Shock is uncommonly caused by blood loss from a fracture, except in the setting of extensive pelvic fractures or multiple long bone fractures; therefore, the presence of other injuries should be evaluated if shock is present After the initial trauma evaluation and resuscitation, a thorough secondary survey is important to identify other possible orthopedic as well as nonorthopedic injuries Thoracic and lumbar spine fractures are challenging to diagnose by physical examination in the setting of multisystem trauma If the injury mechanism or examination is concerning for possible spinal injury, radiographs should be obtained and careful immobilization maintained In the setting of multisystem trauma, fractures may be common and sometimes are the most obvious injury, but they are rarely life-threatening The usual trauma evaluation and resuscitation protocol should be followed for any child with concern for multisystem trauma and/or a severe mechanism of injury After the child has been stabilized, the injured extremity should be immobilized For unstable pelvic injuries with associated bleeding, wrapping the pelvis tightly in a sheet or the application of an external fixator device may help tamponade the bleeding