Technical Note

Immediate application of improvised pelvic binder as first step in extended resuscitation from life-threatening hypovolaemic shock in conscious patients with unstable pelvic injuries

In isolated high energy pelvic ring injuries, early surgical and nonsurgical fixation belongs to the rescue tools required for rapid recovery. With the increasing use of pelvic binders on scene, these patients frequently arrive in a better condition at the level I trauma centre than without any measures of immobilisation. We describe our surgical tools to achieve rapid fixation within the first hours after arrival, taking into account if additional injuries or special stations are relevant

Pelvic ring fractures are common following high-energy blunt trauma and can lead to substantial haemorrhage, morbidity and mortality. Pelvic circumferential compression devices (PCCDs) improve position and stability of open-book type pelvic fracture, and can improve haemodynamics in patients with hypovolaemic shock. However, PCCDs may cause adverse outcomes including worsening of lateral compression fracture patterns and routine use is associated with high costs. Controversy regarding indication of PCCDs exists with some centres recommending PCCD in the setting of hypovolaemic shock compared to placement for any suspected pelvic injury.

To assess the need for PCCD application based on pre-hospital vital signs and mechanism of injury.

A retrospective cohort study was conducted in a single adult major trauma centre examining a 2-year period. Patients were sub-grouped based on initial pre-hospital and emergency department observations as haemodynamically normal (heart rate <100 bpm, systolic blood pressure ≥100 mmHg and Glasgow Coma Scale ≥13) or abnormal. Diagnostic accuracy of pre-hospital haemodynamics as a predictor of pelvic fracture requiring intervention within 24 h was assessed.

There were 376 patients with PCCD in-situ on hospital arrival. Pelvic fractures were diagnosed in 137 patients (36.4%). Of these, 39 (28.5%) were haemodynamically normal and 98 (71.5%) were haemodynamically abnormal.

The most common mechanisms of injury were motor vehicle collision (57.7%) and motorcycle collision (13.8%). Of those with fractures, 40 patients (29.2%) required pelvic intervention within 24 h of admission; of these, 8 (20%) were haemodynamically normal and 32 (80%) were haemodynamically abnormal. As a test for pelvic fracture requiring intervention within 24 h, abnormal pre-hospital haemodynamics had a sensitivity of 0.80 (95% CI 0.64-0.91), specificity of 0.32 (95% CI 0.27-0.38) and negative predictive value (NPV) of 0.93 (95% CI 0.88-0.96). Combined with absence of a major mechanism of injury, normal haemodynamics had a sensitivity 1.00, specificity 0.51 (95% CI 0.36-0.66) and NPV of 1.00 for pelvic intervention within 24 h.

Normal haemodynamic status, combined with absence of major mechanism of injury can rule out requirement for urgent pelvic intervention. Ongoing surveillance is recommended to monitor for any adverse effects of this change in practice.

Pelvic ring injuries are a major cause of morbidity and mortality in the polytrauma patient. Mortality rates from pelvic ring injuries have declined, unrelated to injury severity. This is due to an improved understanding of trauma as a disease, initial and subsequent management options. There are a number of guidelines pertaining to these injuries. These have been brought together to provide an overview of the current guidance on the emergent management of these complex injuries. The foundations of treatment for these injuries includes the following: recognition of the high energy involved, rapid assessment, resuscitation and temporary stabilization of bony and soft tissue injuries. It is important to involve a multidisciplinary team prior to definitive management. By following the guidance set out by this article, the orthopaedic trauma team in the receiving hospital can optimize the patient and prepare them for transfer to the regional major trauma centre. This will improve patient morbidity and mortality and ensure standardization of pelvic trauma management in the first 24 hours.

Increased fracture displacement has previously been described with the application of pelvic circumferential compression devices (PCCDs) in patients with lateral compression–type pelvic fracture. We describe the first reported case of hemodynamic deterioration temporally associated with the prehospital application of a PCCD in a patient with a complex acetabular fracture with medial displacement of the femoral head. Active hemorrhage from a site adjacent to the acetabular fracture was subsequently demonstrated on angiography. Caution in the application of PCCDs to patients with lateral compression–type fractures is warranted.

Hip fractures with unstable pelvic ring have great morbidity and mortality rates. These fractures result from high energy trauma such as falls from heights, road accidents and collapsing structures or other similar mechanisms of action. We report the case of a 63 years old man, construction worker, who stood inside a ditch during a wall construction when he was surprised by this collapse, which resulted in direct trauma to the right thigh and pelvis. The autopsy revealed diaphysis fracture of the right femur with an open book pelvic fracture with severe hemorrhagic infiltration and hematoma of the pelvic muscles without arterial injury. Bone bleeding and the vascular damage associated with disruption of the sacroiliac ligaments promote a very significant bleeding. Simple maneuvers such as sheet circumferential compression to promote pelvic ring closure are effective on stabilizing and closure of the sacroiliac joint. Hip manipulation of the fracture was performed during the necropsy to demonstrate and prove how a simple sheet contention can promote stabilization of the pelvic ring by closing the sacroiliac joints in open book fractures.

Unstable pelvic fractures can be life-threatening due to catastrophic haemorrhage. Non-invasive methods of reducing and stabilising these injuries include pelvic binder application and also lower limb bandaging over a knee-flexion bolster. Both of these methods help close the pelvic ring and should tamponade bleeding. This study aimed to quantify the intra-pelvic pressure changes that occurred with 3 different manoeuvres: lower limb bandaging over a bolster; a Trauma Pelvic Orthotic Device (T-POD) pelvic binder, and a combination of both.

Following a pilot study with 2 soft embalmed cadavers, a formal study with 6 unembalmed cadavers was performed. For each specimen an unstable pelvic injury was created (OA/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3–4 cm manometric water-filled balloon was placed in the retropubic space and connected to a 50 ml syringe and water manometer via a 3-way tap. A baseline pressure of 8cmH₂O (equating to the average central venous pressure) was used for each cadaver. Steady intra-pelvic pressures (more reliably reflecting the pressures achieved following an intervention) were used in the subsequent statistical analysis, using R statistical language and Rstudio. Paired t-test or Wilcoxon’s rank sum test were used (depending on the normality of the dataset) to determine the impact of each intervention on the intra-pelvic pressure.

The mean steady intra-pelvic pressures were significantly greater than the baseline pressure for each intervention. The binder and limb bandaging over a bolster alone increased the mean steady pelvic pressures significantly to 24 (SE = 5) (p < 0.036) and 15.5 (SE = 2) (p < 0.02)cmH₂O respectively. Combining these interventions further increased the mean steady pressure to 31 (SE = 7)cmH₂O. However, this was not significantly greater than pressures for each of the individual interventions.

Both lower limb bandaging over a bolster and pelvic binder application significantly increased intra-pelvic pressure above the baseline pressure. This was further increased through combining these interventions, which could be useful clinically to augment haemorrhage control in these fractures.

Lower-limb bandaging over a bolster, and pelvic binder application, both significantly increased intra-pelvic pressures, and were greatest in combination. These findings support the use of these techniques to facilitate non-surgical haemorrhage control.