UNSTABLE PELVIC FRACTURE: INITIAL MANAGEMENT AND HEMORRHAGE CONTROL

Abstract

DOI: https://doi.org/10.46296/yc.v10i19.0988

Abstract

Introduction: Unstable pelvic ring fractures associated with hemorrhagic shock constitute a time-critical emergency. Mortality is linked not only to the anatomical severity of the injury but also to the speed with which mechanical and hemostatic control is achieved. Controversies persist regarding the optimal sequence of preperitoneal pelvic packing (PPP), angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA). Objective: To synthesize the evidence available up to April 30, 2026, regarding initial management and hemorrhage control strategies in adults with unstable pelvic fractures and hemodynamic instability, prioritizing studies with retrievable full text. Methods: A systematic review guided by PRISMA 2020. Reproducible search strategies were designed for PubMed/MEDLINE, Google Scholar, SciELO, and Scopus, using terms related to pelvic fracture, hemodynamic instability, hemorrhage, pelvic binder, preperitoneal packing, angioembolization, and REBOA. Primary studies involving adults, published between 2000 and April 30, 2026, with retrievable full text and clinical outcomes regarding hemorrhage control, were included. Due to the heterogeneity of populations, definitions, and therapeutic sequences, as well as the overlap of national cohorts, a structured narrative synthesis was performed instead of a *de novo* meta-analysis. Results: Fifteen primary studies were included. Circumferential pelvic stabilization is an immediate measure that can be implemented quickly, although recent studies show frequent placement errors. PPP provides rapid control of predominantly venous/osseous bleeding and is consistently associated with reduced transfusion requirements; between 9% and 31% of patients in some series required secondary AE. AE is the definitive treatment for arterial bleeding, and contemporary studies emphasize that its benefit depends on rapid access. Adjusted comparisons between PPP and AE do not show uniform causal superiority; The choice is strongly conditioned by the severity and the context. REBOA can transiently raise central pressure, but the evidence remains observational, inconsistent, and subject to confounding by indication; it should be considered a rescue bridge rather than a definitive therapy. Conclusions: Evidence supports a physiological and resource-dependent algorithm: damage-control resuscitation, a correctly placed binder, rapid exclusion of other sources of hemorrhage, and prompt access to the most readily available definitive treatment. In centers with immediate endovascular capabilities, arterial embolization (AE) is appropriate when arterial bleeding is suspected; in cases of profound shock, the need for laparotomy, or delays in endovascular intervention, pelvic packing (PPP) combined with mechanical stabilization offers rapid control and can be supplemented by AE. There is no high-certainty evidence to justify a "one-size-fits-all" strategy for all patients.

Keywords: pelvic fractures; hemorrhage; hemorrhagic shock; therapeutic embolization; preperitoneal packing; REBOA; damage control.