Pelvic Fracture Management: The Trauma Surgeon's Perspective

Abstract

 Pelvic fractures present a wide spectrum of clinical severity, ranging from minimal physiological impact to profound instability depending on the degree of associated retroperitoneal bleeding. As such, these injuries are among the most complex trauma surgeons encounter, requiring proficiency across trauma care, critical care medicine, and surgical intervention. While each case is unique, the following principles guide the management of pelvic fractures with severe physiological compromise:

• Early recognition of the fracture and its physiological impact

• Hemorrhage control through timely interventions

• Blood-based resuscitation strategies to counter coagulopathy

• Identification of associated injuries

• Optimization for definitive pelvic stabilization surgery

Pelvic fractures often result from high-energy trauma. Early recognition is essential and should follow a standardized approach, such as the Advanced Trauma Life Support® (ATLS) primary survey, to identify and address the fracture and possible exsanguinating hemorrhage.

When bleeding is suspected, rapid intervention is critical. Pelvic binders are a first-line tool to reduce pelvic volume and tamponade retroperitoneal bleeding. When bleeding persists, additional measures are necessary. Options include external fixation, REBOA, angioembolization, and preperitoneal packing.

Concurrently, a blood-based resuscitation strategy must be initiated. Whole blood is preferred when available; otherwise, massive transfusion protocols using a 1:1 ratio of RBCs to FFP, along with early platelet administration, are essential. Thromboelastography (TEG) is increasingly used to guide resuscitation by assessing clot formation, strength, and breakdown, helping tailor blood product administration.

Once stabilized, patients transition to the ICU for multidisciplinary critical care. Optimization focuses on resolving shock, correcting coagulopathy and electrolyte imbalances, and initiating venous thromboembolism prophylaxis. Given the force required to fracture the pelvis, associated injuries must be carefully evaluated for as well—particularly injuries to the solid abdominal organs, the bladder, and urethra. Throughout the ICU phase of care close communication with the Orthopedic Trauma surgeon is necessary to ensure the patient is optimized for pelvic stabilization surgery, as surgery can be lengthy and at times associated with significant blood loss.

With management strategies rooted in the fundamental principles above, the Trauma Surgeon can find great reward in providing truly life-saving care to some of our sickest patients.