Pelvic fracture is one of the most complex injuries in trauma treatment and is often the result of high-energy blunt trauma, accounting for approximately 3% of all skeletal injuries [2–4]. Patients are typically young and exhibit a high Injury Severity Score (ISS). Mortality rates remain elevated, ranging from 5 to 16%, particularly in patients with hemodynamic instability and severe associated injuries [5–7].

Bleeding continues to be one of the primary causes of death from pelvic fracture, and the severity of bleeding is not necessarily correlated with the fracture pattern. In patients with pelvic trauma, the prognosis is more closely linked to the severity of pelvic vascular injury than to pelvic ring fractures [8]. The initial management of pelvic trauma primarily focuses on physiological alterations and associated injuries, placing less emphasis on fracture patterns. The priorities in managing pelvic fractures include controlling bleeding, stabilizing hemodynamics, correcting coagulopathy and physiology, followed by achieving definitive mechanical stabilization of the pelvic ring.

Historically, the Young–Burgess [9] and Tile [10] classifications are the two most commonly recognized in the literature. These two classification systems only consider the anatomical fracture pattern, which does not correlate with the outcomes of patients with pelvic trauma. Rommens et al. [11] recently developed a radiographic classification (anatomical fracture pattern) for managing fragility fractures of the pelvis (FFPs) [11,12].

In 2017, the World Society of Emergency Surgery (WSES) published its guidelines for the classification and management of pelvic trauma. The WSES classification categorizes pelvic trauma injuries into mild, moderate, and severe, taking into consideration both the pelvic fracture pattern and the hemodynamic condition of the patient [13]. Pelvic fractures may be open or closed. Open pelvic fractures are relatively rare but more complex due to concurrent internal and external bleeding [14]. They are also usually associated with the onset of infection that may progress to sepsis, contributing to mortality [4,15–18]. Sepsis is associated with only 2–4% of all pelvic fractures but carries a mortality rate of up to 45% [19–21]. Therefore, an open pelvic fracture can be regarded as a specific pattern of disease with distinct injury severity and treatment strategies [22].

The Young–Burgess classification (Figure 1) categorizes pelvic fractures according to the mechanism of injury [9]:

The Tile Classification (1980) is based on the type of mechanical instability of the pelvic ring [10].

The Rommens Classification is a classification for managing FFPs resulting from low-energy impacts (typically in elderly patients). It is based on morphological criteria and corresponds to the degree of instability of the pelvis [11,12].

The WSES classification takes into account both the anatomical pattern of pelvic fracture and physiological changes in the patient (hemodynamic stability or instability). The WSES Classification divides pelvic ring injuries into three classes (Table 1):

As previously mentioned, the ATLS definition considers a patient “hemodynamically unstable” when blood pressure <90 mmHg and heart rate >120 bpm, with evidence of cutaneous vasoconstriction (cold, moist, reduced capillary refill), an altered level of consciousness and/or dyspnea [23].

Based on this classification, WSES has provided a management algorithm for patients with pelvic trauma [13].

The management of pelvic trauma continues to be a challenge. Pelvic fractures are often the result of high-energy impact and are generally associated with multisystem injuries and catastrophic bleeding. Most deaths related to pelvic fractures have been caused by associated injuries (i.e., brain trauma) [24–26]. Vascular injuries caused by pelvic fractures are potentially lethal because they often manifest as non-compressible multifocal venous bleeding (80–85% of pelvic bleeding) and less frequently arterial bleeding (15–20% of pelvic bleeding). In pelvic trauma, hemorrhage is indeed the most common cause of preventable death [8]. However, the Young–Burgess and Tile classification models do not correlate with the number of transfusions and do not show a consistent correlation with the need for urgent embolization.

The WSES classification of pelvic trauma, in addition to pelvic fracture stability, takes into consideration the hemodynamic conditions of the patient, allowing for an approach that directly targets the stabilization of hemodynamics and the control of pelvic bleeding.

Wang et al. [27], in line with the WSES classification, confirm that in patients with pelvic trauma mortality rates increase significantly with the severity of the injury class (from minor to severe injuries). They also note that the stability/instability of the pelvic ring does not have a significant impact on mortality. Furthermore, Wang et al. highlight the presence of vascular injury and open pelvic fractures as independent factors contributing to mortality [27]. Pelvic vascular injuries have been identified in 7–10% of stable pelvic fractures, often considered minor injuries and typically managed conservatively. Some of these fractures may even require angiographic embolization. Not only should the mechanical stability be assessed, but the associated vascular injury should also be considered in the management algorithm. The impact of mechanical pelvic stability on pelvic fracture mortality was statistically non-significant. However, the associated vascular injury served as an independent risk factor for mortality. Unlike closed fractures, open pelvic fractures can lead to concurrent external bleeding, internal hemorrhage, associated injuries to the ano-rectal or urogenital regions, infections related to contaminated wounds, and other complications (sepsis and multi-organ dysfunction). Patients with open pelvic fractures exhibit significantly worse outcomes (higher mortality rate, increased infection rate, longer hospitalization time, and extended stay in the intensive care unit) compared to patients with closed pelvic fractures of the same WSES class (minor, moderate, and severe) [27].

Li et al. [22] evaluated the application of the WSES classification to patients with open pelvic fractures. In their study, they highlight that even in the case of open pelvic fractures, mortality, duration of intensive care unit admission, and hospitalization duration increase with the rising WSES grade of pelvic trauma. Furthermore, there is a correlation between open pelvic fractures and the development of sepsis. Sepsis proves to be an independent risk factor for mortality in patients with open pelvic fractures. Additionally, patients with sepsis exhibit significantly higher percentages of pelvic instability and associated vascular injuries compared to patients without septicemia. Besides hemorrhage control, the management of wound infection and the potential development of sepsis are crucial in the management of open pelvic fractures (broad-spectrum antibiotics for gram-positive and gram-negative bacteria, surgical debridement, and creation of a diverting colostomy). According to Li et al., the WSES classification is applicable when managing patients with open pelvic fractures; however, they emphasize that by adding the onset of sepsis as an additional variable (WSES classification + sepsis), a better prediction of mortality is achieved in cases of open pelvic fractures [22].

Another fundamental factor in the management of pelvic vascular trauma is time [1]. In this context, the assessment of potentially significant vascular injury and timely hemorrhage control should be the highest priorities in acute management [8].

In a retrospective cohort study, Spering et al. proposed a score to detect pelvic vascular injury in patients with severe pelvic fractures in pre-hospital trauma management. They identified nine predictive factors incorporated into a clinical score to identify patients with pelvic fractures at risk of significant vascular injury (P-VIS) [1].

A score of 0–2 points represents almost no risk of vascular injury, 3–5 points indicate a probable pelvic vascular injury, 6–8 points identify a very probable pelvic vascular injury, and 9 points represent an apparent vascular injury. This score is easy to apply and would suggest early pelvic stabilization through pelvic binding, as well as immediate transfer to a Level I Trauma Center and the subsequent early activation of an extended trauma team with vascular repair capabilities and high transfusion availability.

The severity of hemodynamic and physio-metabolic derangement represents a fundamental issue in the early management of patients with pelvic trauma.

Therefore, a classification of pelvic injuries that considers both the fracture pattern and the hemodynamic status of the patient, such as the WSES classification, appears to have greater utility in clinical practice compared to the diffused anatomical classification.