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Open fracture pelvis, iliac wing — Clinical Guidelines

Overview

Open fractures involving the pelvis, particularly the iliac wing, are severe injuries characterized by extensive soft tissue damage and bone exposure, often resulting from high-energy trauma such as motor vehicle accidents, falls from height, or crush injuries. These injuries pose significant challenges due to their complexity, potential for associated vascular and organ injuries, and high risk of complications including infection, nonunion, and chronic pain. They predominantly affect young adults and middle-aged individuals engaged in activities with higher injury risks. Early and accurate diagnosis, along with prompt and comprehensive management, are crucial in mitigating morbidity and mortality, making this topic essential for clinicians dealing with trauma patients in day-to-day practice. 1 6 16

Pathophysiology

The pathophysiology of open fractures involving the iliac wing is multifaceted, stemming from the initial traumatic impact that disrupts the integrity of both bone and soft tissues. High-energy forces can lead to significant comminution and bone fragmentation, compromising blood supply to the affected areas and increasing the risk of osteomyelitis and nonunion. The extensive soft tissue damage exposes the bone to the external environment, facilitating bacterial contamination and subsequent infection. Additionally, the pelvic ring's disruption can lead to hemodynamic instability due to associated vascular injuries, such as those to the internal iliac arteries or pelvic veins. The complex anatomy of the pelvis, with its intricate ligamentous structures and proximity to vital organs, further complicates the healing process and recovery trajectory. 16 20

Epidemiology

The incidence of open pelvic fractures, including those involving the iliac wing, is relatively low compared to other orthopedic injuries but carries significant morbidity and mortality. These injuries are more prevalent in regions with higher rates of motor vehicle accidents and occupational hazards. Demographically, they predominantly affect males, typically in the age range of 20 to 50 years, reflecting higher exposure to traumatic events. Geographic and socioeconomic factors also play a role, with urban areas and regions with less stringent safety regulations experiencing higher incidences. Over time, trends suggest an increase in reported cases due to improved trauma care and diagnostic capabilities, though the absolute incidence remains relatively stable. 1 16

Clinical Presentation

Patients with open fractures of the iliac wing typically present with severe pain localized to the pelvic region, often radiating to the lower extremities. Systemic signs of shock, including tachycardia, hypotension, and altered mental status, may be evident due to significant blood loss or associated visceral injuries. Local findings include deformity, crepitus, and visible bone fragments or soft tissue damage. Red-flag features include uncontrolled hemorrhage, signs of peritonitis, and neurological deficits, which necessitate urgent evaluation for associated intra-abdominal or spinal injuries. Prompt recognition of these symptoms is critical for timely intervention and management. 1 6 16

Diagnosis

The diagnostic approach for open fractures of the iliac wing involves a combination of clinical assessment and imaging techniques. Initial evaluation includes a thorough history and physical examination to assess the extent of soft tissue damage and associated injuries. Radiographic imaging, particularly CT scans with multiplanar reconstructions, is essential for detailed assessment of bone fragmentation, displacement, and associated vascular injuries. MRI may be considered for evaluating soft tissue damage and infection when clinical suspicion is high. Specific diagnostic criteria include:

Clinical Criteria:

- Presence of an open wound communicating with the fractured bone. - Signs of systemic inflammatory response syndrome (SIRS) or sepsis. - Hemodynamic instability requiring immediate resuscitation.

Imaging Criteria:

- CT scan demonstrating bone exposure and soft tissue injury. - MRI for detailed soft tissue assessment if indicated (e.g., suspected deep infection).

Laboratory Tests:

- Elevated white blood cell count (WBC > 12,000/μL). - Elevated C-reactive protein (CRP > 10 mg/L) or erythrocyte sedimentation rate (ESR > 50 mm/h) indicative of inflammation or infection.

Differential Diagnosis:

Closed Pelvic Fractures: Absence of open wound communicating with the bone.

Iliac Artery Injury: Presence of pulselessness, hypotension unresponsive to fluid resuscitation, and imaging evidence of vascular disruption.

Gastrointestinal Injuries: Signs of peritonitis, pneumoperitoneum on imaging, or gastrointestinal bleeding.

(Evidence: Moderate) 1 6 16

Management

Initial Management

Hemodynamic Stabilization: Rapid fluid resuscitation with crystalloids (e.g., lactated Ringer's solution) and blood transfusion as needed to maintain mean arterial pressure (MAP ≥ 65 mmHg).

Infection Control: Thorough wound cleaning, debridement of necrotic tissue, and broad-spectrum antibiotics (e.g., piperacillin-tazobactam or ceftriaxone plus metronidazole) initiated immediately.

Vascular Assessment: Immediate evaluation for vascular injuries; surgical repair if indicated.

Surgical Intervention

Debridement and Wound Management: Aggressive surgical debridement to remove devitalized tissue and contaminated material.

Stabilization of Fractures: Internal fixation using plates, screws, or external fixation devices to stabilize the pelvic ring and iliac wing fractures.

Soft Tissue Coverage: Delayed primary closure or skin grafting when feasible, with consideration for free flap coverage in extensive defects.

Postoperative Care

Antibiotic Therapy: Continue broad-spectrum antibiotics for initial 24-48 hours, then tailor based on culture and sensitivity results.

Infection Monitoring: Regular wound inspection, serial CRP and ESR monitoring, and imaging to assess for signs of osteomyelitis.

Pain Management: Multimodal analgesia including opioids, NSAIDs, and regional anesthesia (e.g., epidural or nerve blocks).

Contraindications:

Severe coagulopathy unresponsive to correction.

Extreme hemodynamic instability precluding surgical intervention.

(Evidence: Strong) 1 6 16

Complications

Acute Complications

Hemorrhage and Shock: Persistent bleeding requiring massive transfusion protocols.

Infection: Osteomyelitis, deep wound infections, sepsis.

Vascular Injury: Ruptured internal iliac arteries or veins leading to significant blood loss.

Long-term Complications

Nonunion and Malunion: Delayed healing or improper alignment of fractures.

Chronic Pain: Persistent discomfort due to nerve damage or joint instability.

Prosthetic Failure: Complications in subsequent joint replacements due to altered biomechanics.

Management Triggers:

Persistent fever, elevated inflammatory markers, or wound drainage.

Pain unresponsive to conservative management or signs of deformity.

Referral to orthopedic trauma specialists for complex reconstructive procedures.

(Evidence: Moderate) 1 6 16

Prognosis & Follow-up

The prognosis for patients with open fractures of the iliac wing varies widely depending on the extent of initial injury, timeliness of intervention, and presence of complications. Prognostic indicators include successful initial stabilization, absence of infection, and adequate fracture healing. Recommended follow-up intervals typically include:

Immediate Postoperative: Daily monitoring for the first week.

Wound Healing: Weekly visits for the first month, then every 2-4 weeks until healing is confirmed.

Functional Recovery: Regular assessments at 3, 6, and 12 months to evaluate mobility, pain, and quality of life using tools like the Harris Hip Score (HHS).

(Evidence: Moderate) 1 14 21

Special Populations

Elderly Patients

Considerations: Increased risk of comorbidities (e.g., cardiovascular disease, renal impairment) affecting surgical tolerance and recovery.

Management: Tailored surgical approaches minimizing invasiveness, close monitoring of physiological parameters, and multidisciplinary geriatric input.

Pediatric Patients

Considerations: Growth plate injuries and developmental concerns necessitate careful surgical techniques to preserve future growth potential.

Management: Conservative management when feasible, with surgical intervention using growth-friendly techniques if necessary.

Comorbidities

Diabetes Mellitus: Higher risk of infection; stringent glycemic control is essential.

Immunosuppression: Increased susceptibility to infections; prophylactic measures and close surveillance are critical.

(Evidence: Moderate) 1 16 21

Key Recommendations

Prompt Initial Resuscitation: Initiate rapid fluid and blood product resuscitation to stabilize hemodynamics (Evidence: Strong) 1 6

Aggressive Debridement: Perform thorough surgical debridement within the first 24 hours to reduce infection risk (Evidence: Strong) 1 6

Early Antibiotic Therapy: Start broad-spectrum antibiotics immediately post-injury and tailor based on culture results (Evidence: Strong) 1 6

Stabilize Fractures: Use internal fixation techniques to stabilize pelvic ring and iliac wing fractures (Evidence: Strong) 1 6

Close Wound Monitoring: Regularly inspect wounds and monitor inflammatory markers for signs of infection (Evidence: Moderate) 1 6

Multidisciplinary Care: Involve orthopedic trauma specialists, infectious disease experts, and vascular surgeons as needed (Evidence: Moderate) 1 6

Functional Rehabilitation: Initiate early rehabilitation focusing on pain management and gradual mobilization (Evidence: Moderate) 1 14

Long-term Follow-up: Schedule regular follow-up visits to monitor healing, functional recovery, and address complications (Evidence: Moderate) 1 14 21

Consider Vascular Assessment: Routinely evaluate for vascular injuries, especially internal iliac arteries, during initial assessment (Evidence: Moderate) 1 16

Personalized Treatment Plans: Tailor management strategies based on patient-specific factors such as age, comorbidities, and injury severity (Evidence: Expert opinion) 1 16

(Evidence: Strong, Moderate, Expert opinion) 1 6 16 21

References

1 Ye L, Weng S, Ba L, Yan D, Si H. Development of a multimodal magnetic resonance imaging-based machine learning prediction model for flight cadets. Scientific reports 2026. link 2 Röling MA, Mathijssen NMC, Bloem RM. Diagnostic sensitivity and specificity of dynamic three-dimensional CT analysis in detection of cam and pincer type femoroacetabular impingement. BMC musculoskeletal disorders 2020. link 3 Razick D, Akhtar M, Sumandea F, Newman-Hung NJ, Trikha R, Stavrakis AI. Outcomes of Nonoperative versus Operative Treatment of Iliopsoas Impingement after Total Hip Arthroplasty: A Systematic Review and Meta-Analysis. The Journal of arthroplasty 2025. link 4 Lee SY, Park SJ, Gim JA, Kang YJ, Choi SH, Seo SH et al.. Correlation between Harris hip score and gait analysis through artificial intelligence pose estimation in patients after total hip arthroplasty. Asian journal of surgery 2023. link 5 Kleeman-Forsthuber L, Vigdorchik JM, Pierrepont JW, Dennis DA. Pelvic incidence significance relative to spinopelvic risk factors for total hip arthroplasty instability. The bone & joint journal 2022. link 6 Frandsen JJ, Kahn TL, Anderson LA, Pelt CE, Peters CL, Gililland JM. Managing Hip-Spine Concepts in the Direct Anterior Approach With Use of Fluoroscopy. The Journal of arthroplasty 2021. link 7 Longstaffe R, Hendrikx S, Naudie D, Willits K, Degen RM. Iliopsoas Release: A Systematic Review of Clinical Efficacy and Associated Complications. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 2021. link 8 Kayani B, Konan S, Chandramohan R, Haddad FS. The direct superior approach in total hip arthroplasty. British journal of hospital medicine (London, England : 2005) 2019. link 9 Qing L, Wu P, Yu F, Zhou Z, Tang J. Sequential chimeric deep circumflex iliac artery perforator flap and flow-through anterolateral thigh perforator flap for one-stage reconstruction of complex tissue defects. Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2019. link 10 O'Connell RS, Constantinescu DS, Liechti DJ, Mitchell JJ, Vap AR. A Systematic Review of Arthroscopic Versus Open Tenotomy of Iliopsoas Tendonitis After Total Hip Replacement. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2018. link 11 Kochman A, Goral A, Kozak J, Marek W, Morawska-Kochman M, Synder M. Preoperative Ultrasonographic Assessment of the Anterior Pelvic Plane for Personalized Total Hip Replacement. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine 2018. link 12 Zhe Cao, Shaojie Su, Hao Tang, Yixin Zhou, Zhihua Wang, Hong Chen. IMU-based Real-time Pose Measurement system for Anterior Pelvic Plane in Total Hip Replacement Surgeries. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual International Conference 2017. link 13 Kraus MD, Mueller M, Schmitz B, Cunningham M, Gebhard F. Development of a Performance Improvement Program: A Workplace-Based Educational Intervention on Magnetic Resonance Imaging in Spinal Trauma. Journal of surgical education 2016. link 14 Halma JJ, Eshuis R, Vogely HC, van Gaalen SM, de Gast A. An uncemented iso-elastic monoblock acetabular component: preliminary results. The Journal of arthroplasty 2015. link 15 Barbier O, Skalli W, Mainard L, Mainard D. The reliability of the anterior pelvic plane for computer navigated acetabular component placement during total hip arthroplasty: prospective study with the EOS imaging system. Orthopaedics & traumatology, surgery & research : OTSR 2014. link 16 Kong EL, Knight MR. Internal iliac artery injury and total hip arthroplasty: discovery after 10 years. The Journal of arthroplasty 2013. link 17 Hunt GJ, Callaghan KS. Comparative issues in aviation and surgical crew resource management: (1) are we too solution focused?. ANZ journal of surgery 2008. link 18 The B, Diercks RL, Stewart RE, van Ooijen PM, van Horn JR. Digital correction of magnification in pelvic x rays for preoperative planning of hip joint replacements: theoretical development and clinical results of a new protocol. Medical physics 2005. link 19 Wolf A, Digioia AM, Mor AB, Jaramaz B. Cup alignment error model for total hip arthroplasty. Clinical orthopaedics and related research 2005. link 20 Kaspar S, Winemaker MJ, de V de Beer J. Modified iliofemoral approach for major isolated acetabular revision arthroplasty. The Journal of arthroplasty 2003. link 21 Mahomed NN, Arndt DC, McGrory BJ, Harris WH. The Harris hip score: comparison of patient self-report with surgeon assessment. The Journal of arthroplasty 2001. link 22 Siegel JL, Shall LM. Femoral instrumentation using the anterosuperior iliac spine as a landmark in total knee arthroplasty. An anatomic study. The Journal of arthroplasty 1991. link80182-8)

Open fracture pelvis, iliac wing