What is a pelvic open book fracture?

What is a Pelvic Open Book Fracture?

A pelvic open book fracture is a rotationally unstable injury pattern characterized by disruption of the pubic symphysis with widening (diastasis) of the anterior pelvic ring, typically classified as APC-II or APC-III in the Young-Burgess system, and represents a severe trauma requiring urgent stabilization and often surgical fixation. 1

Mechanism and Classification

• Open book fractures result from anteroposterior compression (APC) forces that cause the pelvis to "open" like a book, creating separation at the pubic symphysis anteriorly 1

• These injuries are classified as:

  • APC-II: Rotationally unstable with pubic symphysis diastasis and anterior sacroiliac ligament disruption 1
  • APC-III: Both rotationally and vertically unstable with complete sacroiliac joint disruption 1

• According to the Tile classification, these represent unstable type C fractures associated with significantly higher mortality (11.5% vs 7.5% for stable fractures) and greater transfusion requirements 1

Clinical Significance and Associated Injuries

• Open book fractures are considered radio-anatomical criteria of severe pelvic trauma due to high risk of hemorrhagic vascular injuries and posterior pelvic ring instability 1

• Urogenital injuries occur in 4-15% of cases, particularly with bilateral pubic rami fractures and sacroiliac dislocation, including posterior urethral injuries (4-19%) and bladder rupture 1

• These injuries commonly result from high-energy trauma (motor vehicle crashes, motorcycle accidents) and frequently present with hemodynamic instability requiring massive transfusion 2, 3

Surgical Indications

Pubic symphysis plating is the definitive treatment of choice for open book injuries with diastasis >2.5 cm (Grade 1A recommendation). 1

• APC-II and APC-III patterns require definitive internal fixation to achieve anatomic reduction and stable fixation for early functional rehabilitation 1

• Posterior pelvic ring fixation is mandatory in addition to anterior symphyseal plating, as posterior instability drives the need for surgical intervention 1, 4

Timing of Intervention

• Hemodynamically unstable patients must be successfully resuscitated before definitive fixation (Grade 1B), with bleeding control procedures (angioembolization or preperitoneal packing) performed within 60 minutes of hospital admission 1, 4

• Hemodynamically stable patients can safely undergo early definitive fixation within 24 hours post-injury (Grade 2A) 4

• Physiologically deranged polytrauma patients should have fixation postponed until after day 4 post-injury (Grade 2A) 4

Common Pitfalls

• Failure to recognize posterior ring instability: The anterior symphyseal disruption is obvious, but the critical posterior sacroiliac injury determines stability and surgical approach 1

• Inadequate hemorrhage control: These injuries require aggressive hemostatic resuscitation with average blood loss of 15-29 units; arterial contrast extravasation on CT (sensitivity 82-89%) indicates need for angioembolization 1, 5, 3

• Missing urogenital injuries: Retrograde urethrocystogram with CT is the gold standard when symptoms suggest lower urinary tract injury, though systematic screening is not warranted 1

• Delayed or inadequate fixation: Chronic disability with severe impairment in physical functioning and role performance is common, particularly after open fractures, emphasizing the importance of anatomic reduction and stable fixation 3