Comparison of external fixation versus the trauma pelvic orthotic device on unstable pelvic injuries: a cadaveric study of stability. J Trauma Acute Care Surg. 2012;72:1671-1675. [PMID: 22695439 DOI: 10.1097/ta.0b013e31824526a7]

Biomechanical validation of the field-expedient pelvic splint

INTRODUCTION

Morbidity and mortality from pelvic ring injuries can be mitigated by early and effective external pelvic stabilisation. The field-expedient pelvic splint (FEPS) is a recently described technique to improvise an effective pelvic binder for an austere environment. This technique has not been biomechanically validated. We hypothesise that the FEPS will be biomechanically equivalent to a commercially available pelvic binder routinely used in the austere environment.

METHODS

Compressive force generation of the FEPS was measured using a commercial load frame. A SAM Pelvic Sling was used as a control. The FEPS was tested for initial force generation, persistence of force generation over a 6-hour longitudinal test period and force generation after repeated assembly/disassembly.

RESULTS

The FEPS generated 203N (±7N) with one windlass turn and 420N (±34N) with two windlass turns. The SAM Pelvic Sling generated 197N (±11N) of force. There was no significant difference between FEPS after one windlass crank and the SAM Pelvic Sling but the force generated by the FEPS with two windlass cranks was significantly higher than the SAM Pelvic Sling. Longitudinal testing showed that after 6 hours of continuous compression, the FEPS generated 189N (±19N) and the force generated at hour 6 was not significantly different from the initial force generated by SAM Pelvic Sling. Reusability testing showed no significant difference with force generation by the FEPS after repeated assembly/disassembly with one crank of the windlass but there was a significantly increased force generation by FEPS after repeated use trials with two cranks of the windlass.

CONCLUSION

The FEPS exerted equivalent pelvic compressive forces to its commercial equivalent and this force generation persists at effective levels over a 6-hour time course. The FEPS remained effective after repeated use. The FEPS is a viable alternative in the austere or resource-limited environment for temporary pelvic stabilisation.

Emergency treatment of pelvic ring injuries: state of the art

High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined.

Increasing the Threshold to Perform Preperitoneal Pelvic Packing Decreases Morbidity Without Affecting Mortality

OBJECTIVES

To determine the effectiveness of an updated protocol that increased the transfusion threshold to perform preperitoneal pelvic packing in patients with pelvic ring injuries and hemodynamic instability (HDI).

METHODS

DESIGN

Retrospective review.

SETTING

Urban level 1 trauma center.

PATIENTS SELECTION CRITERIA

Severely injured (injury severity score > 15) patients with pelvic ring injuries treated before and after increasing the threshold to perform preperitoneal pelvic packing from 2 to 4 units of red blood cells (RBCs). HDI was defined as a systolic blood pressure <90 mm Hg.

OUTCOME MEASURES AND COMPARISONS

Mortality from hemorrhage, anterior pelvic space infections, and venous thromboembolisms before and after increasing preperitoneal pelvic packing threshold.

RESULTS

One hundred sixty-six patients were included: 93 treated under the historical protocol and 73 treated under the updated protocol. HDI was present in 46.2% (n = 43) of the historical protocol group and 49.3% (n = 36) of the updated protocol group (P = 0.69). The median age of patients with HDI was 35.0 years (interquartile range 26.0-52.0), 74.7% (n = 59) were men, and the median injury severity score was 41.0 (interquartile range 29.0-50.0). Patients with HDI in the updated protocol group had a lower heart rate on presentation (105.0 vs. 120.0; P = 0.004), required less units of RBCs over the first 24 hours (6.0 vs. 8.0, P = 0.03), and did not differ in age, injury severity score, systolic blood pressure on arrival, base deficit or lactate on arrival, resuscitative endovascular balloon occlusion of the aorta, resuscitative thoracotomy, angioembolization, or anterior pelvis open reduction internal fixation (P > 0.05). The number of PPPs performed decreased under the new protocol (8.3% vs. 65.1%, P < 0.0001), and there were fewer anterior pelvic infections (0.0% vs. 13.9%, P = 0.02), fewer VTEs (8.3% vs. 30.2%; P = 0.02), and no difference in deaths from acute hemorrhagic shock (5.6% vs. 7.0%, P = 1.00).

CONCLUSIONS

Increasing the transfusion threshold from 2 to 4 units of red blood cells to perform pelvic packing in severely injured patients with pelvic ring injuries decreased anterior pelvic space infections and venous thromboembolisms without affecting deaths from acute hemorrhage.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluating the stability of external fixators following pelvic injury: A systematic review of biomechanical testing methods

INTRODUCTION

This systematic review aims to identify previously used techniques in biomechanics to assess pelvic instability following pelvic injury, focusing on external fixation constructs.

METHODS

A systematic literature search was conducted to include biomechanical studies and to exclude clinical trials.

RESULTS

Of an initial 4666 studies found, 38 met the inclusion criteria. 84% of the included studies were retrieved from PubMed, Scopus, and Web of Science. The studies analysed 106 postmortem specimens, 154 synthetic bones, and 103 computational models. Most specimens were male (97% synthetic, 70% postmortem specimens). Both the type of injury and the classification system employed varied across studies. About 82% of the injuries assessed were of type C. Two different fixators were tested for FFPII and type A injury, five for type B injury, and fifteen for type C injury. Large variability was observed for external fixation constructs concerning device type and configuration, pin size, and geometry. Biomechanical studies deployed various methods to assess injury displacement, deformation, stiffness, and motion. Thereby, loading protocols differed and inconsistent definitions of failure were determined. Measurement techniques applied in biomechanical test setups included strain gauges, force transducers, and motion tracking techniques.

DISCUSSION AND CONCLUSION

An ideal fixation method should be safe, stable, non-obstructive, and have low complication rates. Although biomechanical testing should ensure that the load applied during testing is representative of a physiological load, a high degree of variability was found in the current literature in both the loading and measurement equipment. The lack of a standardised test design for fixation constructs in pelvic injuries across the studies challenges comparisons between them. When interpreting the results of biomechanical studies, it seems crucial to consider the limitations in cross-study comparability, with implications on their applicability to the clinical setting.

Damage-control orthopedics or early total care: What you need to know

ABSTRACT

Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.

Comparison of T-POD and SAM Pelvic Sling II and the influence of attachment level in the initial management of unstable pelvic type C injuries - a cadaveric study

BACKGROUND

Type C pelvic fractures (AO/OTA) are severe injuries that frequently lead to bleeding and hemodynamic instability. Pelvic binders play a crucial role in their initial management. Placement at the correct level in the prehospital setting is challenging. The aim of this study was to compare two pelvic binders regarding their effectiveness in reducing intrapelvic volume and increasing intrapelvic pressure in patients with type C pelvic fractures (AO/OTA) when applied at three different levels.

METHODS

Rotationally and vertically unstable pelvic injuries (AO/OTA classification 61-C1.1) were produced in five fresh-frozen human cadaveric specimens. Intrapelvic volume, vesical pressure and compression pressure within the pubic symphysis and the sacroiliac joint were measured when applying a SAM Pelvic Sling II and a T-POD at the level of the greater trochanter as well as levels higher and lower than recommended.

RESULTS

Comparison of the two pelvic binders positioned at the recommended level (greater trochanter) showed no significant difference in volume reduction (13.85 ± 31.37 cm3, p = 0.442), however, increase in vesical pressure was significantly higher when using the T-POD (5.80 ± 3.27 cmH2O, p = 0.017). When positioned at the level of the iliac crest, vesical pressure increase and intrapelvic volume reduction were significantly greater with the T-POD (14.00 ± 8.57 cmH2O, p = 0.022 and 10.45 ± 5.45 cm3, p = 0.031 respectively). Application of the SAM Pelvic Sling II below the greater trochanter led to a significantly greater decrease in volume (-32.26 ± 7.52 cm3, p = 0.003) than the T-POD. Comparison of the recommended attachment level with incorrect positioning led to no significant differences for the T-POD, while the SAM Pelvic Sling II achieved a significantly lower volume reduction when placed at the iliac crest (40.15 ± 14.57 cm3, p = 0.012) and a significantly lower increase in vesical pressure when applied below the greater trochanter (3.40 ± 1.52 cmH2O, p = 0.007).

CONCLUSION

Direct comparison of the two pelvic binders showed that the T-POD achieved significantly greater results when applied at the recommended level and was less susceptible to incorrect positioning. These outcomes support the preferred use of the T-POD for prehospital emergency pelvic stabilisation.

Comparison between external fixation and pelvic binder in patients with pelvic fracture and haemodynamic instability who underwent various haemostatic procedures

Haemostatic procedures such as preperitoneal pelvic packing (PPP), pelvic angiography (PA), and internal iliac artery ligation are used for haemorrhage control in pelvic fracture patients with haemodynamic instability. Pelvic external fixation (PEF) and pelvic binder (PB) are usually applied with haemostatic procedures to reduce the pelvic volume. This study aimed to compare the clinical outcomes between patients who underwent PEF and PB. Among 173 patients with pelvic fracture admitted to the emergency room of three regional trauma centres between January 2015 and December 2018, the electronic charts of haemodynamically unstable patients were retrospectively analysed. Among the 84 patients included in the analysis, 20 underwent PEF with or without PB, and 64 underwent only PB. There were significant differences in tile classification and laparotomy between the PEF and PB groups (p = 0.023 and p = 0.032). PPP tended to be more frequently preformed in the PEF group (p = 0.054), whereas PA tended to be more commonly performed in the PB group than in the PEF group (p = 0.054). After propensity score matching to adjust for differences in patient characteristics and adjunct haemostatic procedure, there was no significant difference in 7-day, 30-day, and overall mortality rates between the PEF and PB groups (10.5% vs 21.1%, p = 0.660, 21.1% vs 26.3%, p = 1.000, and 26.3% vs 26.3%, p = 1.000). Cox proportional hazard regression analysis and multivariate analysis for correction of covariates (age, lactate, and abdominal injury) showed that PEF was not an independent factor for 30-day mortality compared with PB (adjusted hazard ratio, 0.526; 95% confidence interval, 0.092-3.002; p = 0.469). Among the volume reduction procedures performed with other haemostatic procedures in patients with pelvic fracture and haemodynamic instability, PEF did not significantly reduce the 30-day mortality rate compared to PB.

Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control

ABSTRACT

Major pelvic hemorrhage remains a considerable challenge of modern trauma care associated with mortality in over a third of patients. Efforts to improve outcomes demand continued research into the optimal employment of both traditional and newer hemostatic adjuncts across the full spectrum of emergent care environments. The purpose of this review is to provide a concise description of the rationale for and effective use of currently available adjuncts for the control of pelvic hemorrhage. In addition, the challenges of defining the optimal order and algorithm for employment of these adjuncts will be outlined.

LEVEL OF EVIDENCE

Review, level IV.

Early fixation strategies for high energy pelvic ring injuries - the Zurich algorithm

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.

Management of Pelvic Ring Injury Patients With Hemodynamic Instability

Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.

Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017

BACKGROUND

In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries.

METHODS

The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held.

RESULTS

The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb.

CONCLUSION

Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions.

LEVEL OF EVIDENCE

Systematic review of predominantly level II studies, level II.

The T-pod is as stable as supraacetabular fixation using 1 or 2 Schanz screws in partially unstable pelvic fractures: a biomechanical study

INTRODUCTION

Unstable fractures of the pelvis remain the predominant cause of severe hemorrhage, shock and early death in severely injured patients. The use of pelvic binders has become increasingly popular, particularly in the preclinical setting. There is currently insufficient evidence available about the stability of the pelvic binder versus supraacetabular fixation using 1 or 2 Schanz screws. We aimed to analyze the stability of the pelvic binder and supraacetabular fixateurs using either 1 or 2 Schanz screws in a cadaver model of an induced pelvic B-type fracture.

MATERIALS AND METHODS

The study was undertaken in 7 human fresh-frozen cadaveric pelvises with induced AO-type B fractures. Three stabilization techniques were compared: T-POD (pelvic bandage), supraacetabular external fixator with 1 pin on each side and external fixator with 2 pins on each side. Stability and stiffness were analyzed in a biomechanical testing machine using a 5-step protocol with static and dynamic loading, dislocation data were retrieved by ultrasound sensors at the fracture sites.

RESULTS

No significant differences in fracture fragment displacement were detected when using either the T-POD, a 1-pin external fixator or a 2-pin external fixator (P > 0.05). The average difference in displacement between the three methods was < 1 mm.

CONCLUSIONS

Pelvic binders are suitable for reduction of pelvic B-type fractures. They provide stability comparable to that of supraacetabular fixators, independently of whether 1 or 2 Schanz screws per side are used. Pelvic binders provide sufficient biomechanical stability for transferring patients without the need to first replace them with surgically applied external fixators. However, soft tissue irritation has to be taken into consideration and prolonged wear should be avoided.

LEVEL OF EVIDENCE

Level III.

Identifying risk factors for suboptimal pelvic binder placement in major trauma

AIMS

This study aimed to identify the frequency of sub-optimal pelvic binder placement at a tertiary-level trauma centre, produce a reproducible, quantitative measure of pelvic binder fit, and identify risk factors for sub-optimal placement.

PATIENTS AND METHODS

We identified all consecutive patients who had a pelvic binder in place on arrival to the Royal Brisbane and Women's Hospital in Queensland, Australia from 2012-2016. The X-Rays were reviewed by two senior clinicians for position and measured for degree of displacement if not optimally placed between the greater and lesser trochanters. Risk factors for sub-optimal position of the binder were assessed using multiple logistic regression with inclusion of all variables that had a statistical association (to p<0.05) at the univariate analysis stage. Secondary assessment was conducted of patients who had undergone CT imaging for subcutaneous body fat distribution.

RESULTS

In total, 496 X-Rays were assessed for pelvic binder fit, finding 43.5% sub-optimally placed. 39.7% binders were superior to the greater trochanter line and 3.8% inferiorly placed below the lesser trochanter line. The majority of the sub-optimally placed binders were within 60 mm of the ideal position. Female patients had a greater risk of sub-optimal binder placement compared to males (62.5% vs 37%). Increasing intertrochanteric height was found to be protective for ideal binder placement with an aOR 0.62 for each cm in increased height. There was no association with sub-optimal placement and age, sex, mechanism of trauma, injury severity score, number of body regions injured or Glasgow Coma Scale. There was strong kappa agreement between the X-Ray assessors for binder position assessment on the plain radiological imaging.

CONCLUSION

Sub-optimal positioning of pelvic binders is common in our trauma population. This study has described the risk factors associated with higher rates of sub-optimal fit and provides a description of rapid radiological assessment for optimal fit for the bedside clinician caring for injured patients in the resuscitation room.

Prehospital use of pelvic circumferential compression devices in a physician-based emergency medical service: A 6-year retrospective cohort study

Fractures of the pelvic ring are a potential source of significant bleeding. Pelvic circumferential compression devices (PCCDs) can reduce and immobilize unstable fractures, but their hemostatic effect is unproven. Our aim was to assess the current practice of prehospital PCCD application and to identify factors available in the field predictive of significant pelvic ring injuries. All interventions (n = 13,435) in the Lausanne University Hospital Emergency Medical Service (EMS) were screened for PCCD placements from January 2008 to November 2014. Significant pelvic ring injuries (Tile types B or C) were considered as potentially benefitting from a PCCD. Data were extracted from the local prehospital registry. During the study period, 2366 trauma missions were performed. A PCCD was applied to 552/2366 (23%) patients. Significant pelvic ring injuries were present in 105/2366 (4.4%). Factors associated with the presence of significant pelvic ring injury were increased respiratory rate (OR 1.04), prolonged capillary refill time (OR 2.11), increased shock index (OR 3.91), pedestrians hit by a vehicle (OR 2.19), and presenting with falls from more than 2 m (OR 1.91). Among patients with a significant pelvic ring injury, a PCCD was placed in 79 (75%) and omitted in 26 (25%). One sixth of patients with a PCCD had a final diagnosis of significant pelvic ring injury. Further studies are needed to better understand which patient-, or accident-related factors are associated with prehospital PCCD omission among patients with significant pelvic ring injury.

Effect of door-to-angioembolization time on mortality in pelvic fracture: Every hour of delay counts

INTRODUCTION

Angioembolization (AE) is widely used for hemorrhagic control in patients with pelvic fracture. The latest version of the Resources for Optimal Care of the Injured Patient issued by the American College of Surgeons Committee on Trauma requires interventional radiologists to be available within 30 minutes to perform an emergency AE. However, the impact of time-to-AE on patient outcomes remains unknown. We hypothesized that a longer time-to-AE would be significantly associated with increased mortality in patients with pelvic fracture.

METHODS

This is a 2-year retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2014. We included adult patients (age ≥ 18 years) with blunt pelvic fracture who underwent pelvic AE within 4 hours of hospital admission. Patients who required any hemorrhage control surgery for associated injuries within 4 hours were excluded. Hierarchical logistic regression was performed to evaluate the impact of time-to-AE on in-hospital and 24-hour mortality.

RESULTS

A total of 181 patients were included for analysis. The median age was 54 years (interquartile range, 38-68) and 69.6% were male. The median injury severity score was 34 (interquartile range, 27-43). Overall in-hospital mortality rate was 21.0%. The median packed red blood cell transfusions within 4 and 24 hours after admission were 4 and 6 units, respectively. After adjusting for other covariates in a hierarchical logistic regression model, a longer time-to-pelvic AE was significantly associated with increased in-hospital mortality (odds ratio, 1.79 for each hour; 95% confidence interval, 1.11-2.91; p = 0.018).

CONCLUSION

The current study showed an increased risk of in-hospital mortality related to a prolonged time-to-AE for hemorrhagic control following pelvic fractures. Our results suggest that all trauma centers should allocate resources to minimize delays in performing pelvic AE.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Damage control orthopaedics: State of the art

Damage control orthopaedics (DCO) originally consisted of the provisional immobilisation of long bone - mainly femur - fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised (the “second hit” effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains. Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too, normalised parameters associated with the acid-base system have been proposed, under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.

False negative computed tomography scan due to pelvic binder in a patient with pelvic disruption: a case report and review of the literature

Background

Pelvic binders are routinely used in the prehospital setting for stabilization of pelvic injuries in patients with trauma. Emergency department trauma management relies on primary and secondary survey assessment and imaging, most often computed tomography, in hemodynamically stable patients. Maintaining the pelvic binder in situ allows stabilization of pelvic injuries during imaging but may hinder the visualization of some pelvic lesions. We report a very rare case of severe pelvic disruption with an absolutely normal computed tomography scan due to the effective placement of a pelvic binder.

Case presentation

We report the case of a 49-year-old Caucasian man referred to our Emergency Department after a high velocity motorcycle accident. Primary assessment revealed a left wrist deformation and pelvic pain, and a pelvic binder was applied by paramedics. A total body computed tomography scan was performed after arrival in our Emergency Department and did not reveal any pelvic injury. The pelvic binder was removed and because of persisting symphyseal pain, pelvic plain radiography was performed revealing a pelvic disruption with an opening of the pubic symphysis and of the left sacroiliac joint (“open book” type pelvic injury) requiring surgical stabilization.

Conclusions

Pelvic binders may mask pelvic disruption in patients with trauma. Pelvic plain radiography should be repeated after pelvic binder removal in patients with high velocity trauma and pelvic symptoms or neurological alterations limiting the reliability of clinical examination.

Electronic supplementary material

The online version of this article (10.1186/s13256-018-1808-7) contains supplementary material, which is available to authorized users.

Pre-hospital and emergency department management of pelvic fractures and major trauma centre status: Has practice changed?

Introduction

Pelvic fractures are indicative of high-energy injuries and carry a significant morbidity and mortality and pelvic binders are used to stabilise them in both the pre-hospital and emergency department setting. Our unit gained major trauma centre status in April 2012 as part of a national programme to centralise trauma care and improve outcomes. This study investigated whether major trauma centre status led to a change in workload and clinical practice at our centre.

Methods

A retrospective analysis of all patients admitted with a pelvic fracture for the six-month periods before, after and at one-year following major trauma centre status designation. Data were retrospectively collected from electronic patient records and binder placement assessed using an accepted method. Patients with isolated pubic rami fractures were excluded.

Results

Overall, 6/16 (37.5%) pelvic fracture admissions had a binder placed pre-major trauma centre status, rising to 14/34 (41.2%) immediately post-major trauma centre status and 22/32 (68.8%) ( p = 0.025) one year later. Binders were positioned accurately in 4 patients (80%, one exclusion) pre-major trauma centre status, 12 (92.4%) post-major trauma centre status and 22 (100%) at one year. CT imaging was the initial imaging used in 9 (56.3%) patients pre-major trauma centre status, 29 (85.3%) ( p = 0.04) post-major trauma centre status and 27 (84.4%) at one year.

Discussion

Pelvic fracture admissions doubled following major trauma centre status. Computed tomography, as the initial imaging modality, increased significantly with major trauma centre status, likely a reflection of the increased resources made available with this change. Although binder application rates did not change immediately, a significant improvement was seen after one year, with binder accuracy increasing to 100%. This suggests that although changes in clinical practice often do not occur immediately, with the increased infrastructure and clinical exposure afforded through centralisation of trauma services, they will occur, ultimately leading to improvements in trauma patient care.

Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a Propensity Score Analysis

Background

An option for emergency control of pelvic hemorrhage is Extra-peritoneal Pelvic Packing (EPP), which addresses the retroperitoneal source of exsanguination in pelvic fractures. The aim of this study was to demonstrate the efficacy of early EPP in reducing mortality due to hemorrhage from pelvic fractures, and to evaluate the impact of packing on transfusion requirements within the first 24 h and ICU length of stay (ICU-LOS).

All data pertaining trauma patients admitted from October 2002 and December 2103 with hemodynamic instability and pelvic fractures were selected from the Hospital Trauma Registry. Patients with severe brain injury and bleeding from extra-pelvic sources were excluded. Patient population was divided into two groups: EPP group, including patients admitted from 2009 to 2013, with EPP as part of the treatment algorithm, and NO-EPP group, from 2002 to 2008, without EPP as atherapeutic option. Descriptive statistical analysis was performed on allpatients. Twenty-five patients of each group with similar features were matched using Propensity Score Analysis (PSA).

Results

Six hundred eighty out of 4659 major trauma (14.6 %) presented a pelvic fracture. In 78 hemodynamically unstable patients (30 in EPP group,48 in NO-EPP group) the major source of bleeding was the pelvis. Among patients selected by PSA early mortality was significantly reduced in EPP group (20 vs 52 %, p = .03) compared to NO-EPP, notwithstanding similar hemodynamic impairment. No difference was observed in transfusion requirements and ICU-LOS.

Conclusions

The EPP is a safe and quick procedure, able to improve hemodynamic stabilization and to reduce acute mortality due to hemorrhage in patients with pelvic fracture, in combination with optimized transfusion protocol. EPP may be useful as a bridge for time-consuming procedures, such as angio-embolization.

Effectiveness of non invasive external pelvic compression: a systematic review of the literature

Introduction

Pelvic fractures might carry a significant risk of bleeding. A wide variety of pelvic binders together with pelvic sheets are available and offer an adjunct to the initial management of poly-trauma patients with pelvic injuries. These devices are collectively referred to as pelvic circumferential compression devices (PCCDs). The aim of this study was to review the literature for evidence pertinent to the efficacy and safety of PCCDs.

Methods

Using the PRISMA guidelines a systematic search on PubMed, Web of Science, CINAHL, Embase and Scopus was carried out. Articles included were in English language and published between 1999 and 2015. Studies included were appraised with narrative data synthesis.

Results

Seven articles addressed mechanical properties of non-invasive external mechanical devices, six articles focused on physiological aspects, and three studies evaluated the pressure characteristics of these devices. We found 4 case reports regarding adverse effects. None of the studies identified addressed the cost effectiveness or pain relief issues related to the use of PCCDs.

Conclusions

Based on available literature, PCCDs are widely used in the initial management of patients with suspected pelvic bleeding. There is evidence to suggest that external compression reduces disrupted pelvic rings. There are some complications reported following application of PCCDs. Hemorrhagic source and physiological effectiveness of PCCDs needs to be addressed in future studies. In the meantime judicious application of PCCDs will continue to be recommended.

Comparison of skin pressure measurements with the use of pelvic circumferential compression devices on pelvic ring injuries

OBJECTIVES

Pelvic circumferential compression devices are commonly used in the acute treatment of pelvic fractures for reduction of pelvic volume and initial stabilisation of the pelvic ring. There have been reports of catastrophic soft-tissue breakdown with their use. The aim of the current investigation was to determine whether various pelvic circumferential compression devices exert different amounts of pressure on the skin when applied with the force necessary to reduce the injury. The study hypothesis was that the device with the greatest surface area would have the lowest pressures on the soft-tissue.

METHODS

Rotationally unstable pelvic injuries (OTA type 61-B) were surgically created in five fresh, whole human cadavers. The amount of displacement at the pubic symphysis was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). The T-POD, Pelvic Binder, Sam Sling, and circumferential sheet were applied in random order for testing. The devices were applied with enough force to obtain a reduction of less than 10mm of diastasis at the pubic symphysis. Pressure measurements, force required, and contact surface area were recorded with a Tekscan pressure mapping system.

RESULTS

The mean skin pressures observed ranged from 23 to 31kPa (173 to 233mm of Hg). The highest pressures were observed with the Sam Sling, but no statistically significant skin pressure differences were observed with any of the four devices (p>0.05). The Sam Sling also had the least mean contact area (590cm(2)). In greater than 70% of the trials, including all four devices tested, skin pressures exceeded what has been shown to be pressure high enough to cause skin breakdown (9.3kPa or 70mm of Hg).

CONCLUSIONS

Application of commercially available pelvic binders as well as circumferential sheeting commonly results in mean skin pressures that are considered to be above the threshold for skin breakdown. We therefore recommend that these devices only be used acutely, and definitive fixation or external fixation should be performed early as patient physiology allows. There may be some advantage of use of a simple sheet given its low cost, versatility, and ability to alter contact surface area.

Resuscitation of Polytrauma Patients: The Management of Massive Skeletal Bleeding

The term ‘severely injured patient’ is often synonymous of polytrauma patient, multiply-injured patient or, in some settings, polyfractured patient. Together with brain trauma, copious bleeding is the most severe complication of polytrauma. Consequently hypotension develop. Then, the perfusion of organs may be compromised, with the risk of organ failure. Treatment of chest bleeding after trauma is essential and is mainly addressed via surgical manoeuvres. As in the case of lesions to the pelvis, abdomen or extremities, this approach demonstrates the application of damage control (DC). The introduction of sonography has dramatically changed the diagnosis and prognosis of abdominal bleeding. In stable patients, a contrast CT-scan should be performed before any x-ray projection, because, in an emergency situation, spinal or pelvic fractures be missed by conventional radiological studies. Fractures or dislocation of the pelvis causing enlargement of the pelvic cavity, provoked by an anteroposterior trauma, and in particular cases presenting vertical instability, are the most severe types and require fast stabilisation by closing the pelvic ring diameter to normal dimensions and by stabilising the vertical shear. Controversy still exists about whether angiography or packing should be used as the first choice to address active bleeding after pelvic ring closure. Pelvic angiography plays a significant complementary role to pelvic packing for final haemorrhage control. Apart from pelvic trauma, fracture of the femur is the only fracture provoking acute life-threatening bleeding. If possible, femur fractures should be immobilised immediately, either by external fixation or by a sheet wrap around both extremities.

Pelvic Trauma

The leading cause of death in the pediatric population is trauma, of which pelvic injuries make up a very small percentage. Trauma to the pelvis can result in multiple injuries to the bony pelvis, rectum, bladder, and or the urethra. Although mortality in the pediatric population is typically secondary to associated injuries, pelvic hemorrhage can be a life-threatening event. The management of patients with complex pelvic injuries requires a multidisciplinary approach in order to achieve the best possible outcomes.

Sacroiliac secure corridor: analysis for safe insertion of iliosacral screws

Objective

Posterior pelvic lesions, especially of the sacral-iliac joint, have high mortality and morbidity risks. Definitive fixation is necessary for the joint stabilization, and one option is the sacral percutaneous pinning with screws. Proximity to important structures to this region brings risks to the fixation procedure; therefore, it is important to know the tridimensional anatomy of the pelvis posterior region. Deviations of the surgeon's hand of four degrees may target the screws to those structures; dimorphisms of the upper sacrum and a poor lesion reduction may redound in a screw malpositioning. This study is aimed to evaluate the dimensions of a safe surgical corridor for safe sacroiliac screw insertion and relations with age and sex of the patients.

Method

One hundred randomly selected pelvis CTs of patients with no pelvic diseases, seen at a tertiary care teaching Hospital. Measurements were made by computer and the safest area for screw insertion was calculated by two methods. The results were expressed in mm (not in degrees), in order to be a further surgical reference.

Results

There was a significant size difference in the analyzed sacral vertebra, differing on a wider size in men than in women. There was no significant statistical difference between vertebral size and age. By both methods, a safe area for screw insertion could be defined.

Conclusion

Age does not influence the width of the surgical corridor. The surgeon has a safe corridor considered narrower when inserting screws in a female pelvis than when in a male one. However, as the smallest vertebra found (feminine) was considered for statics, it was concluded that this corridor is 20 mm wide in any direction, taking as a reference the centrum of the vertebra.