Displaced anterior pelvic fracture on initial pelvic radiography predicts massive hemorrhage

Published:March 22, 2018DOI:



      Massive hemorrhage is often associated with unstable pelvic fractures with posterior ring injury. Initial pelvic radiography alone may not detect these posterior lesions. We examined whether the presence of an anterior pelvic fracture on initial pelvic radiography alone may identify patients who are at a high risk of major hemorrhage.

      Materials and methods

      A total of 288 patients with pelvic fractures were admitted to the Fukui Prefectural Hospital during an 11-year period. After excluding 33 patients who were in cardiopulmonary arrest on arrival and nine with concomitant abdominal organ injuries requiring emergency laparotomy, 246 eligible patients were retrospectively reviewed. Anterior pelvic fractures were defined as displacement of the obturator ring, obturator ring with laterality, or displacement of the pubic symphysis on pelvic radiography.


      Massive hemorrhage was identified in 106 of 246 patients. Patients with massive hemorrhage had a higher frequency of anterior pelvic fractures on pelvic radiography and higher frequency of posterior pelvic fractures on computed tomography than those without massive hemorrhage. Logistic regression analysis identified displacement of the obturator ring by ≥5 mm, obturator ring with laterality of ≥5 mm, and displacement of the pubic symphysis by ≥4 mm on pelvic radiography as predictors of massive pelvic hemorrhage.


      The results of the present study suggested that the presence of displaced anterior lesions of the pelvic ring on pelvic radiography alone, without the use of computed tomography during the initial treatment stage, may promptly identify patients at high risk of massive pelvic hemorrhage who require intervention for hemorrhage control.


      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dalal S.A.
        • Burgess A.R.
        • Siegel J.H.
        • Young J.W.
        • Brumback R.J.
        • Poka A.
        • et al.
        Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome.
        J Trauma. 1989; 29: 981-1000
        • Moreno C.
        • Moore E.E.
        • Rosenberger A.
        • Cleaveland H.C.
        Haemorrhage associated with major pelvic fracture.
        J Trauma. 1986; 26: 987-994
        • Rotheberger D.A.
        • Fischer R.P.
        • Strate R.G.
        • Velasco R.
        • Perry Jr., J.F.
        The mortality associated with pelvic fractures.
        Surgery. 1978; 84: 356-361
        • Rommens P.M.
        • Hofmann A.
        • Hessmann M.H.
        Management of acute hemorrhage in pelvic trauma: an overview.
        Eur J Trauma Emerg Surg. 2010; 36: 91-99
        • Young J.W.R.
        • Burgess A.R.
        • Brumback R.J.
        • Poka A.
        Pelvic fractures: value of plain radiography in early assessment and management.
        Radiology. 1986; 160: 445-451
        • Hauschild O.
        • Aghayev E.
        • von Heyden J.
        • Strohm P.C.
        • Culemann U.
        • Pohlemann T.
        • et al.
        Angioembolization for pelvic hemorrhage control: results from the German pelvic injury resister.
        J Trauma Acute Care Surg. 2012; 73: 679-684
        • Brown C.V.
        • Kasotakis G.
        • Wilcox A.
        • Rhee P.
        • Salim A.
        • Demetriades D.
        Does pelvic hematoma on admission computed tomography predict active bleeding at angiography for pelvic fracture?.
        Am Surg. 2005; 71: 759-762
        • Blackmore C.C.
        • Cummings P.
        • Jurkovich G.J.
        • Linnau K.F.
        • Hoffer E.K.
        • Rivara F.P.
        Predicting major hemorrhage in patients with pelvic fracture.
        J Trauma. 2006; 61: 346-352
        • Cryer H.M.
        • Miller F.B.
        • Evers B.M.
        • Rouben L.R.
        • Seligson D.L.
        Pelvic fracture classification: correlation with hemorrhage.
        J Trauma. 1988; 28: 973-980
        • Courtney P.M.
        • Taylor R.
        • Scolaro J.
        • Donegan D.
        • Mehta S.
        Displaced inferior ramus fractures as a marker of posterior pelvic injury.
        Arch Orthop Trauma Surg. 2014; 134: 935-939
        • Scheyerer M.J.
        • Osterhoff G.
        • Wehrle S.
        • Wanner G.A.
        • Simmen H.P.
        • Werner C.M.
        Detection of posterior pelvic injuries in fractures of the pubic rami.
        Injury. 2012; 43: 1326-1329
        • Pennal G.F.
        • Tile M.
        • Waddell J.P.
        • Garside H.
        Pelvic disruption: assessment and classification.
        Clin Orthop Relat Res. 1980; 12-21
        • Weaver M.J.
        • Bruinsma W.
        • Toney E.
        • Dafford E.
        • Vrahas M.S.
        What are the patterns of injury and displacement seen in lateral compression pelvic fractures?.
        Clin Orthop Relat Res. 2012; 470: 2104-2110
        • Lefaivre K.A.
        • Padalecki J.R.
        • Starr A.J.
        What constitutes a Young and Burgess lateral compression- I (OTA 61-B2) pelvic ring disruption? A description of computed tomography-based fracture anatomy and associated injuries.
        J Orthop Trauma. 2009; 23: 16-21
        • Edeiken-Monroe B.S.
        • Browner B.D.
        • Jackson H.
        The role of standard roentgenograms in the evaluation of instability of pelvic ring disruption.
        Clin Orthop Relat Res. 1989; 63-76
        • Tonne B.M.
        • Kempton L.B.
        • Lack W.D.
        • Karunakar M.A.
        Posterior iliac offset: description of a new radiological measurement of sacroiliac joint instability.
        Bone Joint J. 2014; 96-B: 1535-1539
        • Huittinen V.M.
        • Slätis P.
        Postmortem angiography and dissection of the hypogastric artery in pelvic fractures.
        Surgery. 1973; 73: 454-462
        • Hamill J.
        • Holden A.
        • Paice R.
        • Civil I.
        Pelvic fracture pattern predicts pelvic arterial haemorrhage.
        Aust N Z J Surg. 2000; 70: 338-343
        • Eastridge B.J.
        • Starr A.
        • Minei J.P.
        • O'Keefe G.E.
        • Scalea T.M.
        The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruption.
        J Trauma. 2002; 53: 446-450