CORE EM: Pelvic Vertical Shear Fractures

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Written by Bess Storch, MD and Edited by Tim Greene, MD

Definition: Unstable ipsilateral anterior and posterior fractures of the pelvic ring, with resultant superior displacement of one hemipelvis. Also known as the Malgaigne fracture.


  •  High energy blunt trauma, with significant axial loading
  • Most commonly a fall or jump from a height with impact onto the lower extremities
  • Pelvic ring is disrupted, with both anterior pelvis injury (pubic rami), and ipsilateral posterior pelvis injury (sacrum, SI joint, iliac wing)
  • Ruptures the sacrotuberous and posterior sacroiliac ligaments which provide vertical stability to the pelvis
  • As a result, the “lateral fragment”, the fracture component containing the acetabulum, is displaced superiorly

Vertical Shear Fracture Mechanism (


  • 5% of all pelvic fractures (Dalal 1989)
  • Least common of the three categories of pelvic fractures based on the Young-Burgess Classification System (see “Injury Classification System” below). (Burgess 1990)
  • Poor prognosis – overall mortality rate 28% (Dalal 1989)

Physical Exam

  • Tenderness on palpation of the pelvis is the most reliable indicator of pelvic ring injury (Durkin 2006)
  • Pelvic instability
    • Traditional assessment
      • Gentle bimanual compression to both iliac wings.
      • Should only be performed only once, given risk of disrupting early clot formation and tamponade.
      • Poor sensitivity (59%) and specificity (71%) (Scott 2013)
      • Vertical instability
        • Place one hand on the iliac crest and with the other hand applying traction to the leg
        • If there is vertical instability, this maneuver will cause inferior displacement of the leg
    • Alternate approach: because of the potential to disrupt clot or worsen bleeding in severely injured trauma patients, it is reasonable to simply place a pelvic binder and obtain imaging instead of applying these maneuvers.
  • Assess for limb length discrepancy, with shortening of the lower extremity ipsilateral to the pelvic injury.
  • Assess for evidence of surrounding soft tissue injuries:
    • Scrotal/labial/perineal/flank hematomarectal /vaginal/perineal lacerationsrectal exam for sphincter tone and sensation to evaluate for lumbosacral plexus injuries
    • Gross hematuria for GU injury.
  • Thoroughly evaluate for other injuries given the high energy mechanism needed to sustain this type of fracture

Injury Classification System

  • Tile System: Divided into three categories based on the stability of the posterior sacroiliac complex
Type Stability Examples
A Stable Isolated iliac wing fractures, avulsion fractures of the iliac spines or ischial tuberosity, nondisplaced pelvic ring fractures.
B Rotationally unstable; vertically stable Open book fractures, lateral compression fractures, and bucket-handle fractures.
C Rotationally and vertically unstable Vertical shear injuries

Tile Classification (

  • Young-Burgess system: Based on the direction of force applied to the pelvic ring
Pattern Characteristics Incidence
Lateral compression (LC) I. Rami fracture and ipsilateral sacral compression. 48.7%
II. Rami fracture and ipsilateral crescent fracture. 7.4%
III. Rami fracture and contralateral APC injury. 9.3%
Anterior-posterior compression (APC) I. Symphysis diastasis <2cm; SI joints intact. 0%
II. Symphysis diastasis with disruption of the anterior SI ligaments. 11.1%
III. Symphysis diastasis with disruption of the anterior and posterior SI ligaments. 4.3%
Vertical shear (VS) Vertical displacement of one or both hemipelvices. 5.6%
Combined A combination of the above injuries. 6.8%

Young-Burgess Classification (

Vertical Shear Fracture with Diastasis of the Pubic Symphysis (

X-Ray Findings

  • Views: Anterior-Posterior (AP) image most commonly obtained
  • Diagnostic Findings
    • Separation of the pubic symphysis greater than 0.5 cm
    • Vertically oriented fractures through components of both the anterior and posterior pelvis
    • Results in superior displacement of the lateral “acetabulum-containing” fragment of the pelvis
  • Isolated anterior ring injury
    • Uncommon in high-energy mechanism
    • Pelvis is a ring structure and a single disruption of the ring is uncommon
    • If a concomitant posterior injury is not visualized, consider obtaining a CT to further evaluate
    • In one study of patients with apparent isolated pubic ramus fractures on X-ray, 96.8% (171/177) had posterior injuries revealed on CT (Scheyerer 2012)
  • Additional Images:
    • Consider pelvic inlet and outlet views to better demonstrate hemipelvis displacement
    • Should only be performed in hemodynamically stable patients

Fracture involving left sacroiliac joint and left pubic rami, with superior displacement of the lateral fragment (

Malgaigne Fracture (Case courtesy of Dr Hani Salam, From the case rID: 12132)

Emergency Department Management

  • Early recognition and treatment of hemorrhagic shock is the most important factor for survival. (Halawi 2015)
    • 63% prevalence of hemorrhagic shock in these injuries
    • Potential for massive retroperitoneal hemorrhage from bony fragments and lacerated blood vessels
    • Venous bleeding more common but arterial hemorrhage can also occur
    • Retroperitoneal space can accumulate up to 4 liters of blood before venous tamponade occurs
  • With only 3 cm of additional pubic symphysis diastasis (separation), the pelvis doubles in volume, allowing for significantly more bleeding before tamponade.
  • Emergency Stabilization Approach
  • Traction Set Up (

    Orthopedic Stabilization Approach

    • Goals: Prevent movement of fracture fragments, stabilize pelvis and reduce pelvic volume (Halawi 2015)
    • Apply axial traction to vertically align the two pelvic fracture fragments
    • Place supracondylar femoral pin into side with migrated fragment
    • Apply 25-30 lbs of traction to reduce pelvis
    • Attempt to obtain equal leg lengths as indicator of alignment
    • After traction accomplished, apply pelvic binder or bedsheet
  • Continued management depends on other traumatic injuries and priorities but may include external fixation, angiography with embolization, laparotomy with pelvic packing. Consult trauma surgery, orthopedics, and interventional radiology for embolization


  • High associated mortality rate
    • Isolated pelvic fracture with hypotension: 15-40%
    • Associated intra-abdominal injury: > 50%
    • Associated intra-abdominal and head injuries: > 90%
    • Hemorrhagic shock is the leading cause of death
  • Chronic pain
    • At a median follow up of 52 months, 64% of patients reported chronic post-traumatic pelvic pain (Halawi 2016)
  • Sexual dysfunction
    • 61% of men reported sexual dysfunction after pelvic ring injury (Halawi 2016)

Take Home Points

  • Suspect vertical shear pelvic fracture in any patient with a high-energy axial-directed force of injury. Common exam findings include leg length discrepancy and pelvic instability
  • Superior displacement of hemipelvis on radiography is diagnostic but may be absent. Consider CT imaging if posterior injuries are not visible on X-ray and if patient is hemodynamically stable.
  • Immediate management focuses on placement of a pelvic binder and a focus on trauma resuscitation


Burgess AR et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990;30(7):848-56. PMID: 2381002

Dalal SA et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma  1989;29(7): 981-1000. PMID: 2746708

Durkin A et al. Contemporary management of pelvic fractures. Am J Surg 2006;192(2): 211-23. PMID: 16860634

Halawi MJ. Pelvic ring injuries: Emergency assessment and management. J Clin Orthop Trauma 2015;6(4): 252-8. PMID: 26566339

Halawi, MJ. Pelvic ring injuries: Surgical management and long-term outcomes. J Clin Orthop Trauma 2016;7(1): 1-6. PMID: 26908968

Scheyerer MJ et al. Detection of posterior pelvic injuries in fractures of the pubic rami. Injury 2012; 43(8): 1326-9. PMID: 22682148

Scott I et al. The prehospital management of pelvic fractures: initial consensus statement. Emerg Med J 2013;30: 1070-1072. PMID: 24232012

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