A 36-year-old woman is brought to the emergency department 20 minutes after being involved in a high-speed motor vehicle collision. On arrival, she is unconscious. Her pulse is 140/min, respirations are 12/min and shallow, and blood pressure is 76/55 mm Hg. 0.9% saline infusion is begun. A focused assessment with sonography shows blood in the left upper quadrant of the abdomen. Her hemoglobin concentration is 7.6 g/dL and hematocrit is 22%. The surgeon decided to move the patient to the operating room for an emergent explorative laparotomy. Packed red blood cell transfusion is ordered prior to surgery. However, a friend of the patient asks for the transfusion to be held as the patient is a Jehovah's Witness. The patient has no advance directive and there is no documentation showing her refusal of blood transfusions. The patient's husband and children cannot be contacted. Which of the following is the most appropriate next best step in management?

Transfusion of packed red blood cells

Consult hospital ethics committee

Administer high-dose iron dextran

A 35-year-old patient is brought into the emergency department post motor vehicle crash. Stabilization of the patient in the trauma bay requires endotracheal intubation. The patient has a laceration on the femoral artery from shrapnel and seems to have lost large quantities of blood. The patient is transfused with 13 units of packed red blood cells. His vitals are T 96.5, HR 150, BP 90/40. Even with the direct pressure on the femoral artery, the patient continues to bleed. Results of labs drawn within the last hour are pending. Which of the following is most likely to stop the bleeding in this patient?

Fresh frozen plasma and platelets

A 36-year-old woman comes to the physician for a 2-month history of urinary incontinence and a vaginal mass. She has a history of five full-term normal vaginal deliveries. She gave birth to a healthy newborn 2-months ago. Since then she has felt a sensation of vaginal fullness and a firm mass in the lower vagina. She has loss of urine when she coughs, sneezes, or exercises. Pelvic examination shows an irreducible pink globular mass protruding out of the vagina. A loss of integrity of which of the following ligaments is most likely involved in this patient's condition?

Cardinal ligament of the uterus

A 33-year-old man is brought to the emergency department because of trauma from a motor vehicle accident. His pulse is 122/min and rapid and thready, the blood pressure is 78/37 mm Hg, the respirations are 26/min, and the oxygen saturation is 90% on room air. On physical examination, the patient is drowsy, with cold and clammy skin. Abdominal examination shows ecchymoses in the right flank. The external genitalia are normal. No obvious external wounds are noted, and the rest of the systemic examination values are within normal limits. Blood is sent for laboratory testing and urinalysis shows 6 RBC/HPF. Hematocrit is 22% and serum creatinine is 1.1 mg/dL. Oxygen supplementation and IV fluid resuscitation are started immediately, but the hypotension persists. The focused assessment with sonography in trauma (FAST) examination shows a retroperitoneal fluid collection. What is the most appropriate next step in management?

Take the patient to the OR for an exploratory laparotomy

Perform an MRI scan of the abdomen and pelvis

CT of the abdomen and pelvis with contrast

Obtain a retrograde urethrogram

Perform a diagnostic peritoneal lavage

A 67-year-old man is brought to the emergency room after being involved in a traffic accident. He currently complains of bilateral hip pain. His vital signs are within the normal range, and he is hemodynamically stable. The pelvic compression test is positive. External genitalia appears normal, except there is blood at the urethral meatus and a contusion at the base of the scrotum. Digital rectal examination (DRE) shows a high-riding ballotable prostate. An X-ray reveals the presence of a pelvic fracture. Which of the following initial actions is the most appropriate for this patient?

Obtain a retrograde urethrogram (RUG), including a pre-injection kidney, ureter, and bladder (KUB) film

Take the patient emergently to the operating room and check for a urethral injury with IV indigo carmine

Obtain a urinalysis to detect microscopic hematuria

Perform a suprapubic cystostomy

A 56-year-old man is brought to the emergency department 25 minutes after he was involved in a high-speed motor vehicle collision where he was the unrestrained passenger. He has severe lower abdominal and pelvic pain. On arrival, he is alert and oriented. His pulse is 95/min, respirations are 22/min, and blood pressure is 106/62 mm Hg. Examination shows severe tenderness to palpation over the lower abdomen and over the left anterior superior iliac spine. There is no limb length discrepancy. Application of downward pressure over the pelvis shows no springy resistance or instability. Rectal examination is unremarkable. A focused assessment with sonography shows no free fluid in the abdomen. There is no blood at the urethral meatus. Placement of a Foley catheter shows gross hematuria. An x-ray of the pelvis shows a fracture of the left pelvic edge. Which of the following is the most appropriate next step in management?

External fixation of the pelvis

Pelvic fractures and hemorrhage for USMLE Step 1: High-Yield Surgery Lessons

Anatomy & Classification - The Pelvic Puzzle

Pelvic Ring: Composed of two innominate bones and the sacrum. Stability depends on the posterior ligamentous complex.
Key Ligaments: Sacrospinous, sacrotuberous, and the critical posterior sacroiliac (SI) ligaments.

Pelvic Ligaments: Anterior and Posterior Views

Young-Burgess Classification (by mechanism):
- Anteroposterior Compression (APC): "Open book" injury.
- Lateral Compression (LC): Most common type.
- Vertical Shear (VS): High-energy, unstable; disrupts pelvic floor.

⭐ The posterior SI ligament complex is the primary stabilizer of the pelvis; its disruption signifies major instability.

Initial Assessment & Resuscitation - Code Red Protocol

Primary Survey (ATLS): Focus on C (Circulation). Suspect pelvic fracture in any high-energy trauma, especially with hypotension.
Hemodynamic Instability: SBP < 90 mmHg or HR > 120 bpm despite initial fluid bolus.
Immediate Actions:
- Apply pelvic binder at the level of greater trochanters.
- Activate Massive Transfusion Protocol (MTP) / Code Red.

Pelvic binder application steps with anatomical overlay

⭐ Early administration of Tranexamic Acid (TXA) within 3 hours of injury significantly reduces mortality from bleeding in trauma patients. Administer a 1g load over 10 min, then 1g infusion over 8 hours.

Hemorrhage Control - Plugging the Dam

Source of Bleeding: Primarily from the posterior venous plexus (85%) and raw bone surfaces, not major arteries.
Immediate Management:
- Apply a pelvic binder or sheet at the level of the greater trochanters.
- This reduces pelvic volume, stabilizes fracture, and promotes tamponade.
- Initiate massive transfusion protocol for persistent hypotension.

Pelvic Venous Anatomy and Sacral Plexus

⭐ Most bleeding is venous. However, persistent hemodynamic instability despite binder application and fluid resuscitation strongly suggests an arterial injury requiring intervention.

Definitive Management & Complications - The Aftermath

Surgical Fixation (ORIF):
- Indicated for unstable fractures after the patient is hemodynamically stable.
- Goal: Restore pelvic ring integrity, enabling early mobilization.

$Pelvic fracture fixation: X-ray and 3D CT reconstruction$

Major Complications:
- Neurologic Injury: Damage to the lumbosacral plexus (L5/S1 nerve roots common), potentially causing foot drop.
- Urogenital Injury: Urethral tears and bladder rupture are frequent. Suspect with blood at the meatus.
- Thromboembolism: High risk for DVT/PE; requires chemical and/or mechanical prophylaxis.
- Long-term: Chronic pain, gait disturbance, sexual dysfunction.

⭐ Injury to the lumbosacral plexus is a classic complication, especially with posterior pelvic ring disruptions. Always perform a thorough neurovascular exam of the lower extremities.

High‑Yield Points - ⚡ Biggest Takeaways

Pelvic fractures from high-energy trauma can cause life-threatening hemorrhage, a key ATLS priority.

Initial management: apply a pelvic binder to stabilize the pelvis and control common venous bleeding.

For unstable patients with ongoing bleeding, angiography with embolization is critical for arterial hemorrhage.

CT imaging is the gold standard for stable patients to define fracture anatomy.

Always suspect associated urogenital injuries, like posterior urethral disruption in males.

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