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Fill a large pot with lightly salted water and bring to a rolling boil. Cook fettuccine at a boil until almost tender, about 8 minutes.
While the pasta is cooking, heat oil in a skillet over medium heat. Add onion and cook until starting to soften, about 3 minutes. Add garlic and cook until fragrant, about 1 minute. Pour in sardines and tomato sauce, stir to combine, and cook until heated through, about 3 minutes. Reduce the heat to low and keep at a simmer.
Drain pasta, add to sauce, and stir to combine. Cover, turn off the heat, and let stand for 3 minutes. Squeeze lemon over top and divide onto four serving plates. Garnish with Parmesan and red pepper flakes.