compared to the adult trauma patient A high index of suspicion for the presence of potential pelvic fractures should be maintained for high-energy injury mechanisms, including motor vehicle collisions, pedestrians hit by a motor vehicle, and significant falls As the physical examination has moderate sensitivity for pelvic fractures, those with abnormal pelvis and hip examinations with instability, pain on palpation of the pelvis, or the inability to walk due to pelvic pain should be evaluated for possible pelvic fractures Triage considerations Most pelvic fractures are stable; however, those with abnormal vital signs indicating trauma-related hemorrhage require immediate resuscitative measures Clinical assessment Mechanism of injury and any comorbid conditions should be emphasized in the history The initial assessment should include the vital signs and a thorough examination of the abdomen, pelvis, lower extremities, skin, genitourinary, and neurologic systems Vital signs must be closely monitored and appropriate fluid and/or blood product resuscitation should be administered if tachycardia and/or hypotension are present Anterior and lateral compression of the pelvis should be performed to assess pelvic stability Management Pelvis and hip radiographs are the initial diagnostic test of choice If further evaluation of the pelvis is needed, CT may be considered to further visualize the fracture(s) Immediate orthopedic consultation is required for all pelvic fractures except for minor avulsion fractures The emergent application of an external fixator or a pneumatic antishock garment in the ED compresses the pelvis, leading to a tamponade effect to decrease the bleeding in some pelvic fractures If commercial devices are not available, wrapping the pelvis in a sheet can provide temporary stability Pelvic fractures can be categorized as (1) avulsion fractures, (2) pelvic ring fractures, and (3) acetabular fractures AVULSION FRACTURES Sports are the most common mechanism causing avulsion fractures as they can result in strong, active contractions of the muscular attachments against resistance to the secondary centers of ossification (anteriorsuperior iliac spine, anterior-inferior iliac spine, and ischial tuberosity) ( Fig 111.31 ) The patient usually presents with localized pain and tenderness over the ossification sites ( Fig 111.32 ) The typical treatment is crutches with partial or no weight bearing for to weeks with a slow resumption of activities The patient should be referred for outpatient orthopedic follow-up