Mechanism of injury (e.g., IED blast, crush injury, and high velocity penetrating wounds to the pelvis) and hypotension can indicate high risk for pelvic fracture. Care for casualties with pelvic fractures ideally starts in the prehospital environment with initiation of Tactical Combat Casualty Care (TCCC) interventions to include early blood transfusion, Tranexamic acid (TXA), and pelvic binder placement. If suspicion is high for an unstable pelvic fracture (if not already placed in the prehospital setting), pre-position binders/sheet on the litter (bed) prior to transferring the patient over, so that a binder/sheet may be utilized quickly. Signs of pelvic fracture on physical exam include pain on palpation, leg length discrepancy with foreshortening and internal rotation of the lower extremity, and a perineal hematoma which can look like scrotal bruising in men.

Two key determinations must be made in patients with pelvic fractures: hemodynamic stability and if the pelvic fracture is mechanically stable. If the patient is not hemodynamically stable, it is imperative to identify all site(s) of hemorrhage, as pelvic fractures often occur in conjunction with other life-threatening injuries. Appropriate evaluation of the chest, abdomen, extremities, and other potential sites of hemorrhage cannot be overemphasized. Additionally, a thorough examination of the pelvis and perineum is required to rule out associated injuries to the rectum and genitourinary/gynecologic systems. Open pelvic fractures have a higher morbidity; if there is concern for an open pelvic fracture a rectal and vaginal exam must be performed. Additionally, injury to the urethra and bladder should be ruled out. Urethral injury is more common in men.

The steps to initially evaluate and treat patients with pelvic fractures are as follows: