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Straddle Fracture
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
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Aortic dissection
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Atrial fibrillation and flutter
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Respiratory Presentations
Acute bronchitis
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Croup
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Pleural effusion
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Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
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Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Straddle Fracture
POCUS
Procedures
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ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Hemorrhage control priorities
Hemodynamic status on arrival
▶
SBP < 90 mmHg or HR > 120 bpm — activate massive transfusion protocol
▶
Pelvic fracture hemorrhage mortality up to 32% (JAMA Surgery 2023)
Retroperitoneal hematoma may not manifest as peritonitis
Apply pelvic binder immediately at the level of greater trochanters
▶
Reduces pelvic volume and tamponades venous bleeding
NAEMSP 2025 guideline recommendation
Two large-bore IV access or IO if required
Initiate 1:1:1 pRBC:FFP:platelets ratio if MTP activated
Genitourinary injury screening
▶
Blood at urethral meatus — do NOT insert Foley catheter
▶
Retrograde urethrogram required first (ACS Best Practices 2025)
Gross hematuria — CT cystogram to exclude bladder injury
Perineal butterfly hematoma — marker of urethral or perineal vessel injury
Immediate imaging decision
▶
AP pelvis radiograph — first-line screening in hemodynamically unstable patients
▶
CT pelvis with contrast if hemodynamically stable
Active contrast extravasation on CT prompts IR consultation for angioembolization
Resuscitation targets
Permissive hypotension until hemorrhage controlled
▶
Target SBP 80–90 mmHg in penetrating trauma; 90 mmHg in blunt
MAP target > 50 mmHg to preserve end-organ perfusion
Transfusion and coagulation targets
▶
Hemoglobin target > 70 g/L (> 80 g/L in elderly or cardiac disease)
Platelet count > 50 x 10^9/L
Fibrinogen > 1.5 g/L
INR < 1.5
Lactate clearance
▶
Lactate > 2 mmol/L indicates tissue hypoperfusion
Reassess after initial resuscitation
Consult triggers
Orthopedic surgery — all pelvic ring injuries requiring operative evaluation
▶
Unstable fracture pattern on CT
Failed non-operative management
Interventional radiology — active hemorrhage on CT with contrast extravasation
▶
Angioembolization for arterial hemorrhage
Reduces pelvic bleeding mortality
Urology or trauma surgery — blood at meatus, voiding dysfunction, gross hematuria
▶
Timing of urethral repair: suprapubic catheter acutely, urethroplasty 3–6 months
Trauma surgery — polytrauma, open fracture, hemodynamic instability
History
Mechanism of injury
High-energy mechanisms
▶
Fall astride a hard object — classic straddle mechanism (fence, beam, bicycle crossbar)
Motor vehicle collision
Motorcycle collision
Pedestrian struck by vehicle
Fall from height
Crush injury
Low-energy and insufficiency mechanisms
▶
Osteoporotic pubic rami fracture — fall from standing in elderly
▶
Female sex, advanced age, corticosteroid use, pelvic irradiation (Seminars in Arthritis and Rheumatism 1996)
Stress fracture in athletes — long-distance runners, female athletes
▶
Insidious groin or perineal pain with activity (JBJS 1982)
Presenting symptoms
Pain location
▶
Groin, perineum, or suprapubic region
Low back or sacral pain — suggests posterior ring injury
Hip pain — consider associated acetabular fracture (28.8% on CT, Injury 2012)
Functional limitation
▶
Inability to bear weight or ambulate
▶
Inability to mobilize in 42% of geriatric patients indicates occult instability (J Orthopaedic Trauma 2023)
Pain with sitting or standing
Genitourinary symptoms
▶
Hematuria — gross or microscopic
Inability to void or urinary retention
Blood at urethral meatus
Vaginal bleeding (in female patients)
Alarm features in history
Hemodynamic alarm
▶
Syncope or presyncope at scene — suggests significant hemorrhage
Delayed hemodynamic deterioration — corona mortis artery avulsion can present 48–72 hours post-injury (Orthopedics 2012)
Neurologic alarm
▶
Lower extremity weakness or numbness
Saddle anesthesia — lumbosacral plexus or cauda equina involvement
Bowel or bladder incontinence
Open fracture alarm
▶
Perineal laceration, rectal wound, or vaginal laceration — dramatically increases infection risk (JAAOS 2013)
Rectal bleeding — 5% of pelvic fractures with urethral injury have concomitant rectal injury (ACS 2025)
Risk factors
Traumatic fracture risk factors
▶
High-energy mechanism as above
Anticoagulant or antiplatelet use — increases hemorrhagic risk (Orthopedics 2012)
Male sex — urethral injury in 6.1% of males vs 0.5% of females (J Clinical Medicine 2023)
Insufficiency fracture risk factors
▶
Osteoporosis or osteopenia
Age > 65 years
Female sex
Chronic corticosteroid use
Pelvic irradiation
Rheumatoid arthritis (Annals of the Rheumatic Diseases 1993)
Renal failure or metabolic bone disease
Prior fragility fracture
Past medical and medication history
Relevant medical conditions
▶
Osteoporosis, prior fragility fractures
History of DVT or pulmonary embolism
Prior pelvic fracture or pelvic surgery
Rheumatoid arthritis, chronic steroid use
Chronic kidney disease
Anticoagulation or bleeding disorders
Medications to review
▶
Warfarin, direct oral anticoagulants (DOACs)
Antiplatelet agents (aspirin, clopidogrel)
Corticosteroids — bone loss risk
Physical Exam
Vital signs
Hemodynamic assessment
▶
SBP < 90 mmHg — hemorrhagic shock threshold
HR > 120 bpm — tachycardia suggests significant blood loss
Shock index (HR/SBP) > 1.0 — predicts transfusion requirement
Serial vital signs — delayed deterioration possible
Inspection
Perineal and genital examination
▶
Perineal ecchymosis (butterfly hematoma) — urethral or perineal vascular injury
Scrotal or labial swelling and ecchymosis
Blood at urethral meatus — do NOT attempt Foley catheterization (ACS Best Practices 2025)
Open wounds in perineum, rectum, or vagina — open fracture
Lower extremity
▶
Leg length discrepancy — suggests vertical shear component
Rotational deformity of lower limb
Palpation
Pelvic ring palpation
▶
Tenderness over pubic symphysis and pubic rami
Tenderness over sacroiliac joints or posterior iliac spine
Avoid repeated pelvic compression-distraction testing
▶
Neither sensitive nor specific for instability (Prehospital Emergency Care 2025)
May worsen hemorrhage by disrupting retroperitoneal clot
Abdomen
▶
Peritoneal tenderness — intraperitoneal bladder rupture or associated injury
Expanding or rigid abdomen — significant hemorrhage or bowel injury
Rectal and vaginal examination
Rectal examination
▶
High-riding or non-palpable prostate — historically associated with urethral injury (low sensitivity/specificity)
Rectal mucosal integrity — laceration indicates open fracture
Rectal tone — lumbosacral plexus injury assessment
Vaginal examination (females)
▶
Vaginal laceration — indicates open fracture
Vaginal bleeding
Neurovascular examination
Lower extremity neurologic
▶
Motor strength — hip flexors, knee extensors, ankle dorsiflexors
Sensation — L2 to S3 dermatomal distribution
Perineal sensation — pudendal nerve (S2–S4)
Vascular examination
▶
Femoral and pedal pulses bilaterally
Capillary refill
Limb temperature comparison
Functional assessment
Weight-bearing ability
▶
Inability to mobilize suggests occult instability even in apparently stable patterns
Particularly important in geriatric patients
PITFALLS
▶
Apparent hemodynamic stability can mask ongoing retroperitoneal hemorrhage
Perineal findings may be subtle — thorough inspection required
Posterior ring injury frequently clinically silent — imaging mandatory
Differential Diagnosis
Pelvic ring injuries
Unstable pelvic ring disruption
▶
APC-II and APC-III (open book injury)
▶
ICD-10: S32.810 — fracture of pubis with disruption of pelvic ring
Lateral compression LC-II and LC-III
Vertical shear fracture (Malgaigne fracture)
▶
ICD-10: S32.810
Combined mechanism injury
CT required to exclude posterior ring instability — posterior ring lesions in 96.8% of pubic rami fractures (Injury 2012)
Straddle fracture (bilateral superior and inferior pubic rami fractures)
▶
ICD-10: S32.591, S32.592 — fractures of pubic rami bilateral
Free-floating anterior pelvic segment
Most commonly lateral compression Type I mechanism
Associated injuries
Acetabular fracture
▶
Found in 28.8% of patients with pubic rami fractures on CT (Injury 2012)
ICD-10: S32.40 to S32.49
Sacral fracture
▶
Present in nearly all straddle fractures on CT
ICD-10: S32.10 to S32.19
Symphysis pubis diastasis
▶
ICD-10: S33.4 — traumatic rupture of symphysis pubis
Bladder injury — extraperitoneal or intraperitoneal rupture
▶
ICD-10: S37.20 to S37.29
Urethral injury
▶
ICD-10: S37.30 to S37.39
Mimics and alternatives
Hip fracture
▶
Femoral neck fracture — ICD-10: S72.00 to S72.09
Intertrochanteric fracture — ICD-10: S72.10 to S72.19
Overlapping presentation of groin pain and inability to ambulate
Pubic rami insufficiency fracture in elderly
▶
Low-energy mechanism, osteoporosis background
ICD-10: M84.659 — pathological fracture, pelvis
Pubic ramus stress fracture in athlete
▶
Insidious onset, no acute trauma
ICD-10: M84.351 — stress fracture, pelvis
Osteitis pubis or athletic pubalgia
▶
Chronic groin pain without acute fracture line
Laboratory Tests
Hemorrhage assessment
Complete blood count
▶
Serial hemoglobin and hematocrit to monitor for ongoing hemorrhage
Initial hemoglobin may be normal despite significant blood loss — dilutional effect delayed
Platelet count — target > 50 x 10^9/L in active hemorrhage
Coagulation studies
▶
PT/INR and aPTT — essential if on anticoagulants or in massive hemorrhage
Fibrinogen level — target > 1.5 g/L
Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) if available
▶
Guides goal-directed transfusion in massive hemorrhage
Type and screen / crossmatch
Blood bank
▶
Type and screen for all pelvic ring injuries
Type and crossmatch (4 units pRBC) if hemodynamically unstable
Activate MTP if SBP < 90 mmHg or HR > 120 bpm with pelvic fracture
Metabolic and renal panel
Basic or comprehensive metabolic panel
▶
Renal function (creatinine, urea) — baseline before contrast imaging and analgesia
Electrolytes — hyponatremia, hyperkalemia in trauma
Glucose — stress hyperglycemia common
Lactate
▶
Lactate > 2 mmol/L — tissue hypoperfusion, occult hemorrhage
Serial lactate to trend resuscitation adequacy
Urinalysis
Urinalysis interpretation
▶
Gross hematuria — present in most significant bladder injuries
Microscopic hematuria — threshold of > 25 RBC/hpf warrants further evaluation in pelvic trauma
Dipstick hematuria has high sensitivity but low specificity
Catheterize only after urethral injury excluded (retrograde urethrogram first)
VTE prophylaxis monitoring
Anti-Factor Xa levels
▶
Monitor if on LMWH — many pelvic fracture patients underdosed (Injury 2022)
Therapeutic range for prophylaxis: 0.2–0.5 IU/mL
Check 4 hours after third or fourth dose of LMWH
Diagnostic Tests
Scoring Systems
Young-Burgess Classification
▶
Anteroposterior compression (APC)
▶
APC-I: pubic symphysis diastasis < 2.5 cm, ligaments intact
APC-II: symphysis diastasis > 2.5 cm, anterior SI ligament disruption, posterior ligaments intact
APC-III: complete hemipelvic displacement, all SI ligaments disrupted
Lateral compression (LC)
▶
LC-I: sacral compression fracture, ipsilateral pubic rami fractures (straddle mechanism)
LC-II: iliac wing fracture or posterior SI disruption, ipsilateral rami fractures
LC-III: LC contralateral open-book pattern (windswept pelvis)
Vertical shear (VS): complete ligamentous and bony disruption, vertical displacement
Combined mechanism (CM): two or more patterns
Predicts transfusion need, mortality, and non-orthopedic injuries (J Orthopaedic Trauma 2010)
Tile/AO Classification
▶
Type A: stable — posterior arch intact
▶
Type A1: fractures of pelvis not involving ring
Type A2: stable fractures of pelvic ring including isolated rami
Type B: rotationally unstable, vertically stable
▶
B1: open book (external rotation)
B2: lateral compression (internal rotation)
Type C: rotationally and vertically unstable
▶
Complete disruption of posterior arch
WSES Pelvic Trauma Classification
▶
Grade I (minor): hemodynamically stable, APC-I or LC-I
Grade II (moderate): hemodynamically stable, APC-II/III or LC-II/III or VS or CM
Grade III (severe): hemodynamically unstable regardless of injury pattern
WSES Classification and Guidelines (World Journal of Emergency Surgery 2017)
MRI
MRI indications
▶
Occult sacral fracture or posterior ring injury not visible on CT
▶
Particularly in geriatric patients who cannot mobilize (J Orthopaedic Trauma 2023)
Suspected insufficiency or stress fracture when plain films and CT are negative
Neurologic deficit — evaluation of lumbosacral plexus or nerve root injury
Soft tissue injury characterization (pelvic floor, sphincter complex)
MRI protocols
▶
Pelvis MRI without contrast — STIR and T2 sequences detect marrow edema in occult fractures
STIR sequence sensitivity for occult sacral fracture > 95%
Diffusion-weighted imaging may add sensitivity for stress fractures
MRI limitations
▶
Limited availability in acute trauma setting
Not suitable for hemodynamically unstable patients
Duration and patient cooperation requirements
CT
CT pelvis indications
▶
All suspected pelvic ring injuries in hemodynamically stable patients
Gold standard for full characterization — detects posterior ring injuries, acetabular fractures, active hemorrhage
CT detects posterior ring lesions in 96.8% of patients with pubic rami fractures on plain film (Injury 2012)
CT protocol
▶
CT pelvis with IV contrast (portal venous phase)
▶
Arterial phase or dual-phase if active hemorrhage suspected
Active contrast extravasation — arterial or venous blush indicates ongoing hemorrhage
CT cystogram — if bladder injury suspected (gross hematuria + pelvic fracture)
▶
Retrograde fill with dilute contrast via catheter (350 mL)
ACS Best Practices Guidelines 2025 recommendation
CT trauma survey — include chest and abdomen in polytrauma
CT interpretation pearls
▶
Assess four rami systematically — bilateral superior and inferior rami in straddle fracture
Sacral fractures frequently occult on plain film — review axial and coronal CT images
Acetabular involvement in 28.8% — carefully review anterior and posterior columns
Corona mortis vessel — anastomosis between obturator and epigastric vessels, lies along superior pubic ramus, vulnerable to avulsion injury
Ultrasound
FAST/E-FAST examination
▶
Rapid bedside assessment for intraabdominal free fluid
▶
Perisplenic, perihepatic, pericardiac views
Pelvic window for free fluid in pouch of Douglas
Sensitivity for hemoperitoneum — approximately 73–88% in trauma (JAMA Network Open 2022)
Pubic symphysis assessment
▶
Symphyseal widening > 2.5 cm visible on FAST
Subcostal cardiac view — pericardial effusion, global function, IVC collapsibility
Limitations
▶
Cannot reliably detect retroperitoneal hemorrhage
Cannot characterize posterior ring injury
Operator dependent
Bowel gas and obesity reduce sensitivity
Disposition
Admission criteria
ICU admission indications
▶
Hemodynamic instability requiring ongoing resuscitation
MTP activation or transfusion > 4 units pRBC
Active arterial hemorrhage requiring angioembolization
Polytrauma with associated thoracic, abdominal, or head injuries
Open pelvic fracture — mortality significantly elevated
General surgical ward or orthopedic admission
▶
Stable straddle fracture with associated injuries requiring monitoring
Urethral or bladder injury with suprapubic catheter in situ
Elderly patients with isolated pubic rami fractures unable to mobilize
Discharge criteria
Copy
Discharge eligibility for stable isolated straddle fracture
▶
Hemodynamically stable with no hemorrhage concerns
No genitourinary injury identified
Pain controlled with oral analgesics
Able to mobilize with appropriate assistive device (non-weight-bearing or partial)
Appropriate follow-up arranged within 1–2 weeks
Patient and caregiver capable of safe home management
Exclusions to discharge
▶
Inability to safely mobilize or care for self at home
Ongoing hematuria or voiding difficulty
Suspected posterior ring instability on imaging
Transfer criteria
Transfer to major trauma center indications
▶
Hemodynamically unstable pelvic fracture without on-site IR capability
Unstable pelvic ring injury requiring complex operative fixation
Open pelvic fracture
Associated injuries beyond local surgical capability
Transfer of unstable patients within 6 hours associated with reduced mortality (European J Trauma and Emergency Surgery 2026)
Follow-up
Copy
Outpatient follow-up
▶
Orthopedic surgery within 1–2 weeks with repeat pelvic imaging
Urology follow-up if any genitourinary injury — timing for urethroplasty 3–6 months (J Urology 2023)
VTE prophylaxis for up to 4 weeks post-injury in high-risk patients (Western Trauma Association 2020)
Treatment
Hemorrhage control
Pelvic binder application
▶
Apply at level of greater trochanters (not iliac crests)
▶
Reduces pelvic volume and tamponades venous plexus bleeding
Remove for CT imaging when hemodynamic stability allows
Commercial pelvic binders preferred over improvised sheet binders
Resuscitation strategy
▶
Damage control resuscitation
▶
1:1:1 ratio pRBC:FFP:platelets when MTP activated
Minimize crystalloid — excessive saline worsens coagulopathy and acidosis
Tranexamic acid (TXA) 1 g IV over 10 minutes within 3 hours of injury
▶
CRASH-2 trial — reduces all-cause mortality in traumatic hemorrhage
Second dose 1 g IV over 8 hours
Massive transfusion protocol criteria
▶
SBP < 90 mmHg despite initial fluids
HR > 120 bpm
Penetrating mechanism or high suspicion for ongoing pelvic hemorrhage
Surgical hemorrhage control options
▶
Angioembolization
▶
First-line for arterial hemorrhage identified on CT
Transcatheter arterial embolization (TAE) of internal iliac arteries or branches
Associated with reduced mortality in hemodynamically unstable pelvic fractures (JAMA Surgery 2023)
Preperitoneal pelvic packing (PPP)
▶
Alternative or adjunct to angioembolization for venous hemorrhage
Performed in operating room under anesthesia
Resuscitative endovascular balloon occlusion of the aorta (REBOA)
▶
Zone III (infrarenal aorta) for pelvic hemorrhage
Bridge to definitive hemorrhage control in extremis
Analgesia
Multimodal analgesia
▶
Acetaminophen 1 g IV/PO every 6 hours (if no hepatic contraindication)
NSAIDs — ibuprofen 400 mg PO every 8 hours or ketorolac 15–30 mg IV
▶
Avoid if acute kidney injury, hemodynamic instability, or platelet dysfunction concern
Opioid analgesia for moderate-to-severe pain
▶
Morphine 2.5–5 mg IV every 4 hours PRN (weight-based: 0.05–0.1 mg/kg)
Hydromorphone 0.2–0.4 mg IV every 4 hours PRN
Use lowest effective dose; titrate to pain relief
Regional analgesia consideration
▶
Fascia iliaca compartment block — useful for pubic rami and hip fracture pain
PENG (pericapsular nerve group) block if acetabular involvement
Urethral injury management
Acute urethral injury
▶
Suprapubic catheter insertion — indicated when urethral injury confirmed or suspected
▶
Avoid urethral Foley catheterization until retrograde urethrogram completed
AUA Urotrauma Guideline 2020 and ACS Best Practices 2025
Retrograde urethrogram (RUG) — mandatory before any urethral catheterization attempt
▶
If complete urethral disruption — suprapubic catheter; delayed urethroplasty 3–6 months
If partial injury — trial of gentle urethral catheterization under fluoroscopy
CT cystogram — to exclude bladder injury when gross hematuria present with pelvic fracture
VTE prophylaxis
Chemoprophylaxis — initiate within 24 hours if hemostasis achieved
▶
Enoxaparin 40 mg SC daily (standard prophylaxis) or 30 mg SC twice daily
▶
Adjust dose for weight > 100 kg or renal impairment (CrCl < 30 mL/min)
Anti-Xa level monitoring if dose uncertainty (target 0.2–0.5 IU/mL)
Aspirin 81 mg twice daily — alternative to LMWH
▶
PREVENT CLOT RCT (NEJM 2023): aspirin noninferior to LMWH for death from any cause after fracture
Duration: minimum 14 days; up to 4 weeks for high-risk patients (Western Trauma Association 2020)
Mechanical prophylaxis
▶
Sequential compression devices (SCD) to bilateral lower extremities
▶
Initiate immediately if hemostasis allows
Continue until ambulatory or chemoprophylaxis established
VTE epidemiology in pelvic fracture
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Proximal DVT incidence up to 34% without prophylaxis (ACS Best Practices 2015)
Orthopedic management
Conservative management for stable straddle fracture
▶
Non-weight-bearing or toe-touch weight-bearing for 6–8 weeks
Progressive weight-bearing as tolerated with pain as guide
Physical therapy — early mobilization under orthopedic guidance
Expected healing time — 6 to 12 weeks for stable fractures (J Orthopaedic Trauma 2023)
Operative fixation indications
▶
Significant displacement or instability on CT
Failed conservative management
Anterior plating vs retrograde transpubic screws
▶
Biomechanical study (J Clinical Medicine 2021): both provide comparable stability for anterior ring
Retrograde transpubic screws allow less invasive approach
Combined anterior and posterior fixation for unstable patterns
External fixation — temporary stabilization in damage control setting
Special Populations
Pregnancy
Physiologic considerations in pregnancy
▶
Increased pelvic vascularity — higher hemorrhage risk from pelvic ring injury
Pelvic ligamentous laxity, especially in third trimester — relaxin-mediated
▶
May confer some resilience to traumatic pubic rami fractures at low energy
May make assessment of ligamentous stability more difficult
Uterine displacement of pelvic organs alters injury pattern
Imaging in pregnancy
▶
Plain radiograph — use abdominal/pelvic shielding if possible; do not withhold if clinically indicated
CT pelvis — indicated in hemodynamically unstable or high-energy mechanism
▶
Fetal radiation dose from CT pelvis approximately 25–50 mGy — below threshold for deterministic harm
Benefit outweighs risk in significant pelvic trauma
MRI preferred over CT when clinically feasible for isolated rami fractures
Fetal monitoring
▶
Continuous fetal heart rate monitoring after 24 weeks gestation
Obstetrics consultation for all pregnant trauma patients with pelvic fracture
Risk of placental abruption, uterine rupture, preterm labor
VTE prophylaxis in pregnancy
▶
LMWH is safe in pregnancy — does not cross placenta
Aspirin may be used in pregnancy but discuss with obstetrics
DOACs are contraindicated in pregnancy
Geriatric
Epidemiology and risk
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Pubic rami fractures are the most common pelvic fracture in patients > 65 years
90-day mortality up to 16% in geriatric patients with pelvic rami fractures (J Orthopaedic Trauma 2023)
Osteoporosis increases fracture displacement and complication risk
Occult instability
▶
42% of geriatric patients with apparent isolated rami fractures have posterior ring instability on CT or MRI (J Orthopaedic Trauma 2023)
Inability to mobilize after pubic rami fracture — MRI mandatory to detect occult injury
Dynamic instability: fracture stable at rest but displaces with weight-bearing
Hemorrhage considerations
▶
Anticoagulation reversal — warfarin (4F-PCC or vitamin K + FFP), DOAC reversal agents (idarucizumab for dabigatran, andexanet alfa for Xa inhibitors)
Delayed hemorrhage from corona mortis avulsion — present 48–72 hours after seemingly minor pubic rami fracture (Orthopedics 2012)
Lower hemodynamic reserve — tachycardia may be blunted by beta-blockers
Analgesia modifications
▶
Acetaminophen preferred — reduce dose to 2 g/day if frailty or hepatic impairment
Avoid NSAIDs — increased GI bleeding, renal impairment, and platelet dysfunction risk
Opioids — start low (morphine 1–2.5 mg IV PRN); high risk of delirium
Regional blocks preferred where available
VTE prophylaxis in geriatric patients
▶
Enoxaparin dose adjustment for CrCl < 30 mL/min — enoxaparin 20 mg SC daily or consider UFH
Initiate within 24–48 hours once hemostasis established
Long-term considerations
▶
Calcium 1000–1200 mg daily and vitamin D 800–1000 IU daily for bone health
Osteoporosis treatment initiation — bisphosphonates or other agents after fracture
Pediatrics
Epidemiology in pediatrics
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Pelvic fractures are uncommon in children — protected by cartilaginous pelvic ring and ligamentous elasticity
When they do occur, high-energy mechanism in majority
Straddle mechanism more common than in adults — bicycle injuries, playground falls
Anatomic differences
▶
Triradiate cartilage (acetabular growth plate) — open until age 12–14; fractures involve this structure
Avulsion fractures common — apophysis at ischium, AIIS, ASIS from sudden muscle contraction
Greater pelvic elasticity means higher energy required for ring disruption
Hemorrhage in pediatric pelvic fracture
▶
Children can maintain blood pressure until 25–30% blood volume loss — decompensation rapid
Weight-based MTP: 20 mL/kg pRBC; 20 mL/kg FFP
Angioembolization effective in pediatric pelvic hemorrhage
Imaging considerations in children
▶
AP pelvis radiograph first
CT with contrast — use low-dose pediatric protocols to minimize radiation
MRI preferred when diagnosis uncertain to avoid radiation
Analgesia in pediatrics (weight-based dosing)
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Acetaminophen 15 mg/kg PO/IV every 6 hours (max 75 mg/kg/day; 4 g/day)
Ibuprofen 10 mg/kg PO every 6–8 hours (max 40 mg/kg/day) if no contraindication
Morphine 0.05–0.1 mg/kg IV every 4 hours PRN (max 5 mg/dose)
VTE prophylaxis in pediatrics
▶
Pediatric VTE risk lower than adults; individualized assessment required
LMWH for high-risk: enoxaparin 0.5 mg/kg SC twice daily (age < 2 months: 0.75 mg/kg)
Anti-Xa monitoring recommended: target 0.5–1.0 IU/mL (therapeutic) or 0.2–0.5 IU/mL (prophylactic)
Background
Epidemiology
Incidence and demographics
▶
Pelvic fractures account for 3–8% of all skeletal injuries in trauma
Bimodal age distribution: high-energy trauma in young adults and low-energy falls in elderly
Straddle fracture is a subset of anterior pelvic ring injury
Pubic rami fractures are the most common pelvic fracture in patients > 65 years
Male predominance in high-energy trauma; female predominance in insufficiency fractures
Mortality and morbidity
▶
Hemodynamically unstable pelvic fractures: mortality up to 32% (JAMA Surgery 2023)
Open pelvic fractures: historically up to 50% mortality; improved with multidisciplinary care
90-day mortality in geriatric patients with pubic rami fractures: 16% (J Orthopaedic Trauma 2023)
DVT incidence without prophylaxis: up to 34% (ACS Best Practices 2015)
Associated injuries
▶
Posterior ring lesions in 96.8% of pubic rami fractures on CT (Injury 2012)
Acetabular fracture in 28.8% (Injury 2012)
Genitourinary injury in 6–25% of pelvic fractures overall
▶
Urethral injury in 6.1% of males vs 0.5% of females (J Clinical Medicine 2023)
Pathophysiology
Mechanism of straddle fracture
▶
Classic mechanism: fall astride a fixed object
▶
Direct compression force to perineum and anterior pelvis
Bilateral superior and inferior pubic rami fracture — free-floating anterior segment
High-energy mechanism: crush or MVC
▶
Lateral compression or mixed force vector
Pelvic ring principle
▶
Pelvis is a ring structure — disruption at one point usually implies second disruption
Anterior disruption (rami fractures) almost always paired with posterior ring lesion
Hemorrhage mechanism
▶
Rich pelvic venous plexus (Batson's plexus) and pelvic arterial branches
Retroperitoneal space can accommodate large hematoma volume (> 4 L)
Corona mortis artery — anastomosis between obturator and inferior epigastric arteries, injured by superior pubic ramus fracture
▶
Avulsion can cause delayed, life-threatening hemorrhage (Orthopedics 2012)
Posterior ring disruption with arterial source (internal iliac branches) drives major hemorrhage
Urethral injury mechanism
▶
Posterior urethra (membranous segment) most vulnerable in pelvic fracture
Shear force between prostate (fixed to pubis) and bulbar urethra (fixed to perineum)
Urethral injury more common with pubic symphysis diastasis or bilateral rami fractures
Therapeutic Considerations
Hemorrhage control hierarchy
▶
Pelvic binder — immediate, non-invasive, first-line
Damage control resuscitation — 1:1:1 MTP activation
Angioembolization — first-line for arterial hemorrhage (JAMA Surgery 2023)
Preperitoneal pelvic packing — effective for venous hemorrhage refractory to binder
External fixation — mechanical stabilization, adjunct to hemorrhage control
VTE prophylaxis evidence
▶
PREVENT CLOT trial (NEJM 2023): aspirin 81 mg BID noninferior to LMWH for death after fracture
Western Trauma Association guidelines 2020: initiate within 24 hours of injury when hemostasis achieved
Chemoprophylaxis underuse remains a problem — underdosing in obese or renally impaired patients
Fixation strategy considerations
▶
Anterior ring fixation alone insufficient for rotationally or vertically unstable patterns
Retrograde transpubic screws: minimally invasive, comparable biomechanical stability to anterior plating for straddle pattern (J Clinical Medicine 2021)
Posterior ring fixation (SI screws, iliosacral screws) required for LC-II/III or VS patterns
Urethral injury management evolution
▶
Early primary realignment vs suprapubic catheter with delayed urethroplasty debated
AUA 2020 guideline: suprapubic catheter acceptable; early endoscopic realignment may reduce stricture rate
Urethroplasty timing: 3–6 months post-injury with best outcomes (J Urology 2023)
Patient Discharge Instructions
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Your diagnosis
▶
You have been diagnosed with a straddle fracture — breaks to the bones at the front of your pelvis (pubic bones on both sides)
Your pelvis was stabilized and no dangerous bleeding or urinary injury was found
Activity restrictions
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Non-weight-bearing on the injured side using crutches or a walker as instructed
Avoid lifting anything heavier than 2 kg until cleared by your orthopedic surgeon
Limit stairs and prolonged standing until follow-up
Do not drive while on opioid pain medication
Pain management at home
▶
Acetaminophen (Tylenol) 500–1000 mg every 6 hours as needed — do not exceed 4 g per day
Ibuprofen (Advil/Motrin) 400–600 mg every 8 hours with food if tolerated and no contraindication
Use prescription opioid medication only as directed and only if needed for breakthrough pain
Ice packs to pelvic area 20 minutes on, 20 minutes off for the first 48–72 hours
Blood clot prevention
▶
Take your prescribed blood thinner medication as directed (low-molecular-weight heparin injection or aspirin)
Stay as mobile as is safely possible — leg movements and ankle pumps help prevent clots
Wear compression stockings if prescribed
Wound and skin care
▶
Keep any skin wounds clean and dry — change dressings daily or as instructed
Watch for signs of wound infection: increasing redness, warmth, swelling, or discharge
Bladder and urinary care
▶
If you have a urinary catheter, keep the drainage bag below bladder level and empty it regularly
Report any inability to urinate, blood in urine, or catheter blockage immediately
Follow-up appointments
▶
Orthopedic surgery: within 1–2 weeks — bring imaging results and current medication list
Urology if applicable: as scheduled for ongoing urinary care
Return to the emergency department immediately if
▶
Worsening pelvic or groin pain not controlled with medications
Unable to urinate or new blood in urine
Leg swelling, calf pain, or redness — possible blood clot
Shortness of breath or chest pain — possible pulmonary embolism
Lightheadedness, fainting, or feeling faint
Fever above 38.3 degrees Celsius
New numbness, tingling, or weakness in your legs
Wound becomes red, warm, swollen, or begins to drain
References
Guidelines and key sources
American College of Surgeons — Best Practices Guidelines: Management of Genitourinary Injuries
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Johnsen N, Wessells H, Archer-Arroyo K, et al. ACS Best Practices 2025
Recommendations on retrograde urethrogram before Foley, CT cystogram for bladder injury
American College of Surgeons — Best Practices in the Management of Orthopaedic Trauma
▶
Davis ML, Della Rocca GJ, Brenner MD, et al. ACS Best Practices 2015
VTE prophylaxis, MTP activation, pelvic stabilization recommendations
World Journal of Emergency Surgery — WSES Pelvic Trauma Classification and Guidelines
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Coccolini F, Stahel PF, Montori G, et al. WJES 2017
Classification grade I–III and treatment algorithm by hemodynamic status
AUA Urotrauma Guideline 2020
▶
Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. J Urology 2021
Management algorithm for posterior urethral disruption injury
Western Trauma Association — Updated Guidelines to Reduce VTE in Trauma
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Ley EJ, Brown CVR, Moore EE, et al. J Trauma Acute Care Surgery 2020
Initiate chemoprophylaxis within 24 hours; continue minimum 14 days
Key clinical trials and studies
PREVENT CLOT trial — aspirin vs LMWH for thromboprophylaxis after fracture
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Major Extremity Trauma Research Consortium (METRC), O'Toole RV, Stein DM, et al. NEJM 2023
Aspirin 81 mg BID noninferior to LMWH for all-cause death after orthopaedic fracture
Hemorrhage control interventions and mortality — hemodynamically unstable pelvic fractures
▶
Anand T, El-Qawaqzeh K, Nelson A, et al. JAMA Surgery 2023
Angioembolization associated with reduced mortality in hemodynamically unstable pelvic fractures
Detection of posterior pelvic injuries in pubic rami fractures
▶
Scheyerer MJ, Osterhoff G, Wehrle S, et al. Injury 2012
Posterior ring lesions present in 96.8% of patients with pubic rami fractures on CT
Geriatric pubic rami fractures and occult instability
▶
Tucker NJ, Scott B, Mauffrey C, Parry JA. J Orthopaedic Trauma 2023
42% of geriatric patients with apparent isolated rami fractures have posterior instability
Biomechanical comparison — anterior plating vs retrograde transpubic screws for straddle fracture
▶
Lodde MF, Katthagen JC, Schopper CO, et al. J Clinical Medicine 2021
Both fixation techniques provide comparable stability for anterior ring straddle injuries
Young-Burgess classification and prediction of outcomes
▶
Manson T, O'Toole RV, Whitney A, et al. J Orthopaedic Trauma 2010
Classification predicts transfusion requirements, mortality, and non-orthopaedic injuries
Corona mortis avulsion and delayed hemorrhage
▶
Garrido-Gomez J, Pena-Rodriguez C, Martin-Noguerol T, Hernandez-Cortes P. Orthopedics 2012
Corona mortis avulsion can cause delayed life-threatening hemorrhage after stable pubic ramus fracture
Urethral stricture disease guideline amendment
▶
Wessells H, Morey A, Souter L, Rahimi L, Vanni A. J Urology 2023
Timing and technique for urethroplasty following pelvic fracture urethral injury
Insufficiency fractures of the pubic ramus
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Schapira D, Militeanu D, Israel O, Scharf Y. Seminars in Arthritis and Rheumatism 1996
Osteoporosis, rheumatoid arthritis, and pelvic irradiation as risk factors
Pelvic ring fractures imaging review
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Khurana B, Sheehan SE, Sodickson AD, Weaver MJ. Radiographics 2014
Comprehensive imaging review of Young-Burgess and Tile classification systems
VTE chemoprophylaxis in pelvic and acetabular fractures — systematic review
▶
Shu HT, Yu AT, Lim PK, Scolaro JA, Shafiq B. Injury 2022
Anti-Xa monitoring important; many patients underdosed on LMWH
Prehospital pelvic fracture management — NAEMSP position statement
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Lyng JW, Corsa JG, Raetzke BD, et al. Prehospital Emergency Care 2025
Pelvic binder application at greater trochanters; avoid repeated manual compression testing
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Management Protocols
Straddle Fracture