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BOAST Guidelines
BOAST 3
Trauma

The Management of Patients with Pelvic Fractures

BOAST 3 outlines the acute resuscitation, specialist network transfer, and surgical governance pathways for pelvic ring disruptions to mitigate catastrophic haemorrhage and long-term functional morbidity. It sets explicit standards for pre-hospital binder application, trauma CT imaging, haemostatic interventions, timing of definitive fixation, and MDT rehabilitation.

Key standards

  • ›Apply a pelvic binder pre-hospital or immediately on arrival centred at the level of the greater trochanters.
  • ›Haemodynamically unstable patients must bypass directly to an accredited Major Trauma Centre.
  • ›Avoid repeated manual physical examination or 'springing' of the pelvis.
  • ›Perform early contrast-enhanced trauma CT with arterial phase to identify vascular extravasation ('blush').
  • ›Have rapid, established 24/7 institutional pathways for transcatheter arterial embolisation, pre-peritoneal pelvic packing, and provisional external skeletal fixation.
  • ›Perform definitive surgical stabilization within 72 hours of injury in physiologically stable patients.
  • ›Early multidisciplinary intervention and diverting stoma consideration for open pelvic fractures with perineal contamination.
  • ›Routine provision of written information and referral pathways for sexual, urological, and psychological dysfunction.

Introduction

Pelvic ring fractures represent high-energy trauma associated with significant early mortality secondary to exsanguinating haemorrhage, as well as complex soft tissue, neurological, and urogenital morbidity. In the elderly, low-energy fragility fractures of the pelvis carry rising morbidity and mortality requiring tailored care. BOAST 3 sets the national benchmark across trauma networks for prompt identification, mechanical stabilization, physiological resuscitation, and definitive reconstruction.

  • Scope includes patients of all ages sustaining fractures of the pelvic ring.
  • Excludes isolated acetabular fractures, isolated low-energy pubic rami fractures, and pathological fractures.

Standards for Practice

  • Pre-hospital & Emergency Department Resuscitation:
    • When active bleeding from a pelvic fracture is suspected, a non-invasive pelvic circumferential compression device (pelvic binder) must be applied promptly in the correct anatomical position (centred over the greater trochanters). This should ideally be placed in the pre-hospital setting.
    • Haemodynamically unstable patients with suspected pelvic fractures must be transferred directly to a Major Trauma Centre (MTC) within networked pre-hospital bypass protocols.
    • Avoid manual pelvic 'springing' or repeated mechanical testing of instability, as this can dislodge haemostatic clot formations.

Investigation and Imaging

  • Urgent contrast-enhanced arterial-phase CT (trauma scan) must be performed promptly in haemodynamically resuscitated or responder patients to evaluate skeletal disruption, retroperitoneal haematoma, and arterial contrast extravasation ('blush').
  • Plain pelvic radiographs (anteroposterior, inlet, outlet views) and specialized CT reconstructed views must be acquired to guide operative planning.
  • Proactively evaluate for associated Morel-Lavallée closed degloving lesions, rectal/perineal tears (open fractures), and lower urinary tract disruption.

Management of Haemodynamic Instability

  • Activation of the institutional Major Haemorrhage Protocol (MHP) alongside immediate structural pelvic stabilization.
  • Patients refractory to initial resuscitation with ongoing pelvic source haemorrhage require immediate specialist intervention via established pathways: interventional radiology (transcatheter pelvic arterial embolization), emergent pre-peritoneal pelvic packing (PPP), or direct mechanical stabilization (pelvic C-clamp or external fixator).
  • Management should involve a consultant-led multidisciplinary trauma team including trauma surgeons, pelvic orthopaedic surgeons, and interventional radiologists.

Timing and Definitive Fixation

  • Definitive internal fixation of mechanically unstable pelvic ring injuries in physiologically optimized patients should be completed within 72 hours of injury where feasible.
  • If definitive reconstruction is delayed due to physiological compromise, associated injuries, or soft tissue considerations, early provisional mechanical stabilization should be maintained.

Associated Injuries and Open Fractures

  • All open pelvic fractures require urgent surgical debridement. Diverting colostomy/faecal diversion should be performed for open wounds communicating with the perineum, rectum, or anus following specialist surgical consultation.
  • Suspected urethral injuries (e.g., blood at the meatus, perineal haematoma, high-riding prostate) require early urological consultation and retrograde urethrography or gentle single catheterization attempt by experienced personnel in line with BOAST urological trauma guidelines.

Documentation, Rehabilitation and Governance

  • Post-acute follow-up must occur through specialized pelvic trauma clinics providing access to multidisciplinary teams addressing chronic pelvic pain, mobility, mental health, and persistent urological and neurological deficits.
  • Sexually active patients must receive both verbal and written guidance regarding sexual and erectile dysfunction according to BAUS standards.
  • Units must register and submit complete injury and treatment datasets to national audits including the Trauma Audit & Research Network (TARN), National Hip Fracture Database (NHFD), or Fracture Liaison Service Database (FLS-DB) where appropriate.

Exam-tested points

  • ›Binder anatomy: The pelvic binder must be applied over the greater trochanters and pubic symphysis, not the iliac crests/abdomen; high placement worsens open-book deformity and fails to reduce retroperitoneal volume.
  • ›Mechanism of bleeding: 80-85% of pelvic fracture haemorrhage is low-pressure venous (presacral and prevesical plexus) and cancellous bone surfaces, responsive to reduction and tamponade; 15-20% is arterial (e.g., internal pudendal, superior gluteal, obturator, lateral sacral arteries), requiring transcatheter embolization.
  • ›Indications for Pelvic C-clamp vs Anterior External Fixator: C-clamps achieve direct posterior sacroiliac compression in vertical shear/posterior disruption but are strictly contraindicated in iliac wing fractures and sacral comminution/trans-alar fractures.
  • ›Open pelvic fracture debridement & diverting colostomy: Association of Coloproctology/BOAST rules state wounds in the perineal/groin/rectal 'danger zone' mandate a diverting sigmoid stoma away from surgical pelvic access approaches (e.g., Stoppa/ilioinguinal).
  • ›Fragility fractures of the pelvis (FFP): Rommens classification is increasingly tested; fragility fractures require orthogeriatric co-management, early mobilization, and evaluation for osteoporotic posterior ring insufficiency.
Official BOA source
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