After clinical evaluation and POD placement, anteroposterior supine pelvis x-ray is obtained. If the fracture pattern is mechanically unstable in a rotational plane (Tile B), the reduction of pelvic volume by POD closure followed by external fixator is obtained. If the fracture is mechanically unstable also in a vertical plane (Tile C), its reduction is better achieved by traction of the displaced extremity and POD placement associated with gluteal rolls, in order to obtain a greater pressure on posterior elements. A C-clamp or an external fixation with supra-acetabular fiches provides a more definitive closure. An E-FAST is then performed to detect intra-abdominal free fluid. If the amount of fluid suggests an intraperitoneal injury [13], explorative laparotomy is performed, maintaining pelvic stabilization. If a larger retroperitoneal hematoma is observed, and the patient is still unstable notwithstanding intraperitoneal hemostasis has been achieved, a PPP is made contemporaneously through a second suprapubic incision. After patient stabilization a CECT is performed in order to check for persistent bleeding amenable by angioembolization. If the E-FAST is negative for intraperitoneal injury, and patient is too unstable to undergo CECT, a PPP is a life-saving procedure to be quickly performed directly in ER to attempt hemodynamic stabilization, allowing for subsequent CECT/angiography.

After clinical exam, pelvis x-ray and E-FAST are performed. In stable patient, CECT is immediately obtained, maintaining POD placement with low compression force, in order to evaluate the need for subsequent angiography if arterial blushing is demonstrated. Associated extrapelvic injuries are managed according to specific protocols. Mechanically unstable pelvic fractures are managed with external fixator as bridge to internal fixation, according to the type of fracture and to the general severity of patients (especially of a concomitant brain injury). A high ISS or a moderate to severe traumatic brain injury suggests to delay definitive fixation.

Because of the close relationship of the genitourinary tract, intestinal tract, bony pelvis, and other soft tissues, multiple structures are frequently injured in pelvic trauma. Involvement of perineum skin may lead to massive blood loss and shock from the open pelvic wound. After bleeding control from skin wound has been achieved by packing, ligation, or clamping of vascular structures, endoscopic and vaginal examination should be performed to check for evidence of rectal, vaginal, genitourinary, or anal injuries and to determine the need for further investigations (urethrography, NMR for urinary lesions, contrast enema for intestinal injuries). Management of associated urogenital and intestinal injuries depends on patient hemodynamic stability [28]. Extraperitoneal bladder injuries are managed by a Foley catheter left in place at least 15 days. If an internal fixation of pelvic fracture is performed, the bladder injury may be contemporaneously sutured. Intraperitoneal bladder injuries, greater than 2 cm, should be directly sutured during a laparotomy, in emergency setting if needed because of associated injuries, or a planned one, once other priorities have been ruled out. A urethral injury, if incomplete, is usually well managed by a direct or endoscopic placement of a Foley catheter. In alternative, if retrograde cannulation is impossible, a suprapubic cystostomy and a subsequent endoscopic or surgical repair are needed. If an intestinal laceration is detected, a fecal diversion through a colostomy is mandatory. Because of the presence of the retroperitoneal hematoma, diverting colostomy has to be performed far away from iliac fossa, in order also not to interfere with external fixator placement. In this case, preferred surgical site is the proximal transverse colon. Debridement of soft tissues has to be adequate, extending through area that has vigorous, bright red bleeding, and laceration repair should be performed as soon as possible after patient hemodynamic stabilization [29].