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