Pelvic Fracture Management

Initial Assessment and Stabilization

For hemodynamically unstable patients with pelvic fractures, immediate pelvic ring closure using a pelvic binder is the critical first intervention, followed by transfusion and preparation for angiographic embolization or preperitoneal packing, as recommended by the American College of Surgeons, with a strength of evidence of high 1, 2
Apply pelvic binder immediately around the greater trochanters within 2 minutes of identification, which is life-saving and takes priority over all imaging, according to the Eastern Association for the Surgery of Trauma, with a strength of evidence of high 1, 2
Resuscitation strategy should target systolic BP 80-90 mmHg using permissive hypotension until hemorrhage is controlled, as recommended by the Western Trauma Association, with a strength of evidence of moderate 2
Transfuse packed red blood cells while minimizing crystalloids to avoid dilutional coagulopathy, as recommended by the American College of Surgeons, with a strength of evidence of high 2

Perform E-FAST within 30 minutes to identify intra-abdominal bleeding, as recommended by the Eastern Association for the Surgery of Trauma, with a strength of evidence of high 1
Obtain pelvic X-ray upon arrival to confirm fracture pattern, as recommended by the Orthopaedic Trauma Association, with a strength of evidence of moderate 1
CT "blush" (active arterial extravasation) or pelvic hematoma >500 ml strongly indicates need for angioembolization, as recommended by the Society of Interventional Radiology, with a strength of evidence of high 3, 1, 2

Angiography with embolization is the primary definitive intervention for ongoing instability despite adequate pelvic ring stabilization, with success rates of 73-97%, as recommended by the Western Trauma Association, with a strength of evidence of high 2
Preperitoneal packing can be performed in <20 minutes if angiography is not immediately available, decreases need for subsequent embolization to only 13-20%, and should be removed only after 48 hours, as recommended by the Eastern Association for the Surgery of Trauma, with a strength of evidence of moderate 1, 2

Urethral injuries should be evaluated with retrograde urethrogram (RUG) prior to urethral catheterization when local signs or disruption on X-ray are present, as recommended by the American Urological Association, with a strength of evidence of high 3
Ano-rectal injuries should be evaluated with perineal and rectal digital examination to detect blood, rectal wall weakness, and non-palpable prostate, as recommended by the American Society of Colon and Rectal Surgeons, with a strength of evidence of moderate 3

All patients with severe pelvic trauma should be transported to a Level I trauma center with 24/7 availability of trauma surgery, interventional radiology, and orthopedic surgery, as recommended by the American College of Surgeons, with a strength of evidence of high 1

Time to hemorrhage control should be <163 minutes, as mortality increases approximately 1% every 3 minutes of delay, as recommended by the Western Trauma Association, with a strength of evidence of high 2