Unstable pelvic fractures in patients with hemodynamic instability: global treatment controversies

Pelvic fractures associated with hemodynamic instability present a major challenge in trauma care, carrying mortality rates up to 30%. Successful management requires a multidisciplinary approach focused on resuscitation, mechanical stabilization, and hemorrhage control. Based on the 2024 International Orthopaedic Trauma Association (IOTA) Annual Meeting Pelvic Symposium, this review summarizes current recommendations for the management of hemodynamically unstable patients with pelvic fractures. Initial skeletal stabilization typically involves noninvasive pelvic binding devices, such as sheets or commercially available binders, employed in both pre-hospital and hospital settings. Subsequent resuscitation strategies include hypotensive resuscitation-restricting fluid administration to maintain lower blood pressure until bleeding is controlled-and damage control resuscitation-consisting of rapid surgical interventions aimed at achieving hemostasis. Current best practice also includes early empirical administration of balanced transfusion products guided by massive transfusion protocols, with targeted adjustments based on point-of-care testing results. Hemorrhage control methods vary depending on available resources: angioembolization effectively manages arterial bleeding in well-resourced facilities, whereas preperitoneal pelvic packing offers a quick, accessible solution for venous and bone-related hemorrhage, particularly in low-resource environments. Although the timing of pelvic binder removal and definitive invasive skeletal stabilization remains controversial, recent evidence supports early definitive internal fixation within 24 hours post-injury.