Elsevier

Injury

Volume 40, Issue 10, October 2009, Pages 1031-1035
Injury

Review
Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: A systematic review of literature

https://doi.org/10.1016/j.injury.2009.06.164Get rights and content

Abstract

Background

Pelvic fractures can cause massive haemorrhage. Early stabilisation and compression of unstable fractures is thought to limit blood loss. Reposition of fracture parts and reduction of pelvic volume may provide haemorrhage control. Several non-invasive techniques for early stabilisation have been proposed, like the specifically designed pelvic circumferential compression devices (PCCD). The purpose of this systematic review was to investigate current evidence for the effectiveness and safety of non-invasive PCCDs.

Methods

To investigate current literature the search string: pelvi* AND fract* AND (bind* OR t-pod OR tpod OR wrap OR circumferential compression OR sling OR sheet)” was entered into EMBASE, PubMed (Medline), PiCarta, WebofScience, Cochrane Online, UptoDate, CINAHL, and Scopus. All scientific publications published in indexed journals were included.

Results

The search resulted in 17 included articles, none of which were level I or II studies. One clinical cohort study (level III) and 1 case–control study (level IV) were found. These showed a significant reduction of pelvic volume after applying a PCCD, without an effect on outcome. Other included literature consisted of 4 case series (level V). Two biomechanical analysis studies of fractures in human cadavers showed pelvic stabilisation and effective volume reduction by PCCD, especially when applied around the greater trochanters. Finally, 7 case reports (level VI) and 3 expert opinions (level VII) were identified. These case reports suggested complications such as pressure sores and nerve palsy.

Conclusion

PCCDs seem to be effective in early stabilisation of unstable pelvic fractures. However, prospective data concerning mortality and complications is lacking. Some complications, like pressure sores have been described.

Introduction

The pelvis is comprised of a bony ring, made up by the sacrum and 2 fused bone planes on each side, consisting of the ischiac, iliac and the pubic bones. Distortion of this ring due to fractures may lead to extensive haemorrhage, pelvic instability and organ damage (e.g., urinary bladder). Blood loss can occur from several sources, like venous plexus lesions, bleeding fracture sites and, less common, arterial injuries. Life threatening bleeding from arterial origin may occur in 5–20% of patients.3, 8, 11 Theoretically, the reduction of pelvic fracture fragments diminishes the pelvic volume, thereby reducing the potential space for bleeding. Moreover, a reduction of fracture surfaces may reduce bony bleeding.8, 9 Unstable pelvic fractures should be considered as life threatening at all time, and constitute a high incidence of mortality causes in polytraumatised patients.29

During resuscitation of polytraumatised patients, priority is given to preventing and treating the lethal triad; hypothermia, acidosis, and progressive coagulopathy.12, 27, 28, 29 In this context, the most efficient resuscitative measure to reduce blood loss in pelvic fractures is early cessation of bleeding. Application of a non-invasive pelvic circumferential compression device at the scene of the accident is frequently applied as early fracture fixation. With a PCCD in place, patients can be transported to a trauma centre, where definitive stabilisation of the pelvis can be performed by the application of a pelvic C-clamp, operative placement of an external fixation device, or coiling of an arterial haemorrhage.

Several non-invasive stabilisation methods have been developed over time. Ways to reduce hemorrhaging from pelvic fractures date from as early as 1974 with the introduction of the Medical Anti-Shock Trouser (MAST) or Pneumatic Anti-Shock Garment (PASG).2, 18 Randomised trials revealed no survival benefit from these devices.20, 21 Several complications, like abdominal compartment syndrome and pressure sores have been reported.1, 6 Moreover, these devices severely limited the surgical access to the abdomen, groin and upper legs. Overall, these limitations have rendered their use obsolete.

Circumferential compression can be achieved by using a simple bed sheet, tightened around the pelvis, or by using a specially designed commercial device. These pelvic circumferential compression devices (PCCDs) were first described in 1999.30 The use of PCCDs in the initial care for pelvic fracture patients is currently incorporated in the Advanced Trauma Life Support guidelines, as put forward by the American college of Surgeons.27 PCCDs are easy to use, can be applied quickly, thereby significantly contributing to survival of severely injured patients. However, evidence for the effectiveness for this treatment modality is scarce.

The purpose of this systematic review was to make an inventory of the current evidence for the use of PCCDs in patients with unstable pelvic ring fractures, both in terms of biomechanics (fracture reduction) and clinical efficacy (haemostasis, clinical applicability, and patient outcome in the initial treatment).

Section snippets

Materials and methods

In order to investigate the effectiveness of PCCDs in the initial treatment of unstable pelvic fractures, a systematic review of literature was performed. For this, a systematic search of relevant databases in medical literature was used.

Results

The search strings used resulted in 176 hits. After comparison and removal of duplicate manuscripts, 100 manuscripts remained. After reading all abstracts, 16 relevant articles concerning the use of PCCDs were identified (Table 2). Screening the references of these articles yielded 1 additional publication. In total, 17 articles concerning the use of PCCDs were included in the review. These consisted of 3 biomechanical laboratory studies, 2 clinical studies, 1 experimental in vivo study, 1 case

Discussion

Pelvic fractures are life-threatening injuries.29 Reduction and stabilisation lead to haemostasis. Early intervention may decrease blood loss, resulting in reduced morbidity and mortality. A method of early fracture stabilisation that has been increasingly used in recent years is the use of non-invasive pelvic circumferential compression devices. These devices are well suited for use in the acute (out of hospital) phase of resuscitation, as they can easily be applied at the accident scene.

Conclusions

The currently available literature on PCCDs in patients with suspected pelvic fractures indicates a reduction of blood loss, and does not show life threatening complications associated with the PCCD use. Despite the absence of level I and II evidence for the clinical effectiveness of PCCDs, publications so far (level III–V) report that PCCDs are effective in reducing fractures and associated hemorrhaging. The nature, severity, and rates of PCCD related complications are not fully known. The

Conflicts of interest

All authors state that no conflict of interest, neither financial nor personal, exists.

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