Incidence of and Risk Factors for

Unstable Pelvic Fractures in Motor

Vehicle Collisions: An Analysis of
NASS and CIREN Data
University of Alabama at Birmingham
CIREN Center

Outline
Purpose: To analyze risk factors and
mechanisms for unstable pelvic fractures

Background
NASS Analysis
Validation
NASS/CIREN Analysis
Finite Element Modeling

Background
Stable fractures
Fracture not involving the posterior arch
Pelvic floor intact and able to withstand
normal physiological stresses without
displacement

Background
Partially stable fractures
Posterior osteoligamentous integrity partially
maintained and pelvic floor intact

Background
Unstable fractures
Complete loss of posterior osteoligamentous
integrity
Pelvic floor disrupted

Background
Pelvic fractures occur in approximately
25% of fatal MVCs (Adams 2002)
Radiographs in review of cases from the
Jefferson County Coroner/Medical Examiner
Office
1994-1996
Utilized Tiles classification of pelvic fractures

Background
A study from Greece observed a similar
pelvic fracture incidence in MVCs (25.4%)
Higher associated ISS
Shorter median survival time
Of those that died, 81.5% died within 5 hours
Accounted for 13% of all trauma deaths

Background
It has been reported that 15% of patients
with MVC-related injuries have pelvic ring
fractures (Giannoudis 2007)
Most fractures were AIS 2
AIS 4 and 5 associated with much higher
mortality
Associated with AIS 3+ chest injury (21%),
head injury (16.9%)

Background
Previous research utilizing CIREN data
(Rowe 2004)
Examined radiographs
Pelvic ring fractures classified according to
Burgess and Young method
15.8% of examined patients had pelvic ring
fractures
Fractures associated with female gender,
lateral impact, crash severity

Background
A more recent study utilizing CIREN data
observed pelvic fractures occurred in
27.6% (n=511) of patients examined
(Stein 2006)
Limited to frontal and near-side collision
Excluded individuals younger than 15
Pelvic fractures associated with smaller
vehicle, no airbag deployment, and lateral
deformation

Background
Stein 2006
Significant factors differed by frontal/near-side
collision
Frontal: High BMI, injury severity, high DV,
larger vehicle, no seatbelt use
Near-side: Low BMI, injury severity, female
gender, small vehicle, high DV

Background
Both studies utilizing CIREN data limited
by:
Inability to determine pelvic ring fracture risk
among all MVCs
Limited generalizability
Only severe crashes

Background
To date, no study has provided a nationally
representative estimate of MVC-related
pelvic ring fracture incidence
Prior research limited in generalizability

Outline
Purpose: To analyze risk factors and
mechanisms for unstable pelvic fractures

Background
NASS Analysis
Validation
NASS/CIREN Analysis
Finite Element Modeling

Objective
To provide an estimate of MVC-related
pelvic ring fracture incidence in the United
States
Estimate associations between occupant,
vehicle, and collision characteristics and
pelvic ring fracture
More generalizable interpretation

Methods
NASS data from 2000-2009
All ages and impacts included
Excluded occupants of vehicles older than
MY 1998
Side airbag

Excluded occupants not in front seat of

vehicle

Methods
Unstable pelvic fractures
Malgaigne/Bucket handle fracture
Straddle fracture
Pelvic ring disruption (AIS 4 or 5)
Combination of the above

Pelvic Fractures
Anterior (Aspect = 5)
Symphysis: AIS 853000.3
Rami: AIS 852600.2, 852602.2, 852604.3
Posterior (Aspect = 6)
Sacrum: AIS 852600.2, 852602.2, 852604.3,
852800.3
Left/Right/Posterior (Aspect = 1, 2 or 6)
Ilium: AIS 852600.2, 852602.2, 852604.3,
852800.3
High severity fractures
AIS code 852606.4, 852608.4, 852610.5

Methods
Statistical Analysis
Categorical and continuous variables compared
between occupants with and without unstable
fractures using chi-square and t-tests, respectively
Logistic regression used to estimate odds ratios
(ORs) and 95% confidence intervals (CIs) for the
association between occupant, vehicle, and
collision characteristics and unstable pelvic fracture
Analyses accounted for sampling weights

Results
An estimated 34,285 unstable pelvic fractures
from 2000-2009
Compared to those with no unstable pelvic
fractures, significant differences in regards to:

Age (p=0.0208)
Seatbelt use (p<0.0001)
Ejection (p<0.0001)
Frontal and side airbag deployment (p<0.0001)
Body type (p=0.0023)
Impact, delta-V, and maximum crush (p<0.0001)

Results
Adjusted OR (95% CI)
Age
< 20
20-29
30-39
40-49
50-59
60-69
70-79
80+
BMI
Underweight
Normal
Overweight
Obese
Male gender

0.69 (0.37-1.29)
Ref
0.94 (0.33-2.70)
1.48 (0.71-3.10)
0.55 (0.26-1.20)
1.18 (0.60-2.33)
1.30 (0.79-2.14)
2.82 (1.68-4.71)
1.33 (0.70-2.53)
Ref
0.68 (0.46-1.01)
1.33 (0.75-2.38)
0.69 (0.39-1.22)

Results
Adjusted OR (95% CI)
Used a seatbelt

0.58 (0.38- 0.88)

Front seat track position

1.17 (0.61- 2.24)

Ejection

8.17 (3.19- 20.9)

Frontal airbag deployment

1.21 (0.79- 1.85)

Torso side airbag deployment

5.33 (2.18-13.01)

Results
Adjusted OR (95% CI)
Model year (%)
1998-2000

Ref

2001-2003

1.30 (0.77-2.20)

2004-2006

1.78 (1.05-2.99)

2007-2010

0.44 (0.21-0.92)

Body type (%)

Passenger car

Ref

SUV/Van

0.42 (0.25-0.70)

Truck

0.54 (0.21-1.41)

Results
Adjusted OR (95% CI)
Impact
Frontal
Near-side
Far-side
Rear
Rollover
Delta-V (km-h)
0-25
26-49
50-74
75+
Maximum crush (cm)
0-39
40-59
60-79
80+

1.57 (0.44-5.59)
9.41 (3.12-28.4)
Ref
0.70 (0.18-2.81)
0.99 (0.58-1.70)
Ref
6.29 (3.47-11.40)
11.90 (5.39-26.21)
15.16 (2.57-89.41)
Ref
2.93 (1.83- 4.70)
3.62 (2.25- 5.82)
8.06 (3.12-20.80)

But wait
AIS codes for pelvic fractures are not
specific
Until 2010, NASS used the 1998 update of
the AIS90 codebook
AIS codes for general pelvic fracture
Use of aspect codes helps to identify specific
part of pelvis, but NASS only includes one
aspect per injury
An individual bony assessment is needed to
improve the stability classification

theres more
CIREN has two advantages over NASS in
regards to injury
With complete medical documentation and
prospective injury capture, CIREN allows
greater injury detail
CIREN has always coded multiple aspects
per injury

theres more
ICD codes
ICD coding in CIREN allows for a bone-bybone analysis

Sacrum (805.6, 805.7, 806.6, 806.60, 806.70, 839.42)

Ilium (808.41, 808.51)
Ischium (808.42, 808.52)
Pubis (808.2, 808.3)

When in doubt, we can always check the

radiology

Outline
Purpose: To analyze risk factors and
mechanisms for unstable pelvic fractures

Background
NASS Analysis
Validation
NASS/CIREN Analysis
Finite Element Modeling

Validation
In a subsequent analysis, injury data from
CIREN was used to validate AIS codes
NASS definitions applied to CIREN data
ICD codes used as the gold standard for
fractures of specific pelvic bones
Definition of pelvic fractures and unstable
fractures compared when using AIS/ICD
codes using Kappa and McNemars Q

Validation Results
Pelvic fracture incidence among front seat occupants of model year 1998 or
newer vehicles
NASS-CDS

CIREN

Total Pelvic Fractures (%)

78,903 (1.1)

617 (22.9)

Stable (%)

44,737 (56.7)

349 (56.6)

Unstable (%)

34,166 (43.3)

268 (41.3)

28,166 (82.4)

218 (81.3)

433 (1.3)

2 (0.8)

Open Book

1,590 (4.7)

0 (0.0)

Pelvic floor disruption

1,265 (3.7)

9 (3.3)

Multiple fracture types

2,712 (7.9)

39 (14.6)

Malgaigne/Bucket Handle
Straddle

Validation Results
Agreement between pelvic fractures in CIREN as defined using ICD or AIS codes
ICD
Yes

No

Kappa

p-value

AIS
Pubis fracture
Yes
No

265 (90.1)
29 (9.9)

80 (24.8)
243 (75.2)

0.65

<0.0001

Sacrum fracture
Yes
No

233 (96.7)
8 (3.3)

105 (27.9)
271 (72.1)

0.64

<0.0001

Iliac fracture
Yes
No

61 (72.6)
23 (27.4)

277 (52.0)
256 (48.0)

0.09

<0.0001

Validation Results
Agreement between pelvic fractures in CIREN as defined using ICD or AIS codes
ICD
Yes

No

Kappa

p-value

AIS
Unstable
Yes
No

205 (89.1)
25 (10.8)

63 (16.3)
324 (83.7)

0.71

<0.0001

Malgaigne/Bucket Handle
Yes
No

158 (88.8)
20 (11.2)

60 (13.7)
379 (86.3)

0.70

<0.0001

Straddle
Yes
No

2 (18.2)
9 (81.8)

0 (0.0)
606 (100.0)

0.30

0.0027

Multiple Types
Yes
No

31 (96.9)
1 (3.1)

8 (1.3)
609 (98.7)

0.87

0.0196

Validation Results
Pelvic fractures are more prevalent in
CIREN data than in NASS
Distribution of pelvic fractures is similar
between datasets
Good agreement between datasets regarding
Pubis, sacral fractures
Unstable fractures

Use of AIS codes overestimates unstable

fracture incidence

Outline
Purpose: To analyze risk factors and
mechanisms for unstable pelvic fractures

Background
NASS Analysis
Validation
NASS/CIREN Analysis
Finite Element Modeling

NASS/CDS Analysis
Based on the validation results, a
combined NASS/CDS analysis was
performed
Utilized definitions of unstable pelvic
fractures used in NASS-only analysis
Data pseudo-weighted in manner
suggested by Elliott et al (2010)

Results
Adjusted OR (95% CI)
Age
< 20
20-29
30-39
40-49
50-59
60-69
70-79
80+
BMI
Underweight
Normal
Overweight
Obese
Male gender

NASS

NASS/CIREN

0.69 (0.37-1.29)
Ref
0.94 (0.33-2.70)
1.48 (0.71-3.10)
0.55 (0.26-1.20)
1.18 (0.60-2.33)
1.30 (0.79-2.14)
2.82 (1.68-4.71)

0.46 ( 0.25- 0.85)

Ref
0.73 ( 0.29- 1.86)
1.28 ( 0.64- 2.53)
0.88 ( 0.40- 1.91)
1.02 ( 0.55- 1.88)
1.25 ( 0.79- 1.98)
3.14 ( 2.08- 4.74)

1.33 (0.70-2.53)
Ref
0.68 (0.46-1.01)
1.33 (0.75-2.38)
0.69 (0.39-1.22)

1.61 ( 0.91- 2.85)

Ref
0.67 ( 0.48- 0.92)
1.20 ( 0.75- 1.93)
0.53 ( 0.31- 0.92)

Results
Adjusted OR (95% CI)
NASS

NASS/CIREN

Used a seatbelt

0.58 (0.38- 0.88)

0.61 ( 0.37- 1.01)

Front seat track position

1.17 (0.61- 2.24)

1.25 ( 0.70- 2.23)

Ejection

8.17 (3.19- 20.9)

6.43 ( 2.71-15.28)

Frontal airbag deployment

1.21 (0.79- 1.85)

1.26 ( 0.86- 1.85)

Torso side airbag deployment

5.33 (2.18-13.01)

6.27 ( 3.15-12.47)

Results
Adjusted OR (95% CI)
NASS
NASS/CIREN
Model year (%)
1998-2000

Ref

Ref

2001-2003

1.30 (0.77-2.20)

1.64 ( 1.00- 2.69)

2004-2006

1.78 (1.05-2.99)

1.75 ( 1.09- 2.81)

2007-2010

0.44 (0.21-0.92)

0.43 ( 0.25- 0.74)

Ref

Ref

SUV/Van

0.42 (0.25-0.70)

0.52 ( 0.33- 0.80)

Truck

0.54 (0.21-1.41)

0.55 ( 0.25- 1.19)

Body type (%)

Passenger car

Results
Adjusted OR (95% CI)
NASS
NASS/CIREN
Impact
Frontal
Near-side
Far-side
Rear
Rollover
Delta-V (km-h)
0-25
26-49
50-74
75+
Maximum crush (cm)
0-39
40-59
60-79
80+

1.57 (0.44-5.59)
9.41 (3.12-28.4)
Ref
0.70 (0.18-2.81)
0.99 (0.58-1.70)

0.96 ( 0.40- 2.28)

6.68 ( 3.29-13.55)
Ref
0.36 ( 0.12- 1.14)
2.60 ( 1.39- 4.85)

Ref
6.29 (3.47-11.40)
11.90 (5.39-26.21)
15.16 (2.57-89.41)

Ref
4.17 ( 2.63- 6.61)
6.71 ( 2.59-17.38)
10.37 ( 1.60-67.36)

Ref
2.93 (1.83- 4.70)
3.62 (2.25- 5.82)
8.06 (3.12-20.80)

Ref
4.27 ( 2.75- 6.65)
4.85 ( 2.86- 8.23)
11.12 ( 4.35-28.44)

Discussion
Pelvic fractures are not frequent in all MVCs
(1.1%), but are common among severe
collisions (23%)
The most common unstable fracture involves
both the ramus and ilium/sacrum
Risk factors include older age, ejection, being in
a passenger car, being unbelted, near-side
impact, high crash severity, and torso SAB
deployment

Strengths
Large study sample
Included a representative sample of MVCs
Included both injured and non-injured
individuals
Use of CIREN data allowed for validation
of AIS and aspect codes in identifying
pelvic fractures in NASS data

Limitations
NASS utilizes codes for the 1998 revision of the
AIS90
These codes do not identify specific bones of the
pelvis
It is likely that the incidence of pelvic fractures is
overestimated in NASS, but the extent of which is
unknown
Secondary aspects specific to pelvic bones available
since 2004, but not included in public data until
recently

AIS05 includes codes that can more accurately

identify unstable pelvic fractures

Limitations
Two of epidemiologys uses are estimating
incidence of an outcome and identifying risk
factors for the outcome
To complete the clinical picture, the mechanism
behind the outcome must also be understood

Outline
Purpose: To analyze risk factors and
mechanisms for unstable pelvic fractures

Background
NASS Analysis
Validation
NASS/CIREN Analysis
Finite Element Modeling

Development of Pelvis Finite Element Model

GHBMC

50th

percentile
male

Muscles added

Sacrum & right

coxal bone
received

Flesh added
Final result: Pelvis finite element model
including muscle and flesh

Meshed (hexa and

tet elements)

Completed Validations
Validationstudies:
Guillemotetal.(1997;1998)
Details:QuasiStaticandDynamic
LateralLoading
Input:DisplacementandImpactForce
Output:Load,displacement,time

QuasiSteadyDynamic

QuasiSteadyDynamic

ExperimentalSetup

SimulationSetup

Conclude:
Model
response
within
experimental
corridors

BRM2PelvisModelsimulationsshownforexplicit
solutionswithruntimesof0.5,5,50mm/s
*Simulationincludedfracturesimulation

Dynamicimpactresponse(forcetime)oftheBRM2
pelvismodelagainstnormalizedexperimentaldata,
Thecurveisalignedtemporallyforcoincidenceof
peakforce

Completed Validations
Validationstudies:
Beasonetal.(2003)
Details:Lateralimpactstogreater
trochanter
Input:Impactforce
Output:Load,displacement,fracture
Injuryprediction:Rami/Sacralfracture

Experimentalsetup

Simulationsetup

Conclude:
Model predictions of
rami/sacral fracture
within experimental
corridor

Initialspikesremovedfromexperimentalcurves
Experimentaldataisshiftedtomatchthepeakforceofsimulationresults.
Peakvalueagreeswellagreedwithexp.data,andforcetimeresultsarewithin
corridor(mostly).
FracturesmodeledusingelementerosiontechniqueinLSDyna

Vehicle Model

Taurus model obtained from National Crash Analysis Center

(NCAC) archive (http://www.ncac.gwu.edu)
Total 28,502 elements 1 hour CPU time with 4 processors
No cushion for seats required for project

Side Impact Setup

Extract bumper from Taurus model

Add mass representing another Taurus model
Save CPU time a lot and easy to setup contact
information
Focus on the side panel intrusion magnitude
However, impact absorption in the hitting car is not
considered, which may be a factor of reducing impact
energy through pelvis or car components.

CIREN Case
27 y/o male
BMI 24.5 (175 cm, 75kg)

1997 Chevy Monte Carlo

PDOF: 280
Near-side impact
32 kmh V
35cm maximum crush
No SAB available

CIREN Case
The case vehicle (V1), a 1997 Chevrolet Monte Carlo
two door sedan, was traveling south on a three-lane
undivided roadway attempting to travel straight across
an intersection. It was daylight and the asphalt road was
dry. The other vehicle (V2), a 2000 GMC 3500 pickup,
was traveling west in the third of six undivided lanes of
the intersecting roadway. As V1 entered the intersection,
it was struck in the left side by the front of V2. Both
vehicles came to rest still in the intersection, and were
towed from the scene due to disabling damage. The 27
year old male driver of V1, the case study participant,
was unrestrained. The Monte Carlo was equipped with
frontal airbags which did not deploy.

CIREN Case
Injuries
Subarachnoid hemorrhage
Laceration of spleen
Left ilium fracture
Left acetabulum fracture
Left pubic ramus fracture

Parametric Study for Intrusion

To obtain 22 cm intrusion, initial velocity of
bumper varied from 10 to 30 mph with 5
mph intervals

mph

intrusion(mm)
10
111.6337891
15
205.046814
20
261.5072327
25
391.1533508
30
523.5005493

Interpolation result:
16.3424 mph yields 22 cm intrusion

Setup for CIREN Case

Cushion from detailed Taurus

model from NCAC

Pelvis model (with muscles and

flesh) positioned in drivers seat

Unit conversion of our pelvis and

femur model to match with units
used in Taurus model

Femur was simplified with one

material properties due to the
unit conversion problems

Preliminary Results

Stress mostly concentrated on ramus

- Left, anterior (match with CIREN
data)
No fracture predicted
Why not?
- No consideration of upper body and
legs (mass)

Whats Next?
Next step
Add equivalent masses
Upper body mass on the sacrum
Leg mass on the cut femur
Improve bullet vehicle model to match actual
bullet vehicle

Incidence of and Risk Factors for

Unstable Pelvic Fractures in Motor
Vehicle Collisions: An Analysis of
NASS and CIREN Data
University of Alabama at Birmingham
CIREN Center

Intrusion

Age
< 20
20-29
30-39
40-49
50-59
60-69
70-79
80+
BMI
Underweight
Normal
Overweight
Obese
Male gender
Used a seatbelt
Ejection
Torso SAB deployment

None

Mild

Moderate/Severe

OR (95% CI)

OR (95% CI)

OR (95% CI)

0.11 ( 0.02- 0.68)

Ref
0.19 ( 0.03- 1.41)
0.42 ( 0.09- 1.99)
0.76 ( 0.12- 4.79)
0.78 ( 0.06- 10.80)
1.42 ( 0.38- 5.34)
11.13 ( 2.09- 59.26)

0.07 ( 0.01- 0.48)

Ref
0.68 ( 0.11- 3.99)
0.66 ( 0.13- 3.20)
1.40 ( 0.28- 6.93)
0.37 ( 0.11- 1.21)
1.36 ( 0.35- 5.23)
2.02 ( 0.23- 17.92)

0.93 ( 0.29Ref
1.41 ( 0.383.11 ( 1.451.57 ( 0.632.31 ( 0.741.36 ( 0.322.41 ( 0.95-

2.79 ( 0.36- 21.91)

Ref
0.10 ( 0.02- 0.49)
1.82 ( 0.16- 20.56)
0.64 ( 0.14- 2.91)
0.22 ( 0.06- 0.79)
10.23 ( 1.82- 57.50)
7.54 ( 1.37- 41.54)

4.32 ( 0.85- 21.96)

Ref
0.62 ( 0.24- 1.58)
1.18 ( 0.16- 8.55)
0.51 ( 0.25- 1.06)
1.81 ( 0.30- 10.75)
8.29 ( 1.44- 47.55)
3.46 ( 1.49- 8.04)

0.68 ( 0.40Ref
0.58 ( 0.290.71 ( 0.280.68 ( 0.430.93 ( 0.513.59 ( 1.601.53 ( 0.76-

2.94)
5.14)
6.64)
3.90)
7.23)
5.73)
6.09)
1.18)
1.17)
1.80)
1.08)
1.69)
8.02)
3.09)

Intrusion

Model year
1998-2000
2001-2003
2004-2006
2007-2010
Body type (%)
Passenger car
SUV/Van
Truck
Impact
Frontal
Near-side
Far-side
Rear
Rollover
Delta-V (km-h)
Maximum crush (cm)

None

Mild

Moderate/Severe

OR (95% CI)

OR (95% CI)

OR (95% CI)

Ref
3.40 ( 0.74- 15.55)
3.13 ( 0.63- 15.43)
3.09 ( 0.90- 10.55)

Ref
3.91 ( 1.02- 14.99)
2.39 ( 0.90- 6.38)
0.28 ( 0.02- 4.34)

Ref
1.40 ( 0.90- 2.19)
2.28 ( 1.30- 3.99)
0.78 ( 0.18- 3.46)

Ref
0.17 ( 0.05- 0.53)
1.25 ( 0.20- 7.85)

Ref
0.75 ( 0.34- 1.67)
0.26 ( 0.04- 1.65)

Ref
0.39 ( 0.25- 0.61)
0.43 ( 0.18- 1.01)

0.26 ( 0.07- 0.94)

1.53 ( 0.14- 16.47)
Ref
0.36 ( 0.09- 1.40)
1.72 ( 0.31- 9.39)
1.09 ( 1.06- 1.11)
1.01 ( 1.00- 1.03)

4.24 ( 0.67- 26.70)

5.33 ( 0.63- 44.89)
Ref
3.07 ( 1.46- 6.45)
1.04 ( 0.97- 1.11)
1.00 ( 0.95- 1.06)

1.10 ( 0.24- 4.98)

3.24 ( 0.80- 13.04)
Ref
0.82 ( 0.08- 8.40)
0.36 ( 0.20- 0.64)
1.00 ( 0.98- 1.02)
1.02 ( 1.01- 1.03)