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

Abstract

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.

Graphical abstract

1. Introduction

Pelvic ring fractures result from high-energy trauma and are frequently accompanied by severe polytrauma.1, 2, 3 Haemorrhage is the principal cause of early death, with mortality in haemodynamically unstable pelvic fractures ranging from 20 to 40% despite modern trauma care.¹³

Two related but distinct concepts underpin this review. Biomechanical instability denotes loss of structural pelvic ring integrity causing displacement under physiological load, classified by the Young–Burgess and Tile systems.⁴ Haemodynamic instability denotes persistent hypotension attributable to pelvic haemorrhage refractory to resuscitation. This review concerns haemodynamically compromised patients with mechanically disrupted pelvic ring injuries, representing the highest-acuity and highest-mortality cohort.

DCO provides the unifying framework, advocating the minimum intervention necessary to achieve temporary stability and control haemorrhage before physiological restoration allows definitive repair.⁵ Management strategies are divided by temporal phase: early or emergent interventions (binders, external fixation, PPP, AE, REBOA) target haemorrhage control; delayed definitive interventions (ORIF, percutaneous iliosacral fixation) address structural restoration once physiology permits.^6,7

Despite the clinical importance of this topic, several significant gaps remain. No review has comprehensively integrated all tiers of the haemorrhage control pathway within a DCO framework; PPP and AE remain uncompared in any direct randomised trial; the role of REBOA in isolated pelvic fractures is contentious following the UK-REBOA RCT; and existing reviews treat haemorrhage control and definitive fixation as separate topics, failing to reflect the clinical reality in which fixation contributes to haemorrhage control. The aim of this review is to evaluate and integrate haemorrhage control strategies and definitive fixation approaches in haemodynamically unstable pelvic ring fractures within a DCO framework.

2. Methods

A structured literature search of MEDLINE (PubMed), Embase, and the Cochrane Library was performed in January 2025 without language restriction. Search terms combined: ("pelvic fracture" OR "pelvic ring injury") AND ("haemorrhage control" OR "pelvic packing" OR "angiographic embolisation" OR "REBOA" OR "damage control orthopaedics" OR "pelvic fixation" OR "external fixation" OR "pelvic binder"). Reference lists and relevant guidelines — including the World Society of Emergency Surgery (WSES), the Eastern Association for the Surgery of Trauma (EAST), and British Orthopaedic Association standards — were hand-searched.6, 7, 8

Studies were included if they reported outcomes of haemorrhage control or fixation strategies in adults with pelvic ring injuries associated with haemodynamic or mechanical instability; case reports with fewer than five subjects and paediatric studies were excluded. Results are presented as a narrative synthesis; no formal meta-analysis was performed owing to clinical and methodological heterogeneity. Research Objective 1 (RO1): to evaluate early mechanical stabilisation as first-line haemorrhage control within a DCO framework. Research Objective 2 (RO2): to critically compare PPP, AE, and REBOA with respect to efficacy, mortality, complications, and algorithmic role. Research Objective 3 (RO3): to evaluate definitive fixation including DCO timing, surgical approaches, and functional outcomes.

3. Section 1: haemorrhage control in pelvic trauma

3.1. Pathophysiology of pelvic haemorrhage

Haemorrhage arises from three sources: the presacral venous plexus, fractured cancellous bone surfaces, and branches of the internal iliac arterial system.^4,9 Venous and bony sources account for approximately 80–90% of cases and produce diffuse low-pressure bleeding amenable to mechanical tamponade.^4,9 Arterial injury occurs in 10–20% of patients but drives persistent haemodynamic instability disproportionate to its frequency owing to higher intravascular pressure.^9,10 Identifying the dominant bleeding source is fundamental to selecting the most appropriate haemorrhage control strategy.^10,11

Pelvic ring disruption removes the structural constraint on pelvic volume, permitting rapid concealed haemorrhage accumulation.¹² Early mechanical reduction — whether by binder or external fixator — re-establishes this constraint and constitutes the first and most immediately available haemorrhage control intervention.^13,14 Damage-control resuscitation with massive transfusion protocol activation, correction of coagulopathy, hypothermia, and acidosis provides the haemostatic environment within which these interventions can be effective.^15,16

3.2. Early mechanical stabilisation: pelvic binders and external fixation

Consistent with DCO principles, early mechanical stabilisation is the first intervention in the haemorrhage control pathway, achievable without operative access or specialist equipment.^5,6 Circumferential pelvic binders — including commercial devices such as the SAM Pelvic Sling (SAM Medical) and T-POD (Pyng Medical), and universally available improvised alternatives such as a folded sheet secured with a clamp at the greater trochanter level — are applied on clinical suspicion of ring disruption prior to definitive imaging.¹⁷ Bottlang et al. demonstrated biomechanically that circumferential compression reduces pelvic ring diastasis and restores pelvic volume in anteroposterior compression injuries, and Chesser et al. confirmed the importance of early binder application as a temporising measure across prehospital and emergency department phases.^13,14 Binders are most effective in anteroposterior compression injuries; they may paradoxically worsen displacement in lateral compression or vertically unstable patterns.^13,17

External fixation provides greater mechanical rigidity and is applied in the operative DCO phase.¹⁵ Croce et al. reported that emergent anterior external fixation facilitated haemostasis in exsanguinating pelvic fractures, and Ertel et al. demonstrated that C-clamp application combined with pelvic packing reduced early mortality in vertically unstable posterior ring injuries.^18,19 Ghanayem et al. established that emergent pelvic stabilisation — regardless of modality — significantly reduced transfusion requirements and improved early survival.²⁰ These early mechanical interventions collectively represent the orthopaedic component of damage control resuscitation, and their integration with surgical and endovascular haemorrhage control defines the conceptual framework of the entire management pathway.

3.3. Pre-peritoneal pelvic packing

PPP is the preferred operative haemorrhage control technique when mechanical stabilisation alone fails.^6,21 Via a lower midline or Pfannenstiel incision, surgical packs are placed against the pelvic sidewalls and presacral region without entering the peritoneal cavity.^21,22 Its mechanism — direct compression tamponade — is the operative extension of binder application within the DCO framework, and PPP can be performed in any operating theatre without interventional radiology infrastructure.^4,9

Cothren et al. reported mortality reduction from 40% to 24% following PPP protocol adoption, and Burlew et al. demonstrated a statistically significant reduction from 45% to 21% (p < 0.05).^21,22 Smith et al. reported successful haemostasis in 85% of patients.²³ PPP can be performed within 20–30 min of theatre access — a critical advantage over AE where delays of 30–60 min or more are common.²⁴ Limitations include reduced efficacy for isolated arterial haemorrhage, wound infection, abdominal compartment syndrome, and requirement for pack removal under a second anaesthetic at 24–48 h.²²

3.4. Angiographic embolisation

AE provides targeted endovascular control of arterial haemorrhage: Agolini et al. reported 85% haemostasis with 7% mortality in embolised patients, and Velmahos et al. achieved 97% technical success, noting that overall mortality was predominantly determined by polytrauma severity.^25,26 Tanizaki et al. demonstrated significantly higher haemorrhage control rates when AE was performed within 60 min of arrival, establishing time-to-embolisation as a key determinant of outcome.²⁴ Contrast-enhanced CT demonstrating arterial extravasation is the principal imaging trigger for AE.

AE is constrained by resource and infrastructure dependency: mobilisation of an interventional radiology team can impose hazardous delays in the rapidly deteriorating patient.^7,24 Contemporary protocols therefore employ PPP as the initial operative intervention, with AE reserved for patients with persistent instability or CT-confirmed arterial extravasation.^6,7 Hybrid operating theatres combining surgical and fluoroscopic capability may mitigate this time penalty in high-volume centres.⁶

3.5. REBOA: evidence and current role

REBOA involves Zone III balloon inflation to reduce distal haemorrhage while maintaining cardiac and cerebral perfusion.²⁷ Jansen et al.’s UK-REBOA Randomised Clinical Trial found no statistically significant survival benefit over standard care at 90 days.²⁸ Chien et al., using propensity-matched Trauma Quality Improvement Program (TQIP) registry data, found REBOA in isolated severe pelvic fractures was associated with significantly higher in-hospital mortality (32.3% vs 19.0%, p = 0.008) and greater venous thromboembolism rates.²⁹ Castellini et al.’s systematic review found no demonstrable benefit over standard damage control approaches, and Harfouche et al.’s GRADE (Grading of Recommendations, Assessment, Development and Evaluation)-based EAST meta-analysis of 31 studies concluded that evidence is insufficient to support routine REBOA use.^{8, 30} Recognised risks include limb ischaemia, femoral access site injury, and acute kidney injury.

Current consensus supports REBOA only as a bridge in highly selected patients at centres with established expertise, training, and governance, and explicitly states it should not replace PPP or AE.^6,8 When evidence quality is graded, REBOA is the only strategy in this review supported by an RCT — and that RCT is negative.

A comparison of the principal haemorrhage control strategies, including pre-peritoneal pelvic packing (PPP), angiographic embolisation (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA), is summarised in Table 1.

Table 1.

Comparison of haemorrhage control strategies in haemodynamically unstable pelvic fractures.

Feature	PPP	Angiographic Embolisation	REBOA
Mechanism	Surgical tamponade venous/bony; DCO operative extension21	Selective endovascular occlusion arterial bleeders; coils/particles25,26	Zone III balloon inflation; reduces distal aortic outflow; preserves cardiac perfusion27
Primary target	Venous/bony (80-90%)4,9	Arterial (10-20%; disproportionate haemodynamic impact)9,10	Non-compressible torso/pelvic; arterial or mixed
Setting	Any operating theatre; no IR resources	Angiography suite or hybrid theatre; IR team essential	ED or theatre; endovascular expertise required
Speed	∼20-30 min from theatre access21,22	30-60+ min delay for IR mobilisation24	Potentially rapid; femoral access + fluoroscopy required
Mortality evidence	Burlew et al.: 45% to 21% (p < 0.05)22 Cothren et al.: 40% to 24%21	Agolini et al.: 7% mortality25 Velmahos et al.: 97% technical success26	Jansen et al. RCT: no survival benefit28 Chien et al.: 32.3% vs 19% (p = 0.008)29
Evidence grade	Before-after protocol studies; no RCT vs AE. Moderate.	Retrospective series and registry data; no RCTs. Moderate.	1 RCT (no benefit); GRADE very low-low across 31 studies28,30,8
Role in algorithm	First-line operative; bridge to AE if arterial source suspected	Definitive arterial haemostasis; after PPP or in stabilised patients with CT blush	Selected patients in extremis at experienced centres only; not to replace PPP/AE6,8

Abbreviations: PPP = pre-peritoneal pelvic packing; AE = angiographic embolisation; REBOA = resuscitative endovascular balloon occlusion of the aorta; DCO = damage control orthopaedics; IR = interventional radiology; ED = emergency department; RCT = randomised controlled trial; CT = computed tomography; GRADE = Grading of Recommendations, Assessment, Development and Evaluation.

3.6. Mortality and algorithm: synthesis

The integrated management pathway synthesised from the reviewed literature is illustrated in Fig. 1. PPP data are compelling in directionality but use before-and-after designs susceptible to confounding.^21,22 For AE, the critical insight from Tanizaki et al. is not superiority over PPP but the decisive importance of time: delays beyond 60 min are independently associated with worse outcomes.²⁴ REBOA is the only strategy in this review supported by an RCT — and that RCT is negative, with no survival benefit demonstrated and statistically significant harm in isolated pelvic fractures reported.^28,29 These findings suggest that time to haemorrhage control, rather than choice of modality alone, is the dominant determinant of survival.

Fig. 1.

Suggested Management Algorithm for Haemodynamically Unstable Pelvic Ring Fractures. This algorithm was developed by the authors based on synthesis of the reviewed literature and current international guidelines.

Contemporary algorithms, guided by the WSES classification, implement binder application on clinical suspicion, activate massive transfusion protocol, then stratify by haemodynamic response: stabilised patients proceed to CT; those with persistent instability proceed to the operative phase with external fixation or C-clamp followed immediately by PPP.^6,15,19 Post-packing reassessment determines whether AE is required.^6,7 The choice between PPP and AE should not be framed as binary: as Suzuki et al. demonstrated, the two techniques address physiologically distinct sources and function optimally in sequence.³¹ A pre-agreed, protocol-driven algorithm that removes decision-making latency is the fundamental requirement.⁶

4. Section 2: definitive internal fixation in unstable pelvic ring injuries

4.1. Classification and fixation Goals

Pelvic ring injuries range from stable fractures to severely disrupted unstable patterns. The posterior pelvic ring — specifically the sacroiliac complex — provides the majority of structural stability; posterior ring disruption defines the most unstable injury patterns.⁴ The Young–Burgess and Tile classifications characterise mechanism and instability type to guide fixation strategy, and the WSES classification integrates haemodynamic status into stratification, bridging the haemorrhage control and definitive fixation phases.^4,6

Definitive fixation aims to restore anatomical alignment, achieve durable structural stability, and enable early mobilisation.^4,32 Non-operative management of unstable injuries is associated with malunion, chronic pain, neurological deficit, and long-term functional impairment.^32,33 Importantly, definitive fixation is not merely a rehabilitative procedure: by restoring pelvic ring integrity, it eliminates residual fracture surface motion and abolishes ongoing cancellous bone haemorrhage that persists when the ring remains disrupted.^4,32

4.2. Evidence for outcome benefit

Papakostidis et al. found operative stabilisation was consistently associated with superior functional recovery compared with non-operative management.³² Pohlemann et al., in the German Pelvic Trauma Registry, demonstrated improved functional outcomes and significantly earlier mobilisation following surgical stabilisation.³³ Trikha et al. reported that combined anterior and posterior fixation was associated with superior reduction quality and lower implant failure rates compared with isolated anterior fixation, with functional outcomes at one year favouring anatomical reduction.³⁴ Kabak et al. demonstrated that operatively managed patients achieved significantly higher Majeed Pelvic Scores at two-year follow-up, with combined anterior-posterior fixation conferring the most durable stability in rotationally and vertically unstable patterns.³⁵

The evidence base is predominantly observational; randomised trials are absent. Quality of reduction is a recognised determinant of outcome, and the consistency of observational evidence supports operative stabilisation as current standard of care, reflected in international guidelines.^6,36,37

4.3. DCO principles and timing of definitive fixation

DCO governs the timing of definitive fixation just as it governs early haemorrhage control. Pape et al. established that fracture fixation during the early “first hit” of major trauma contributes an additional systemic inflammatory “second hit” that can precipitate multiorgan failure.⁵ DCO mitigates this risk by substituting temporary external fixation — achieved rapidly at low physiological cost — for early definitive repair, with conversion once lactate, base deficit, coagulopathy, and core temperature normalise.^5,15,18 Early total care is appropriate only in haemodynamically stable patients with isolated injuries and rapid physiological recovery; the decision requires individualised multidisciplinary assessment.

4.4. Surgical approaches and fixation techniques

Anterior ring disruption is stabilised by symphyseal plating or the anterior subcutaneous internal fixator (INFIX), which offers superior patient comfort, eliminates the external frame, reduces pin-site complications, and has lateral femoral cutaneous nerve irritation as the most common complication.^38,39 Posterior ring stabilisation is most commonly achieved by minimally invasive percutaneous iliosacral screw fixation offering reduced surgical trauma and improved accuracy with CT-based navigation, while spinopelvic fixation is reserved for transverse sacral fractures with spinopelvic dissociation (Denis Zone II/III).^4,40,41

In summary, definitive fixation should be understood as the final and necessary step in the haemorrhage control pathway. The principal temporary and definitive fixation strategies, together with their indications, advantages, and limitations, are summarised in Table 2. Anatomical reduction and combined anterior-posterior fixation are associated with the best functional outcomes, though the absence of prospective comparative trials limits the ability to determine superiority between fixation strategies, and current practice remains guided by fracture pattern and surgeon experience rather than high-level evidence — a deficit that future multicentre registries must address.32, 33, 34, 35

Table 2.

Fixation Strategies for Unstable Pelvic Ring Injuries: Early Stabilisation vs Definitive Fixation.

Phase	Technique	Principal indication	Advantages	Limitations
Early	Circumferential binder	Suspected ring disruption — prehospital/ED	Immediate; no operative access; reduces pelvic volume13,14,17	Limited in LC/VS patterns; soft tissue risk if prolonged
Early	Anterior external fixation	Anterior ring instability; DCO operative phase	Rapid; low physiological burden; widely available15,18	Insufficient alone for posterior instability; pin-site risk
Early	Pelvic C-clamp	Posterior ring instability in extremis	Direct posterior compression; effective with PPP19	Technique-demanding; iatrogenic risk if malpositioned
Definitive	Symphyseal plating (ORIF)	Pubic symphysis diastasis (APC II/III)	Anatomical reduction; durable anterior stability4	Open approach; wound risk with urological injury
Definitive	Percutaneous SI screws	Posterior ring disruption (SI joint/sacral)	Minimally invasive; low blood loss; navigation-assisted40,41	Technique-demanding; neurovascular risk; sacral dysmorphism
Definitive	Spinopelvic fixation	Transverse sacral fracture — Denis Zone II/III	Robust stability; early mobilisation4	Extensive dissection; higher complication rate
Definitive	INFIX	Anterior ring instability; alternative to ex-fix	No external frame; improved comfort38,39	LFCN irritation; not all fracture patterns suitable

Abbreviations: ED = emergency department; DCO = damage control orthopaedics; PPP = pre-peritoneal pelvic packing; APC = anteroposterior compression; ORIF = open reduction and internal fixation; SI = sacroiliac; LC = lateral compression; VS = vertical shear; INFIX = anterior subcutaneous internal fixator; LFCN = lateral femoral cutaneous nerve.

5. Future directions

The most pressing gap is the absence of prospective multicentre data evaluating integrated haemorrhage control pathways as complete systems.^6,7 For REBOA, Jansen et al.’s negative RCT does not preclude benefit in specific subgroups, and prospective evaluation of partial REBOA and intermittent inflation strategies is ongoing.^28,42 In the fixation domain, adoption of validated patient-reported outcome measures — such as the Majeed Pelvic Score and EQ-5D — as standard registry endpoints, and rigorous prospective evaluation of CT-based navigation for iliosacral fixation, would substantially improve the evidence base.

5.1. Limitations

This narrative review has several limitations. The structured literature search was not subject to formal PRISMA-compliant dual independent screening. The evidence base for PPP and AE consists predominantly of retrospective before-and-after protocol studies; no randomised controlled trial has directly compared these interventions. The UK-REBOA RCT enrolled 90 patients across a limited number of UK centres, restricting generalisability. Heterogeneity in functional outcome measures across fixation studies — Majeed Pelvic Score, Hannover Pelvic Outcome Score, SF-36, and EQ-5D — precludes quantitative synthesis.

6. Conclusion

DCO provides the unifying framework for management of haemodynamically unstable pelvic ring fractures. Early mechanical stabilisation with binders and external fixation addresses the predominant venous and bony haemorrhage source through volume reduction and tamponade and must precede all other interventions.^13,14,20 PPP extends this tamponade surgically; AE provides targeted definitive control of arterial haemorrhage. These techniques are complementary, deployed in sequence guided by patient physiology, bleeding source, and institutional infrastructure.^6,31

REBOA remains a technique of uncertain benefit. Jansen et al.’s RCT found no survival advantage, Chien et al.’s analysis raised concerns about harm in isolated pelvic fractures, and Harfouche et al.’s GRADE meta-analysis found evidence insufficient for a positive recommendation.^8,28,29 REBOA should be reserved for highly selected patients at experienced centres and must not replace PPP or AE.

Definitive pelvic ring fixation, timed according to physiological recovery and DCO principles, restores structural stability, eliminates ongoing fracture surface haemorrhage, and improves long-term functional outcomes.32, 33, 34, 35 Optimal outcomes depend on trauma systems that can deliver this integrated, sequential, protocol-driven pathway from first contact to definitive reconstruction.

Guardian/patient's consent

Not applicable. This study did not involve human participants, patient data, or identifiable patient information.

Ethical statement

Ethical approval was not required for this narrative review as it involved analysis and synthesis of previously published literature only.

CRediT author statement

Mohammed Tanvir Shah: Conceptualization, methodology, literature review, writing – original draft, writing – review & editing.

Shuheda Khatun Shah: Literature review, writing – review & editing.

Muhammed Monjur Ahmed: Literature review, writing – review & editing.

Ismail Abdullah Rahim: Writing – review & editing.

Declaration of generative AI in scientific writing

AI-assisted writing tools were used for grammar checking. All clinical content, data interpretation, literature selection, and scientific conclusions were generated, reviewed, and verified by the authors. No AI tool was used to generate original data, produce figures or tables, or replace the intellectual contribution of the authors.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.