Quick Recap
Trauma System, Protocol 4/8. Built on ATLS 11th Edition (2023).
1. Mechanism and Classification
Four injury force patterns: AP compression, lateral compression, vertical shear, combined mechanism.
- AP compression: motorcycle or head-on MVC — EXTERNAL rotation of the hemipelvis, symphysis pubis separation, posterior ligamentous complex tearing -> the pelvic ring WIDENS, tearing the posterior venous plexus and internal iliac arterial branches -> hemorrhage can be severe and life-threatening.
- Lateral compression: the MOST COMMON pelvic fracture mechanism in MVC — hemipelvis rotates INTERNALLY (opposite of AP compression), which REDUCES pelvic volume and REDUCES tension on pelvic vascular structures (theoretically less hemorrhage-prone by this mechanism alone) — but internal rotation can drive the pubis into the lower genitourinary system, risking bladder/urethral injury. Elderly/frail patients can develop significant bleeding from LOWER-FORCE lateral compression injuries than would be expected in a younger patient — do not underestimate hemorrhage risk in this population based on mechanism severity alone.
- Vertical shear: high-energy shear force along a vertical plane, typically from a FALL FROM HEIGHT — disrupts the sacrospinous/sacrotuberous ligaments and iliac vasculature -> significant instability AND severe hemorrhage.
"AP compression III" and "vertical shear" patterns are most likely to require hemorrhage-control interventions. Additional predictors of needing hemorrhage control: open pelvic fracture, age >64.
2. WSES (World Society of Emergency Surgery) Grading — Hemodynamics-Driven, Not Anatomy-Driven
Critical principle: differentiating hemodynamically stable vs unstable patients matters far more than fracture pattern nuance when a patient is ACTIVELY BLEEDING. ANY hemodynamically unstable pelvic fracture patient is categorized as Grade IV, REGARDLESS of fracture pattern.
WSES Grade | Description | Hemodynamic status | Early treatment |
I | Minor (APC I, LC I) | Normal | Routine evaluation |
II | Moderate (LC II/III, APC II/III) | Normal but mechanically unstable | Pelvic binder, possible angioembolization; possible external fixation/operative management |
III | Moderate vertical shear | Normal but mechanically unstable | Pelvic binder, possible angioembolization; operative management |
IV | Severe | SHOCK (any pattern) | Pelvic binder, preperitoneal packing, mechanical fixation, REBOA, angioembolization |
Concomitant injuries present in up to 50% of pelvic fracture patients — actively screen the rest of the body, do not anchor on the pelvis alone.
3. Clinical Assessment
Clinical factors associated with pelvic fracture:
- Mechanism: MVC/motorcycle crash, fall from height, fall in a frail patient, fall from animal transport, crush, bicycle crash
- Symptoms: pelvic/low abdominal/hip pain, pain radiating to lower extremities, low back pain
- Signs: hypotension, tachycardia, pain on pelvic palpation, lower abdominal tenderness, pain with hip movement, external rotation of lower extremities, sacral/coccyx tenderness, suprapubic widening, suprapubic/iliac/perineal ecchymosis, blood at urethral meatus, vaginal blood
AVOID aggressive distraction/manual displacement of pelvic fractures to test anatomic stability — this can WORSEN hemorrhage. Instead, use GENTLE anterior compression at the ASIS and lateral compression at the iliac crest; pain, motion, or crepitus indicates fracture. The pelvic ring stability exam has documented poor diagnostic reliability — do not rely heavily on this exam alone to exclude a mechanically unstable fracture.
The pelvis can accommodate 4-6 LITERS of blood — even an isolated pelvic injury can produce profound hemodynamic instability on this basis alone.
Do NOT place a urinary catheter if urethral injury is potentially present (blood at meatus, high-riding prostate, perineal/scrotal hematoma) — obtain a retrograde urethrogram first or defer to urology.
4. Immediate Stabilization — Pelvic Binder
A pelvic compression device ("pelvic binder") may be LIFESAVING when a pelvic fracture is clinically suspected — apply based on clinical scenario, do not wait for imaging confirmation in an unstable patient.
Technique: center the device at the level of the GREATER TROCHANTERS (not higher on the iliac crests) — correct positioning is essential for effective pelvic volume reduction. Additionally bind the lower extremities with INTERNAL rotation of the hips (if possible) — pelvic injuries with major hemorrhage cause EXTERNAL rotation of the hemipelvis, so internal rotation of the limbs helps reduce pelvic volume and promote vessel tamponade, working synergistically with the binder itself.
Binders are a TEMPORARY emergency measure — proper application and vigilant monitoring are essential; tight devices or prolonged application can cause skin breakdown/ulceration over bony prominences — do not leave in place indefinitely without reassessment.
A sheet or commercial device is equally acceptable for this temporary fixation, relevant particularly in resource-limited initial-assessment settings before transfer to definitive care.
5. Definitive Hemorrhage Control — Multidisciplinary, Multi-Technique
Hemorrhage is THE major potentially reversible factor contributing to pelvic fracture mortality. Optimal care requires a team effort: traumatologists, orthopedic specialists, interventional radiologists/vascular surgeons — no single specialty owns this problem.
Techniques (not mutually exclusive — more than one may be needed):
- Angiographic embolization: frequently used to stop ARTERIAL pelvic hemorrhage
- Preperitoneal packing: an alternative/complementary technique, used either as an INITIAL procedure or when angioembolization is delayed/unavailable — a paradigm-shifting approach (Cothren et al., 2007) for rapid hemorrhage control, particularly valuable for the VENOUS component of pelvic bleeding that angioembolization (arterial-focused) does not address
- Mechanical/external fixation: for the mechanically unstable component
- REBOA (resuscitative endovascular balloon occlusion of the aorta): stops/slows aortic blood flow to targeted injury zones while resuscitation continues and definitive intervention is pursued. Critical limitation: REBOA is NOT a stabilization tool for transfer to another facility — it should only be placed when definitive surgical care and hemostasis are available at the SAME institution. Do not use REBOA as a bridge for inter-facility transfer.
An experienced traumatologist should direct the therapeutic plan based on available institutional resources — the specific combination/sequence of these techniques is individualized, not protocolized to a single fixed algorithm.
6. Response to Resuscitation — The General xABCDE Framework Applied to Pelvic Hemorrhage
Responders: normal hemodynamics after initial fluid administration, perfusion resolves — have not lost significant blood volume; further fluid not immediately needed, but maintain type-and-crossmatch access; proceed with further injury evaluation.
Transient responders: improve initially but perfusion DECLINES as fluid rate is reduced — indicates ongoing hemorrhage or inadequate resuscitation of already-lost blood; further transfusion indicated; obtain surgical consultation or initiate transfer, since operative/other invasive hemorrhage-control therapy is likely needed.
Non-responders: failure to improve with volume indicates ongoing bleeding, inadequate resuscitation, or NON-hemorrhagic shock — reassess and REPEAT the xABCDE survey to identify a treatable alternative cause.
Reasons for non-response to resuscitation (differential to actively work through):
Category | Causes |
Continuing hemorrhage | Inadequately treated compressible bleeding (unrecognized injury, inadequate packing/pelvic device/tourniquet); noncompressible bleeding (intra-abdominal, pelvic arterial, penetrating junctional vessel injury); coagulopathy (preinjury medications, unbalanced blood product ratio, hyperfibrinolysis) |
Inadequate resuscitation | Soft-tissue/intramuscular contusion and shearing injuries; fracture blood loss elsewhere; concomitant burns; unrecognized pre-arrival blood loss |
Non-hemorrhagic shock | Obstructive (tension pneumothorax, tension hemothorax, cardiac tamponade); neurogenic; cardiogenic (blunt cardiac injury, AMI); septic (intra-abdominal sepsis, pneumonia, urinary sepsis); endocrine/metabolic (DKA, adrenal insufficiency) |
Review medication history for anticoagulants/antiplatelets/glucocorticoids in any non-responder. Verify external hemorrhage control adequacy (tourniquet function) and pelvic compression device positioning/tightness, and consider tube thoracostomy as part of this reassessment.
7. Immediate Stabilization (ABCDE) Checklist
Checklist:
8. Investigations
AP pelvic X-ray (helps establish bleeding source in hemodynamically abnormal patients or those with pelvic pain/tenderness; NOT mandated in an alert patient without pelvic pain/tenderness), FAST/eFAST, CT (hemodynamically normal patients only, unless it would delay transfer), retrograde urethrogram if urethral injury suspected before catheter placement, serial Hb/Hct.
9. Organ Support
Damage control resuscitation per the Hypovolemic Shock protocol (Cardiovascular System); pelvic binder + definitive hemorrhage-control technique(s) per Section 5; REBOA where institutionally appropriate; standard ICU supportive care.
10. Consultation Matrix
Consultation | Trigger | Timing |
Trauma/General Surgery | All significant pelvic trauma | Immediate |
Orthopedic Surgery | Mechanical instability, external/internal fixation need | Immediate |
Interventional Radiology/Vascular Surgery | Angioembolization candidacy | Immediate for WSES Grade II-IV |
Urology | Suspected urethral/bladder injury | Immediate |
11. Monitoring Framework
Continuous hemodynamic monitoring, serial Hb/Hct, pelvic binder skin integrity checks (bony prominence surveillance), response-to-resuscitation category reassessment, urine output/catheter status per urethral injury workup.
12. Complications
Exsanguinating hemorrhage (the dominant mortality driver), bladder/urethral injury (lateral compression mechanism), skin breakdown from prolonged/tight binder application, missed concomitant injury (up to 50% co-occurrence rate), REBOA-related complications if used inappropriately (e.g., without same-site definitive care available). Prevention: correct binder technique and timely application/removal, multidisciplinary hemorrhage-control approach, avoiding manual pelvic distraction testing, appropriate REBOA institutional-capability restriction. Rescue: preperitoneal packing/angioembolization/REBOA escalation per WSES grade, repeat xABCDE survey for non-responders.
13. Escalation & De-escalation
Escalate: WSES Grade IV (hemodynamic instability) -> full multimodal hemorrhage control (binder + packing/embolization/fixation/REBOA as institutionally available); transient response or non-response to resuscitation -> reassess per Section 6 differential, escalate intervention.
De-escalate: hemodynamically stable (responder), mechanically stable fracture pattern -> routine evaluation, definitive orthopedic management on a non-emergent timeline.
14. ICU Discharge Criteria
Hemodynamically stable off blood products, definitive or temporizing hemorrhage control achieved and stable, pelvic binder removed with skin integrity intact or appropriately managed, urologic injury (if present) addressed, orthopedic definitive fixation plan established.
15. Documentation & Medicolegal Checklist
16. Key Guidelines
American College of Surgeons. Advanced Trauma Life Support, 11th Edition Course Manual, 2023 (Chapter 6: Circulation Assessment and Volume Resuscitation; Chapter 10: Musculoskeletal Trauma; Chapter 21: Thoracic, Abdominopelvic, and Genitourinary Trauma).
17. Landmark Evidence
Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitoneal pelvic packing for hemodynamically unstable pelvic fracture: a paradigm shift. J Trauma. 2007;62(4):834-839. Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF III. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma. 1997;43(3):395-399. Brenner M, Bulger EM, Perina DG, et al. Joint statement from ACS-COT and ACEP regarding the clinical use of REBOA. Trauma Surg Acute Care Open. 2018;3(1):e000154.
18. Controversies
The pelvic ring stability examination has documented poor diagnostic reliability (Shlamovitz et al., 2009), yet remains taught/performed — clinical practice should weight hemodynamic status far more heavily than manual stability testing. Optimal sequencing between preperitoneal packing, angioembolization, and REBOA for Grade IV injuries is institution/resource-dependent rather than protocolized by a single evidence-based algorithm, explicitly requiring an experienced traumatologist's judgment per the primary reference. REBOA patient-selection criteria continue to be refined by ongoing systematic review efforts.
19. References
- American College of Surgeons. Advanced Trauma Life Support, 11th Edition Course Manual, 2023 (Chapter 6, Chapter 10, Chapter 21).
- Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitoneal pelvic packing for hemodynamically unstable pelvic fracture: a paradigm shift. J Trauma. 2007;62(4):834-839.
- Brenner M, Bulger EM, Perina DG, et al. Joint statement from the ACS-COT and ACEP regarding the clinical use of REBOA. Trauma Surg Acute Care Open. 2018;3(1):e000154.
- Maiga AW, Kundi R, Morrison JJ, et al. Systematic review to evaluate algorithms for REBOA use in trauma. Trauma Surg Acute Care Open. 2022;7(1):e000984.
See also: Hypovolemic Shock (Cardiovascular System) for the full damage control resuscitation framework; Abdominal Trauma (Trauma System) for the shared FAST/CT diagnostic approach; Polytrauma (Trauma System) for the xABCDE framework this protocol nests within.