Vertical shear (VS) pelvic fractures are rotationally and vertically unstable injuries caused by axial loading forces that produce cephalad displacement of the hemipelvis. They account for <1% of all fractures but carry significant morbidity due to complete disruption of both anterior and posterior pelvic ring structures. [1-2] Under the Young & Burgess classification, VS is the most unstable pattern (AO/OTA type 61C), and the WSES classifies hemodynamically stable VS injuries as Grade III (moderate-severe) and any hemodynamically unstable pelvic fracture as Grade IV (severe). [3]
1. History
- Mechanism: High-energy axial loading — fall from height (landing on one leg), motorcycle/MVC, pedestrian struck, crush injury
- Key HPI: Height of fall, speed of impact, position at landing, direction of force
- Symptom characterization: Severe pelvic/hip pain, inability to bear weight, leg-length discrepancy on the affected side
- Associated symptoms: Perineal pain, hematuria, rectal bleeding, lower extremity numbness/weakness
- Important negatives: Loss of consciousness, chest/abdominal pain, back pain (spinal injury), prior anticoagulant use [4-5]
2. Alarm Features
- Hemodynamic instability (SBP <90, HR >120, altered mental status, skin vasoconstriction) — hemorrhagic shock is the primary killer [3][6]
- Expanding perineal/scrotal hematoma — suggests major vascular or urethral injury [3]
- Blood at the urethral meatus or high-riding prostate — posterior urethral disruption (more common with vertical shear forces) [7]
- Open fracture with perineal wound — dramatically increases mortality and infection risk [8]
- Progressive neurologic deficit in lower extremities — lumbosacral plexus injury (up to 33% of major pelvic injuries) [9]
- Gross rectal bleeding — rectal laceration requiring fecal diversion [3]
3. Medications
- Acute resuscitation: Massive transfusion protocol (1:1:1 pRBC:FFP:platelets or whole blood); tranexamic acid (TXA) within 3 hours of injury [4]
- DVT prophylaxis: Early pharmacologic prophylaxis (LMWH) recommended; delays >48 hours should be reviewed [5]
- Pain management: IV opioids, ketamine for procedural sedation; avoid NSAIDs acutely if hemorrhage concern
- Anticoagulant/antiplatelet reversal: Patients on warfarin, DOACs, or antiplatelets have lower threshold for angiography and may need reversal [5]
- Avoid excessive crystalloid resuscitation — permissive hypotension until hemorrhage control achieved [10]
4. Diet
- NPO status on arrival — anticipate operative intervention
- Nutritional optimization post-stabilization: high-protein, calcium, and vitamin D supplementation for fracture healing
- Prolonged immobilization increases caloric needs; early enteral nutrition when feasible
5. Review of Systems
- GU: Hematuria, difficulty voiding, blood at meatus, vaginal bleeding (females)
- GI: Rectal bleeding, fecal incontinence, abdominal distension
- Neuro: Lower extremity weakness, numbness, saddle anesthesia, bowel/bladder incontinence (cauda equina)
- MSK: Back pain (concurrent thoracolumbar fracture), ipsilateral lower extremity fractures
- Vascular: Cold/pulseless extremity, expanding hematoma
- Respiratory: Dyspnea, chest pain (concurrent thoracic injury — present in ~56% of unstable pelvic fractures) [11]
6. Collateral History and Family History
- Witnesses to mechanism (height of fall, ejection from vehicle, crush duration)
- Pre-injury ambulatory status and functional baseline (especially in elderly)
- Anticoagulant/antiplatelet medication list
- Advance directives in polytrauma patients
- Family history is generally not contributory in acute traumatic VS fractures, though osteoporosis history may be relevant in elderly patients
7. Risk Factors
- High-energy trauma: Falls from height, motorcycle crashes, pedestrian vs. vehicle
- Young males (high-energy mechanisms) and elderly patients (osteoporotic bone, lower-energy falls)
- Anticoagulation — increases hemorrhage risk and lowers threshold for intervention [5]
- Osteoporosis/metabolic bone disease — lower energy required to produce VS pattern in elderly [12]
- Occupational hazards (construction, industrial work)
8. Differential Diagnosis
- APC-III ("open book") — bilateral SI disruption but horizontal displacement predominates; distinguished by widened symphysis without cephalad hemipelvic migration [2]
- LC-III ("windswept pelvis") — contralateral APC component; internal rotation on one side, external on the other
- Combined mechanism (CM) — features of multiple injury vectors
- Acetabular fracture — axial load through femoral head; CT distinguishes pelvic ring vs. acetabular involvement
- Hip dislocation/femoral neck fracture — can mimic leg-length discrepancy; AP pelvis X-ray differentiates
- Lumbar spine fracture-dislocation — concurrent injury in up to 41% of unstable pelvic fractures [11]
- Pathologic fracture — consider in low-energy mechanism with lytic lesion on imaging
9. Past Medical History
- Prior pelvic/hip fractures or surgery
- Osteoporosis, metabolic bone disease, malignancy (pathologic fracture risk)
- Chronic anticoagulation or bleeding disorders
- Prior abdominal/pelvic surgery (altered anatomy for packing or angiography)
- Vascular disease (atherosclerosis may affect angioembolization approach)
- Pregnancy — pelvic binder use requires caution [3]
10. Physical Exam
- Vitals: Tachycardia and hypotension are the most critical early findings; tachycardia may precede hypotension
- Inspection: Leg-length discrepancy (affected limb appears shortened and externally rotated), perineal/scrotal ecchymosis ("butterfly sign"), open wounds
- Palpation: Pelvic instability on gentle AP and lateral compression (perform only once — repeated manipulation worsens hemorrhage); symphyseal widening, SI joint tenderness
- Rectal exam: High-riding prostate (males), rectal tone, blood on glove
- Vaginal exam (females): Lacerations indicating open fracture
- Neurovascular: Distal pulses, motor/sensory exam of L4-S3 dermatomes, perineal sensation (pudendal nerve) [9][13]
- FAST exam: Rule out concurrent intra-abdominal hemorrhage [5]
11. Lab Studies
- Type and crossmatch — immediate; anticipate massive transfusion
- CBC — baseline hemoglobin (serial monitoring)
- Coagulation panel (PT/INR, PTT, fibrinogen) — assess for coagulopathy/lethal triad
- Lactate and base deficit — markers of hemorrhagic shock severity and resuscitation adequacy [14]
- BMP — renal function (contrast for CTA/angiography)
- Urinalysis — hematuria screening for GU injury [15]
- ABG — acidosis assessment
- TEG/ROTEM — if available, guides targeted blood product resuscitation
- Pregnancy test — all females of childbearing age
12. Imaging
- AP pelvis X-ray — first-line; look for cephalad migration of hemipelvis (pathognomonic for VS), symphyseal disruption, sacral fracture lines [2]
- CT pelvis with IV contrast (CTA) — gold standard for definitive fracture characterization, posterior ring assessment, and identification of active arterial extravasation (contrast blush) [5]
- Inlet/outlet views — supplement AP film; inlet shows AP displacement, outlet shows vertical displacement
- CT abdomen/pelvis — evaluate for concurrent visceral injury
- Contrast blush on CTA is predictive of need for angioembolization [5]
- Imaging is unnecessary only in the most minor pelvic injuries; VS fractures always require advanced imaging
13. Special Tests
- Young & Burgess classification — categorizes mechanism (APC, LC, VS, CM) and guides management [2-3]
- Tile/AO classification — Type C (rotationally and vertically unstable) corresponds to VS [1]
- WSES grading — integrates hemodynamic status with mechanical stability for management algorithm [3]
- FAST/DPA — rule out intra-abdominal hemorrhage as competing source [5]
- Retrograde urethrogram — if blood at meatus or suspected urethral injury; perform before Foley placement [7]
- Cystogram — if bladder injury suspected (gross hematuria with pelvic fracture)
- Angiography — both diagnostic and therapeutic for arterial hemorrhage [5-6]
14. ECG
- Obtain ECG in all trauma patients — rule out cardiac contusion (concurrent thoracic trauma), dysrhythmia from hemorrhagic shock
- PEA/bradycardia — may indicate severe hypovolemia or tension pneumothorax
- Tachycardia is expected; new ST changes or arrhythmias warrant further cardiac evaluation
- Elderly patients: ECG may reveal pre-existing cardiac disease affecting resuscitation strategy
15. Assessment
Vertical shear pelvic fractures are the most mechanically unstable pelvic ring injury pattern, with complete disruption of anterior and posterior stabilizing structures resulting in cephalad hemipelvic displacement. [1-2] Key clinical summary points:
- Bleeding is predominantly venous (80%) from the presacral and prevesical plexus, with arterial bleeding (20%) from branches of the internal iliac artery [3]
- Mortality from VS fractures is paradoxically reported as lower than severely displaced APC-III injuries, though morbidity remains high [1]
- Neurologic injury occurs in up to 33% and is proportional to posterior ring displacement [9]
- Long-term sexual dysfunction (43%) and urinary dysfunction (41%) are common, with VS pattern carrying the highest odds ratios for both compared to LC injuries [16]
- Complications: DVT/PE (high risk), malunion, chronic pain, infection (especially open fractures), heterotopic ossification
16. Treatment Plan
Initial Stabilization (ED)
- Pelvic binder over greater trochanters — apply immediately; first-line for all VS injuries [3][5][17]
- Activate massive transfusion protocol (1:1:1 or whole blood) [4][10]
- TXA 1g IV bolus (within 3 hours of injury) [4]
- Permissive hypotension (target SBP ~90 mmHg) until hemorrhage control
- Avoid excessive crystalloid
Hemodynamically Unstable — Stepwise Hemorrhage Control
- FAST/DPA to rule out intra-abdominal source → if positive, emergent laparotomy [5]
- If FAST negative: preperitoneal pelvic packing (PPP) ± external fixation for counterpressure [3][5]
- Persistent instability after packing → angioembolization (selective preferred over nonselective) [5-6]
- REBOA (Zone III) as bridge in extremis [4][12]
Hemodynamically Stable
- CT angiography for definitive fracture characterization and hemorrhage assessment [5]
- Contrast blush → early angiography consultation [5]
Definitive Fixation
- All VS fractures require definitive internal fixation — both anterior and posterior ring [3]
- Posterior fixation options: percutaneous iliosacral screws (most common), spinopelvic fixation ("triangular osteosynthesis"), tension band plating [1][3][18]
- Anterior fixation: symphyseal plating or anterior internal fixator
- Timing: hemodynamically stable patients → within 24 hours; physiologically deranged polytrauma → delay to day 4+ post-injury [3]
- Spinopelvic fixation allows immediate weight bearing in vertically unstable sacral fractures [3]
17. Disposition
- All VS fractures require admission — typically to a Level I trauma center ICU [11]
- Transfer criteria: any unstable pelvic ring disruption at a facility without orthopedic trauma, angiography, or pelvic packing capability [5]
- ICU admission: hemodynamic instability, massive transfusion, polytrauma, post-angioembolization monitoring
- Step-down when hemodynamically stable, no ongoing transfusion requirement, pain controlled
- Orthopedic trauma surgery consultation is mandatory [5]
- Additional consults as needed: vascular surgery, urology (GU injury), general surgery (abdominal injury), interventional radiology, neurosurgery (concurrent spine injury)
18. Follow Up / Return Precautions
- Post-operative follow-up: Orthopedic trauma at 2 weeks (wound check, X-ray), then 6 weeks, 3 months, 6 months, 1 year
- Weight-bearing status per surgeon — typically non-weight-bearing or toe-touch for 8–12 weeks (unless spinopelvic fixation allows earlier weight bearing) [3]
- DVT prophylaxis continued per protocol; screening duplex if symptomatic [5]
- Return precautions (patient counseling):
- Return immediately for increasing pain, new leg weakness/numbness, inability to urinate, blood in urine, fever, wound drainage
- Expected recovery: prolonged (months); chronic pain and functional limitations are common even with anatomic reduction [19]
- Screen for sexual and urinary dysfunction at follow-up — affects 40%+ of patients; early urology/gynecology referral recommended [16][20]
- Neurologic recovery: begins ~3 months post-injury, plateaus at ~2 years; complete recovery is uncommon in severe nerve injuries [9]
- Physical therapy and rehabilitation planning — critical for functional recovery
- Mental health screening — PTSD and depression are common after major pelvic trauma
References
1. Vertical Shear Pelvic Injury: Evaluation, Management, and Fixation Strategies. — Blum L, Hake ME, Charles R, et al. International Orthopaedics. 2018.
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. Pelvic Trauma: WSES Classification and Guidelines. — Coccolini F, Stahel PF, Montori G, et al. World Journal of Emergency Surgery : WJES. 2017.
4. Novel Resuscitation Strategies in Patients With a Pelvic Fracture. — Copp J, Eastman JG. Injury. 2021.
5. 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.
6. 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.
7. Pelvic Fracture and Associated Urologic Injuries. — Brandes S, Borrelli J. World Journal of Surgery. 2001.
8. Pelvic Fractures: Part 1. Evaluation, Classification, and Resuscitation. — Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. The Journal of the American Academy of Orthopaedic Surgeons. 2013.
9. Neurologic Deficits in Major Pelvic Injuries. — Majeed SA. Clinical Orthopaedics and Related Research. 1992.
10. 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.
11. Transferrals and Clinical Pathways of Unstable Pelvic Fractures Over the Last 10 Years - A Retrospective Analysis of the Trauma Register DGU®. — Weuster M, Pfeifer R, Seekamp A, et al. European Journal of Trauma and Emergency Surgery : Official Publication of the European Trauma Society. 2026.
12. Bleeding Management in Pelvic Trauma: State of the Art. — Puchwein P, Hallmann B, Eibinger N. Current Opinion in Anaesthesiology. 2025.
13. Pudendal Nerve in Pelvic Bone Fractures. — Báča V, Báčová T, Grill R, et al. Injury. 2013.
14. Current Management and Clinical Outcomes for Patients With Haemorrhagic Shock Due to Pelvic Fracture in Korean Regional Trauma Centres: A Multi-Institutional Trial. — Jang JY, Bae KS, Chang SW, et al. Injury. 2022.
15. Incidence and Immediate Management of Genitourinary Injuries in Pelvic and Acetabular Trauma: A 10-Year Retrospective Study. — Bhatt NR, Merchant R, Davis NF, et al. BJU International. 2018.
16. High Rates of Sexual and Urinary Dysfunction After Surgically Treated Displaced Pelvic Ring Injuries. — Odutola AA, Sabri O, Halliday R, Chesser TJ, Ward AJ. Clinical Orthopaedics and Related Research. 2012.
17. Comparison of Pelvic C-Clamp and Pelvic Binder for Emergency Stabilization and Bleeding Control in Type-C Pelvic Ring Fractures. — Audretsch CK, Mader D, Bahrs C, et al. Scientific Reports. 2021.
18. Minimally Invasive Surgery Technique for Unstable Pelvic Ring Fractures With Severe Vertical Shear Displacement: A Retrospective Study. — Morita T, Takigawa T, Ishihara T, et al. Orthopaedics & Traumatology, Surgery & Research : OTSR. 2023.
19. Pelvic Fractures: Part 2. Contemporary Indications and Techniques for Definitive Surgical Management. — Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. The Journal of the American Academy of Orthopaedic Surgeons. 2013.
20. Quantifying Urinary and Sexual Dysfunction After Pelvic Fracture. — Lefaivre KA, Roffey DM, Guy P, O'Brien PJ, Broekhuyse HM. Journal of Orthopaedic Trauma. 2022.