ReviewEffectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: A systematic review of literature
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.
References (32)
- et al.
Emergent pelvic fixation in patients with exsanguinating pelvic fractures
J Am Coll Surg
(2007) - et al.
Use of the trauma pelvic orthotic device (T-POD) for provisional stabilisation of anterior–posterior compression type pelvic fractures: a cadaveric study
Injury
(2008) - et al.
Hypothermia, coagulopathy, and acidosis
Surg Clin North Am
(2000) - et al.
Pelvic antishock sheeting
Air Med J
(2006) - et al.
MAST-associated compartment syndrome (MACS): a review
J Trauma
(1989) - et al.
Value of the G suit in patients with severe pelvic fracture. Controlling hemorrhagic shock
Arch Surg
(1974) - et al.
Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures
Ann Surg
(2001) - et al.
Emergent management of pelvic ring fractures with use of circumferential compression
J Bone Joint Surg
(2002) - et al.
Noninvasive reduction of open-book pelvic fractures by circumferential compression
J Orthop Trauma
(2002) Pneumatic antishock garments (PASG): do they precipitate lower-extremity compartment syndromes?
J Trauma
(1986)
Pelvic fracture classification: correlation with hemorrhage
J Trauma
Butt binder
J Trauma
The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions
J Trauma
A review of pressure reduction device studies
J Vasc Nurs
Pressure characteristics of pelvic binders
Injury
Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial
J Trauma
Cited by (90)
Early management of severe pelvic injury (first 24 hours)
2019, Anaesthesia Critical Care and Pain MedicineAmerican Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient
2024, Journal of Trauma and Acute Care Surgery
- 1
Current address: University Medical Center Leiden, Department of Surgery-Traumatology, Leiden, The Netherlands.