Pelvic fractures represent a clinically important component of high-energy trauma because disruption of the pelvic ring can be accompanied by substantial hemorrhage and injury to adjacent abdominal, vascular, neurologic, and genitourinary structures. The configuration of a pelvic ring injury reflects both the direction of applied force and the degree of structural instability. Early radiographic descriptions by Young and colleagues emphasized recognizable force-related patterns, and the subsequent Young-Burgess system organized pelvic ring disruptions into lateral compression, anteroposterior compression, vertical shear, and combined-mechanism categories [1,2]. This framework remains widely used in trauma practice because it provides a practical description of injury mechanism and helps communicate the expected degree of pelvic instability [3,4]. The lower urinary tract is anatomically vulnerable in pelvic trauma. The bladder lies immediately behind the pubic symphysis, while the posterior urethra is tethered within the pelvic floor and can be injured when the anterior and posterior pelvic arches are displaced. Bladder rupture, urethral disruption, bladder-neck injury, and combined lesions can therefore accompany severe pelvic fractures [5]. Urethral injury has been linked particularly to pubic arch disruption, fractures involving multiple pubic rami, and concomitant posterior pelvic injury, indicating that the geometry of the fracture is clinically relevant rather than merely descriptive [6]. Several studies have attempted to identify radiographic features that predict lower urinary tract injury. Fractures involving the pubic symphysis and sacroiliac region have been associated with increased rates of urethral or bladder injury [7]. In male blunt-trauma patients, displaced inferomedial pubic fractures and symphyseal diastasis were strong predictors of urethral injury [8]. Similarly, pubic symphysis widening and displaced obturator-ring fractures have been associated with bladder rupture in patients with pelvic trauma [9]. These observations suggest that specific markers of mechanical disruption could provide greater diagnostic value than broad pelvic fracture categories alone. The reported frequency of lower urinary tract injury varies according to trauma severity, case selection, sex distribution, and diagnostic strategy. Large trauma-registry data indicate that bladder and urethral injuries form a relatively small proportion of all pelvic fractures, whereas selected cohorts with severe or unstable injuries show substantially higher rates [10]. Multidisciplinary assessment is therefore important because delayed recognition can complicate pelvic fixation, urinary drainage, and subsequent reconstructive management [11,12]. Contemporary urotrauma guidance emphasizes targeted evaluation for urethral and bladder injury when clinical findings such as blood at the urethral meatus, inability to void, or significant hematuria are present [13]. Management also depends on whether bladder injury is intraperitoneal or extraperitoneal and on the presence of associated pelvic fixation requirements [14]. The present study was undertaken to determine the frequency and clinical pattern of lower urinary tract injuries among adult trauma patients with pelvic fractures and to evaluate their relationship with pelvic fracture morphology. The specific objectives were to describe the distribution of Young-Burgess fracture patterns, characterize associated bladder and urethral injuries, and assess whether unstable pelvic ring injury, pubic symphysis diastasis, sacroiliac joint disruption, and bilateral pubic ramus fractures were associated with lower urinary tract injury.

Study design and setting: This prospective observational study was conducted at RVM Institute of Medical Sciences, Laxmakkapally, Siddipet, Telangana, India. The hospital provides emergency, trauma, orthopaedic, surgical, radiological, and urological services. The study was carried out over six months, from January 2026 to June 2026. Adult trauma patients with a confirmed pelvic fracture were assessed consecutively during the study period. Study participants: Patients aged 18 years or older with a pelvic ring fracture confirmed on radiography and/or computed tomography were eligible. Patients with isolated acetabular fractures without pelvic ring disruption, penetrating pelvic trauma, pathological fractures, previous major pelvic reconstructive surgery, or incomplete diagnostic information regarding the lower urinary tract were excluded. Eligible patients were enrolled consecutively until the planned sample of 50 participants was achieved. This approach was used to reduce investigator-driven selection and reflect the spectrum of pelvic trauma encountered during recruitment. Clinical and radiological assessment: Demographic details, mechanism of injury, hemodynamic status at presentation, and associated abdominal or long-bone injuries were recorded on a structured data form. Pelvic radiographs and computed tomography images were reviewed to identify fracture configuration. Pelvic ring injuries were categorized as lateral compression, anteroposterior compression, vertical shear, or combined-mechanism injuries according to the Young-Burgess framework [1-4]. Pelvic ring instability, pubic symphysis diastasis greater than 2.5 cm, sacroiliac joint disruption, and bilateral pubic ramus fractures were documented separately because these structural features have been linked to genitourinary injury [6-9]. Assessment of lower urinary tract injury: Participants underwent focused examination for gross hematuria, blood at the urethral meatus, inability or difficulty in voiding, suprapubic tenderness, and bladder distension. When urethral injury was suspected, retrograde urethrography and urological assessment were undertaken before urethral instrumentation whenever clinically feasible. Suspected bladder injury was evaluated using appropriate contrast-enhanced imaging or cystography according to hemodynamic condition and clinical findings, consistent with accepted urotrauma principles [11,13]. Lower urinary tract injury was classified as isolated urethral injury, isolated bladder injury, or combined bladder and urethral injury. Initial urinary diversion and operative bladder repair were recorded when performed. Outcome measures: The primary outcome was the presence of lower urinary tract injury. Secondary outcomes included injury type, presenting features, initial management, and associations between lower urinary tract injury and specific pelvic fracture characteristics. Statistical analysis: Continuous variables were summarized as mean and standard deviation, while categorical variables were expressed as frequencies and percentages. Associations between the four Young-Burgess categories and lower urinary tract injury were assessed using the chi-square test. Fisher's exact test was used for two-by-two comparisons involving specific fracture characteristics and sex. A two-sided p-value below 0.05 was considered statistically significant. Ethical considerations: The study was conducted after approval from the Institutional Ethics Committee of RVM Institute of Medical Sciences. Written informed consent was obtained from participants or legally authorized representatives when required by the clinical condition. Patient confidentiality was maintained throughout the study.

A total of 50 adult patients with pelvic fractures were included in the final analysis. The mean age of the study population was 40.2 ± 13.6 years, and 38 (76.0%) patients were male. Road traffic accidents were the predominant mechanism of injury, accounting for 31 (62.0%) cases, followed by falls from height in 12 (24.0%) and crush injuries in 7 (14.0%). Hemodynamic instability at presentation was documented in 11 (22.0%) patients. Associated abdominal injuries were present in 9 (18.0%), while 13 (26.0%) had an associated long-bone fracture. Baseline characteristics are presented in Table 1. Table 1. Baseline demographic and injury characteristics of patients with pelvic fractures (n = 50) Characteristic n (%) / Mean ± SD Age, years 40.2 ± 13.6 Age group, years 18-30 13 (26.0) 31-40 14 (28.0) 41-50 11 (22.0) >50 12 (24.0) Sex Male 38 (76.0) Female 12 (24.0) Mechanism of injury Road traffic accident 31 (62.0) Fall from height 12 (24.0) Crush injury 7 (14.0) Hemodynamic instability at presentation 11 (22.0) Associated abdominal injury 9 (18.0) Associated long-bone fracture 13 (26.0) Note. Data are expressed as mean ± standard deviation or number (percentage), as appropriate. According to the Young-Burgess classification, lateral compression fractures were the most frequent pattern, occurring in 20 (40.0%) patients. Anteroposterior compression injuries were observed in 16 (32.0%), vertical shear injuries in 8 (16.0%), and combined-mechanism injuries in 6 (12.0%). Overall, 31 (62.0%) fractures were classified as relatively stable pelvic ring injuries, whereas 19 (38.0%) demonstrated unstable pelvic ring disruption. Lower urinary tract injury was identified in 14 of 50 patients, yielding an overall frequency of 28.0%. The proportion was highest in the anteroposterior compression and vertical shear groups, with 37.5% of patients in each category having lower urinary tract injury. Corresponding proportions were 15.0% for lateral compression and 33.3% for combined-mechanism injuries. The overall association between the four Young-Burgess categories and lower urinary tract injury was not statistically significant (χ² = 2.84, p = 0.418) (Table 2). Table 2. Association between pelvic fracture pattern and lower urinary tract injury (n = 50) Pelvic fracture pattern Total, n LUTI present, n (%) LUTI absent, n (%) Lateral compression 20 3 (15.0) 17 (85.0) Anteroposterior compression 16 6 (37.5) 10 (62.5) Vertical shear 8 3 (37.5) 5 (62.5) Combined mechanism 6 2 (33.3) 4 (66.7) Total 50 14 (28.0) 36 (72.0) Note. Overall Pearson chi-square comparison: χ² = 2.84, p = 0.418. LUTI = lower urinary tract injury. Among the 14 patients with lower urinary tract involvement, isolated urethral injury was the most frequent lesion, occurring in 6 (42.9%) patients. Isolated bladder injury was observed in 5 (35.7%), while 3 (21.4%) had combined bladder and urethral injuries. Thus, bladder involvement, either isolated or combined, was present in 8 (57.1%) patients with lower urinary tract injury. Gross hematuria was the most common clinical finding, recorded in 10 (71.4%) patients, followed by blood at the urethral meatus in 7 (50.0%), difficulty or inability to void in 6 (42.9%), and suprapubic tenderness or distension in 5 (35.7%) (Table 3). Table 3. Characteristics of lower urinary tract injuries among affected patients (n = 14) Characteristic n (%) Type of lower urinary tract injury Isolated urethral injury 6 (42.9) Isolated bladder injury 5 (35.7) Combined bladder and urethral injury 3 (21.4) Clinical presentation* Gross hematuria 10 (71.4) Blood at urethral meatus 7 (50.0) Inability/difficulty to void 6 (42.9) Suprapubic tenderness/distension 5 (35.7) Initial management* Urethral catheterization 5 (35.7) Suprapubic catheterization 6 (42.9) Operative bladder repair 5 (35.7) Note. *More than one clinical feature or management procedure could be present in the same patient; therefore, percentages can exceed 100%. Specific indicators of mechanical pelvic instability demonstrated stronger relationships with lower urinary tract injury than the broad fracture categories. Lower urinary tract injury occurred in 10 of 19 (52.6%) patients with unstable pelvic ring injuries compared with 4 of 31 (12.9%) patients with relatively stable injuries (p = 0.004). Pubic symphysis diastasis greater than 2.5 cm was associated with lower urinary tract injury in 7 of 11 (63.6%) patients compared with 7 of 39 (17.9%) without this finding (p = 0.006). Sacroiliac joint disruption was present in 13 patients, of whom 7 (53.8%) had lower urinary tract injury, compared with 7 of 37 (18.9%) patients without sacroiliac disruption (p = 0.029). Bilateral pubic ramus fractures were also associated with lower urinary tract injury, which occurred in 8 of 16 (50.0%) patients with bilateral involvement compared with 6 of 34 (17.6%) patients without bilateral ramus fractures (p = 0.040) (Table 4). Table 4. Association of specific pelvic fracture characteristics with lower urinary tract injury Fracture characteristic LUTI with characteristic, n/N (%) LUTI without characteristic, n/N (%) p-value Unstable pelvic ring injury 10/19 (52.6) 4/31 (12.9) 0.004 Pubic symphysis diastasis >2.5 cm 7/11 (63.6) 7/39 (17.9) 0.006 Sacroiliac joint disruption 7/13 (53.8) 7/37 (18.9) 0.029 Bilateral pubic ramus fracture 8/16 (50.0) 6/34 (17.6) 0.040 Note. Associations were evaluated using Fisher's exact test. A p-value <0.05 was considered statistically significant. LUTI = lower urinary tract injury. When demographic factors were evaluated, lower urinary tract injury was identified in 12 of 38 (31.6%) male patients and 2 of 12 (16.7%) female patients. This difference was not statistically significant (p = 0.468). No clear association was observed between age group and lower urinary tract injury. Overall, the results indicate that specific markers of pelvic ring instability were more closely associated with lower urinary tract involvement than the broad Young-Burgess fracture categories.

The present prospective study identified lower urinary tract injury in 28.0% of adults presenting with pelvic fractures. This frequency is higher than the 4.2% reported by Johnsen et al. in a large contemporary trauma-registry cohort [10], but it is close to the burden observed in selected high-risk pelvic fracture populations. Koraitim et al., in a prospective series of male patients, documented urethral, bladder, or combined injuries in a substantial proportion of pelvic fracture cases and showed that the risk increased with disruption of both anterior and posterior pelvic structures [6]. Differences between studies are expected because case severity, sex distribution, referral pattern, and thresholds for urological imaging vary considerably. Lateral compression was the most frequent Young-Burgess pattern in the present cohort, followed by anteroposterior compression. Although lower urinary tract injury was numerically more frequent with anteroposterior compression and vertical shear patterns, the overall association across the four Young-Burgess categories was not statistically significant. This finding is clinically relevant because the Young-Burgess system is primarily a mechanistic classification and does not consistently predict every associated nonorthopaedic injury [3,4]. Manson et al. similarly demonstrated that grouping injuries by stability improved prediction of adverse outcomes compared with relying solely on individual Young-Burgess categories [4]. Specific markers of pelvic instability showed much stronger associations with lower urinary tract injury. More than half of patients with unstable pelvic ring injury had lower urinary tract involvement, compared with 12.9% of those with relatively stable fractures. Pubic symphysis diastasis greater than 2.5 cm was associated with the highest observed injury frequency. This agrees with Basta et al., who reported that symphyseal diastasis strongly predicted urethral injury and that increasing displacement further increased risk [8]. Avey et al. also found pubic symphysis diastasis to be an independent predictor of bladder rupture in blunt pelvic trauma [9]. The significant relationships observed with sacroiliac disruption and bilateral pubic ramus fractures are additionally consistent with work by Koraitim et al. and Aihara et al., which linked combined anterior-posterior ring disruption and specific fracture locations to urethral and bladder injury [6,7]. Urethral injury was the most frequent isolated lower urinary tract lesion in this study, and the predominance of male participants probably contributed to this distribution. Population-level data show a marked sex difference in urethral injury after pelvic fracture, whereas bladder injury rates are more similar between men and women [10]. Gross hematuria was the most common presenting sign, followed by blood at the urethral meatus and voiding difficulty. These features remain important triggers for targeted bladder and urethral assessment [11,13]. Taken together, the findings indicate that clinicians should not depend on the broad pelvic fracture label alone when estimating urological risk. Careful evaluation of symphyseal widening, sacroiliac disruption, bilateral ramus fractures, and overall ring instability can help identify patients who require early urological assessment. Such multidisciplinary evaluation is particularly important when pelvic stabilization and urinary diversion must be coordinated [11,12,14]. Limitations This study has several limitations. It was conducted at a single institution with a relatively small sample of 50 patients, limiting precision for subgroup comparisons. The six-month recruitment period restricted evaluation of uncommon injury patterns. Fracture assessment depended on available trauma imaging and clinical documentation, and long-term urological outcomes were not examined. Multivariable analysis was not performed because of the limited number of lower urinary tract injury events.

Lower urinary tract injury was identified in more than one-quarter of adults with pelvic fractures in this prospective cohort. Urethral injury was the most frequent isolated lesion, while gross hematuria was the leading clinical finding. Broad Young-Burgess fracture categories were not significantly associated with lower urinary tract injury. In contrast, unstable pelvic ring injury, marked pubic symphysis diastasis, sacroiliac joint disruption, and bilateral pubic ramus fractures showed significant associations with urinary tract involvement. These findings support radiological assessment of pelvic instability and early urological evaluation in high-risk fracture configurations. Coordinated management between trauma, orthopaedic, radiology, and urology teams can facilitate prompt diagnosis, appropriate urinary diversion, and safe definitive pelvic treatment.

1. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology. 1986;160(2):445-451. 2. Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990;30(7):848-856. 3. Alton TB, Gee AO. Classifications in brief: Young and Burgess classification of pelvic ring injuries. Clin Orthop Relat Res. 2014;472(8):2338-2342. 4. Manson T, O'Toole RV, Whitney A, Duggan B, Sciadini M, Nascone J. Young-Burgess classification of pelvic ring fractures: does it predict mortality, transfusion requirements, and non-orthopaedic injuries? J Orthop Trauma. 2010;24(10):603-609. 5. Brandes S, Borrelli J Jr. Pelvic fracture and associated urologic injuries. World J Surg. 2001;25(12):1578-1587. 6. Koraitim MM, Marzouk ME, Atta MA, Orabi SS. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol. 1996;77(6):876-880. 7. Aihara R, Blansfield JS, Millham FH, LaMorte WW, Hirsch EF. Fracture locations influence the likelihood of rectal and lower urinary tract injuries in patients sustaining pelvic fractures. J Trauma. 2002;52(2):205-209. 8. Basta AM, Blackmore CC, Wessells H. Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma. J Urol. 2007;177(2):571-575. 9. Avey G, Blackmore CC, Wessells H, Wright JL, Talner LB. Radiographic and clinical predictors of bladder rupture in blunt trauma patients with pelvic fracture. Acad Radiol. 2006;13(5):573-579. 10. Johnsen NV, Dmochowski RR, Young JB, Guillamondegui OD. Epidemiology of blunt lower urinary tract trauma with and without pelvic fracture. Urology. 2017;102:234-239. 11. Figler BD, Hoffler CE, Reisman W, Carney KJ, Moore T, Feliciano D, et al. Multi-disciplinary update on pelvic fracture associated bladder and urethral injuries. Injury. 2012;43(8):1242-1249. 12. Barratt RC, Bernard J, Mundy AR, Greenwell TJ. Pelvic fracture urethral injury in males-mechanisms of injury, management options and outcomes. Transl Androl Urol. 2018;7(Suppl 1):S29-S62. 13. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. Urotrauma Guideline 2020: AUA Guideline. J Urol. 2021;205(1):30-35. 14. Khabiri SS, Keihani S, Myers JB. Extraperitoneal bladder injuries associated with pelvic fracture requiring internal fixation: what is the evidence? Am Surg. 2021;87(8):1203-1206.