Mortality following pelvic fractures has declined dramatically as better methods of controlling haemorrhage, such as angioembolisation to control arterial bleeding, have been introduced. But about 10% of patients still die, despite these advances. To save these patients, the key questions in managing pelvic fractures are: which patients are at highest risk for a life-threatening bleed, in these patients, what is the exact anatomical source of the bleeding and what is the best way to stop it? There is wide consensus that bleeding is most likely to occur with unstable fractures. However, it remains difficult to predict which fractures will actually cause excessive bleeding. Current treatment protocols rely on angiographic embolisation and external fixation, either alone or in combination. Direct pelvic packing is gaining in popularity, but, ultimately, the ideal treatment method remains unclear. The purpose of this review is to examine our current understanding of the pathophysiology and management of bleeding pelvic fractures.