Summary Ilium fractures are high energy pelvic fractures that are often unstable and typically progress from the iliac crest to the greater sciatic notch. Diagnosis can made with pelvis radiographs but frequently require pelvic CT scan for full characterization. Treatment may be nonoperative or operative depending on fracture displacement, associated pelvic ring instability and patient activity demands. Epidemiology Associated injuries Iliac wing fractures have high incidence of associated injuries open injuries bowel entrapment soft tissue degloving Anatomy Osteology pelvic girdle is comprised of sacrum 2 innominate (coxal) bones each formed from the union of 3 bones: ilium, ischium, and pubis ilium 2 important anterior prominences anterior-superior iliac spine (ASIS) origin of sartorius and transverse and internal abdominal muscles anterior-inferior iliac spine (AIIS) origin of direct head of rectus femoris and iliofemoral ligament (Y ligament of Bigelow) posterior prominences posterior-superior iliac spine (PSIS) located 4-5 cm lateral to the S2 spinous process posterior-inferior iliac spine (PIIS) Imaging Plain radiographs standard set of AP pelvis, inlet/outlet, and judet views helpful for evaluating the iliac wing in addition to pelvic stability and possible acetabular involvement CT scan carefully assess CT scan for signs of bowel entrapment evaluate for presence of gas or air in the soft tissues which can be associated with open injury or bowel disruption Classification No specific classification for iliac wing fractures Generally described as specific subtypes of more common classification systems Tile Classification Tile Classification Stable (intact posterior arch) A1-1: iliac spine avulsion injury A1-2: iliac crest avulsion A2-1: iliac wing fractures often from a direct blow Partially stable (incomplete disruption of posterior arch) B2-3: incomplete posterior iliac fracture Unstable (complete disruption of posterior arch) C1-1: unilateral iliac fracture Treatment Nonoperative mobilization with an assist device indications nondisplaced fractures isolated iliac wing fractures Operative open reduction and internal fixation indications displaced fractures of ilium Techniques Wound Management evaluate all wounds for soft tissue disruption or internal degloving injury possible soft tissue or bowel entrapment in the fracture site prophylactic antibiotics as appropriate serial debridements as necessary Open Reduction Internal Fixation approach posterior approach ilioinguinal approach Stoppa approach (lateral window) recommend early reconstruction single pelvic reconstruction plate or lag screw along the iliac crest percutaneous screws and reduction techniques possible as well supplemented with a second reconstruction plate or lag screw at the level of the pelvic brim or sciatic buttress coordination with trauma team injury to bowel may require diversion procedures plan surgical intervention with trauma team to minimize recurrent trips to the operating room Complications Malunion with deformity of the iliac wing Internal iliac artery injury Bowel perforation Lumbosacral plexus injury