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Tile classification pelvic fractures types A B C images diagram

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Tile Classification of Pelvic Fractures

The Tile classification (also aligned with the AO/OTA system) categorizes pelvic ring fractures based on stability - both rotational and vertical. This directly guides treatment decisions and predicts prognosis. It was developed by Marvin Tile in 1984 and later modified by Helfet to align with the AO/OTA fracture system.

Source: Campbell's Operative Orthopaedics 15th Ed 2026; Rockwood & Green's Fractures in Adults 10th Ed 2025

Overview Principle

The key biomechanical question is: Are the posterior pelvic ligaments (sacroiliac + sacrospinous + sacrotuberous) intact?

Type	Stability	Posterior Ligaments
A	Stable	Intact
B	Rotationally unstable, vertically stable	Partially disrupted
C	Rotationally AND vertically unstable	Completely disrupted

TYPE A - Stable Pelvic Ring Injuries

The posterior ligamentous complex is intact. The pelvic ring is not significantly disrupted. These can be managed non-operatively.

Subtype	Description	Example
A1	Fractures NOT involving the ring	Avulsions of ASIS, AIIS, ischial tuberosity; isolated iliac wing fracture
A2	Stable, minimally displaced ring fractures	Iliac wing fracture (Duverney), isolated anterior ring injury
A3	Transverse sacrococcygeal fractures	Sacral or coccyx fractures - considered spinal injuries, not ring disruptions

Management: Non-operative (protected weight bearing). Early mobilization is safe.

TYPE B - Rotationally Unstable, Vertically STABLE

The posterior sacroiliac (SI) ligaments and interosseous ligaments are partially intact - they prevent vertical displacement but the pelvis can rotate. Requires surgical fixation.

Type B - Lateral compression mechanism showing internal rotation force on hemipelvis

Subtype	Description	Mechanism	Notes
B1	Open-book injury (external rotation)	Anteroposterior compression (APC)	Symphysis diastasis; stages by width: Stage 1 (<2.5 cm, intact sacrospinous), Stage 2 (>2.5 cm, sacrospinous ruptured), Stage 3 (bilateral)
B2	Lateral compression - ipsilateral	LC (internal rotation)	B2.1: ipsilateral sacral fracture; B2.2: posterior SI ligament rupture; B2.3: crescent fracture (ilium)
B3	Bilateral injury	Combined APC + LC	B3.1: bilateral open book; B3.2: "windswept pelvis" (LC-III); B3.3: bilateral LC

Key radiographic sign: Symphysis widening >2.5 cm = rupture of sacrospinous ligament = rotational instability.

Management: Anterior fixation (external fixator or symphyseal plating) is usually sufficient due to intact posterior column.

TYPE C - Rotationally AND Vertically Unstable

Complete disruption of all posterior ligamentous structures. The hemipelvis is free to displace in all directions - the most severe and life-threatening pattern.

Type C - Vertical shear force showing complete posterior disruption with upward displacement

Subtype	Description	Notes
C1	Unilateral	C1-1: iliac fracture; C1-2: SI fracture-dislocation; C1-3: sacral fracture
C2	Bilateral - one side B, one side C	One hemipelvis vertically stable, one unstable
C3	Bilateral - both sides C	Both hemipelves rotationally AND vertically unstable; may have associated acetabular fracture

Mechanism: Vertical shear (VS) - upward force through one lower extremity (e.g., fall from height).

Management: Requires BOTH anterior AND posterior fixation. Associated with worst outcomes, highest rate of neurologic injury.

Denis Sacral Zone Classification (used alongside Tile for C1-3)

When the posterior injury involves the sacrum (C1-3), the Denis zones define neurologic risk:

Denis classification zones of the sacrum - Zone I (ala, lateral), Zone II (foraminal), Zone III (central/spinal canal)

Zone	Location	Nerve injury rate
Zone I	Lateral to sacral foramina (sacral ala)	1.9-5.9% (L5 root)
Zone II	Through sacral foramina (transforaminal)	5.8-28.4% (L5-S2)
Zone III	Medial to foramina (central/spinal canal)	8.6-56.7% (bowel/bladder in 76%)

Complete Tile/AO-OTA Classification Summary

Tile	AO/OTA	Description	Stability
A1	61-A1	Avulsion of innominate bone	Stable
A2	61-A2	Stable iliac wing or minimally displaced ring fracture	Stable
A3	61-A3	Transverse sacrum/coccyx	Stable
B1	61-B1	Open book (external rotation)	Rotationally unstable
B2	61-B2	LC ipsilateral (internal rotation)	Rotationally unstable
B3	61-B3	Bilateral (windswept/LC-III)	Rotationally unstable
C1	61-C1	Unilateral complete disruption	Rotationally + vertically unstable
C2	61-C2	Bilateral (one B, one C)	Rotationally + vertically unstable
C3	61-C3	Bilateral complete disruption	Rotationally + vertically unstable

Clinical Pearls

Type B vs C distinction is the most critical: check for vertical displacement on AP pelvis X-ray (hemipelvis riding up = C-type).
Symphysis >2.5 cm on X-ray = sacrospinous rupture = at minimum Type B1.
Type C injuries have the worst outcomes, primarily due to associated neurologic injuries (S1-S3 nerve roots, cauda equina).
Hemorrhage risk increases with injury severity: Tile B and C injuries are associated with high transfusion requirements and hemodynamic instability.
Open-book injuries (B1) increase pelvic volume - circumferential binder placed at the level of the greater trochanters (not the iliac crests) reduces volume and tamponades venous bleeding.

Sources: Campbell's Operative Orthopaedics 15th Ed 2026, p. 3530-3531; Rockwood & Green's Fractures in Adults 10th Ed 2025, p. 2328-2329

Young and burges classification of pelvis with images explain

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Young-Burgess Classification of Pelvic Fractures

Introduced by Young and Burgess (1987), this is the most widely used classification for pelvic ring injuries. It is based on the mechanism of injury (force vector) rather than stability alone. It has four main types: LC, APC, VS, and CM.

Sources: Rockwood & Green's Fractures in Adults 10th Ed 2025; Miller's Review of Orthopaedics 9th Ed; Campbell's Operative Orthopaedics 15th Ed 2026

Classification Overview Diagram

Young-Burgess classification showing LC types I-III (internal rotation), APC types I-III (external rotation/open book), and Vertical Shear

Fig. 11.6 from Miller's Review of Orthopaedics - The three main injury vectors. Arrows indicate direction of applied force.

TYPE 1: LATERAL COMPRESSION (LC) - Most Common (~41%)

Mechanism: Side-impact force causing internal rotation of the hemipelvis. Classic cause: T-bone motor vehicle collision, direct blow to the side.

Anterior injury: Oblique/horizontal pubic rami fractures (ipsilateral)

$LC injury - AP pelvis X-ray showing internally rotated hemipelvis with rami fractures$

Subtype	Posterior Injury	Ligaments	Stability	Tile Equivalent
LC I	Sacral impaction fracture on side of impact (sacral ala crushed)	Intact	Rotationally stable	B2.1
LC II	Crescent fracture - fracture-dislocation of iliac wing through SI joint	Partially disrupted	Rotationally unstable	B2.3
LC III	LC I or II on side of impact + contralateral open-book (windswept pelvis)	Contralateral SS/ST disrupted	Unstable	B3.2

$LC-III windswept pelvis: inlet reconstruction showing right sacral ala fracture + crescent fracture with left SI joint widening on stress$

LC-III "windswept pelvis" - Note ipsilateral sacral fracture entering the SI joint (crescent fracture), with contralateral SI joint widening on stress examination (panel D)

Associated injuries: Brain injury (LC-I, LC-II), bowel injury (LC-III). LC-III is usually from a crush injury.

TYPE 2: ANTEROPOSTERIOR COMPRESSION (APC) - "Open Book" (~26%)

Mechanism: Force applied front-to-back causing external rotation of the hemipelvis - hinged posteriorly at the SI joint. Causes: head-on collision, motorcycle accident, fall landing on extended leg.

Anterior injury: Symphysis pubis diastasis or rami fractures

Ligament failure progresses in a domino pattern: Symphysis → Sacrospinous → Sacrotuberous → Anterior SI ligament → Posterior SI ligament

Subtype	Symphysis	Ligaments Disrupted	SI Joint	Tile Equivalent
APC I	<2.5 cm diastasis	Symphysis only; posterior ligaments intact	Minor anterior opening	A2/B1
APC II	>2.5 cm diastasis	Sacrospinous + Sacrotuberous + Anterior SI	Anterior SI opens; posterior SI intact	B1
APC III	Wide diastasis	ALL ligaments including posterior SI	Complete disruption	C1

$APC I - AP pelvis X-ray with symphysis widening <2.5 cm, CT confirming measurement, 3D CT reconstruction showing left ramus fracture with external rotation$

APC I: Note the symphysis widening on AP X-ray (A), CT measuring <2.5 cm diastasis (B,C), and 3D CT reconstructions showing the externally rotated hemipelvis (D-F)

APC II - AP, inlet, outlet X-rays showing wide symphysis diastasis >5.7 cm, axial CT confirming posterior SI opening, 3D CT reconstruction

APC II: AP, inlet, and outlet radiographs (A-C), axial CT showing right SI joint widening (D), CT measuring 5.7 cm diastasis (E), 3D reconstruction (F)

Key rule: Symphysis >2.5 cm = sacrospinous ligament disrupted = at least APC II

Associated injuries: Urethral/bladder injuries (most common in APC), splenic/liver/bowel/vascular injuries increase APC I → III. APC III has the highest transfusion requirements of all types.

TYPE 3: VERTICAL SHEAR (VS) - (~5%)

Mechanism: Vertical force directed cephalad through one lower extremity - the hemipelvis is displaced superiorly. Cause: fall from height, high-energy impact.

Injuries: Complete disruption of ALL pelvic ligaments (equivalent to APC III). Vertical displacement of entire hemipelvis.

Anterior injury: Vertical rami fractures or symphysis diastasis

Posterior injury: Iliac wing fracture, sacral fracture, or SI joint dislocation

Key radiographic clue: Iliac crest on the injured side rides cephalad (higher) compared to the normal side on AP pelvis. L5 transverse process fracture (avulsion by iliolumbar ligament) may indicate vertical instability.

Tile equivalent: C1 (most severe single-sided pattern)

Associated injuries: Mortality and injury pattern similar to APC II and APC III.

TYPE 4: COMBINED MECHANISM (CM) - (~10%)

Mechanism: Multiple force vectors acting simultaneously. These injuries exhibit features from two or more of the above patterns.

Examples: LC + VS, APC + LC (the latter producing the "windswept" appearance)

Stability: Variable - determined by the components present.

3D CT of a Severe Pelvic Ring Injury

3D CT reconstruction of complex pelvic ring injury showing bilateral sacral/SI disruption, displaced rami, and comminution

3D CT reconstruction illustrating a high-energy pelvic ring disruption - essential for pre-operative planning

Full Classification Summary Table

Type	Subtype	Mechanism	Anterior Injury	Posterior Injury	Ligaments	Hemorrhage Risk	Tile
LC I	Lateral compression	Side impact (internal rotation)	Horizontal rami #	Sacral impaction	Intact	Low	B2.1
LC II	Lateral compression	Side impact	Horizontal rami #	Crescent fracture (iliac wing-SI)	Partial	Moderate	B2.3
LC III	Lateral compression	Crush / T-bone	Rami ± symphysis	LC + contralateral APC (windswept)	Bilateral	High	B3.2
APC I	Open book	AP force	Symphysis <2.5 cm	None/minimal	Symphysis only	Low	A2/B1
APC II	Open book	AP force	Symphysis >2.5 cm	Anterior SI opens	SS + ST + Ant. SI	High	B1
APC III	Open book	AP force	Wide diastasis	Complete SI disruption	All (including post. SI)	Highest	C1
VS	Vertical shear	Fall from height	Vertical rami/symphysis	SI dislocation/sacral #	All disrupted	High	C1
CM	Combined	Variable	Variable	Variable	Variable	Variable	B/C

Clinical Pearls

LC injuries are most common (41%) but APC injuries bleed more (pelvic volume increases with external rotation).
APC II vs APC III distinction is key: APC II has intact posterior SI ligaments - so anterior fixation (symphyseal plate) alone may suffice. APC III needs posterior fixation too.
VS injuries are easiest to miss - always check if one hemipelvis rides higher than the other on AP X-ray.
Circumferential pelvic binder is most effective for APC injuries (reduces pelvic volume). It is LESS effective for VS (no volume reduction needed).
Transfusion prediction: APC III > VS > LC III > APC II; LC I and APC I have minimal blood loss.
The Young-Burgess system predicts associated injuries better than Tile, while Tile is better for guiding surgical fixation strategy.

Sources: Rockwood & Green's Fractures in Adults 10th Ed 2025, pp. 2328-2332; Miller's Review of Orthopaedics 9th Ed, p. 907

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