Pelvic Open Book Fracture Management

Mechanism and Classification

A pelvic open book fracture is a rotationally unstable injury pattern characterized by disruption of the pubic symphysis with widening 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, 2
Open book fractures result from anteroposterior compression forces that cause the pelvis to "open" like a book, creating separation at the pubic symphysis anteriorly 1, 2
These injuries are classified as APC-II: Rotationally unstable with pubic symphysis diastasis and anterior sacroiliac ligament disruption, and APC-III: Both rotationally and vertically unstable with complete sacroiliac joint disruption 1, 2
According to the Tile classification, these represent unstable type C fractures associated with significantly higher mortality and greater transfusion requirements 3, 4

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 3, 4
Urogenital injuries occur in 4-15% of cases, particularly with bilateral pubic rami fractures and sacroiliac dislocation, including posterior urethral injuries and bladder rupture 3, 4

Pubic symphysis plating is the definitive treatment of choice for open book injuries with diastasis >2.5 cm (Grade 1A recommendation) 1, 2
APC-II and APC-III patterns require definitive internal fixation to achieve anatomic reduction and stable fixation for early functional rehabilitation 1, 2
Posterior pelvic ring fixation is mandatory in addition to anterior symphyseal plating, as posterior instability drives the need for surgical intervention 1, 2, 5

Hemodynamically unstable patients must be successfully resuscitated before definitive fixation (Grade 1B), with bleeding control procedures performed within 60 minutes of hospital admission 3, 4, 5
Hemodynamically stable patients can safely undergo early definitive fixation within 24 hours post-injury (Grade 2A) 5
Physiologically deranged polytrauma patients should have fixation postponed until after day 4 post-injury (Grade 2A) 5

Failure to recognize posterior ring instability: The anterior symphyseal disruption is obvious, but the critical posterior sacroiliac injury determines stability and surgical approach 1, 2
Inadequate hemorrhage control: These injuries require aggressive hemostatic resuscitation with average blood loss of 15-29 units; arterial contrast extravasation on CT indicates need for angioembolization 3, 4
Missing urogenital injuries: Retrograde urethrocystogram with CT is the gold standard when symptoms suggest lower urinary tract injury, though systematic screening is not warranted 3, 4