What is the immediate management for an older adult with a pelvic fracture seen on imaging, potentially due to osteoporosis or high-energy trauma?

Immediate Management of Pelvic Fracture on Imaging

Apply a pelvic binder immediately around the greater trochanters as the first-line intervention for any suspected pelvic fracture, regardless of hemodynamic status, and then proceed with a hemodynamic status-driven algorithm to determine subsequent interventions. 1, 2

Initial Stabilization (First 5 Minutes)

• Apply external pelvic compression with a commercial pelvic binder immediately - position it around the greater trochanters (not the iliac crests) to achieve compression equivalent to surgical C-clamp 1, 2
• Do NOT use sheet wrapping as it provides no benefit 1
• This single intervention directly reduces transfusion requirements, ICU length-of-stay, and hospital length-of-stay 1
• Assess hemodynamic stability: systolic blood pressure <90 mmHg indicates instability requiring urgent intervention 1

Hemodynamic Status-Driven Algorithm

For Hemodynamically UNSTABLE Patients (SBP <90 mmHg):

• Obtain pelvic X-ray immediately upon arrival to confirm fracture pattern 1, 2
• Perform E-FAST within 30 minutes to identify intra-abdominal bleeding source (97% negative predictive value for ruling out intra-abdominal hemorrhage) 1, 2
• Initiate permissive hypotension targeting systolic BP 80-90 mmHg until bleeding is controlled 2
• Transfuse packed red blood cells in 1:1:1 ratio with FFP and platelets while minimizing crystalloid to avoid dilutional coagulopathy 2, 3

If E-FAST shows abundant hemoperitoneum (≥3 positive sites):

• Proceed to laparotomy (61% rate of appropriate therapeutic intervention) 2

If E-FAST is negative or minimal free fluid:

• Proceed directly to angiographic embolization as primary definitive intervention (73-97% success rate) 2
• Alternative: Preperitoneal pelvic packing if angiography unavailable (can be completed in <20 minutes, only 13-20% require subsequent angioembolization) 2
• Time to hemorrhage control must be <163 minutes, as mortality increases approximately 1% every 3 minutes of delay 2

For Hemodynamically STABLE Patients:

• Skip pelvic X-ray entirely (Grade 2- recommendation against X-ray in stable patients) 1
• Proceed directly to CT scan with IV contrast of entire pelvis 1
• Consider angiography/angioembolization if CT shows arterial contrast extravasation ("blush") regardless of hemodynamic status 4, 1

Special Considerations for Older Adults

• Elderly patients with pelvic fractures should be considered for pelvic angiography/angioembolization regardless of hemodynamic status (Grade 2C recommendation) 4
• Osteoporotic fractures in elderly patients often present diagnostic difficulties - initial type A fractures may have occult insufficiency fractures that become apparent with persistent pain, requiring repeat imaging 5
• External fixation with supra-acetabular screw positioning is particularly effective in elderly patients to avoid secondary insufficiency-instability 5
• Type A fractures can be treated non-surgically, but types B and C fractures usually require surgical stabilization 5

Critical Markers of Ongoing Hemorrhage

• CT "blush" (active arterial extravasation) - strongest predictor requiring intervention 1, 3
• Pelvic hematoma volume >500 mL on CT 1
• Lactate >3.4 mmol/L - independent predictor of arterial bleeding 3
• Core temperature <36°C - predicts coagulopathy and need for angioembolization 3
• Anterior-posterior and vertical shear deformations on radiographs 1

Definitive Stabilization Based on Fracture Type

Rotationally unstable injuries (APC and LC-type):

• Stabilize with external fixation or anterior internal fixation 4

Vertically unstable injuries (VS-type):

• Best stabilized by posterior C-clamp 4
• Contraindications for C-clamp: comminuted sacral fractures, transforaminal sacral fractures, iliac wing fractures, lateral compression-type injuries 4

Critical Pitfalls to Avoid

• Never perform non-therapeutic laparotomy in pelvic fracture patients as it increases mortality 1
• Never remove pelvic packs before 48 hours to lower risk of re-bleeding 1
• Never delay pelvic ring closure in hemodynamically unstable patients 1
• Recognize that 85% of pelvic bleeding originates from bone, soft tissues, or venous structures (not arterial), so angioembolization alone has been associated with high mortality 4
• More than 75% of high-energy pelvic injuries have associated head, thorax, abdominal, or genitourinary injuries requiring systematic evaluation 2, 6

Transport Considerations

• All patients with severe pelvic trauma must be transported to a Level I trauma center with 24/7 availability of trauma surgery, interventional radiology, and orthopedic surgery 1
• This approach decreases mortality by 15-30% compared to non-specialized facilities 1