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Excessive blood loss does not just happen when the skin is broken, a bone can be fractured and blood can be lost inside the body. For example, if a thigh bone is broken and the skin is not broken you can loose half to one litre of blood if the skin is broken and there is a bleed this can be increased to one to two litres.
Fractures in the pelvis can cause from minor blood loss of about half a litre to major injuries where you can loose all your blood. The main femoral artery runs over the pelvis which is a major artery.
Injuries to the spleen, liver or chest can cause very minimal blood loss to total blood loss.
The big problem is recognising that severe blood loss is possible or actually happening. It's best to assume the worst and treat as if there is severe blood loss. It is very hard to work out how much blood has been lost with an external bleed and even harder with an internal bleed. It is also difficult to assess blood loss as different people will react in different ways which can cover up signs and symptoms until it gets very serious. Things that can affect the way signs and symptoms show are age, size, weight, underlying medical conditions, their fitness and any medications they are taking.
You need to get as much information as possible about the history of what happened and the assess the mechanism of the injury.
Things to look out for are:
The treatment is to: