Fragility pelvic fractures


Fragility fracture




Fracture of the pelvis caused by a low energy fall

Usually secondary to osteoporosis




Incidence of bleeding low unless on anticoagulation


Fracture pattern


Lateral compression injury

- pubic rami fracture

- sacral alar fracture


Fragility # CT 1Fragility # CT 2




Rommens and Hofmann Injury 2013

- case series of 245 patients

- only 17.5% had isolated anterior ring injury on CT


Rommens and Hofmann Classification (CT)

Type I:     Anterior pelvic ring only (17.5%)

Type II:    Non displaced posterior pelvic ring (50%)

Type III:  Displaced unilateral posterior pelvic ring (10%)

Type IV:   Displaced bilateral posterior pelvic ring (20%)


Natural History


Omichi et al Eur J Trauma Emerg Surg 2022

- 552 fragility fractures treated nonoperatively with 2 year follow up

- 90% survival at one year, 80% survival at two years

- walking ability affected in Type III

- type III had lowest survival


Nonoperative Management




Type I

Type II


Operative Management




Type III

Type IV






Posterior SI screws +/- cement augmentation

Trans-sacral screws




Retrograde trans-pubic screws





Operative versus Nonoperative


Osterhoff et al J Orthop Trauma

- comparison of 82 patients treated nonoperative to group of 148 treated with early surgery if failed early mobilization

- at one year, mortality 17% in nonoperative compared to 23% early operative

- higher mortality rate and early complication rate in early operative group

- no difference functional outcome


Walker et al J Orthop Trauma 2018

- retrospective review of isolated sacral fragility fracture

- 16 operative (trans-iliac trans-sacral screw) and 25 nonoperatively

- surgery reduced early pain, improved early walking, and improved discharge to home


Surgical Technique


Wilson et al BMC Musculoskeletal Disorder 2021

- systematic review

- increased failure rate when a single unaugmented SI screw was used


Balling Spine 2019

- RCT percutaneous screw +/- sacroplasty

- 26 in each group

- no improvement of clinical outcome with sacroplasty