01Approach to the Critical Patient/attcp51

Immediate hemorrhage control

›Hemorrhagic shock recognition

›SBP < 90 mmHg with tachycardia > 120 bpm

›High probability of major pelvic vascular injury

›Activate massive transfusion protocol immediately

›Skin vasoconstriction, altered mental status, cold extremities

›Class III-IV hemorrhagic shock physiology

›Permissive hypotension target SBP ~90 mmHg until hemorrhage control

›Pelvic binder application over greater trochanters

›First-line hemorrhage control for all VS fractures

›Apply before transport or CT if hemodynamically unstable

›Resuscitation priorities

›Massive transfusion protocol 1:1:1 pRBC:FFP:platelets or whole blood

›Initiate before lab confirmation of coagulopathy

›Damage control resuscitation principles (AAST/ACS 2024)

›Tranexamic acid 1 g IV bolus within 3 hours of injury

›Follow with 1 g IV infusion over 8 hours

›Beyond 3 hours: insufficient evidence, reassess

›Avoid excessive crystalloid resuscitation

›Worsens dilutional coagulopathy

›Contributes to abdominal compartment syndrome

Stepwise hemorrhage control algorithm

›FAST examination immediately on arrival

›Positive FAST (intraperitoneal hemorrhage)

›Emergent laparotomy for abdominal source control

›Combined pelvic packing at laparotomy if indicated

›Negative FAST (pelvic source dominant)

›Preperitoneal pelvic packing (PPP) with external fixation

02History/hx57

Mechanism and presentation

›High-energy axial loading mechanism

›Fall from height landing on one leg

›Most common civilian mechanism for true VS pattern

›Height and surface characteristics

›Motorcycle or motor vehicle collision

›Speed of impact and ejection status

›Crush injury duration

›Pedestrian struck by vehicle

›Speed of vehicle, part of body struck

›Secondary impact or ground contact

›Symptom characterization

›Severe pelvic and hip pain

›Inability to bear weight or stand

›Leg-length discrepancy on affected side (limb shortened)

›Perineal and perianal pain

›Suggests posterior ring and soft tissue injury

›Perineal hematoma or swelling

›Neurologic symptoms

›Lower extremity weakness or numbness

›Saddle anesthesia (S2-S4 involvement)

›Bowel or bladder incontinence

Associated injury symptoms

›Genitourinary symptoms

›Hematuria (gross or microscopic)

›Bladder or urethral injury concern

›Blood at urethral meatus: do not pass Foley until urethrogram

›Vaginal bleeding (females)

03Physical Exam/exam60

Vital signs and hemodynamic assessment

›Hemodynamic status

›Blood pressure

›SBP < 90 mmHg: hemorrhagic shock threshold

›Persistent hypotension despite resuscitation triggers surgical escalation

›Heart rate

›Tachycardia > 120 bpm may precede hypotension

›HR trend more sensitive than single reading

›Mental status and skin perfusion

›Altered mental status: marker of severe hemorrhagic shock

›Cool, mottled extremities: peripheral vasoconstriction

›Temperature and respiratory

›Hypothermia

›Component of lethal triad (hypothermia, acidosis, coagulopathy)

›Target normothermia with warming measures

›Respiratory rate and effort

›Elevated RR with concurrent thoracic injury (56%)

›Tension pneumothorax if absent breath sounds

Pelvic and musculoskeletal exam

›Inspection

›Leg-length discrepancy

›Affected limb shortened and externally rotated

›Pathognomonic for significant cephalad hemipelvic displacement

›Perineal and scrotal ecchymosis (butterfly sign)

›Indicates major pelvic soft tissue disruption

›Increasing ecchymosis suggests ongoing hemorrhage

›Open wounds

›Perineal or gluteal lacerations indicate open fracture

04Differential Diagnosis/ddx47

Pelvic ring injury patterns

›Young and Burgess classification differentials

›Anteroposterior compression type III (APC-III)

›ICD-10 S32.81 multiple fractures of pelvis

›Bilateral SI disruption, widened symphysis, horizontal displacement predominates

›Distinguished from VS by absence of cephalad hemipelvic migration

›Lateral compression type III (LC-III)

›Windswept pelvis pattern

›Internal rotation one side, external rotation contralateral

›Lower vertical instability component

›Combined mechanism (CM)

›Features of multiple injury vectors

›Most complex pattern, highest associated injury burden

›Vertical shear subtype confirmation

›AO/OTA Type 61C classification

›Complete disruption anterior and posterior pelvic ring

›Rotationally and vertically unstable

›WSES Grade III (hemodynamically stable)

›Hemodynamically stable, mechanically unstable

›WSES Grade IV (hemodynamically unstable)

›Unstable pelvic fracture with hemodynamic instability

Mimics and concurrent injuries

›Isolated hip and femur injuries

›Acetabular fracture

›Axial load transmitted through femoral head

›CT differentiates pelvic ring vs acetabular involvement

›Hip dislocation or femoral neck fracture

›Can mimic leg-length discrepancy

05Laboratory Tests/lt42

Resuscitation and hemorrhage labs

›Type and crossmatch

›Immediate on arrival, anticipate massive transfusion

›6-10 units pRBC minimum crossmatch for VS fractures

›Emergency release O-negative blood if crossmatch not available

›Complete blood count

›Baseline hemoglobin and hematocrit

›Serial monitoring every 4-6 hours during resuscitation

›Hemoglobin does not reflect acute blood loss until hemodilution

›Platelet count

›Target > 50 x 10^9/L during active hemorrhage

›Target > 100 x 10^9/L with intracranial injury

›Coagulation panel

›PT/INR, aPTT, fibrinogen

›INR > 1.5 indicates coagulopathy requiring FFP

›Fibrinogen < 1.5 g/L: cryoprecipitate 10 units or fibrinogen concentrate

›TEG or ROTEM if available

›Guides targeted blood product resuscitation

›Identifies specific coagulopathy pattern

Organ function and monitoring labs

›Metabolic markers

›Lactate

›>= 2 mmol/L indicates tissue hypoperfusion

›Serial measurement (every 1-2 hours) guides resuscitation adequacy

›Clearance target > 10% per hour

›Base deficit

›> -6 mEq/L: significant hemorrhagic shock

›Correlates with volume of blood loss and mortality

06Diagnostic Tests/dt100

Scoring Systems

›Young and Burgess classification

›Mechanism-based pelvic ring injury classification

›APC I, II, III: anteroposterior compression patterns

›LC I, II, III: lateral compression patterns

›VS: vertical shear (most unstable)

›CM: combined mechanism

›VS pattern criteria

›Complete disruption anterior and posterior ring

›Cephalad migration of hemipelvis on AP X-ray

›ACEP Level B recommendation for classification to guide management

›Tile / AO-OTA classification

›Pelvic ring stability classification

›Type A: stable (posterior arch intact)

›Type B: rotationally unstable, vertically stable

›Type C: rotationally and vertically unstable (VS = Type C)

›Type C subclassification

›C1: unilateral disruption

›C2: bilateral with one side rotationally unstable

›C3: bilateral complete instability

›WSES pelvic trauma grading

›Integrates hemodynamic status with mechanical injury

›Grade I: stable hemodynamics, minor injury (APC-I, LC-I)

›Grade II: stable hemodynamics, moderate injury (APC-II, LC-II, LC-III)

›Grade III: stable hemodynamics, severe injury (APC-III, VS, CM)

›Grade IV: any hemodynamically unstable pelvic fracture

›Grade IV triggers immediate hemorrhage control protocol

›WSES 2017 guidelines

›Shock index and transfusion triggers

›Shock index (HR/SBP)

›> 1.0 indicates significant hemorrhagic shock

›> 1.4 associated with massive transfusion requirement

›ABC score for massive transfusion

›Penetrating mechanism, SBP <= 90 mmHg, HR >= 120 bpm, positive FAST

›Score >= 2: activate massive transfusion protocol

MRI

›MRI role in pelvic fracture

›Limited acute utility for VS fractures

›Long acquisition time incompatible with unstable patients

›CT remains gold standard for acute trauma

›Problem-solving indications (subacute and elective)

›Posterior ligamentous complex assessment

›Sacral stress fracture vs acute fracture differentiation

›Nerve root injury characterization post-stabilization

›Sacral fracture nerve involvement

›MRI superior to CT for neural foraminal impingement

›Guides decompression decision-making

›Contraindications

›Hemodynamic instability (absolute contraindication acutely)

›Incompatible metallic implants or pelvic fixation hardware

CT

›CT pelvis with IV contrast (CTA)

›Gold standard for definitive fracture characterization

›Posterior ring anatomy: sacral fractures, SI joint disruption

›Anterior ring: symphyseal and rami fractures

›Active arterial extravasation (contrast blush)

›Contrast blush on CTA

›Predicts need for angioembolization

›Sensitivity ~72%, specificity ~91% for arterial hemorrhage

›ACEP Level B recommendation for CTA as primary imaging in stable patients

›CT abdomen and pelvis combined

›Concurrent visceral injury assessment

›Retroperitoneal hematoma characterization

›Kidney, liver, spleen, bowel survey

›CT protocol specifics

›IV contrast required for vascular assessment

›Arterial phase: active bleeding detection

›Portal venous phase: visceral injury assessment

›Inlet and outlet reformats

›Inlet view: AP displacement of posterior ring

›Outlet view: vertical displacement quantification

›Renal function and contrast precautions

›GFR threshold per local protocol

›Benefit-risk favors CT in unstable pelvic trauma

›Plain radiography role

›AP pelvis X-ray (first-line, performed in trauma bay)

›Cephalad migration of hemipelvis pathognomonic for VS

›Symphyseal widening > 2.5 cm: significant anterior disruption

›Fracture lines through sacrum, rami, ilium

›Inlet and outlet views (supplemental)

›Quantify anterior-posterior and vertical displacement

›May be obtained in OR preoperatively

Ultrasound

›FAST examination

›Focused assessment with sonography in trauma

›Morrison's pouch (hepatorenal)

›Splenorenal recess

›Pelvic free fluid (suprapubic)

›Pericardial window

›Positive FAST with hemodynamic instability

›Competing intraperitoneal hemorrhage source

›Emergent laparotomy decision

›Negative FAST with hemodynamic instability

›Pelvic source hemorrhage dominant

›Preperitoneal pelvic packing pathway

›FAST sensitivity 63-96% for intraperitoneal free fluid

›Retroperitoneal hemorrhage not detected by FAST

›ACEP Level A recommendation for FAST in trauma

›Extended FAST (eFAST)

›Thoracic assessment added

›Pneumothorax: absent lung sliding

›Hemothorax: pleural effusion pattern

›Pericardial tamponade screen

›Concurrent cardiac injury or penetrating mechanism

07Disposition/dispo40

Admission and level of care

›All VS fractures require hospital admission

›Minimum inpatient orthopedic trauma admission

›No outpatient management for any VS pattern

›Level I trauma center preferred for optimal outcomes

›ICU admission criteria

›Hemodynamic instability or massive transfusion requirement

›Post-angioembolization monitoring (minimum 24 hours)

›Polytrauma with concurrent thoracic or abdominal injury

›Neurologic injury with monitoring requirement

›Step-down ward criteria

›Hemodynamically stable after resuscitation

›No ongoing transfusion requirement

›Pain controlled with oral or IV analgesia

›Transfer criteria

›Transfer any VS fracture from facility lacking

›Orthopedic trauma surgery capability

›Interventional radiology / angioembolization

›Preperitoneal pelvic packing capability

›Transfer timing

›Hemodynamically stable: transfer after CT characterization

›Hemodynamically unstable: pelvic binder, resuscitate, transfer with MTP active

›Do not delay transfer for definitive imaging if unstable

Operative timing and planning

›Definitive fixation timing

›Hemodynamically stable patient

›Definitive ORIF within 24 hours of injury

›Minimizes malunion risk and functional deficit

08Treatment/t109

Immediate stabilization and hemorrhage control

›Pelvic binder

›Application over greater trochanters

›Reduces pelvic volume and tamponades venous bleeding

›First intervention in any VS fracture with instability

›Remove and reapply for wound care; avoid prolonged skin pressure

›Pelvic C-clamp alternative

›Targets posterior ring directly at SI joints

›Requires fluoroscopic guidance for safe placement

›Comparable bleeding control to binder for type C fractures

›Massive transfusion protocol (MTP)

›1:1:1 ratio pRBC:FFP:platelets

›Empiric balanced resuscitation before lab results

›Whole blood (if available) as equivalent alternative

›Fibrinogen replacement

›Cryoprecipitate 10 units if fibrinogen < 1.5 g/L

›Fibrinogen concentrate 3-4 g as alternative

›Calcium supplementation

›1 g calcium gluconate IV per 4 units pRBC transfused

›Prevent hypocalcemia-induced cardiac dysfunction

›Tranexamic acid

›1 g IV bolus over 10 minutes

›Within 3 hours of injury (Class I, CRASH-2 and AAST 2024)

›Second dose 1 g IV over 8 hours

›Avoid after 3 hours: risk of increased thromboembolic events

›ACEP Level B recommendation

Preperitoneal pelvic packing

›Indications

›Hemodynamically unstable with negative FAST

›Pelvic source hemorrhage presumed

›PPP as first-line surgical hemorrhage control

›Failed resuscitation (> 4 units pRBC in 30 min without response)

›Proceed directly to packing without delay for CT

›Technique

›Midline infraumbilical incision

›Retroperitoneal dissection to pelvic sidewall

›Three laparotomy pads each side of bladder

›External fixation concurrent

›Anterior external fixator provides counterpressure

›Supraacetabular pin placement

›Packing removal

›At 24-48 hours when hemostasis confirmed

›Combined with definitive fixation planning

Angioembolization

›Indications

›Active arterial hemorrhage on CTA (contrast blush)

›Selective embolization of bleeding internal iliac branch preferred

›Hemodynamically stable: CTA first, then angiography

›Persistent hemodynamic instability after PPP

›Venous bleeding controlled by packing; ongoing arterial source

›Post-PPP re-bleeding

›Repeat CTA and angiography

›Embolization technique

›Selective embolization

›Target specific bleeding vessel identified on angiogram

›Minimizes ischemic complications vs nonselective

›Coils or gelfoam as embolic material

›Nonselective (bilateral internal iliac artery) embolization

›Reserved for diffuse bleeding not amenable to selective

›Risk of gluteal and bladder ischemia

›Impotence risk in males (bilateral internal iliac occlusion)

›ACEP Level B recommendation for angioembolization in arterial pelvic hemorrhage

Definitive surgical fixation

›Posterior ring fixation options

›Percutaneous iliosacral screws

›Most common technique for posterior ring stabilization

›Fluoroscopic or CT-guided insertion

›Closed or minimally invasive approach

›Spinopelvic fixation (triangular osteosynthesis)

›Iliosacral screws plus lumbopelvic rods and iliac screws

›Indicated for Denis Zone III sacral fractures and H-pattern sacral fractures

›Allows immediate weight bearing postoperatively

›Tension band plating (posterior iliac plating)

›Open approach for comminuted sacral fractures

›Higher soft tissue complication rate

›Anterior ring fixation

›Symphyseal plating

›Open reduction and internal fixation of symphysis pubis

›Indicated when symphyseal disruption > 2.5 cm

›Anterior internal fixator (INFIX)

›Percutaneous subcutaneous rod connecting iliac screws

›Less wound complication than open plating

›Lateral femoral cutaneous nerve risk (transient paresthesia)

Pharmacologic management

›Pain management

›IV opioid analgesia

›Morphine 2-4 mg IV q4-6h titrated to pain

›Fentanyl 25-50 mcg IV for procedural pain

›Ketamine for procedural sedation

›0.5-1 mg/kg IV for packing or external fixator application

›Dissociative dose: 1-2 mg/kg IV for complete procedural analgesia

›Avoid NSAIDs acutely

›Platelet dysfunction worsens hemorrhage

›Withhold until hemostasis confirmed

›DVT prophylaxis

›Pharmacologic LMWH when bleeding controlled

›Enoxaparin 40 mg SC daily (standard dose)

›Enoxaparin 30 mg SC twice daily (high-risk protocol)

›Initiate within 48-72 hours of injury when hemostasis confirmed

›Mechanical prophylaxis bridge

›Sequential compression devices bilateral lower extremities

›Until pharmacologic prophylaxis initiated

›IVC filter

›Contraindication to pharmacologic prophylaxis only

›Retrievable filter preferred

›Remove when anticoagulation established

›Antibiotic prophylaxis

›Open fracture protocol

›Cefazolin 2 g IV (< 120 kg) or 3 g IV (>= 120 kg) every 8 hours

›Add metronidazole 500 mg IV q8h for rectal or bowel involvement

›Gentamicin 5 mg/kg IV daily if penicillin allergy

›Duration

›Closed fracture: 24 hours perioperative only

›Open fracture: 48-72 hours post-debridement

09Special Populations/sp83

Pregnancy

›Pregnancy-specific considerations

›Pelvic anatomy changes

›Ligamentous laxity increases even at baseline in pregnancy

›Uterine enlargement alters injury pattern and FAST interpretation

›Pelvic binder use

›Apply cautiously to avoid uterine compression

›Position over greater trochanters, not iliac crests

›If fundus above umbilicus: reassess binder positioning with obstetrics

›Fetal assessment

›Obstetric ultrasound for fetal heart rate and position

›Doppler assessment for placental abruption

›Viable gestation: continuous fetal monitoring after stabilization

›Imaging and radiation

›AP pelvis X-ray with shielding when mandatory

›Benefit outweighs fetal radiation risk in life-threatening injury

›CT pelvis

›Fetal radiation dose ~35 mGy from pelvis CT

›Risk of harm lower than risk of missed injury; perform when indicated

›MRI preferred alternative when hemodynamics permit delay

›Resuscitation modifications

›Left lateral uterine displacement after 20 weeks gestation

›Prevents inferior vena cava compression

›Manual displacement or wedge under right hip

›Blood products

›MTP targets unchanged; coordinate with obstetrics

›TXA: Category not established; use when maternal benefit outweighs risk

›CRASH-2 data did not exclude pregnant patients

›Perimortem cesarean section

›Viable fetus with maternal cardiac arrest

›Within 5 minutes of arrest for best fetal outcome

Geriatric

›Injury mechanism differences

›Low-energy falls sufficient to produce VS in osteoporotic bone

›Bone mineral density reduction lowers fracture threshold

›Fall from standing height or minor stairs

›Pre-injury functional status

›Ambulatory status, cognitive function, fall history

›Frailty score influences operative candidacy

›Hemorrhage and resuscitation differences

›Blunted tachycardic response

›Beta-blockade or calcium channel blocker use masks HR rise

›SBP decline may be the only early hemodynamic indicator

›Permissive hypotension target modified

›Higher MAP target (70-80 mmHg) for adequate cerebral and coronary perfusion

›Pre-existing hypertension shifts threshold

›Anticoagulation reversal

›Warfarin: 4-factor PCC 25-50 units/kg IV + vitamin K 10 mg IV

›DOAC reversal per agent (andexanet alfa for anti-Xa; idarucizumab for dabigatran)

›Operative risk and fixation strategy

›Higher perioperative mortality in geriatric VS fractures

›Frailty assessment guides operative vs non-operative decision

›Non-operative management only for minimally displaced, hemodynamically stable

›Percutaneous fixation preferred

›Lower soft tissue complication risk

›Shorter operative time and blood loss

›DVT risk markedly elevated

›Earlier pharmacologic prophylaxis target

›Baseline renal function for LMWH dosing adjustment

Pediatrics

›Pediatric pelvic injury differences

›Pediatric pelvis more compliant

›True VS pattern rare before skeletal maturity (age ~16)

›High-energy mechanism required to produce VS in child

›Triradiate cartilage involvement

›Growth arrest complication in younger children

›Long-term acetabular dysplasia risk if triradiate injured

›Associated injury pattern

›Solid organ injury more common (liver, spleen) due to smaller torso

›Head injury more common in pediatric polytrauma

›Resuscitation modifications

›Weight-based blood product dosing

›pRBC 10-20 mL/kg IV bolus

›FFP 10-15 mL/kg IV bolus for coagulopathy

›Platelet 10-15 mL/kg for thrombocytopenia

›TXA

›15 mg/kg IV (maximum 1 g) within 3 hours of injury

›Hypotension thresholds age-specific

›Systolic BP lower threshold: 70 + (2 x age in years) mmHg

›Fixation differences

›External fixation preferred acutely

›Growing skeleton: avoid placement through open physes

›Definitive fixation after physiologic stabilization

›Neurologic recovery potential

›Better neurologic recovery than adults after lumbosacral plexus injury

›More aggressive nerve decompression consideration

10Background/b85

Epidemiology

›Incidence and demographics

›VS pattern accounts for < 1% of all fractures

›Rare but carries disproportionate morbidity

›Unstable pelvic fractures (all types): 3-8% of major trauma presentations

›Age and sex distribution

›Bimodal: young males (high-energy) and elderly females (osteoporotic)

›Young males: motorcycle crashes, falls from height, crush injuries

›Mortality

›Acute mortality: 5-20% (hemorrhagic shock dominant cause)

›VS mortality paradoxically lower than APC-III in some series

›Concurrent thoracic injury present in ~56% of unstable pelvic fractures

›Associated injury burden

›Polytrauma common

›Concurrent thoracic injury ~56%

›Spinal fractures concurrent in up to 41%

›GU injuries: 15-25% of pelvic ring fractures

›Long-term morbidity

›Neurologic injury in up to 33% of major pelvic injuries

›Sexual dysfunction in 43% of surgically treated VS fractures

›Urinary dysfunction in 41% of surgically treated VS fractures

›VS pattern carries highest odds ratios for both compared to LC injuries

Pathophysiology

›Injury mechanism

›Axial loading force on single lower extremity

›Force transmitted cephalad through femoral head and acetabulum

›Shears hemipelvis cephalad relative to sacrum and spine

›Complete anterior and posterior ring disruption required

›Anterior: symphysis pubis or bilateral pubic rami

›Posterior: SI joint disruption (diastasis or fracture-dislocation) or sacral fracture

›VS is the most unstable Young-Burgess pattern (AO/OTA 61C)

›Both rotational and vertical instability present

›Hemorrhage anatomy

›Venous hemorrhage: 80% of total pelvic blood loss

›Presacral venous plexus (Batson's plexus)

›Prevesical and paravesical plexus

›Controlled by pelvic packing and binder compression

›Arterial hemorrhage: ~20% of pelvic blood loss

›Superior gluteal artery most commonly injured

›Internal pudendal artery and obturator artery less common

›Requires angioembolization for control

›Retroperitoneal hematoma

›Tamponades itself within intact retroperitoneum

›Surgical disruption of retroperitoneum releases tamponade effect

›Neurologic injury mechanism

›Lumbosacral plexus at risk

›L4-S3 roots traverse posterior pelvis

›Vertical displacement stretches nerve roots

›Sacral root injury correlates with posterior displacement magnitude

›> 1 cm vertical displacement: significant neurologic risk

›Pudendal nerve injury: sexual and urinary dysfunction

›Neurologic recovery begins ~3 months post-injury

›Plateaus at ~2 years; complete recovery uncommon in severe injury

Therapeutic Considerations

›Damage control orthopedics principles

›Priority sequence: life before limb

›Hemorrhage control before fracture reduction

›Physiology normalization before definitive fixation

›Lethal triad avoidance

›Hypothermia: warming blankets, warmed fluids and blood products

›Acidosis: balanced resuscitation, avoid excess crystalloid

›Coagulopathy: early MTP, targeted blood product replacement

›Timing of definitive fixation

›Physiologically normal: within 24 hours for best reduction

›Physiologically deranged: delay to day 4+ post-injury

›Evidence base for hemorrhage control

›PPP vs primary angioembolization debate

›PPP controls venous (80%) and arterial (20%) bleeding simultaneously

›Angioembolization targets only arterial bleeding

›European and WSES guidelines favor PPP + external fixation as primary

›REBOA evidence

›Zone III REBOA increases aortic pressure and reduces pelvic hemorrhage

›JAMA Surgery 2023: association with reduced mortality in hemodynamically unstable pelvic fractures

›Bridge procedure; requires definitive hemorrhage control

›TXA in pelvic trauma

›CRASH-2 trial supports early TXA in hemorrhagic trauma

›AAST/ACS 2024 guidelines: TXA within 3 hours, Class I recommendation

›Long-term rehabilitation

›Physical therapy critical for functional recovery

›Weight-bearing progression per fixation type

›Gait training, strengthening, proprioception

›Sexual and urinary dysfunction management

›Early urology and gynecology referral

›Erectile dysfunction: PDE5 inhibitors, urologic evaluation

›Urinary: urodynamics, urology follow-up

›Mental health

›PTSD and depression common after major pelvic trauma

›Screening and referral at follow-up visits

11Patient Discharge Instructions/pdi45

copy discharge instructions

›Home care after pelvic fracture surgery

›Weight-bearing restrictions strictly as instructed by surgeon

›Do not put weight on affected leg unless told it is safe

›Use crutches or walker as prescribed

›Wound care

›Keep surgical incisions clean and dry

›Change dressings as instructed

›No soaking in bath or pool until wounds fully healed

›Blood clot prevention

›Take blood thinner medication (LMWH or other) exactly as prescribed

›Wear compression stockings or use leg pumps if provided

›Leg exercises as instructed (ankle pumps, quad sets) while in bed

›Activity and mobility

›No driving until cleared by surgeon (typically weeks to months)

›Avoid lifting more than prescribed weight limit

›Gradual return to activity as guided by physical therapist

›Follow-up appointments

›Orthopedic trauma surgeon at 2 weeks (wound check and X-ray)

›Further follow-up at 6 weeks, 3 months, 6 months, 1 year

›Physical therapy as directed

›Warning signs: return to emergency immediately

›New or worsening leg weakness or numbness

›Especially if sudden change in ability to move foot or toes

›Unable to urinate or severe pain with urination

›Blood in urine

›Signs of blood clot in leg

›Calf pain, swelling, redness, warmth

12References/r31

Guidelines and key sources

›Primary guideline sources

›WSES Pelvic Trauma Classification and Guidelines 2017

›Coccolini F et al. World Journal of Emergency Surgery 2017

›WSES grading and management algorithm

›AAST/ACS Damage Control Resuscitation Protocol 2024

›LaGrone LN et al. Journal of Trauma and Acute Care Surgery 2024

›MTP and TXA recommendations

›ACS Best Practices in Orthopaedic Trauma 2015

›Davis ML et al. American College of Surgeons

›Key clinical studies

›Blum L et al. Vertical Shear Pelvic Injury: Evaluation, Management, Fixation Strategies

›International Orthopaedics 2018 (PMID 29582114)

›Grounding source for VS classification and fixation options

›Khurana B et al. Pelvic Ring Fractures: What the Orthopedic Surgeon Wants to Know

›Radiographics 2014 (PMID 25208283)

›Imaging classification and CTA findings

›Anand T et al. Association Between Hemorrhage Control Interventions and Mortality

›JAMA Surgery 2023

›REBOA and PPP evidence in hemodynamically unstable pelvic fractures

›Odutola AA et al. High Rates of Sexual and Urinary Dysfunction After Surgically Treated Displaced Pelvic Ring Injuries

›Clinical Orthopaedics and Related Research 2012 (PMID 22350654)

›VS pattern odds ratios for sexual and urinary dysfunction

›Brandes S, Borrelli J. Pelvic Fracture and Associated Urologic Injuries

›World Journal of Surgery 2001 (PMID 11775195)

›GU injury patterns and retrograde urethrogram indications

›Classification and coding systems

›ICD-10 S32.81 multiple fractures of pelvis with disruption of pelvic ring

Evidence & Review