Pelvic And Acetabular Trauma

Pelvic and Acetabular Trauma: Modern Study Review

High-Yield Summary

Pelvic and acetabular fractures in both adults and children present complex challenges due to associated multisystem injuries and potential long-term biomechanical consequences. Accurate diagnosis is complicated by cartilaginous anatomy in pediatric patients, necessitating advanced imaging and careful clinical assessment. Modern management emphasizes early stabilization to control hemorrhage and restore pelvic ring integrity, with operative intervention guided by fracture stability and displacement. Outcomes hinge on timely hemorrhage control, preservation of neurologic function, and restoration of joint congruity to optimize pain relief and function.

Key Diagnostic Findings

Anatomy

• The pelvic ring comprises the sacrum, ilium, ischium, and pubis, connected by strong ligaments.
• The acetabulum is formed by the fusion of the ilium, ischium, and pubis, with anterior and posterior columns and walls critical for hip stability.
• Pediatric pelvis contains significant cartilage, complicating radiographic interpretation and increasing risk of growth disturbances.

Clinical Presentation

• High-energy trauma often accompanied by head, chest, abdominal, and vascular injuries.
• Signs include pelvic pain, deformity, instability, and potential neurovascular compromise (lumbosacral plexus injury).
• Hemorrhagic shock is a leading cause of early mortality.
• Bladder and urethral injuries are common with pelvic fractures.

Imaging

Classification Systems

Current Gold Standard Treatment

Non-operative Treatment

• Indicated for stable pelvic fractures (Tile A) and undisplaced acetabular fractures.
• Bedrest and protected weight-bearing remain standard for stable injuries without displacement or instability.
• Close monitoring for growth disturbances in pediatric patients.

Operative Treatment

• Indications:
• Pelvic ring instability (Tile B and C fractures).
• Acetabular fractures with >2 mm articular incongruity or instability.
• Pelvic diastasis >3 cm (anterior ring disruption).
• Posterior fracture-dislocations of the sacroiliac complex.
• Techniques:
• Open reduction and internal fixation (ORIF) is preferred for definitive stabilization.
• External fixation serves as a temporizing or adjunctive measure, especially for hemorrhage control.
• Pediatric-specific considerations include smaller hardware (2.5 mm Schanz pins) and minimally invasive pin placement to avoid growth plate injury.
• Surgical planning guided by CT and Judet views to restore anatomy and joint congruity.

Modern Complications & Outcomes

Complications

Outcomes

• Early stabilization reduces mortality and improves functional outcomes.
• Anatomical reduction of acetabular fractures correlates with better long-term hip function and less arthritis.
• Growth disturbances in pediatric patients necessitate long-term follow-up.
• Multidisciplinary care (orthopaedics, trauma surgery, urology) optimizes recovery.

Classic Clinical Notes

Pelvic and Acetabular Trauma

Many of the same considerations as in adult pelvic and acetabular trauma – associated head, chest, abdominal visceral injuries and vascular trauma are common.

• Diagnosis can be made difficult because of cartilage in the region.
• Growth disturbances can lead to biomechanical alterations later in life.
• The major consequences of pelvic fracture are hemorrhage, shock, death; bladder/urethral injury; neurologic injury (lumbosacral plexus); and infection following open fractures.

Pelvic Fracture Classification – translated from adult (Tile)

• A: avulsion, not involving the ring
• B: horizontally unstable, vertically stable
• C: horizontally and vertically unstable
• Don’t forget to check stability on the physical examination! Don’t rely completely on the x-rays!

Acetabular Fracture Classification – also, translated from adult (Letournel)

• Posterior wall
• Posterior wall and posterior column
• Posterior column
• Posterior wall and transverse
• Anterior wall
• T type fracture
• Anterior column
• Anterior wall, posterior hemitransverse
• Transverse
• Bicolumnar

• Judet views are helpful
• If getting CT – get fine slice cuts to help with the small size (2.5 – 3.0 mm)
• Consider hip arthrography in child under 8 in whom you suspect fracture/dislocation of proximal femur

Treatment

In general, these injuries are being treated more and more like adult injuries.

• Historically, acetabular trauma was treated non-operatively. Now, people are going after them if there is 2 mm incongruity or instability.
• 3 cm anterior diastasis can be treated with ORIF or external fixator.
• Posterior fracture dislocations of the SI complex are being treated more commonly now with internal fixation.
• Bedrest is still good for undisplaced acetabular fractures or stable pelvic injuries.

External Fixation

• Biologic treatment for massive hemorrhage.
• Need slightly smaller Schanz pins – usually the 4.0 or 5.0 mm pins are too big. Can get 2.5 mm pins for infants or toddlers. Do a simple frame – one or two pins in each crest through 1 cm stab wounds, with two connecting rods. The pins should be introduced through a predrilled hole of slightly smaller diameter. The hole should just penetrate the superior iliac ring cortex, and the pin should be placed by hand chuck to minimize the chances of perforation. Smooth K-wires can be placed on the inner and outer cortices of the iliac ring as directional guides. Adequate room should be allowed between the bars and the abdomen to allow the patient to sit up and to permit abdominal examination.

Last Updated on January 25, 2026 by orthonet