Open pelvic fractures are among the most devastating injuries encountered in modern trauma surgery, representing approximately 2% - 4% of all pelvic fractures but accounting for disproportionately high rates of morbidity and mortality. Their severity results from the combination of unstable pelvic ring disruption, massive hemorrhage, extensive soft-tissue destruction, and frequent associated injuries involving the genitourinary tract, gastrointestinal tract, and major vascular structures. Despite advances in organized trauma systems and damage control resuscitation, these injuries continue to be associated with mortality rates ranging from 15% to more than 40%, depending on the mechanism of injury, degree of hemodynamic instability, extent of soft-tissue contamination, and associated visceral damage [1].

The mechanism of injury is typically high-energy blunt trauma, most commonly resulting from motor vehicle collisions, motorcycle crashes, crush injuries, or falls from height. Consequently, patients frequently present with severe multisystem trauma, reflected by high Injury Severity Scores and the need for simultaneous management of orthopedic, abdominal, vascular, urologic, and colorectal injuries. Among all patterns of pelvic trauma, unstable open fractures associated with perineal wounds represent a particularly challenging subset because direct communication between the fracture site and the external environment substantially increases the risk of bacterial contamination, pelvic sepsis, necrotizing soft-tissue infection, and multiple organ failure. The extent and anatomical location of the perineal injury have also been shown to correlate with infectious complications and overall prognosis, highlighting the importance of early recognition and appropriate classification of these injuries [2].

Historically, mortality following open pelvic fractures was primarily attributed to uncontrolled hemorrhage during the initial hours after injury. However, improvements in prehospital care, balanced massive transfusion protocols, pelvic stabilization techniques, preperitoneal pelvic packing, and selective angioembolization have significantly improved early survival. As a result, delayed complications—particularly pelvic sepsis resulting from fecal contamination, devitalized soft tissues, and missed anorectal injuries—have become increasingly important determinants of outcome. This evolution has shifted treatment priorities from isolated fracture fixation toward comprehensive physiologic resuscitation and staged multidisciplinary management, in which hemorrhage control, contamination control, and repeated surgical assessment take precedence over immediate definitive orthopedic reconstruction [3].

Current management therefore relies on the principles of damage control surgery integrated with a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, colorectal surgeons, urologists, plastic and reconstructive surgeons, interventional radiologists, and critical care specialists. Contemporary recommendations emphasize early adherence to Advanced Trauma Life Support (ATLS) principles, prompt hemorrhage control, aggressive debridement of contaminated tissues, selective fecal diversion according to wound characteristics, broad-spectrum antimicrobial therapy, serial wound reassessment, and delayed definitive pelvic fixation after physiologic stabilization. Although these principles are widely accepted, the rarity of open pelvic fractures has limited the availability of prospective studies, and most recommendations continue to rely on retrospective series, institutional experience, and expert consensus [4]-[6].

In this report, we describe the staged multidisciplinary management of a young patient with an unstable open pelvic fracture associated with extensive perineal soft-tissue disruption and intra-abdominal injuries. In addition to detailing the sequential surgical strategy employed, we review the contemporary evidence supporting damage control principles, contamination management, staged orthopedic stabilization, and reconstructive techniques in one of the most challenging scenarios encountered in trauma surgery.

A 24-year-old previously healthy male was brought to the emergency department after a high-speed motorcycle collision with a truck. The patient was helmeted at the time of the accident and was transported by advanced life support ambulance as a major trauma activation approximately 45 minutes after injury. On arrival (day 0), he was hemodynamically unstable, with a blood pressure of 82/48 mmHg, heart rate of 136 beats/min, respiratory rate of 30 breaths/min, oxygen saturation of 93% while receiving oxygen through a non-rebreather mask, and a Glasgow Coma Scale (GCS) score of 13 (E3V4M6). Initial laboratory evaluation was consistent with severe hemorrhagic shock, with a hemoglobin concentration of 8.5 g/dL, serum lactate of 6.8 mmol/L, and a base deficit of −11 mmol/L. The Injury Severity Score (ISS) was calculated at 38.

Primary assessment following Advanced Trauma Life Support (ATLS) principles revealed an extensive contaminated perineal laceration extending from the perineum toward the right gluteal region, with complete disruption of the pelvic floor musculature and active hemorrhage. Palpable instability of the pelvic ring was noted, and gross contamination of the wound raised immediate concern for direct communication between the fracture hematoma and the external environment. These findings established the diagnosis of an unstable open pelvic fracture with extensive perineal soft-tissue injury and suspected concomitant visceral trauma, representing an immediately life-threatening injury requiring multidisciplinary intervention (Figure 1).

Figure 1. Initial clinical presentation. Extensive perineal soft-tissue injury associated with an unstable open pelvic fracture following high-energy blunt trauma. The large perineal laceration demonstrates severe disruption of the pelvic floor soft tissues, highlighting the need for immediate hemorrhage control, contamination control, and a staged multidisciplinary surgical approach prior to definitive pelvic fixation.

The massive transfusion protocol was immediately activated, and balanced damage-control resuscitation with packed red blood cells, fresh frozen plasma, and platelets was initiated. A pelvic binder was applied on arrival to provide temporary mechanical stabilization. Focused Assessment with Sonography for Trauma (FAST) demonstrated free intraperitoneal fluid. Following a transient hemodynamic response to resuscitation sufficient to permit further diagnostic evaluation, urgent contrast-enhanced computed tomography (CT) was performed.

Initial anteroposterior pelvic radiography demonstrated marked pubic symphysis diastasis compatible with an unstable anteroposterior compression (APC type III) pelvic ring injury. Contrast-enhanced CT of the abdomen and pelvis demonstrated free intraperitoneal air consistent with hollow-viscus perforation. Additional findings included extensive disruption of the pelvic floor and perineal soft tissues, diffuse emphysema extending throughout the pelvic compartments, traumatic displacement of the right testicle, and active contrast extravasation consistent with ongoing pelvic arterial hemorrhage. No major thoracic injuries were identified. A closed fracture of the right tibial shaft was diagnosed during the secondary survey. Overall, imaging confirmed a complex multisystem injury involving the pelvic ring, gastrointestinal tract, genitourinary structures, and extensive perineal soft tissues (Figure 2).

Figure 2. Initial radiologic assessment of the pelvic injury. (a) Anteroposterior pelvic radiograph obtained at admission demonstrating an unstable anteroposterior compression (APC type III) pelvic ring injury with marked pubic symphysis diastasis. (b) Axial contrast-enhanced computed tomography (CT) showing free intraperitoneal air (arrow), highly suggestive of associated hollow viscus injury. (c) Axial CT demonstrating extensive disruption of the pelvic floor and perineal soft tissues with emphysema extending through the pelvic compartments. (d) Contrast-enhanced CT revealing traumatic displacement of the testicle associated with active contrast extravasation (arrows), consistent with ongoing pelvic hemorrhage.

Given the patient’s profound physiologic derangement and the need for immediate control of both hemorrhage and intra-abdominal contamination, the multidisciplinary trauma team proceeded directly to emergency damage-control surgery on day 0. Exploratory laparotomy confirmed multiple small-bowel perforations with fecal contamination of the abdominal cavity. Segmental small-bowel resection with primary stapled anastomosis was performed, followed by extensive abdominal irrigation. Because of the extensive perineal injury and substantial risk of continued pelvic contamination, a diverting sigmoid loop colostomy was created during the same operative stage. Preperitoneal pelvic packing was simultaneously performed for hemorrhage control, while temporary mechanical stabilization of the pelvic ring was maintained during the resuscitative phase.

Although CT had demonstrated active arterial contrast extravasation, immediate operative management was prioritized because of the concomitant hollow-viscus perforations, fecal contamination, severe perineal injury, and profound physiologic instability requiring urgent surgical source control. During the first 24 hours, the patient required eight units of packed red blood cells, eight units of fresh frozen plasma, and one pooled platelet concentrate. Hemodynamic stabilization was accompanied by progressive correction of metabolic acidosis, providing objective evidence of response to damage-control resuscitation.

Following the initial operation, the patient was admitted to the intensive care unit (ICU), where he remained for eight days under coordinated management involving trauma surgery, orthopedic surgery, colorectal surgery, urology, plastic surgery, anesthesiology, and critical care. During this period, priorities included correction of coagulopathy and metabolic derangement, restoration of adequate tissue perfusion, antimicrobial therapy, nutritional support, and repeated assessment of the contaminated perineal wound. Progression from damage-control management toward definitive reconstruction was based on sustained hemodynamic stability, correction of the initial metabolic derangement and coagulopathy, adequate tissue perfusion, and evidence of satisfactory local source control rather than on a predetermined time interval alone.

Broad-spectrum empirical antimicrobial therapy was initiated because of the open contaminated pelvic fracture, extensive perineal injury, and documented intestinal perforation with fecal contamination. Local control of contamination was assessed through serial operative examinations, including the absence of progressive tissue necrosis or purulent collections, removal of nonviable tissue, and progressive development of a viable wound bed.

Planned serial returns to the operating room were undertaken at approximately 48 - 72-hour intervals for meticulous irrigation, aggressive debridement of devitalized tissue, and repeated assessment of soft-tissue viability. Operative exploration demonstrated extensive disruption of the pelvic floor musculature and perineal soft tissues (Figure 3). Following adequate source control, subsequent examinations showed no evidence of progressive necrosis. As the wound demonstrated viable tissue and favorable evolution, negative-pressure wound therapy was incorporated to promote granulation tissue formation and optimize the wound bed for delayed reconstruction. Thus, progression between surgical stages was guided by both systemic physiologic recovery and serial confirmation of satisfactory local wound control rather than by time alone.

Figure 3. Intraoperative exploration demonstrating extensive disruption of the perineal soft tissues following high-energy blunt pelvic trauma. The operative findings confirmed severe involvement of the pelvic floor with complex soft-tissue injury, emphasizing the need for meticulous debridement, contamination control, serial wound assessment, and staged reconstruction before definitive orthopedic fixation.

After physiologic recovery and control of local contamination, definitive orthopedic reconstruction was undertaken during the fourth operative stage. Open reduction and internal fixation of the anterior pelvic ring was performed, achieving satisfactory reduction of the pubic symphysis. Definitive fixation of the associated right tibial shaft fracture was performed during the same surgical session, thereby restoring overall musculoskeletal stability while avoiding an additional anesthetic exposure. Postoperative radiographs demonstrated satisfactory alignment of the pelvic ring and appropriate positioning of the fixation implants without immediate mechanical complications (Figure 4).

Figure 4. Postoperative anteroposterior radiograph of the pelvis and right leg following definitive surgical stabilization. Internal fixation successfully restored the integrity of the anterior pelvic ring after physiologic stabilization and completion of the damage control phase. Concomitant fixation of the associated tibial fracture was performed during the same reconstructive stage, reflecting the multidisciplinary and staged approach to complex musculoskeletal trauma.

Definitive reconstruction of the residual perineal defect was subsequently performed once serial operative assessments demonstrated adequate source control, absence of progressive necrosis or clinically evident local infection, and satisfactory development of healthy granulation tissue. Progressive wound healing occurred without evidence of recurrent pelvic sepsis or deep surgical-site infection. Early rehabilitation was initiated during hospitalization and included passive and active range-of-motion exercises, respiratory physiotherapy, and progressive mobilization. The patient was discharged home on hospital day 32 in stable clinical condition.

At six-month outpatient follow-up, the patient remained free of clinically apparent infectious complications. Serial radiographic assessment demonstrated maintained pelvic reduction and progressive osseous union of both the pelvic ring and right tibial fracture. The perineal wound had healed completely, and the patient had regained independent ambulation without assistive devices. Mild discomfort persisted during prolonged walking and strenuous physical activity, but there was no clinical or radiographic evidence of recurrent pelvic instability, chronic osteomyelitis, or recurrent soft-tissue infection. Urinary and fecal continence were preserved on clinical follow-up. The diverting colostomy had also been successfully reversed. Overall, the patient’s course demonstrates successful staged management in which hemorrhage control, gastrointestinal and perineal contamination control, serial debridement, delayed skeletal stabilization, soft-tissue reconstruction, and rehabilitation were sequentially prioritized according to evolving physiologic and local wound conditions.

Open pelvic fractures associated with extensive perineal injury remain among the most complex emergencies in trauma surgery, requiring prompt recognition and coordinated multidisciplinary management. Survival depends not only on effective hemorrhage control but also on early contamination control, repeated debridement, physiologic stabilization, and appropriately timed definitive skeletal reconstruction. The favorable outcome achieved in this case supports the effectiveness of a staged damage control strategy integrating trauma, orthopedic, colorectal, urologic, reconstructive, and critical care teams.

The evidence-based management algorithm proposed in Figure 5, together with the staged recommendations summarized in Table 1, provides a practical framework for the sequential management of these devastating injuries. Although additional multicenter studies are needed to strengthen the available evidence, adherence to these fundamental principles may contribute to reducing mortality, minimizing infectious complications, and improving long-term functional outcomes in patients with unstable open pelvic fractures and severe perineal soft-tissue injury.

Written informed consent was obtained from the patient for the publication of this case report and the accompanying clinical images. All identifying information was removed to protect patient confidentiality. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Institutional Review Board approval was not required for the publication of a single anonymized case report, according to local institutional policies.

During the preparation of this manuscript, the authors used Claude (Anthropic) and ChatGPT (OpenAI) solely as AI-assisted editorial tools. Their use was limited to language and copy editing, including correction of grammar, spelling, syntax, and punctuation; refinement of selected sentences to improve semantic clarity, readability, and academic style; and assistance in improving the wording and description of the figures and their corresponding legends. These tools were not used to generate the scientific content of the manuscript, formulate the clinical interpretation or conclusions, analyze data, make diagnostic or therapeutic decisions, or generate or select references. All AI-assisted suggestions were critically reviewed, verified, and revised as necessary by the authors. The authors take full responsibility for the accuracy, integrity, and final content of the manuscript.

Conceptualization, A.D.A.-U., P.C.-M., K.M.-L. and V.L.-M.; investigation, L.B.-L., E.F.-P., B.S.-M. and J.R.-D.; data curation, J.P.P.-C.; writing—original draft preparation, G.C.-N., S.R.-M. and C.B.-T.; writing—review and editing, G.C.-N., S.R.-M., C.B.-T., A.D.A.-U. and K.M.-L.; visualization, A.D.A.-U. and K.M.-L.; project administration, A.D.A.-U. and K.M.-L. All authors have read and agreed to the published version of the manuscript.