Venous thromboembolism (VTE) in patients with major pelvic fractures who undergo preperitoneal pelvic packing (PPP) has not been investigated. We hypothesized that patients who undergo PPP are at high risk for VTE, thus early prophylactic anticoagulation and screening duplex are warranted. All patients requiring PPP from 2015 to 2019 were reviewed. Management and outcomes were analyzed. During the study period, 79 patients underwent PPP. Excluding the early deaths, 17 patients had deep venous thrombosis (DVT) and 6 had pulmonary emboli (PE); 4 patients had both DVT/PE. Overall mortality was 15%. Thirty-two patients underwent screening duplex within 72 h of admission and 10 were positive for DVT. Patients with complex pelvic trauma undergoing PPP have a 23% incidence of DVT and an additional 8% incidence of PE. 31% of screening ultrasounds are positive. The overall mortality was 15%. With a high incidence of VTE in this patient population, we recommend screening duplex ultrasounds. •Preperitoneal pelvic packing (PPP) controls hemorrhage in pelvic fracture patients.•DVT incidence in PPP patients was 23%, with an additional 8% incidence of PE.•Mortality rate for our PPP patient cohort was 15%, versus published rates of 24–32%.•We recommend screening ultrasound, with packs in place, and early DVT prophylaxis.•Studies should investigate use of IVC filters and alternative packing techniques.