01Approach to the Critical Patient/attcp38

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

02History/hx59

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)

03Physical Exam/exam44

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)

04Differential Diagnosis/ddx36

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

05Laboratory Tests/lt29

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

06Diagnostic Tests/dt70

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

07Disposition/dispo31

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

›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

08Treatment/t72

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

›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

09Special Populations/sp67

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

›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

›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)

›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)

10Background/b53

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)

11Patient Discharge Instructions/pdi35

copy discharge instructions

›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

›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

12References/r51

Guidelines and key sources

›American College of Surgeons — Best Practices Guidelines: Management of Genitourinary Injuries

›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

›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

›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

›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

Evidence & Review

Evidence & Review