Lateral compression (LC) fractures are the most common pelvic ring injury pattern (~60% of pelvic fractures), caused by a laterally directed force that internally rotates the hemipelvis, producing ipsilateral pubic rami fractures anteriorly and sacral compression/crescent fractures posteriorly. [1-3] Classified by the Young-Burgess system into LC-I (sacral compression), LC-II (crescent/iliac wing fracture), and LC-III (contralateral "open book" or "windswept pelvis"), these injuries range from stable to life-threatening. [2]
1. History
- Mechanism: Lateral impact — T-bone MVC (side impact), pedestrian struck, motorcycle crash, fall from height with lateral landing, crush injury [1][4]
- Key HPI: Speed/force of impact, direction of force, position in vehicle, seatbelt use, ejection
- Pain location: Groin, lateral hip, sacral/buttock region; pain with log-roll or weight-bearing
- Inability to ambulate or bear weight — a key indicator of instability [5]
- Associated LOC, abdominal pain, hematuria, vaginal bleeding, rectal bleeding
- Pre-injury anticoagulant use (especially in elderly)
2. Alarm Features
- Hemodynamic instability (SBP <90, HR >120) — hemorrhagic shock from pelvic bleeding (venous 80%, arterial 20%) [6-7]
- Open pelvic fracture (perineal laceration, rectal/vaginal wound) — mortality up to 50%
- Blood at urethral meatus, high-riding prostate — urethral injury
- Perineal/scrotal hematoma — vascular or urogenital injury [6]
- Leg-length discrepancy or rotational deformity — vertical instability (LC-III)
- Neurologic deficit in lower extremities — sacral nerve root injury
- LC injuries with fatal outcomes are significantly associated with severe traumatic brain injury and thoracoabdominal visceral injuries [8]
3. Medications
- Acute resuscitation: Balanced transfusion (1:1:1 pRBC:FFP:platelets) or whole blood; consider TXA (1 g IV bolus within 3 hours of injury) [9]
- Analgesia: IV opioids (morphine, fentanyl); regional anesthesia (fascia iliaca block) as adjunct; avoid NSAIDs acutely if hemorrhage concern
- DVT prophylaxis: Early pharmacologic prophylaxis (LMWH) — pelvic fractures carry high VTE risk [10]
- Anticoagulant reversal: Reverse warfarin/DOACs in actively bleeding patients per institutional protocol
- Caution: Avoid excessive crystalloid resuscitation — contributes to coagulopathy and hypothermia
4. Diet
- NPO initially if hemodynamically unstable or surgical intervention anticipated
- Adequate calcium and vitamin D supplementation during recovery
- High-protein diet to support fracture healing
- Assess for osteoporosis in elderly patients with low-energy LC fractures (fragility fractures)
5. Review of Systems
- Neuro: Lower extremity weakness, numbness, saddle anesthesia (sacral plexus injury, especially Denis zone II–III sacral fractures) [11]
- GU: Hematuria, inability to void, vaginal bleeding — bladder/urethral injury occurs in 1.6–25% of pelvic fractures [6]
- GI: Rectal bleeding, fecal incontinence — rectal injury in up to 18–64% of high-grade injuries [6]
- MSK: Extremity pain (concomitant long bone fractures), back pain
- Chest: Dyspnea, chest wall pain — LC mechanism associated with ipsilateral thoracic injuries [8]
- Head: LOC, confusion, amnesia — LC injuries carry a significant association with severe TBI [8]
6. Collateral History and Family History
- Paramedic report: Mechanism details, extrication time, vehicle damage pattern, field vitals
- Bystander account of LOC or neurologic status at scene
- Medication list (anticoagulants, antiplatelets)
- Baseline functional status and ambulatory ability (especially in elderly)
- Osteoporosis history or fragility fracture history in elderly patients [12]
7. Risk Factors
- High-energy trauma: MVC (especially side-impact), pedestrian vs. vehicle, motorcycle crash [1]
- Low-energy falls in elderly: Osteoporotic bone — LC-I pattern common in fragility fractures [13]
- Anticoagulation use — increases hemorrhage risk
- Osteoporosis, chronic steroid use, metabolic bone disease
- Prior pelvic surgery or radiation
8. Differential Diagnosis
- Hip fracture (femoral neck, intertrochanteric) — overlapping mechanism in elderly; pelvic XR and CT differentiate
- Acetabular fracture — may coexist; CT defines involvement
- Isolated pubic rami fracture without posterior ring injury — more benign; CT confirms
- Hip dislocation — assess on AP pelvis; requires emergent reduction
- Lumbar spine fracture — concomitant in high-energy mechanism
- Retroperitoneal hemorrhage from other source (renal, aortic)
- Abdominal solid organ injury mimicking pelvic pain — liver (6.1%), spleen, bladder (5.8%) are commonly co-injured [14]
9. Past Medical History
- Prior pelvic or hip fractures/surgery
- Osteoporosis or osteopenia
- Chronic anticoagulation
- Malignancy (pathologic fracture consideration)
- Neurologic conditions affecting gait/balance
- Prior urologic or gynecologic surgery (relevant for surgical planning)
10. Physical Exam
- Vitals: Tachycardia and hypotension suggest hemorrhagic shock
- Inspection: Pelvic asymmetry, limb-length discrepancy, rotational deformity, perineal/scrotal ecchymosis, open wounds
- Palpation: Tenderness over pubic symphysis, iliac crests, sacrum; avoid repeated manual compression/distraction (single gentle assessment only — can dislodge clot)
- Stability testing: Gentle lateral-to-medial compression and AP distraction — LC injuries classically show internal rotation of the hemipelvis
- Rectal exam: Tone, blood, high-riding prostate
- Vaginal exam (in females): Lacerations suggesting open fracture
- Neurovascular: Distal pulses, motor/sensory exam of lower extremities, perineal sensation (S2–S4)
- FAST exam: Rule out intraabdominal free fluid [10]
11. Lab Studies
- CBC (serial hemoglobin — initial may be normal despite significant hemorrhage)
- Type and crossmatch — order early; anticipate transfusion needs
- BMP, lactate, base deficit — markers of shock severity and resuscitation adequacy
- Coagulation panel (PT/INR, PTT, fibrinogen) — assess for coagulopathy
- Urinalysis — hematuria screening for GU injury
- ABG/VBG — pH, base deficit for shock assessment
- Pregnancy test in women of childbearing age
12. Imaging
- AP pelvis radiograph: First-line screening; look for pubic rami fractures, sacral compression lines, pelvic asymmetry. Sensitivity is limited (50–68%) [6]
- CT pelvis with IV contrast: Gold standard — 100% sensitivity for bony fractures; defines sacral fracture morphology (complete vs. incomplete, Denis zone), crescent fractures, and detects contrast extravasation indicating active hemorrhage [6][15]
- Inlet/outlet views: Helpful adjuncts for displacement assessment
- CT angiography: When active arterial hemorrhage suspected; LC injuries are associated with anterior-division internal iliac artery injuries [16]
- MRI: Superior for occult posterior ring fractures in elderly/fragility fractures when CT is negative but clinical suspicion remains [12]
- Pelvic binder should NOT be removed for imaging
13. Special Tests
- ED stress radiographs (fluoroscopic): Safe and reliable for assessing occult instability in minimally displaced LC-I fractures — positive if ≥10 mm overlap of rami on stress views. Negative stress predicts successful nonoperative treatment [17-18]
- Beckmann instability scoring system: Validated radiographic scoring for LC-I fractures (score <7 stable, 7–9 indeterminate, >9 unstable) — correlates well with ED stress results [18]
- Examination under anesthesia (EUA): For indeterminate stability, especially with comminuted or oblique rami fractures [19]
- Retrograde urethrogram: Before Foley placement if urethral injury suspected (blood at meatus, high-riding prostate) [6]
- Cystogram: If bladder injury suspected
- FAST/DPA: To rule out intraabdominal hemorrhage in unstable patients [10]
14. ECG
- Obtain ECG in all trauma patients — assess for arrhythmia, myocardial contusion (if associated thoracic trauma), or signs of right heart strain from hemorrhagic shock
- Elderly patients: Rule out cardiac event as precipitant of fall/MVC
- Tachycardia on ECG may be the earliest sign of hemorrhagic shock
15. Assessment
Young-Burgess LC Classification: [2-3]
- LC-I fractures are not always benign — overall mortality 8.2% in one large series, with mean ISS of 17 [21]
- Comminuted/oblique rami fractures and complete sacral fractures predict occult instability and subsequent displacement [19]
- Associated injuries: Head (most common cause of death in LC), chest, and abdominal injuries are frequent [8][11]
16. Treatment Plan
Initial stabilization (all subtypes)
- ATLS primary survey; address airway, breathing, circulation
- Pelvic binder placed at level of greater trochanters — use cautiously in LC injuries (pelvis is already internally rotated; over-compression may worsen deformity). Some experts advocate binder placement in all unstable patients regardless of pattern [6][22]
- Hemodynamically unstable: Activate massive transfusion protocol (1:1:1 or whole blood); consider TXA [9-10]
- FAST exam → if positive, OR for laparotomy; if negative, pelvic stabilization + preperitoneal packing [10]
- Angioembolization for persistent instability or CT evidence of arterial extravasation [7][16]
Definitive management by subtype
- LC-I: Majority managed nonoperatively with weight-bearing as tolerated and early mobilization. Consider ED stress exam or EUA for minimally displaced fractures with concerning features (complete sacral fracture, comminuted/oblique rami). Surgical fixation if ≥10 mm displacement or positive stress exam [6][17][19]
- LC-II: Typically requires surgical fixation — posterior ring fixation (iliosacral screws or plating) ± temporary external fixation [6]
- LC-III: Requires surgical fixation of both anterior and posterior ring; damage control external fixation initially if hemodynamically unstable, with definitive fixation delayed until after day 4 in polytrauma [6]
Timing of definitive fixation
- Hemodynamically stable: Within 24 hours [6]
- Polytrauma/physiologically deranged: Delay until after day 4 [6]
- Hemodynamically unstable: Damage control first, definitive fixation after resuscitation [6]
17. Disposition
- Admit (trauma/surgical service): All hemodynamically unstable patients, LC-II and LC-III injuries, LC-I with significant displacement or positive stress exam, polytrauma, significant associated injuries, inability to ambulate, elderly patients on anticoagulation
- ICU: Hemodynamic instability, massive transfusion, post-angioembolization, post-operative
- Observation: Stable LC-I with minimal displacement, pending orthopedic evaluation and stress testing
- Transfer to trauma center: If at a facility without orthopedic trauma, interventional radiology, or angiography capability [10]
- Discharge (rare from ED): Only truly isolated, minimally displaced LC-I fractures in young, ambulatory patients with negative stress exam, reliable follow-up, and no associated injuries — after orthopedic consultation [17]
18. Follow Up / Return Precautions
- Orthopedic follow-up: Within 1–2 weeks for all LC fractures; repeat imaging at 2–3 weeks to assess for displacement
- Weight-bearing status: Per orthopedic guidance — most stable LC-I can weight-bear as tolerated; unstable patterns require restricted weight-bearing
- DVT prophylaxis: Continue pharmacologic prophylaxis throughout immobilization period [10]
- Return precautions: Increasing pain, inability to bear weight, new neurologic symptoms (numbness, weakness, bowel/bladder dysfunction), signs of infection, hematuria, fever
- Expected recovery: LC-I — 6–12 weeks for fracture healing; full recovery rates ~41% for LC-I, ~46% for LC-II, and only ~11% for LC-III [20]
- Long-term considerations: Chronic pain, sacroiliac dysfunction, sexual dysfunction, urologic complications; LC-III/VS/CM injuries have highest rates of reintervention for pain [20]
References
1. Rethinking LC-type in Young-Burgess Classification of Pelvic Fracture: A Retrospective Study. — Gao Y, Lou Z, Tang X. Medicine. 2025.
2. Pelvic Ring Fractures: What the Orthopedic Surgeon Wants to Know. — Khurana B, Sheehan SE, Sodickson AD, Weaver MJ. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2014.
3. What Are the Patterns of Injury and Displacement Seen in Lateral Compression Pelvic Fractures?. — Weaver MJ, Bruinsma W, Toney E, Dafford E, Vrahas MS. Clinical Orthopaedics and Related Research. 2012.
4. Pelvic Fractures: Value of Plain Radiography in Early Assessment and Management. — Young JW, Burgess AR, Brumback RJ, Poka A. Radiology. 1986.
5. High-Energy Lateral Compression Type 1 Injuries of the Pelvis: A Spectrum of Injury. — Tejwani N, Stevens NM, Ganta A. The Journal of the American Academy of Orthopaedic Surgeons. 2020.
6. Pelvic Trauma: WSES Classification and Guidelines. — Coccolini F, Stahel PF, Montori G, et al. World Journal of Emergency Surgery : WJES. 2017.
7. Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures. — Anand T, El-Qawaqzeh K, Nelson A, et al. JAMA Surgery. 2023.
8. Pattern of Organ Injuries in Pelvic Fracture: Impact Force Implications for Survival and Death in Motor Vehicle Injuries. — Siegel JH, Dalal SA, Burgess AR, Young JW. Accident; Analysis and Prevention. 1990.
9. Novel Resuscitation Strategies in Patients With a Pelvic Fracture. — Copp J, Eastman JG. Injury. 2021.
10. Best Practices In The Management Of Orthopaedic Trauma. — Matthew L. Davis MD FACS, Gregory J. Della Rocca MD PhD FACS, Megan Brenner MD MS RPVI FACS, et al American College of Surgeons (2015). 2015.
11. 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. — Lefaivre KA, Padalecki JR, Starr AJ. Journal of Orthopaedic Trauma. 2009.
12. Imaging of Pelvic Ring Fractures in Older Adults and Its Clinical Implications-a Systematic Review. — Mennen AHM, Blokland AS, Maas M, van Embden D. Osteoporosis International : A Journal Established as Result of Cooperation Between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2023.
13. Bleeding Management in Pelvic Trauma: State of the Art. — Puchwein P, Hallmann B, Eibinger N. Current Opinion in Anaesthesiology. 2025.
14. Pelvic Fractures: Epidemiology and Predictors of Associated Abdominal Injuries and Outcomes. — Demetriades D, Karaiskakis M, Toutouzas K, et al. Journal of the American College of Surgeons. 2002.
15. High-Energy Pelvic Ring Injuries: A Comprehensive Imaging Review. — Raniga S, Pal D, Mehta C, et al. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2025.
16. Society of Interventional Radiology Position Statement on Endovascular Intervention for Trauma. — Padia SA, Ingraham CR, Moriarty JM, et al. Journal of Vascular and Interventional Radiology : JVIR. 2020.
17. Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable. — DeKeyser GJ, Kellam PJ, Haller JM, et al. The Journal of Bone and Joint Surgery. American Volume. 2022.
18. Comparing Emergency Department Stress of Lateral Compression Type 1 Pelvis Fractures With a Validated Instability Scoring System. — Dekeyser GJ, Kellam PJ, Higgins TF, et al. The Journal of the American Academy of Orthopaedic Surgeons. 2023.
19. Anterior Pelvic Ring Fracture Pattern Predicts Subsequent Displacement in Lateral Compression Sacral Fractures. — Ellis JD, Shah NS, Archdeacon MT, Sagi HC. Journal of Orthopaedic Trauma. 2022.
20. Functional Status and Health-Related Quality of Life Following Young and Burgess Classified Pelvic Ring Injuries. — Therrien CC, Uil M, Ten Duis K, et al. PloS One. 2025.
21. Young-Burgess Classification of Pelvic Ring Fractures: Does It Predict Mortality, Transfusion Requirements, and Non-Orthopaedic Injuries?. — Manson T, O'Toole RV, Whitney A, et al. Journal of Orthopaedic Trauma. 2010.
22. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical Protocol for Damage-Control Resuscitation for the Adult Trauma Patient. — LaGrone LN, Stein D, Cribari C, et al. The Journal of Trauma and Acute Care Surgery. 2024.