Musculoskeletal

Jeremy W. R. Young, MD #{149} Robert J. Brumback,

#{149} Andrew

Radiology
MD
#{149} Attila

R. Burgess, Poka,

MD MD

Pelvic Radiography

Fractures: Value of Plain In Early Assessment and Management

Assessment of pelvic fractures in severely traumatized, clinically unstable patients presents a diagnostic problem. Traditional plain-radiographic classifications of the fracture are of limited preoperative value to the surgeon who must apply corrective force in opposition to the original force vector causing the fracture. Computed tomographic scanning is an effective method of examining the pelvis but is time consuming and may be impractical in cases of severe injury. In a retrospective analysis of the plain radiographs of 142 cases of pelvic fracture, four patterns of force were identified, presenting distinctive, recognizable radiographic appearances. These patterns are anteropostenor compression, lateral compression, vertical shear, and a complex pattern. The resulting classification of pelvic fracture, based on radiographic and clinical findings, correlates with associated injury to softtissue structures and enables the surgeon to begin corrective procedures rapidly.
Index terms:
Pelvis, 44.11
1986;

ANAGEMENT

of severe

pelvic

fractures and fracture disbocations from massive trauma requires treatment not only of skeletal trauma but also of associated shock and complications in order to lessen morbidity and mortality. The classic treatment of pelvic fractures has consisted of pelvic slings, postural reduction, skeletal traction, or internal fixation.

act assessment of the cluding determination of fracture fragments,

pelvic ring, inof the location but we believe

diagin

that, in most cases, the correct nosis can be made by appreciating the subtle radiographic findings

More recently, external fixation has become increasingly used. A potential management problem is misunderstanding of the exact type of fractune that has occurred. This may be the result of various confusing classifications of pelvic fractures that give little consideration to the mechanism of injury and direction of the causative force but rely more on traditionab observations of individual fracture patterns. Recently, Pennal et al. (1) reported the importance of classifying pelvic injuries according to the direction of the force producing them. They found this of particubar importance in progressive surgicab management. Early stabilization and realignment of the bony pelvis often are effective in achieving hemostasis and reducing loss of blood (2). However, to determine the cornective forces that should be applied, one must recognize the pattern of injury and determine the direction of the disruptive force. Incorrect assessment may bead to incorrect and detnimental application of the stabilizing devices, possibly causing further injury to the associated soft tissue, particubarby to major blood vessels near

each type of injury. This will also bow rapid recognition of the injury type and instigation of appropriate corrective surgical management. More definitive assessment by CT
scanning may be needed at a later

al-

stage

of treatment.

Anatomy An understanding of the anatomy

recogniand of the pelvis is important for tion of the patterns of fracture

associated

ligamentous

injury.

The

fractures,

44.41

#{149}

Pelvis,

pelvis is basically a ring with three components: the sacrum and two pained lateral components, each composed of ilium, ischium, and pubis. These units have no inherent stability and rely totally on ligamentous support for their integrity. The stability of this ring depends overwhebmingly on the stabilizing structunes of the sacroiliac joints (SIJs), with the symphysis acting more as a supporting strut (2).

radiography,
Radiology

The

SIJs are divided

into

two

parts:

160:445-451

to the

posterior

pelvis.

1 From the Departments of Diagnostic Radiology (J.W.R.Y.) and Orthopedic Surgery (A.R.B., R.J.B., A.P.) and the Maryland Institute of Emergency Medical Services Systems, University of Maryland Medical System, 22 South

Greene

Street,

Baltimore,

MD 21201.

From

the

1985 RSNA annual 10, 1986; revision April 14. Address #{176}RSNA,1986

meeting. Received January requested March 17; accepted reprint requests to J.W.R.Y.

Computed tomography (CT) may permit detailed analysis of pelvic trauma. However, we have found that in a patient who initially is extremely unstable and requires rapid surgical stabilization to assist in hemostasis, plain radiographs of the pelvis can be obtained more quickly than CT superior scans. CT scans are to plain radiographs cleanly for ex-

the lower, articular portion and the upper tuberosities. The anticubar pomtion is covered by a thin layer of cartibage. Only very limited movement is possible because of the strong supporting ligaments. The short intemosseous sacroiliac ligaments unite the tuberosities of the ilium and sacrum (3). They are the strongest ligaments in the body and stabilize the posterior sacroiliac

complex

(2).

The posterior sacroiliac ligaments (Fig. 1) make up two groups. The first, shorter fibers anise from the posterior superior and inferior spine

of the
ridge longer

ilium
of the fibers

and

run

obliquely

to the
por-

sacrum. The second, run to the lateral

445

1.

2.
of pelvis. PS! 55 sacrospinous posterior ligaments. sacroiliac ligaments;

Figures 1, 2. (1) Posterior view = anterior sacroiliac ligaments;

ST

sacrotuberous

ligaments.

(2) Anterior

view

of pelvis.

ASI

side, and in places become contiguous with, the sacmospinous ligaments. The medial border forms a portion of the pelvic outlet. The sacrospinous ligaments (Fig. 2) also derive from the lateral border of the sacrum, where they intermingle with the sacrotuberous ligaments and pass directly to the ischiab spine. Stability of the pelvis is also provided by the iliolumban and lateral lurnbosacral ligaments, which run between the fifth lumbar transverse process and the superior bonder of the ilium and sacrum.

from

the

sacrum.

Furthermore,

Tile

(2) has

shown

that severe bleeding, usually from the internal iliac artery or its branches, is invariably associated with injury to the posterior region, with on without resulting instability. This is not surprising, as most of these injuries are the result of blunt trauma, and massive forces are mequired to damage the pelvis or menden it unstable, particularly in young patients. It is clear that accompanying injuries, both at adjacent and me-

In the
Figure 3. Diagram illustrating AP cornpression. The direction of the injury force is in the AP (on postenoantenion) direction (large arrows). This has caused splaying of the symphysis and rupture of the anterior sacroiliac ligaments (R), sacrotuberous/sacroiliac complex (S), and symphysis ligaments (P), with opening of the pelvis.

symphysis

pubis,

the

opposcar-

ing bone is covered with hyabine tibage and supported by fibrocartilage and fibrous tissue. Infemionly, the inferior pubic ligament adds port (3).

mote sites, are to be expected, ulanly when there is posterior involvement.

partic-

PATIENTS
supA retrospective

AND
analysis

METHODS
was made of

Pelvic

Stability

the radiographs of 142 patients with fractunes of the pelvis. In each patient, three views of the pelvis were obtained: an anteroposterior (AP) view with the patient supine; a view of the pelvic inlet with the patient supine, the x-ray tube angled 40#{176}

tion of the inferior sacrurn, intermingbing with the sacrotuberous ligament (3). As their name suggests, the anterior sacroiliac ligaments (Fig. 2) pass from the anterior surface of the sacrum to the adjacent ilium (3). In addition to these fibers, the postenon portion of the pelvis is stabilized by two groups of inferior connecting ligaments (3). The sacrotuberous ligaments (Fig. 1) are extremely strong ligaments that extend from the lateral border of the sacrum (intermingling with fibers of the posterior sacroiliac ligaments from the posterior iliac spines) to the
ischial tuberosity. They run along-

Stability of the pelvis depends on the integrity of the supporting bigaments. Tile (2) has demonstrated that division of the symphysis ligaments while the posterior ligaments are intact allows the anterior pelvis to open approximately 2.5 cm, with the posterior structures preventing further movement. Additional division of the anterior sacroiliac, sacrospinous, and sacrotuberous ligaments allows spines crum. tenor plete wings further opening until the of the iliac bone abut the saAdditional division of the posligaments gives pelvic instability, can now be rise to cornas the iliac freely

caudad,

and

the

beam

centered

on the

umbilicus; and a view of the pelvic outlet with the x-ray tube angled 60#{176} cephalad and the beam centered on the symphysis.

Each view appearances

was

analyzed for of the particular was and

the radiologic fracture established radiographic

type. The fracture type using historic, clinical, criteria.

RESULTS Patterns
Four identified

AND of Force

DISCUSSION

separated

principal types as contributing

of force were to the inju-

446

#{149} Radiology

August

1986

4.

5.
4, 5. (4) Type 2 A?

Figures

compression fracture. There is diastasis of the right SIJ (large arrowhead), indicated by interruption smooth line between the sacral arcuate lines and medial iliac bone. The symphysis is diastased 2.5 cm. This indicates rupture ments of the symphysis, the anterior sacroiliac ligaments, and, most likely, the sacrospinous and sacrotuberous ligaments on dition, there are vertical fractures of the inferior and superior pubic rami on the left (small arrows). (5) Type 1 AP compression There is only a 1 .9-cm separation of the symphysis. No instability was found posteriorly. A vertical fracture of the left inferior seen, together with a largely undisplaced fracture of the posterior column of the left acetabulum (arrowheads). This fracture ing manual examination.

of the of the ligathe right. In adfracture. pubic ramus is was stable dur-

nies studied: AP compression (extennab rotation of the hemipelvis), laterab compression (internal rotation of the hemipelvis), vertical shear, and a complex pattern. In our series, 22 (15%) of our cases revealed AP compression, 81 (57%) involved lateral compression, seven (6%) involved vertical shear, and 32 (22%) involved complex fractures. AP compression.-Injunies resulting from AP compression, which cornpnised 15% of our cases, are the result of direct AP force (Fig. 3). This force vector frequently produces fractures of the pubic ramus and may cause ligamentous injury involving the bigaments of the symphysis, the anterior sacroiliac ligaments, the sacrospinous and sacrotuberous ligaments, and the posterior sacroiliac ligaments, either singly or in combination (Fig. 3). APcompression injuries commonly pro-

been rupture of the ligaments of the symphysis. However, as indicated earlier, it has been shown that the symphysis can be opened by as much as 2.5 cm without rupture of the postenor ligaments of the pelvis. When there is less than 2.5 cm separation, the radiologist cannot determine with plain madiogmaphs the integrity of the posterior ligaments unless obvious diastasis of the SIJ is seen. CT scanning is more accurate is assessing mild SIJ diastasis, but, in practice, we have found that this imaging mode may be oversensitive. Minimal antenor separation of the SIJ seen at CT study and not seen on plain radiographs was not associated with postenor instability in the three cases that occurred in our series (Fig. 5). This likely is due to persistent integrity of the anterior sacroiliac ligament cornplex, with probable mild stretching. This concurs with Tiles observations (2) that no division of the sacroiliac ligament is necessary to open
such

ligaments. the pelvis

In practice, manually

we examine to determine

whether
are stable cunred.

the
when

normal-appearing
acute trauma has

SIJs
oc-

Bucholz

has

designated

three

groups of AP fractures on the basis of the extent of posterior injury (4). We have applied this concept to the madiographic and clinical appearances and have devised a three-stage cbassification of AP compression injuries. Type 1 fractures are those in which there is no posterior instability, madiognaphic or clinical. Type 2 fractunes are those showing separation of the symphysis, with some posterior instability involving the anterior sacroiliac complex. Type 3 injuries are those with associated total disruption of the sacroiliac joint. This cbassification correlates well with the work of both Bucholz and Tile and our own observations (2, 4). In type 1 injuries, an opening of the syrnphysis of less than 2.5 cm is to be expected (Fig. 5).

duce
sprung

the

clinical
pelvis

open
type

book
of injury,

or
which

occurs with or without fractures of the pubic mami. In our series, when fractures of the pubic mami were present, they were oriented verticalby in every case of AP compression. This is an important feature differentiating AP-compression from lateralcompression injuries, where the fractune line is in the horizontal or coronal plane (Fig. 4). Opening of the symphysis indicates that there has

the

symphysis
and

by
with

2.5

cm.
obvious

Under
ex-

conditions

In type 2 injuries, be opened more

anterior sacroiliac

the symphysis may than 2.5 cm, and the

joint will disruption also ap-

temnab

rotation

of the

pelvic

wings,

mild diastasis of the SIJ must occur. This is webb demonstrated in Figure 5, where separation of the symphysis would be expected to cause mild widening of the anterior SIJs. However, at clinical examination, this patients pelvis was stable, indicating intact

pear
injuries,

to be opened
there will

(Fig.
be

4). In type
of

3
and of can

the entire SIJ involving anterior posterior groups (Fig. 6). Even when theme is no widening the symphysis, AP compression be diagnosed nadiographicabby

by

the

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Number

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#{149} 447

vertical fractures,

appearance if present.

of pubic-rarni Of the 22 cases

sacroiliac injuries.

and

were

therefore

type

were

associated

with

fractures

of the

of AP compression in our series, five had less than 2.5-cm splaying of the symphysis, with no demonstrable posterior instability (type 1). Seventeen showed posterior instability. Ten of these were type 2 injuries, and in eight, openings of the symphysis larger than 2.5 cm were demonstrated radiographically. In the other two cases, separation of the symphysis was less than 2.5 cm, but disruption of the sacroiliac was evident on the nadiographs (Fig. 4). Seven cases demonstrated total disruption of the

Of interest
tunes in the acetabulum

is the

finding

of frac-

posterior pillar of the in 14 of the 22 cases of

AP compression,

most

likely

the

me-

sult of anterior compression on a flexed femur at the time of injury (Fig. 6). This pattern was not seen in lateral-compression injuries, where acetabular fractures involve central dislocation or involve the medial aspect of the acetabulum. Lateral compression.-Injuries mesubting from lateral compression accounted for 57% of our patients and

pubic rami (100% in our series), sacmum (88%), and iliac wing (19%). Dislocations in the central hip may also occur (19%). The fracture pattern depends to a large extent on the position along the lateral aspect of the pelvis at which the force was applied (Figs. 7-9). Ligamentous injury may

be minimal,

as the

forces

are pmedOm-

inantly compressive, tune of the posterior ments may occur

although rupsacroiliac ligaif the compressive

force

is delivered

anteriorly

(Figs.

8,

9). Compression fractures of the sacrum or sacroiliac joint may occur. The fractures of the pubic nami are characteristically horizontal or comonal in orientation (5) (Fig. 10).

Recently,
injury found,

because
we have

of the

pattern

of

subdivided

lateral-compression injuries into three types (5). In type 1, the force delivered over the posterior aspect
the pelvis, with little resulting pelvic instability, although crush fractures of the sacrum may be seen (Figs. 7,

is of

10). In type

2, the

force

is more

ante-

nor, tending to cause internal displacement of the anterior hemipelvis and thus, potentially, external rotation of the posterior hemipelvis, with the anterior part of the sacroiliac joint acting as a pivot (Fig. 8).

In type

3 lateral-compression

fracno-

Figure 6. Type 3 AP compression fracture. There is total disruption of the posterior sacroiliac complex on the left (large arrow). An undisplaced fracture of the posterior column of the right acetabulum is seen (arrowhead).

tures, there is such severe internal tation of the ipsilatemal hemipelvis that contralatemal external rotation occurs, with subsequent disruption

of the
ac,

contralatenal

anterior
and

sacroili-

sacrotuberous,

sacmospinous

7.

8.
7-9.

9.
on liga-

Figures

Diagrams showing lateral-compression injuries. (7) A lateral force is applied posteriorly (arrow). This causes a crush effect the SIJ (A), which may be visible as a fracture radiographically. The characteristic fracture pattern of the pubic rami will be seen (B). No mentous injury is seen. (8) A force is applied anteriorly (arrow), causing the typical anterior fracture (B). In this case, however, rotation the pelvis around the anterior sacral margin may occur, causing rupture of the posterior sacroiliac ligaments (R). A crush fracture of the crum (A) may also be seen. (9) A force is applied anteriorly (arrow at bottom right), causing internal rotation of the anterior hemipelvis. tinuing through to the contralateral hernipelvis (arrow at center left), the force causes external rotation. The result is a pattern of lateral pression on the ipsilateral side, with apparent AP compression on the contralateral side and with rupture of the posterior sacroiliac ligaments on the left (R) and rupture of the sacrospinous/sacrotuberous complex and anterior ligaments on the right (5). There may also crush fracture of the sacrum (A). Typical fractures of the pubic rami (B) are to be expected.

of
saConcom-

be a

448

#{149} Radiology

August

1986

ligaments (5) (Fig. 9). The importance of recognizing these fracture patterns is in differentiating them from fractures caused by other force vectors. Fractures of the pubic rami resulting from lateral compression must be differentiated from AP-compression injuries, so

pubic rami, sacrum, or iliac These vertically orientated indicate the inferior-superior
tion of the force vector (Fig. tical displacement fragment can

wing. fractures direc12). Ver-

of the fracture usually be appreciated

that the appropriate are applied. If the

corrective significance

forces of the
is not of a not interand (5). by

horizontal fractures of the nami appreciated, or if the presence crash fracture of the sacrum is recognized, incorrect compressive forces can be applied, causing nab rotation of the hemipelvis compression of the pelvic wing Vertical shear. -Injuries caused

on the AP view but is best visualized on the view of the pelvic outlet, which indicates the severity of the superior displacement. Complex pattern. -Twenty-seven
cases tern demonstrated a complex of injury in which at least pattwo

different force vectors had been applied. In 21 of these cases, the force vector was predominantly of the bateral-compression type with AP cornpression (1 9 cases) or vertical shear

se and is seen with either anteriorcompression (Fig. 14) or lateral-cornpmession injuries (Fig. 10). Posterior injury has been shown to occur in every case of anterior pelvic fracture, confirming this point (6). In cases of anterior compression, diastasis of the SIJ may be seen in addition to fractunes of the pubic nami. In fractures due to the lateral compression, cornpmessive injury to the SIJ on sacrum is seen, and the fractures demonstrate the classic horizontal/coronal onientation. Radiographic Study

vertical of our

shear accounted for only 6% cases. These injuries are caused

by a severe vertical disruptive force delivered over one or both sides of the pelvis lateral to the midline. They generally occur in patients who

(two cases) as the additional vector (Fig. 13). In such cases, the surgeon made aware of the complex

force must nature be of

have fallen or jumped from a height on have had a heavy load delivered
across such Both their head, shoulders or back, as those hit by a falling tree. types of trauma effectively

the injury because correcting forces must reflect opposition to the oniginab force vector. In cases of mixed an-

Review of our cases reveals that the vast majority of diagnoses can be made correctly by using radiogmaphs in the AP projection alone (94% in our series), although we always obtam a series of three views. Inlet views of the pelvis are of use for several reasons. They may demonstrate subtle compression or the

terior

and

lateral
element applied

compression,

theme

must be an ion stability

of posteroanterby the stabilizing

device,
tion.

as well
Simibarby,

as pure
where

lateral
an element

meducof

cause the sacrum to be driven down between the pelvic wings. This type of injury is associated with severe bigamentous stability disruption (Fig. 11). and pelvic inIf the force is on

vertical
the view corrective

shear
of the force

is seen,

identified

by
inferior

outlet, some is needed.

expansion of the pelvic ring seen in lateralor AP-compression fractures. They may also demonstrate the cononal nature of pubic-rami fractures that appear vertically oriented on the AP view, thus indicating the effects of a lateral-compression force. In one case, the inlet view enabled identification of a subtle buckle fracture of

one

side,

the

ipsilateral

posterior

and

anterior sacroiliac, sacrospinous-sacrotuberous, and anterior symphysis ligaments are usually involved. Fractunes may also be seen involving the

Straddle

Fractures

Our experience suggests that the so-called isolated straddle fracture of all four pubic rami does not occur per

the the

sacrum that was not identified on AP view. The outlet view of the pelvis, although not diagnostic of any pelvic

Figure
most

10.
of the

Type
lateral

1 lateral
force was

compression
applied

fracture.
posteriorly,

In this injury,
giving rise to a

lateral

crush

fracture

of the sacrum

on the right

(small

arrow-

Figure 11. Diagram of vertical shear injury. The ipsilatera! posterior and anterior sacroiliac (R), sacrospinous/sacrotuberous (5), and anterior symphysis (P) ligaments are usually involved (compare Fig. 12). Fractures can also be seen involving the pubic rami, sacrum, or iliac wing (Q). These vertically onentated fractures indicate the inferior-superior direction of the force vector (large arrows).

heads). The horizontal and overlap fractures of the (large arrowheads) are typical of this type of injury. displacement of the pelvic ring, and no ligamentous stability was expected or found.

pubic rami There is no injury or in-

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#{149} 449

12. Figures 12, 13. (12) Vertical

13.

shear fracture. There are fractures through the left iliac wing (small open arrows) and both left pubic rami (arrowheads). The fracture fragment in the left hemipelvis is displaced superiorly, indicating the predominantly superior direction of the force of injury. In addition, there is disruption of the right SIJ, superior displacement of the right hemipelvis, and diastasis of the symphysis with an avulsion of the inferior aspect of the right iliac wing (large open arrow). This is a double vertical-shear injury resulting when the patient jumped from a height. (13) Mixed fracture pattern. This fracture demonstrates features of both lateral compression and vertical shear. The horizontal/coronal fracture of the superior left pubic ramus (dotted line) and media! displacement of the major hemipelvic fragment indicate a lateral force as the cause of injury. However, the superior displacement of the major hemipelvic fragment argues for vertical shear. The fracture through the left iliac wing (arrowheads) could occur in either type of injury.

fracture, provided an the amount of vertical

indication displacement

as to

of the fracture fragment in cases of vertical shear. This is of some impontance to the surgeon in planning conrective treatment. As a result of these observations, it is now our standard practice to obtam a single AP view of the pelvis in every patient admitted to the Shock Trauma Unit. If there is any suggestion of pelvic fracture, either radiologic or clinical, inlet and outlet views are then obtained. The role of CT scanning in the evaluation must be considered. There is no doubt that CT scans can provide information not gleaned from plain nadiographs-including subtleties of fragment displacement and the cornplexity of a particular fracture. It is therefore the method of choice for evaluating the acetabulurn for surgicab reconstruction. In cases of pelvic trauma involving the acetabulurn, we always obtained CT scans.

Figure

14.

Example

of AP-compression

fracture

(so-called

strad-

die fracture). rowheads). curred.

Vertical fractures of all four pubic No significant posterior ligamentous

rami are seen (arinjury has oc-

CT scanning
rate method for

is also

the

most
the

accusacro-

visualizing

iliac joint and sacrurn. We therefore frequently use CT scans to define posterior injury when definitive intennal fixation is planned. However, we do not use CT scanning routinely as an admitting procedure in patients with acute injuries to the pelvic ring because we have found plain radio#{149} Radiology

graphs to be highly accurate in the overall assessment of the pelvic ring, and because, in conjunction with clinical examination, plain radiography allows inexpensive and rapid evaluation of pelvic stability. Rapid external surgical immobilization has

resulted from swift analysis of the fracture pattern, and we have found that, as a result, life-threatening hemorrhage is now rare. In over 140 cases of pelvic trauma in this series, angiography was required in only 19. In eight of these, bleeding vessels

450

August

1986

were five,

found surgical

and embolized, stabilization

and in had not

CONCLUSION
Plain radiographs to the pelvis. are of consider-

the

pubic

rami

indicate

that

there

has

yet been performed. patients, in whom was found, external

Of the other 11 no bleeding site fixation had

abbe
trauma

importance

in cases
CT

of severe
scanning is a

been AP compression and should lead to examination of the posterior pillars of the acetabuli.
Diastasis of the sacroiliac may oc-

been performed in seven. In our diagnostic workup, tamed from plain nadiographs,
history of the accident, and examination are integrated

data the
clinical to pro-

ob-

valuable diagnostic tool in the tive evaluation of the fractures

cannot be done in many patients

definibut im-

who

require

immediate

surgical

cur in any form of pelvic injury. Confimmation of the type of injury can be obtained by evaluation of the additionab fracture patterns. U

vide

an overall
with

assessment.
hemorrhage

Severe
is treat-

instability

mobilization. CT scanning available.

Also, in some centers, may not be readily Appreciation of the types

References
1. Penna! GF, Tile M, Waddell JP, Garside H. Pelvic disruption: assessment and classification. Clin Orthop 1980; 151:12-21. Tile M. Fractures of the pelvis and acetabulum. Baltimore: Williams & Wilkins, 1984. Gray H. Anatomy of the human body. Charles Mayo Gross, ed. 28th ed. Philadelphia: Lea & Febiger, 1966; 318-320. Bucholz RW. The pathological anatomy of

ed initially

with

external

fixation,

of pelvic

fracture,

direction

of the

unless angiography and embolization procedures are believed to be more urgent. Frequently, fixation of the pelvis negates the need for angiography. Signs of unobogic damage

forces producing them, and likely ligamentous injuries can be achieved rapidly and inexpensively from plain radiographs, indicating to the sumgeon the enabling type of disruptive force and the planning of the comrec-

2. 3.

are
tion,

sought
and

at the
diagnostic

original

examina-

4.

urethrograms

and cystograrns are obtained, if mdicated. CT scanning is used in a secondary role-either patients, for whom sis is not required in more stable urgent hemostaand a detailed

tive procedure. Fractures of the

themselves indicate

pubic
the

mami may
type of force

of

5.

Ma!gaigne fracture dislocations of the pelvis. J Bone Joint Surg 1981; 63A:400-404. Young JWR, Burgess AR, Brumback RJ. Latera! compression fractures of the pelvis: the importance of plain radiographs in the diagnosis and surgical management. Skeletal Radio! 1986; 15:103-104. Gertzbein SD, Chenoweth DR. Occult injuries of the pelvic ring. Clin Orthop 1977; 128:201-207.

vector producing ever, evaluation

the fracture. of the posterior

Howpel6.

view
quired

of the
for

fractured
definitive

pelvis
surgery,

is meor

when
present, definitive

fractures

of the

acetabulum
for

are

again as a preparation surgical repair.

vic ring is vital. Horizontal fractures of the pubic rami indicate that there has been lateral compression and should bead to careful inspection of the sacrum for additional evidence of sacrab compression and to a determination of the extent of posterior injury. Vertically oriented fractures of

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