Introduction Epidemiological studies have shown that the incidence of fragility fractures of the pelvis in the elderly population is increasing due to ageing. These fractures are often classified as stable and managed predominantly by medical teams. Aggressive surgical management of the neck of femur fractures has resulted in reduced morbidity and mortality in patients. There are no evidence-based guidelines for managing fragility fractures of the pelvis. Our aim was to review the literature and compare operative versus non-operative management of fragility fractures of the pelvis. Materials and Methods Based on the published results, we question whether these fractures have a significant morbidity and mortality to warrant a change in management. We questioned whether the posterior ring should be routinely imaged, which patient groups may benefit from operative intervention, what techniques are available to provide pain relief and to enable full weight bearing to support early mobilisation versus an aesthetic risk and complications of surgery. Results Differences in healthcare systems, rehabilitative provision and social support among hospitals make comparisons between retrospective studies difficult. Conclusion Performing randomised controlled trials to develop evidence-based protocols can reduce the morbidity and mortality in the elderly with fragility fractures of the pelvis. Introduction An increase in the elderly population has resulted in an increased prevalence of fragility fractures of the pelvis1–3. An epidemiological study has found that in the past 12 years, the number of predominantly low energy pelvic fracture admissions in patients aged over 50 years has increased by 58.4% and 110.8% in males and females, respectively4. In past, majority of the patients with fragility pelvic fractures were conservatively managed, often by medical teams, as their immobility resulted in medical complications such as pressure sores, chest infections, urinary tract infections and venous thromboembolism5,6. There have been many studies demonstrating a lower mortality and morbidity with early aggressive surgical management of neck of femur fractures when compared with delayed or conservative management7,8. Treatment facilitating pain relief, early unrestricted mobilisation and an aim of returning patients to pre-injury level of care also has implications in reducing the burden on limited healthcare resources. The British Orthopaedic Association and British Geriatric Society published the Blue Book9 in 2007 to guide the management of these patients and emphasising the role of the Orthogeriatric team. This has been coupled with financial incentives from the best practice tariff10 and monitoring via the National Hip Fracture Database11. Despite the similarities with neck of femur fractures, there are no guidelines regarding the management of fragility fractures of the pelvis. Our aim was to review the literature and compare the morbidity and mortality of operative fixation versus non-operative management of fragility fractures of the pelvis. We investigated the functional outcomes and complications. Using the published results, we questioned whether early aggressive management of pelvic fractures could reduce the mortality and morbidity in elderly patients? Is there evidence to suggest which patient groups may benefit from operative intervention and what techniques are available? Materials and Methods MEDLINE and EMBASE databases were searched on 2nd January 2013 using the following search terms: ‘pelvic fracture’, ‘elderly’, ‘pubic rami’, ‘sacral insufficiency’, ‘fragility’, ‘fall’ and ‘low velocity’. References from the literature, including all relevant studies, were screened to find other studies for inclusion in this review. Biomechanical studies, cadaveric studies, literature reviews, letters to the editor, radiological studies, those not pertaining to management of fractures and studies pertaining to patients under the age of 65 years were excluded. All details including mechanism and velocity of injury, age, treatment, complications, duration of follow-up and outcomes were recorded. Results In literature, two prospective case series have been reported; the evidence is otherwise limited to retrospective case series. Overall, the level of evidence is weak with no randomised controlled trials comparing operative with non-operative management. * Corresponding authors Emails: ben_quansah@yahoo.co.uk john.stammers@nhs.net 1 Royal London Pelvic Unit, Royal London Hospital, United Kingdom 2 Care of the Elderly Department, Royal London Hospital, United Kingdom Tr au m a & Or th op ae di cs