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Pelvic fractures in trauma
An unstable pelvic ring fracture causes heavy bleeding — mainly venous — so in an unstable patient the pelvis is closed with a binder centred over the trochanters, another bleeding source is sought with FAST, and bleeding is controlled by arterial embolisation, preperitoneal packing or fixation.
Why it matters in the exam
The classic question shows a crash victim with hypotension, pelvic pain and an "open book" fracture on X-ray. The correct step is a pelvic binder and early blood products, then a decision by FAST: if FAST is positive — laparotomy with pelvic packing; if negative — angiography and embolisation or preperitoneal packing. A common distractor is sending an unstable patient to CT.
Complications of the fracture are also tested: urethral injury (blood at the meatus, a high-riding prostate, perineal haematoma) requires a retrograde urethrogram before a urinary catheter; bladder rupture is diagnosed by CT cystography; and an open fracture found on rectal or vaginal examination greatly raises mortality. Do not "rock" the pelvis to test stability, because this increases bleeding.
Distinguish the injury mechanisms: anteroposterior compression opens the pelvis ("open book") and increases its volume, so the binder is especially effective; lateral compression closes the pelvis; and vertical shear is the most unstable. In older patients, a pubic rami fracture after a simple fall is usually stable and is treated with analgesia and early walking, but these patients too may bleed when they take anticoagulants.
Key points
- Unstable pelvic ring fracture — heavy bleeding, mainly venous.
- Pelvic binder at the trochanters and early blood products.
- Unstable: FAST positive — laparotomy; negative — embolisation or packing.
- Blood at the meatus — urethrogram before a catheter.
- Open fracture — rectal and vaginal examination, high mortality.
Summary table
| Situation | Finding | Meaning | Action |
|---|---|---|---|
| Open book (APC) | Widened symphysis, open sacroiliac joints | Increased pelvic volume, venous bleeding | Binder centred over the trochanters |
| Unstable, FAST positive | Bleeding in the abdomen and pelvis | Two bleeding sources | Laparotomy and pelvic packing |
| Unstable, FAST negative | Pelvic bleeding | Main pelvic source | Angiography and embolisation or preperitoneal packing |
| Urethral injury | Blood at the meatus, high-riding prostate | Danger in catheter insertion | Retrograde urethrogram before a catheter |
| Pubic rami fracture in an older patient | Simple fall | Usually stable | Analgesia, early walking |
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Sources
- ATLS Advanced Trauma Life Support, Student Course Manual (American College of Surgeons), 10th edition (2018) — Musculoskeletal trauma; Shock
- WSES-AAST guidelines: Pelvic trauma classification and management, 2017 — Haemodynamically unstable pelvic injury
- European guideline on management of major bleeding and coagulopathy following trauma, 6th edition (2023) — Pelvic ring closure and stabilisation
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.