The Danger of Pelvic Fractures
Pelvic fractures are among the most dangerous injuries an EMS provider will encounter. The pelvis is a ring structure surrounded by a rich vascular network, and fractures can disrupt major blood vessels, causing life-threatening hemorrhage into the retroperitoneal space. A patient with an unstable pelvic fracture can lose their entire blood volume into the pelvis and retroperitoneum. Mortality rates for unstable pelvic fractures range from 15 to 25%, and much of this mortality is from hemorrhage.
High-energy mechanisms are required to fracture the pelvis in young adults: motor vehicle collisions, motorcycle crashes, pedestrians struck by vehicles, and falls from significant heights. In elderly patients with osteoporosis, however, even a simple ground-level fall can cause pelvic fractures. The mechanism of injury should guide your index of suspicion.
Assessment of Pelvic Injuries
Do not repeatedly rock or compress the pelvis to check for instability. A single gentle assessment is acceptable: with hands on the iliac crests, apply gentle inward and downward pressure. If instability or crepitus is noted, do not repeat the maneuver, as this can disrupt clots and worsen bleeding. Pain with this maneuver, even without instability, suggests pelvic injury.
Other assessment findings that suggest pelvic fracture include pain in the hips, groin, or lower back; inability to bear weight; lower extremity shortening or rotation; scrotal or labial swelling; blood at the urethral meatus; and signs of hypovolemic shock disproportionate to visible injuries. A patient in shock with no obvious source of bleeding should always be assessed for pelvic and intra-abdominal hemorrhage.
Prehospital Management
The primary prehospital intervention for pelvic fractures is stabilization with a pelvic binder. Commercial pelvic binders (such as the SAM Pelvic Sling or T-POD) are applied at the level of the greater trochanters (not the iliac crests) and tightened to reduce pelvic volume, approximate fracture fragments, and tamponade bleeding. If a commercial binder is not available, a folded sheet can be wrapped around the pelvis at the same level and secured with clamps or knots. Correct placement is critical; a binder placed too high is ineffective.
Associated Injuries and Transport
Pelvic fractures are rarely isolated injuries. Commonly associated injuries include bladder rupture (hematuria is a warning sign), urethral injury (blood at the urethral meatus), lumbar spine fractures, acetabular fractures, and femur fractures. Manage hypovolemic shock aggressively with IV fluid resuscitation per protocol, and transport rapidly to a trauma center. These patients typically require massive transfusion, angiographic embolization, or surgical intervention that cannot be provided in the field. Minimize scene time and focus on rapid transport with ongoing resuscitation en route.