Unstable pelvic fractures are severe and life-threatening orthopedic injuries with a high mortality rate [1]. The mortality risk associated with unstable pelvic fractures ranges from 19% to 31% [1]. Most victims lose their lives because of exposure to high-energy traumas. Polytrauma patients commonly experience additional head and extremity or abdominal and chest injuries while bleeding from damaged venous or arterial vessels of the pelvis [2]. Pelvic fracture patients with unstable blood circulation patterns can have mortality rates between 20% and 50% [3]. Management of unstable pelvic fractures remains a significant challenge. It is compounded especially in resource-limited settings, where there is a trend of an increased burden of trauma-related injuries. [4, 5] Severe associated injuries in patients make them difficult to treat using the existing diagnostic and therapeutic capabilities of local healthcare facilities [6]. The initial optimal care for such injuries must be performed by a trauma surgeon, together with an orthopedic surgeon and radiologist specializing in interventional radiology methods, as well as a urologist and a neurosurgeon [7]. Most hospitals within low- and lower-middle-income countries lack well-structured multidisciplinary teams, as noted in [4, 6, 8]. Research shows that a considerable number of pelvic fracture survivors experience functional impairment due to permanent or temporary disabilities [9]. Unstable pelvic fracture management and related disabilities lead to major financial expenses that intensively impact both victims and their families, and the broader community [10]. Research has examined the functional consequences of unstable pelvic fractures and evaluated the associated influencing elements within a healthcare system that exhibits resource restrictions for diagnosis and therapeutic interventions.

This cross-sectional study was conducted in the Department of Orthopedics, Govt Medical College and Hospital, Wanaparthy, Telangana. Institutional Ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study and possible outcomes in vernacular language.

Inclusion criteria

1. All cases of unstable pelvic fractures were admitted, treated, and followed up at our hospital.
2. Aged 18 and above
3. Males and Females
4. Willing to participate in the study voluntarily.
5. Gave a written consent

Exclusion criteria

1. Patients from whom relevant data could not be obtained
2. Those who did not consent to the study were excluded.
3. Those who were referred to Higher facilities because of the complexity of fractures

On admission, all patients were initially evaluated at the emergency department of the hospital. Patients with unstable clinical states were urgently resuscitated appropriately. All those who were suspected of having a pelvic fracture had a pelvic binder applied at the emergency or were taken to the operating room where external fixators or pelvic clamps were applied. After adequate stabilization, definitive pelvic fixation was planned for the patients. The decision for conservative management and definitive management modality was guided by patients’ age, co-morbidities, clinical condition, injury pattern, and financial constraints.

Management: The standard management of unstable pelvic fractures with an external fixator was done to restore pelvic stability. Initially, a pelvic binder or sheet is applied to reduce pelvic volume and tamponade bleeding. Once the patient was stabilized, an external fixator was applied under imaging guidance. The fixator was typically placed anteriorly, with pins inserted into the iliac crests or supra-acetabular region to provide rigid stabilization. This reduces pelvic displacement, minimizing further soft tissue injury, and facilitates patient mobilization. The procedure was done with careful pin placement to avoid neurovascular structures and ensure optimal stability. Postoperative care includes regular monitoring for pin-site infections and mechanical stability.

Statistical analysis: All the available data was refined, segregated, and uploaded to an MS Excel spreadsheet and analyzed by SPSS version 22 in Windows format. The continuous variables were represented as mean, standard deviation, and percentages. The categorical variables were calculated by Pearson's chi-square test to determine the p values. The values of p (<0.05) were considered as significant.

A total of n=20 cases were included in the study based on the inclusion and exclusion criteria. The age range of the patients was 18–60 years old. Table 1 depicts the age- and sex-wise distribution of the cases in the study. The most common age group was 31-40 years (n = 8, 40%). The age group of 20-30 years had 6 cases (30%). The frequency decreased in the older age groups (41-50 years: 4 cases, 20%; 51-60 years: 2 cases, 10%). Males constituted the majority of the cases (13 cases, 65%). Females accounted for a smaller proportion (7 cases, 35%).

Table 1:  Age and gender-wise distribution of cases in the study

Table 2 shows the applied treatment methods for the different groups of patients from the study.   Treatment Groups: The Patients were divided into three groups: A (Group I), B (Group II), and C (Group III). The number of patients in each group varied (7, 8, and 5, respectively).  Conservative treatment was used in groups I and II, but not in group III. All three groups underwent surgical intervention using different methods. The table demonstrates that unstable pelvic fractures were treated using various methods, reflecting the complexity of these injuries and the need for individualized treatment plans. Combined osteosynthesis was used in all groups and represented a significant portion of the treatments overall, showing that combined approaches were necessary for complex unstable pelvic fractures.

 Table 2: Applied treatment methods in different groups

Figure 1 shows Lower extremity fractures are the most prevalent associated injury, accounting for 30% of all recorded injuries. This shows that the mechanism of injury leading to these cases frequently involves trauma to the legs. Upper extremity fractures also represent a significant portion (20%), indicating that injuries to the arms are also common. Head injuries and acetabulum (pelvic) fractures each constitute 20% of the associated injuries. This shows the potential for severe, multi-system trauma in these patients. The similar percentages of these two injuries may point to the high-force trauma that would cause both types of injuries.

Table 3: Overall functional outcome (n=20)

Table 3 presents the overall functional outcomes of the 20 patients with unstable pelvic fractures who were included in this study. It was categorized into three types (A, B, and C) using Majeed's scoring system. Majeed’s score categorizes the outcomes into four groups: Excellent (85-100), Good (70-84), Fair (55-69), and poor (<55). The overall distribution of functional outcomes showed that the most frequent outcome was "Fair" (30%), followed by "Excellent" and "Good" (both 25%), and “Poor" (20%). Type A: Patients with Type A showed the best overall outcome. Most patients with type A tumors show excellent or good results. Three of them scored in the excellent range and two scored in the good range. The remaining two were split into fair and Poor. This showed that type A patients had a better prognosis or responded more favorably to treatment/intervention. The most common outcome for Type B was Fair. This shows that type B patients may have more complex conditions or face greater challenges in achieving optimal functional recovery. Type C patients also had a wide range of outcomes, with a slight tendency towards a fair outcome. The distribution of results indicates that type C has an outcome that is in between type A and type B.

management and functional outcomes of unstable pelvic fractures reporting to our hospital. During the duration of the study, we included n=20 patients with unstable pelvic fractures. In this study, we found majority of patients were males (65%) aged 31–40 years (40%). A similar study by Tile et al. [11] found that most patients were young males involved in vehicular accidents. The mean age of the cohort was 36.5 ± 5.5 years and similar demographic patterns have been observed in other studies on pelvic fractures.  In this study, we used different treatment methods for three groups (A, B, and C), based on the heterogeneity of unstable pelvic fractures. We reserved conservative treatment for group I and group II while surgical interventions which included open reduction, transosseous osteosynthesis, and combined osteosynthesis were used in all groups. In our study, the frequency of combined osteosynthesis was most commonly used (16%) highlighting its importance in the management of complex fractures. Our results are in concordance with the study of Gansslen et al. [12] who emphasized the role of combined approaches in achieving stability and reducing complications of complex fractures. We used external fixation in 15% of cases which is in agreement with recommendations by Burgess et al. [13] who have shown that external fixation must be done to control hemorrhage and stabilize pelvis in poly trauma patients.

In this study we found the associated injuries were common in the lower extremity in 30% of cases, followed by followed by upper extremity fractures (20%), head injuries (20%), and acetabular fractures (20%). This shows that high-energy mechanisms of injury were involved in the cases of fractures. Dalal et al. [14] in a similar study have reported a similar pattern of injuries in patients involving pelvic fractures. This shows that multi-system trauma is commonly involved in these fractures and requires a multidisciplinary approach to management.  In this study, we used Majeed's scoring system to assess the functional outcomes of the treatment. It was found that 30% of patients achieved a "Fair" outcome, while 25% each had "Excellent" and "Good" outcomes. It was found that Type A fractures showed the best prognosis, with 15% achieving "Excellent" outcomes. These findings were consistent with the findings of Majeed who reported better outcomes in less severe fracture types [15]. Type B and C fractures had a higher proportion of Fair and Poor outcomes, likely due to their complexity and associated injuries. The findings of this study were also consistent with Pohlmann et al. [16] who noted that fracture severity and associated injuries significantly impact functional recovery. Our study highlights the challenges in managing unstable pelvic fractures, particularly in achieving optimal functional outcomes. Surgical interventions especially combined osteosynthesis play a crucial role in the variability in outcomes and underscore the need for tailored treatment plans. The sample size was limited in our study and future studies with larger cohorts and longer follow-up periods are recommended to further refine management strategies and improve patient outcomes.

This study showed that unstable pelvic fractures predominantly affect males and most commonly in the 3rd decade. Treatment of the cases based on the type of fractures and osteosynthesis was a common approach in the cases. Associated injuries were common in the lower extremity with 30% of cases. Majeed’s scores were used to determine the functional outcomes in this study which showed that fair results were obtained in 30% of cases which was the most common outcome, followed by excellent and good outcomes in 25% of cases. This study found that type A fractures have the best prognosis. These findings highlight the need for individualized treatment strategies to optimize recovery and improve functional outcomes in patients with unstable pelvic fractures.

1. Nana CT, Ngo-Yamben MA, Fokam P, Mahamat A, Bombah FM, Boukar ME, Kenedy M, Chichom-Mefire A. Functional outcome of unstable pelvic fractures treated in a level III hospital in a developing country: a 10-year prospective observational study. J Orthop Surg Res. 2022 Apr 4;17(1):198.
2. Guerado E, Bertrand ML, Valdes L, Cruz E, Cano JR. Resuscitation of Polytrauma Patients: The Management of Massive Skeletal Bleeding. Open Orthop J. 2015 Jul 31;9: 283-95.
3. Perumal R, S DCR, P SS, Jayaramaraju D, Sen RK, Trikha V. Management of pelvic injuries in hemodynamically unstable polytrauma patients - Challenges and current updates. J Clin Orthop Trauma. 2021 Jan;12(1):101-112. Erratum in: J Clin Orthop Trauma. 2021 Aug 05; 21:101558.
4. Fola OK, Guifo ML, Tsiagadigui JG, Tolefac P, Biyouma M, Djoko I, Essomba A. Locked book pubic symphysis: a case report in a resource-limited setting in sub-Sahara Africa. Int J Surg Case Rep. 2019; 64:24–27.
5. Ngongang G, Olivier F, Paul F, Mbassi A, et al. Pelvic ring fractures are epidemiological, clinical. J Afr Imag Méd. 2014; 4(6):35–41.
6. Diouf AB, Gueye AB, Dembele B, Daffe M, Dia R, Sarr L, Diop PS, Coulibaly NF, Sane AD, Dieme CB. Trauma of the pelvic ring: epidemiological and etiopathogenic aspects. Biomed J Sci Technol Res. 2018 doi: 10.26717/BJSTR.2018.04.001016.
7. Bach JA, Leskovan JJ, Scharschmidt T, Boulger C, Papadimos TJ, Russell S, Bahner DP, Stawicki SP. The right team at the right time - Multidisciplinary approach to multi-trauma patients with orthopedic injuries. Int J Crit Illn Inj Sci. 2017 Jan-Mar;7(1):32-37.
8. Olasinde AA, Oluwadiya KS, Oginni LM, Akinyoola AL, Orimolade E. Pelvic fractures management in a teaching hospital in Nigeria. Niger J Orthopaedics Trauma. 2004;3(1):10–15.
9. Yu YH, Hsu YH, Chou YC, Liu CH, Tseng IC, Chen IJ. Three-year functional outcome after open pelvic fracture treatment: a retrospective case series from a level I trauma center. Eur J Orthop Surg Traumatol. 2023 May;33(4):937-945.
10. Ariane C, Drusia D, Susana N, Embolo FN, Chendjou W, Wepngong E, et al. Association of health care use and economic outcomes after injury in Cameroon. JAMA Netw Open. 2020;3:e205171.
11. Tile, M. D. Helfet, J. Kellam, et al. Fractures of the Pelvis and Acetabulum. Lippincott Williams & Wilkins.
12. Gänsslen A, et al. Pelvic Ring Fractures: Classification and Management. Journal of Orthopaedic Trauma 2013; 27(5): 259-265.
13. Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990 Jul;30(7):848-56.
14. Dalal SA, Burgess AR, Siegel JH, Young JW, Brumback RJ, Poka A, Dunham CM, Gens D, Bathon H. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma. 1989 Jul;29(7):981-1000; discussion 1000-2. PMID: 2746708.
15. Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg Br. 1989 Mar;71(2):304-06.

Pohlmann T, Gänsslen A, Schellwald O, Culemann U, Tscherne H. Outcome after pelvic ring injuries. Injury. 1996;27 Suppl 2: B31-38