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The management of hemodynamically unstable patients with displaced pelvic ring fractures and associated abdominal, thoracic, or head injuries is controversial. We studied 312 consecutive trauma patients with pelvic fractures admitted from July 1, 1989 through June 30, 1993: thirty-six of these patients were in shock (SBP < 90 mm Hg) and were treated by a protocol including volume resuscitation, and treatment of the associated injuries, without use of acute external fixation. Evaluation of the pelvic fractures revealed 39% to be rotationally unstable; 61% were both rotationally and vertically unstable. The mean Injury Severity Score was 27 ± 12, the average Glasgow Coma Scale score was 12 ± 5, and the Abbreviated Injury Scale (AIS) scores stratified for the abdomen and the thorax were 1.9 ± 1.7 and 1.6 ± 1.8, respectively. Eighteen patients required thoracotomy, laparotomy, or both. The total blood requirement in the initial 24 hours postinjury was 4.0 ± 4 Units. Deaths of four patients (11%) were a function of associated injuries and comorbid factors, not the result of uncontrolled pelvic hemorrhage. The data suggest that aggressive resuscitation of these patients and treatment of extrapelvic injuries in conjunction with early or delayed ORIF, without application of acute external fixation, resulted in a low overall mortality rate.