Haemorrhage control and definitive fixation strategies in unstable pelvic ring fractures: Integrating damage control and endovascular techniques A narrative review

Unstable pelvic ring fractures are associated with life-threatening haemorrhage and mortality rates of 20-40%, requiring rapid and coordinated management. This narrative review synthesises the current evidence for haemorrhage control and definitive fixation strategies in haemodynamically unstable pelvic fractures, encompassing early mechanical stabilisation (pelvic binders, external fixation), pre-peritoneal pelvic packing (PPP), angiographic embolisation (AE), and the evolving role of resuscitative endovascular balloon occlusion of the aorta (REBOA), within a unifying damage control orthopaedics framework. Damage control orthopaedics (DCO) provides the conceptual backbone of the management pathway. Early mechanical stabilisation reduces pelvic volume and re-establishes tamponade; PPP extends this tamponade surgically; and AE provides targeted definitive control of arterial bleeding. These techniques are complementary, not competing, and are integrated in sequence guided by patient physiology and bleeding source. Accumulating evidence from randomised and registry-based studies has raised important questions about routine REBOA deployment - current high-quality evidence, including the UK-REBOA Randomised Clinical Trial, has not demonstrated a survival advantage over standard care, and registry data have raised concerns regarding potential harm in isolated pelvic fractures; however, these findings should be interpreted in the context of the predominantly retrospective and heterogeneous evidence base across this field. Once haemorrhage is controlled and physiology restored, definitive fixation of the pelvic ring - timed according to DCO principles - restores structural stability, enables early mobilisation, and improves long-term functional outcomes. Optimal care requires integration of surgical, endovascular, and orthopaedic strategies within protocol-driven, multidisciplinary trauma systems.