A 35-year-old male is brought in after a high-speed motor vehicle collision. He is hypotensive (BP 80/60 mmHg) with obvious pelvic instability on examination. A pelvic X-ray shows an 'open book' injury (AP compression type II, Young-Burgess classification). The most urgent hemostatic intervention for ongoing pelvic hemorrhage after pelvic binder application has temporarily stabilized the ring is:

• A Immediate exploratory laparotomy for vessel ligation
• B REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) at Zone III followed by pre-peritoneal packing if angiography is unavailable or patient is too unstable ✓
• C Angioembolisation of the internal iliac vessels if CT angiography confirms arterial bleeding
• D External fixator application alone is definitive hemorrhage control

Explanation

Modern damage-control management of hemodynamically unstable pelvic fractures uses a tiered algorithm. After pelvic binder/sheet application (which closes the pelvic volume and tamponades venous bleeding in APC injuries), if hemodynamic instability persists, the next step depends on institutional capability: pre-peritoneal pelvic packing (PPP) directly tamponades the pelvic retroperitoneum and is effective for both arterial and venous sources; REBOA Zone III (infrarenal aorta) provides temporary hemostasis bridging the patient to definitive control. CT angiography with selective angioembolisation is preferred when the patient can tolerate imaging and arterial blush is confirmed. Angioembolisation is poor for venous hemorrhage (predominant in 80% of pelvic fractures). External fixation stabilises the ring but does not address retroperitoneal bleeding.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.