The vast majority of non-major trauma pelvic fractures presenting to Calderdale & Huddersfield A&E will be fragility fractures in elderly patients — almost exclusively:
- Isolated pubic rami fractures (anterior ring, FFP-I)
- Pubic rami fractures with concurrent non-displaced sacral fracture (FFP-II)
These represent 84% of all elderly pelvic fractures nationally, and virtually all are non-operative injuries by definition. The remaining cases are a small minority and are addressed in the referral criteria below.
T&O Referral Criteria:
Trigger |
Reason |
|---|---|
|
Haemodynamic instability or unexplained haemoglobin drop |
Pelvic haemorrhage; may require angio-embolisation or pelvic packing |
|
Neurological symptoms: saddle anaesthesia, new bladder or bowel dysfunction |
Denis Zone III sacral fracture or cauda equina involvement — urgent surgical assessment |
|
CT demonstrating displaced posterior ring injury (sacroiliac joint disruption, displaced sacral fracture) |
FFP-III/IV — surgical stabilisation likely indicated; T&O/pelvic surgeon decision |
|
High-energy mechanism (road traffic collision, fall from height) in any age group |
True pelvic ring disruption; does not fit fragility fracture pathway |
|
Acetabular fracture |
Distinct surgical entity; T&O discussion indicated regardless of energy |
|
Bilateral complex pattern or rotationally/vertically unstable pelvis on imaging |
Requires specialist classification and surgical planning |
Sacral Fractures:
Up to 90% of elderly pubic rami fractures have a concurrent sacral fracture on advanced imaging, missed on plain x-ray in 32–97% of cases. This is important context but does not change the default pathway:
- Non-displaced sacral fractures (FFP-II) are managed conservatively in the first instance —identical to isolated pubic rami fractures
- A 2025 retrospective cohort of 150 FFP-II patients showed no significant difference in functional outcomes between conservative management and minimally invasive surgery at follow-up
- The difference is a more vigilant monitoring framework: if weight bearing is not achievable within 3–5 days, CT review and T&O/spinal discussion is triggered — not an upfront ED referral
- NOTE: even if patient has had initial CT if symptoms worsening consider repeat CT (as a previously invisible well aligned fracture can become obvious)
General Management (No T&O Trigger)
Conservative management is the standard of care: Isolated anterior ring and non-displaced posterior ring fragility fractures (FFP-I and FFP-II) are treated with analgesia, early weight bearing as tolerated, and physiotherapy-led mobilisation. No surgical option is indicated at presentation in the overwhelming majority.
If admission required this would be done under Medical/Frailty teams – ensure adequate analgesia prescribed & any time critical medication
References
- GIRFT Non-Ambulatory Fragility fracture pathway (2024)
- AOAO Isolated Fragility Fractures of the Pelvis (2023)
- GIRFT Adult Orthopaedic Trauma (2024)
Produced with the kind help of Orthopaedic CD: Mr Pennington
