Comparison of three different pelvic circumferential compression devices: a biomechanical cadaver study

Assessment of proprietary and improvised pelvic binders: time to application and displacement during casualty evacuation

INTRODUCTION

Pelvic injuries resulting from high-energy trauma have an approximately 10% mortality rate. Suspected pelvic injuries are treated with pelvic binders to stabilise fractured bones and promote tamponade until surgical treatment. The effectiveness of pelvic binders in reducing mortality risk depends on accurate positioning of the binder. This study quantifies the ability of proprietary and improvised pelvic binders to maintain their positioning during a simulated casualty evacuation.

METHODS

One improvised and three proprietary pelvic binders were tested in their ability to maintain their initial placement. Combat Medical Technicians applied binders to healthy subjects and then performed a simulated casualty evacuation. The time taken to apply each binder was measured. The evacuation consisted of: 20 m casualty drag, transfer onto a soft stretcher, 100 m evacuation on a soft stretcher, transfer onto a rigid stretcher and transfer into a field ambulance. Binder placement was measured using bony landmarks after the initial positioning and after each phase of the simulated casualty evacuation.

RESULTS

The field-expedient pelvic splint (FEPS), SAM Pelvic Sling II (SAM) and T-POD Pelvic Stabilisation Device (TPOD) all remained within 45 mm of vertical displacement from their initial placement, which is considered an acceptable range for optimal binder functionality. The Prometheus Pelvic Splint (PROM) fell within this range in 83% of trials. The SAM was the fastest binder to apply, followed by the TPOD, and then the FEPS and PROM which took similar times to apply.

CONCLUSIONS

Binders were mostly able to maintain their positioning during the simulated casualty evacuations carried out in this study but differed in their application times. The improvised binder (FEPS) performed comparably to the proprietary binders tested, and its low cost and weight make it a good alternative to proprietary binders in the austere environment.

Stop the bleed " - Prehospital bleeding control in patients with multiple and/or severe injuries - A systematic review and clinical practice guideline - A systematic review and clinical practice guideline

PURPOSE

Our aim was to develop new evidence-based and consensus-based recommendations for bleeding control in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

METHODS

MEDLINE and Embase were systematically searched until June 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared interventions for bleeding control in the prehospital setting using manual pressure, haemostatic agents, tourniquets, pelvic stabilisation, or traction splints in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality and bleeding control. Transfusion requirements and haemodynamic stability were surrogate outcomes. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

RESULTS

Fifteen studies were identified. Interventions covered were pelvic binders (n = 4 studies), pressure dressings (n = 1), tourniquets (n = 6), traction splints (n = 1), haemostatic agents (n = 3), and nasal balloon catheters (n = 1). Fourteen new recommendations were developed. All achieved strong consensus.

CONCLUSION

Bleeding control is the basic objective of treatment. This can be easily justified based on empirical evidence. There is, however, a lack of reliable and high-quality studies that assess and compare methods for bleeding control in patients with multiple and/or severe injuries. The guideline provides reasonable and practical recommendations (although mostly with a low grade of recommendation) and also reveals several open research questions that can hopefully be answered when the guideline is revised again.

Pelvic sheet binders: Are doctors placing them in the correct position?

Introduction

Unstable pelvic fractures cause significant bleeding, morbidity, and mortality. Commercially available Pelvic Circumferential Compression Devices (PCCDs) are used in the initial resuscitation and management of these cases. In the trauma-burdened, resource limited setting of Southern Africa, the available alternative is a pelvic sheet binder (PSB). For optimal results placement should be at the greater trochanters (GTs). Prior studies have shown that practitioners are inaccurate in their placement. This study aimed to describe placement of PSBs by doctors and factors influencing placement.

Methods

This was a multicentre, prospective, observational, simulation-based study. Doctors working in Emergency Departments (EDs) and Trauma Emergency Units (TEUs) in Johannesburg were asked to place a PSB on two healthy male models of differing body mass index (BMI), as simulated patients (SPs). Outcomes were based on PSB position relative to the GTs, marked using an ultraviolet pen, and photographed under ultraviolet light. Data on techniques of placement, as well as practitioner factors, were also collected to investigate their influence on accuracy.

Results

In this study 147/176 (83.5 %) of the PSBs placed were correct (trochanteric). Of those placed on the normal BMI SP 71/88 (81 %) were correct and 76/88 (86 %) of those on the increased BMI SP. BMI did not appear to influence accuracy of placement. Practitioner factors that had statistically significant association with accurate placement included the following: Working in the TEU, work experience of ≥6 years, a diploma in primary emergency care (DipPEC, College of emergency medicine, South Africa), all methods of placing the PSB and inspecting to find the GTs.

Conclusion

The overall accuracy of PSBs placement was high (83.5 %). Additional postgraduate training (DipPEC) and work experience improved placement accuracy. This study highlighted the importance of additional trauma training and areas of possible future research, such as optimal binder width and method of securing PSBs.

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.

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.

Imposter or knight in shining armor? Pelvic circumferential compression devices (PCCD) for severe pelvic injuries in patients with multiple trauma: a trauma-registry analysis

BACKGROUND

Pelvic Circumferential Compression Devices (PCCD) are standard in hemorrhage-control of unstable pelvic ring fractures (UPF). Controversial data on their usefulness exists. Aim of the study was to investigate whether prehospital application of PCCD can reduce mortality and transfusion requirements in UPF.

METHODS

Retrospective cohort study. From 2016 until 2021, 63,371 adult severely injured patients were included into TraumaRegister DGU® of the German Trauma Society (TR-DGU). We analyzed PCCD use over time and compared patients with multiple trauma patients and UPF, who received prehospital PCCD to those who did not (noPCCD). Groups were adjusted for risk of prehospital PCCD application by propensity score matching. Primary endpoints were hospital mortality, standardized mortality rate (SMR) and transfusion requirements.

RESULTS

Overall UPF incidence was 9% (N = 5880) and PCCD use increased over time (7.5% to 20.4%). Of all cases with UPF, 40.2% received PCCD and of all cases with PCCD application, 61% had no pelvic injury at all. PCCD patients were more severely injured and had higher rates of shock or transfusion. 24-h.-mortality and hospital mortality were higher with PCCD (10.9% vs. 9.3%; p = 0.033; 17.9% vs. 16.1%, p = 0.070). Hospital mortality with PCCD was 1% lower than predicted. SMR was in favor of PCCD but failed statistical significance (0.95 vs. 1.04, p = 0.101). 1,860 propensity score matched pairs were analyzed: NoPCCD-patients received more often catecholamines (19.6% vs. 18.5%, p = 0.043) but required less surgical pelvic stabilization in the emergency room (28.6% vs. 36.8%, p < 0.001). There was no difference in mortality or transfusion requirements.

CONCLUSION

We observed PCCD overuse in general and underuse in UPF. Prehospital PCCD appears to be more a marker of injury severity and less triggered by presence of UPF. We found no salutary effect on survival or transfusion requirements. Inappropriate indication and technical flaw may have biased our results. TR-DGU does not contain data on these aspects. Further studies are necessary. Modular add-on questioners to the registry could offer one possible solution to overcome this limitation. We are concerned that PCCD use may be unfairly discredited by misinterpretation of the available evidence and strongly vote for a prospective trial.

Effectiveness of pelvic circumferential compression device for lower body trauma: Insights from a Japan Trauma Data Bank retrospective study

Aim

Pelvic ring fractures (PRFs) due to high-energy trauma often result in severe bleeding and high mortality. Pelvic circumferential compression devices (PCCD) are widely used to stabilize PRF and decrease bleeding. However, evidence supporting their effectiveness is still inconclusive.

Methods

We conducted an observational study using the Japan Trauma Data Bank (JTDB) from 2019 to 2021. Patients with blunt lower body trauma aged 15 years or older were included. We used propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) to evaluate the association of PCCD and mortality.

Results

Of the 74,393 patients in the database, 235 PCCD group and 23,429 control group were analyzed. After PSM, 231 patients in both groups were enrolled. Crude analysis indicated significantly higher in-hospital mortality in the PCCD group (odds ratio (OR) = 3.8 [95% CI = 2.51-5.75]). However, PSM and IPTW analysis indicated that PCCD was associated with decreased in-hospital mortality (PSM: OR = 0.79 [0.43-1.42]; IPTW: OR = 0.73 [0.62-0.86]). In a subgroup analysis of the IPTW analysis, PCCD fitting resulted in increased in-hospital mortality in the group without PRF (OR = 2.08 [1.91-2.27]), a decrease in stable PRF (OR = 0.74 [0.6-0.91]), and a further decrease in unstable PRF (OR = 0.18 [0.12-0.27]). Additional factors, such as a fall from a height, a fall downstairs, and pre-hospital PCCD placement also influenced the treatment effect.

Conclusion

The present, large, registry-based study found that PCCD reduced mortality in patients with a lower body injury, especially those with an unstable PRF.

Assessment and management of pelvic fractures from high-energy trauma in adults

Pelvic fractures caused by high-energy trauma such as falling from a height or road traffic collisions have a high mortality rate and patients are also at high risk of life-changing injuries. High-energy trauma to the pelvis is associated with major haemorrhage and injuries to the internal pelvic organs. Emergency nurses have a fundamental role in the initial assessment and management of patients, as well as in their ongoing care once the fracture has been stabilised and bleeding is controlled. This article describes the anatomy of the pelvis, discusses the initial assessment and management of patients who have sustained high-energy pelvic trauma, details the complications of pelvic fractures and explains patients' ongoing care in the emergency department.

The management of pelvic ring fractures in low-resource environments: review

Although improvement of pelvic trauma care has been successful in decreasing mortality rates in major trauma centers, such changes have not been implemented in low-resource environments such as low-middle-income countries (LMICs). This review details the evaluation and management of pelvic ring fractures and recommends improvements for trauma care in low-resource environments. Prehospital management revolves around basic life support techniques. Application of non-invasive pelvic circumferential compression devices, such as bed sheet or pelvic binders, can be performed as early as the scene of the accident. Upon arrival at the emergency department, rapid clinical evaluation and immediate resuscitation should be performed. Preperitoneal pelvic packing and external fixation devices have been considered as important first-line management tools to achieve bleeding control in hemodynamically unstable patients. After patient stabilization, immediate referral is mandated if the hospital does not have an orthopedic surgeon or facilities to perform complex pelvic/acetabular surgery. Telemedicine platforms have emerged as one of the key solutions for informing decision-making. However, unavailable referral systems and inaccessible transportation systems act as significant barriers in LMICs. Tendencies toward more "old-fashioned" protocols and conservative treatments are often justified especially for minimally displaced fractures. But when surgery is needed, it is important to visualize the fracture site to obtain and maintain a good reduction in the absence of intraoperative imaging. Minimizing soft tissue damage, reducing intraoperative blood loss, and minimizing duration of surgical interventions are vital when performing pelvic surgery in a limited intensive care setting.

Commonly performed pelvic binder modifications for femoral access may hinder binder efficacy

BACKGROUND

Pelvic fractures are common and potentially life-threatening. Pelvic circumferential compression devices (PCCD) can temporize hemorrhage, but more invasive strategies that involve femoral access may be necessary for definitive treatment. The aim of our study was to evaluate the efficacy of PCCDs reducing open book pelvic fractures when utilizing commonly described modifications and placement adjustments that allow for access to the femoral vasculature.

METHODS

Open book pelvic fractures were created in adult cadavers. Three commercially available PCCDs were used to reduce fractures. The binders were properly placed, moved caudally, or moved cranially and modified. Fracture reduction rates were then recorded.

RESULTS

The pelvic fracture was completely reduced with every PCCD tested when properly placed. Reduction rates decreased with improper placement and modifications.

CONCLUSION

Modifying PCCD placement to allow femoral access decreased the effectiveness of these devices Clinicians should be aware of this possibility when caring for critically injured trauma patients with pelvic fractures.

Does the accuracy of prehospital pelvic binder placement affect cardiovascular physiological parameters during rescue? A clinical study in patients with pelvic ring injuries

Introduction:

Methods:

Results:

Conclusion:

Level of Evidence:

Benefits of early application of pelvic circumferential compression device to reduce bleeding in pelvic fractures

Background

To study of efficacy of early pelvic circumferential compression device using in patients with suspected pelvic trauma, compared with conventional stepwise approach.

Methods

Traumatic injury and at least one of the following criteria are required for inclusion: loss of consciousness or a Glasgow coma score (GCS) of less than 13; systolic blood pressure less than 90 mmHg; falling from more than 6 m; injury to several important organs; and a positive pelvic compression test. Patients who satisfied the inclusion criteria for the experimental group were given an early application of a commercial pelvic sling beginning in July 2019. The control group consisted of cases who got the device after clinical or radiological confirmation of a pelvic fracture in the previous year. Gender, age, mechanism of injury, GCS, hospital stay, amount of packed red blood cell transfusion, hematocrit in emergency room, and hematocrit 24 h after application of pelvic binder were all assessed and compared.

Results

The study had a total of 30 participants, with 15 in each group. The number of packed red blood cell transfusions in the early pelvic binder group (0.80 ± 1.42) is considerably lower than in the control group (2.4 ± 2.32) (P = 0.008), although the hematocrit change is not statistically different between the groups (2.1 VS 0.7) (P = 0.191). The time it took to install a pelvic binder was considerably shorter in the early pelvic binder group (16.40 ± 5.45) than in the control group (40.40 ± 13.64) (P = 0.001). There were no problems associated to soft tissue and skin necrosis in either group of patients.

Conclusions

The use of the PCCD for 24 h prior to clinical and radiographic confirmation has significantly reduced the rate of packed red blood cell transfusion in any pelvic fracture patient without device-related complications.

Trial registration

The study was entered into the Thai Clinical Trials Registry (TCTR20210809007).

Epidemiologic, Postmortem Computed Tomography-Morphologic and Biomechanical Analysis of the Effects of Non-Invasive External Pelvic Stabilizers in Genuine Unstable Pelvic Injuries

Unstable pelvic injuries are rare (3–8% of all fractures) but are associated with a mortality of up to 30%. An effective way to treat venous and cancellous sources of bleeding prehospital is to reduce intrapelvic volume with external noninvasive pelvic stabilizers. Scientifically reliable data regarding pelvic volume reduction and applicable pressure are lacking. Epidemiologic data were collected, and multiple post-mortem CT scans and biomechanical measurements were performed on real, unstable pelvic injuries. Unstable pelvic injury was shown to be the leading source of bleeding in only 19%. All external non-invasive pelvic stabilizers achieved intrapelvic volume reduction; the T-POD^® succeeded best on average (333 ± 234 cm³), but with higher average peak traction (110 N). The reduction results of the VBM^® pneumatic pelvic sling consistently showed significantly better results at a pressure of 200 mmHg than at 100 mmHg at similar peak traction forces. All pelvic stabilizers exhibited the highest peak tensile force shortly after application. Unstable pelvic injuries must be considered as an indicator of serious concomitant injuries. Stabilization should be performed prehospital with specific pelvic stabilizers, such as the T-POD^® or the VBM^® pneumatic pelvic sling. We recommend adjusting the pressure recommendation of the VBM^® pneumatic pelvic sling to 200 mmHg.

Application of Pelvic Circumferential Compression Devices in Pelvic Ring Fractures-Are Guidelines Followed in Daily Practice?

Early administration of a pelvic circumferential compression device (PCCD) is recommended for suspected pelvic trauma. This study was conducted to evaluate the prevalence of PCCD in patients with pelvic fractures assigned to the resuscitation room (RR) of a Level I trauma center. Furthermore, correct application of the PCCD as well as associated injuries with potential clinical sequelae were assessed. All patients with pelvic fractures assigned to the RR of a level one trauma center between 2016 and 2017 were evaluated retrospectively. Presence and position of the PCCD on the initial trauma scan were assessed and rated. Associated injuries with potential adverse effects on clinical outcome were analysed. Seventy-seven patients were included, of which 26 (34%) had a PCCD in place. Eighteen (23%) patients had an unstable fracture pattern of whom ten (56%) had received a PCCD. The PCCD was correctly placed in four (15%) cases, acceptable in 12 (46%) and incorrectly in ten (39%). Of all patients with pelvic fractures (n = 77, 100%) treated in the RR, only one third (n = 26, 34%) had a PCCD. In addition, 39% of PCCDs were positioned incorrectly. Of the patients with unstable pelvic fractures (n = 18, 100%), more than half either did not receive any PCCD (n = 8, 44%) or had one which was inadequately positioned (n = 2, 11 %). These results underline that preclinical and clinical education programs on PCCD indication and application should be critically reassessed.

[Prehospital Strategies to Stop the Bleeding]

Seriously injured patients represent only a small group of patients in the emergency medical service with 0.5% (ground based) to 5% (HEMS), but they are associated with a high mortality rate. Among people younger than 45, trauma is the most common cause of death, mostly as a result of severe traumatic brain injury (TBI) and/or extreme hemorrhage. As the outcome of severe TBI prehospitally can only be influenced to a very limited extent, a majority of preventable deaths in prehospital setting are caused by "critical" bleeding. The "critical" bleeding is defined by its life-threatening dimension. Anticoagulation medication can have a reinforcing effect. Adequate prehospital therapy strategies exist for external bleeding. In contrast, internal bleeding regularly evades a causal prehospital care, so that in such cases, transport prioritization and rapid definitive surgical intervention remain the only option. In the civilian environment the tested and evaluated "ABCDE" scheme must be preceded by the <C> (for "critical bleeding") in order to react time-critically to compressible external bleeding, possibly even prior to airway management. These findings have found their way into the current version of the S3 guideline on treatment of multi system trauma by the German Society for Trauma Surgery (DGU). According to this "severely bleeding injuries that can impair vital functions should be treated with priority". Thus, this publication focuses on prehospital bleeding control.

Pelvic circumferential compression devices for prehospital management of suspected pelvic fractures: a rapid review and evidence summary for quality indicator evaluation

BACKGROUND

Pelvic fractures, especially when unstable, may cause significant haemorrhage. The early application of a pelvic circumferential compression device (PCCD) in patients with suspected pelvic fracture has established itself as best practice. Ambulance services conduct corresponding performance measurement. Quality indicators (QIs) are ideally based on high-quality evidence clearly demonstrating that the desirable effects outweigh the undesirable effects. In the absence of high-quality evidence, best available evidence should be combined with expert consensus.

OBJECTIVES

The aim of the present study was to identify, appraise and summarize the best available evidence regarding PCCDs for the purpose of informing an expert panel tasked to evaluate the validity of the following QI: A patient with suspected pelvic fracture has a PCCD applied.

METHODS

A rapid review of four databases was conducted to identify relevant literature published up until 9 June 2020. Systematic reviews, experimental, quasi-experimental and observational analytic studies written in English were included. One author was responsible for study selection and quality appraisal. Data extraction using a priori extraction templates was verified by a second reviewer. Study details and key findings were summarized in tables.

RESULTS

A total of 13 studies were assessed to be eligible for inclusion in this rapid review. Of these, three were systematic reviews, one was a randomized clinical trial (crossover design), two were before-after studies, and seven were retrospective cohort studies. The systematic reviews included mostly observational studies and could therefore not be considered as high-level evidence. Overall, the identified evidence is of low quality and suggests that PCCD may provide temporary pelvic ring stabilization and haemorrhage control, although a potential for adverse effects exists.

CONCLUSION

Given the low quality of the best available evidence, this evidence would need to be combined with expert consensus to evaluate the validity of a related quality indicator before its implementation.

How effective are different models of pelvic binders: results of a study using a Pelvic Emergency Simulator

BACKGROUND

The application of pelvic binders in the preclinical and early clinical phase is advisable to avoid or treat C-problems in unstable and potential bleeding pelvic ring fractures, even if the clinical effectivity is not completely proved. The use for pathologies in the posterior pelvic ring is still debatable.

QUESTIONS/PURPOSES

We determined if there is a difference in achievable compression in the dorsal pelvic ring depending on position and pelvic binder model. Can this effect be tested with a simplified artificial model?

METHODS

We simulated a Tile type C fracture within the established pelvic emergency trainer and measured in a test series the effectivity of reduction with a non-invasive stabilization technique using 3 different pelvic binders.

RESULTS

Any therapeutic effect of a pelvic binder with compression to the posterior pelvic ring requires at first a reduction maneuver. While the compression effect in the symphysis depends only on positioning of the binder, in the posterior pelvic ring, the result varies with the used model. The achievable pressure in the SI joint with a pelvic binder is only 20-25% (33.5-47 N) compared to the C-Clamp values (156 N).

CONCLUSIONS

The use of pelvic binders for non-invasive pelvic ring stabilization, even with a posterior pathology, could be proven in a simplified fracture model. A proper fracture reduction and an adequate device positioning influence the effectiveness.

CLINICAL RELEVANCE

The use of an emergency pelvic trainer even for a non-invasive maneuver is advisable.

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.

Efficiency of a pelvic circumferential compression device for continuous hemorrhage of peripheral soft tissue of the pelvis: A case report

Background

A pelvic circumferential compression device (PCCD) is a belt that is wrapped around a fractured pelvis and tightened with a closing mechanism. The SAM Sling® is one of the most common PCCDs used for trauma management. Although the use of the SAM Sling® for reduction and stabilization of unstable pelvic ring fracture has become the standard of care in most relevant trauma scenarios, it is not usually used for stopping continuous hemorrhage of the peripheral soft tissue of the pelvis without unstable pelvic ring fractures.

Case presentation

We report the case of a 79-year-old woman with life-threatening and unexpected continuous subcutaneous and intramuscular hemorrhage of the buttocks and groin area. She did not have unstable pelvic ring fractures but had hemorrhagic shock and acute traumatic coagulopathy (ATC). By use of the SAM Sling®, the hemorrhage was controlled, and she was eventually rescued.

Conclusions

We propose the use of the SAM Sling® to stop continuous bleeding in the state of ATC regardless of unstable pelvic ring fracture.

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.

Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting

Introduction

Exsanguination following trauma is potentially preventable. Extremity tourniquets have been successfully implemented in military and civilian prehospital care. Prehospital control of bleeding from the torso and junctional area’s remains challenging but offers a great potential to improve survival rates. This review aims to provide an overview of potential treatment options in both clinical as preclinical state of research on truncal and junctional bleeding. Since many options have been developed for application in the military primarily, translation to the civilian situation is discussed.

Methods

Medline (via Pubmed) and Embase were searched to identify known and potential prehospital treatment options. Search terms were|: haemorrhage/hemorrhage, exsanguination, junctional, truncal, intra-abdominal, intrathoracic, intervention, haemostasis/hemostasis, prehospital, en route, junctional tourniquet, REBOA, resuscitative thoracotomy, emergency thoracotomy, pelvic binder, pelvic sheet, circumferential. Treatment options were listed per anatomical site: axilla, groin, thorax, abdomen and pelvis Also, the available evidence was graded in (pre) clinical stadia of research.

Results

Identified treatment options were wound clamps, injectable haemostatic sponges, pelvic circumferential stabilizers, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), intra-abdominal gas insufflation, intra-abdominal self-expanding foam, junctional and truncal tourniquets. A total of 70 papers on these aforementioned options was retrieved. No clinical reports on injectable haemostatic sponges, intra-abdominal insufflation or self-expanding foam injections and one type of junctional tourniquets were available.

Conclusion

Options to stop truncal and junctional traumatic haemorrhage in the prehospital arena are evolving and may offer a potentially great survival advantage. Because of differences in injury pattern, time to definitive care, different prehospital scenario’s and level of proficiency of care providers; successful translation of various military applications to the civilian situation has to be awaited. Overall, the level of evidence on the retrieved adjuncts is extremely low.

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.

Effect of Pelvic Binder Placement on OTA Classification of Pelvic Ring Injuries Using Computed Tomography. Does It Mask the Injury?

OBJECTIVES

To assess the diagnostic sensitivity of computed tomography (CT) in patients with an unstable pelvic ring injury after application of a pelvic binder.

DESIGN

An institutional review board approved retrospective study from 2003 to 2010.

SETTING

Level 1 trauma center.

PATIENTS

Inclusion criteria were patients in our trauma database with AO/OTA B or C type pelvic ring injury, which first had an anterior-posterior pelvic x-ray followed by application of a pelvic circumferential compression device (PCCD), then a CT, and a fluoroscopic stress examination under anesthesia (FEUA) (used as gold standard). Of 867 patients, 43 met the inclusion criteria.

INTERVENTION

A senior Orthopaedic Resident and Trauma Attendings assessed x-rays, CTs, and FEUAs. Binomial test was used to compare imaging against final diagnosis.

RESULTS

In Anterior Posterior Compression/Vertical Shear (OTA 61-B1, 61-B3.1, 61-C) injury patterns, prebinder x-rays were diagnostic in 69.4% (CI, 51.9%-83.7%) of cases, compared with 50% (CI, 32.9%-67.1%) with CT + PCCD. The x-ray was superior to CT + PCCD for identification of the anterior pelvic injury (McNemar exact P = 0.0352). If x-ray and CT + PCCD were viewed in tandem, 83.3% (CI, 67.2%-93.6%) of classifications were in agreement with the FEUA. For lateral compression mechanisms, the binder did not effect of the sensitivity of the CT except in the open book component of an lateral compression 3 (61-B3.2) mechanism.

CONCLUSIONS

The placement of a pelvic binder has the potential to mask the severity of unstable pelvic ring injuries when relying only on CT for diagnosis. Fluoroscopic manual pelvic stress examination under anesthesia is an essential adjunct when a binder is placed before imaging.

LEVEL OF EVIDENCE

Diagnostic level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Treatment of an open book pelvic fracture and bilateral femoral fractures with an external fixator in a 14-month-old: a case report

A 14-month-old girl was involved in a road traffic accident that resulted in an open book pelvic fracture and bilateral femoral fractures. Acute treatment involved a novel collar and the cuff pelvic closure technique to tamponade the pelvis and reduce bleeding. The patient was treated surgically with an external fixator, which provided good reduction of the pelvic and femoral fractures. A literature search found no previous information on open book pelvic fractures in infants younger than 2 years. The success of this surgery led us to suggest that the use of an external fixator is a potential treatment method for open book pelvic fractures and bilateral femoral fractures in extremely young infants.

Emergency radiological examination of the externally stabilized pelvis--there is a catch to it: lessons learned from two cases with symphyseal disruption despite initial inconspicuous computed tomography

BACKGROUND

Preclinical and early clinical external pelvic stabilization using commercially available devices has become common in trauma patient care. Thus, in the emergency department an increasing number of patients will undergo radiographic evaluation of the externally stabilized pelvis to exclude injuries. While reports exist where injuries to the pelvis were elusive to radiological examination due to the pelvic immobilization we elaborate on an algorithm to remove an external pelvic stabilizing device, prevent delayed diagnosis of pelvic disruption and thus increase patient safety.

CASE PRESENTATION

We report on two patients with external pelvic stabilization presenting with an inconspicuous pubic symphysis on initial pelvic computed tomography scans. The first patient was an otherwise healthy 51-year old male being run over by his own car. He received external pelvic stabilization in the emergency department. The second patient was a 36-year old male falling from a ladder. In this patient external pelvic stabilization was performed at the scene. In the first patient no pelvic injury was obvious on computed tomography. In the second patient pelvic fractures were diagnosed, yet the presentation of the pubic symphysis appeared normal. Nevertheless, complete symphyseal disruption was diagnosed in both of them upon removal of the external pelvic stabilization and consequently required internal fixation.

CONCLUSION

Based on our experience we propose an algorithm to "clear the initially immobilized pelvis" in an effort to minimize the risk of missing a serious pelvic injury and increase patient safety. This is of significant importance to orthopedic trauma surgeons and emergency physicians taking care of injured patients.

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.

Protocols for massive blood transfusion: when and why, and potential complications

PURPOSE

An update paper on massive bleeding after major trauma. A review of protocols to address massive bleeding, and its possible complications, including coagulation abnormalities, complications related to blood storage, immunosuppression and infection, lung injury associated with transfusion, and hypothermia is carried out.

METHODS

Literature review and discussion with authors' experience.

RESULTS

Massive bleeding is an acute life-threatening complication of major trauma, and consequently its prompt diagnosis and treatment is of overwhelming importance. Treatment requires rapid surgical management together with the massive infusion of colloid and blood.

CONCLUSIONS

Since massive transfusion provokes further problems in patients who are already severely traumatized and anaemic, once this course of action has been decided upon, a profound knowledge of its potential complications, careful monitoring and proper follow-up are all essential. To diagnose this bleeding, most authors favour, as the main first choice tool, a full-body CT scan (head to pelvis), in non-critical severe trauma cases. In addition, focused abdominal sonography for trauma (FAST, an acronym that highlights the necessity of rapid performance) is a very important diagnostic test for abdominal and thoracic bleeding. Furthermore, urgent surgical intervention should be undertaken for patients with significant free intraabdominal fluid and haemodynamic instability. Although the clinical situation and the blood haemoglobin concentration are the key factors considered in this rapid decision-making context, laboratory markers should not be based on a single haematocrit value, as its sensitivity to significant bleeding may be very low. Serum lactate and base deficit are very sensitive markers for detecting and monitoring the extent of bleeding and shock, in conjunction with repeated combined measurements of prothrombin time, activated partial thromboplastin time, fibrinogen and platelets.

Application of current hemorrhage control techniques for backcountry care: part two, hemostatic dressings and other adjuncts

Decade-long advances in battlefield medicine have revolutionized the treatment of traumatic hemorrhage and have led to a significant reduction in mortality. Part one of this review covered the use of tourniquets on the extremities and the newer devices for use in junctional areas. Part two focuses on the use of hemostatic agents or dressings, pelvic binders, and tranexamic acid. Field applicable hemostatic dressings are safe and effective in controlling hemorrhage not amenable to extremity tourniquet application, and newer agents with increasing efficacy continue to be developed. Most of these agents are inexpensive and lightweight, making them ideal products for use in wilderness medicine. The use of pelvic binders to stabilize suspected pelvic fractures has gained new interest as these products are developed and refined, and the prehospital use of tranexamic acid, a potent antifibrinolytic, has been found to be life saving in patients at risk of death from severe hemorrhage. Recommendations are made for equipment and techniques for controlling hemorrhage in the wilderness setting.

Posterior iliac crescent fracture-dislocation: is it only rotationally unstable?

Posterior iliac crescent fracture-dislocation is generally considered rotationally unstable and vertically stable. The current study (1) investigated whether vertical instability may occur in posterior iliac crescent fracture-dislocation and (2) analyzed the clinical features of vertically unstable iliac crescent fracture-dislocation as well as treatment strategies. Patients with pelvic fracture who were treated in the authors' department from June 2009 to June 2012 were retrospectively reviewed. This study analyzed the clinical features, including incidence, hemodynamic state, associated injuries, injury severity score, and treatment methods for vertically unstable iliac crescent fracture-dislocation. Four patients had vertically unstable fracture-dislocation, accounting for 12.9% of all iliac crescent fracture-dislocations. All 4 patients were hemodynamically unstable on admission and had complications of associated injuries with a higher injury severity score. In 3 of the 4 patients, iliac crescent fracture-dislocations were reduced via the posterior approach at the initial stage and these patients underwent fixation with a plate. The remaining patient was initially given transcondylar traction because of severe complications and underwent open reduction and internal fixation (ORIF) via a posterior approach at a later stage. The outcomes of all 4 patients were rated as good or excellent by the Kobbe rating system at the last follow-up. Vertical instability may occur in iliac crescent fracture-dislocation. The authors propose ORIF of the fracture-dislocation via a posterior approach. When initial surgery is not possible because of severe associated organ injuries, the authors propose transcondylar traction to allow reduction of the sacroiliac joint and ORIF at a later stage.

Comparison of circumferential pelvic sheeting versus the T-POD on unstable pelvic injuries: A cadaveric study of stability

OBJECTIVES

Commercially available binder devices are commonly used in the acute treatment of pelvic fractures, while many advocate simply placing a circumferential sheet for initial stabilization of such injuries. We sought to determine whether or not the T-POD would provide more stability to an unstable pelvic injury as compared to circumferential pelvic sheeting.

METHODS

Unstable pelvic injuries (OTA type 61-C-1) were surgically created in five fresh, lightly embalmed whole human cadavers. Electromagnetic sensors were placed on each hemi-pelvis. The amount of angular motion during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). Either a T-POD or circumferential sheet was applied in random order for testing. The measurements recorded in this investigation included maximum displacements for sagittal, coronal, and axial rotation during application of the device, bed transfer, log-rolling, and head of bed elevation.

RESULTS

There were no differences in motion of the injured hemi-pelvis during application of either the T-POD or circumferential sheet. During the bed transfer, log-rolling, and head of bed elevation, there were no significant differences in displacements observed when the pelvis was immobilized with either a sheet or pelvic binder (T-POD).

CONCLUSIONS

A circumferential pelvic sheet is more readily available, costs less, is more versatile, and is equally as efficacious at immobilizing the unstable pelvis as compared to the T-POD. We advocate the use of circumferential sheeting for temporary stabilization of unstable pelvic injuries.

Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques

BACKGROUND

Emergency devices for pelvic ring stabilization include circumferential sheets, pelvic binders, and c-clamps. Our knowledge of the outcome of these techniques is currently based on limited information.

METHODS

Using the dataset of the German Pelvic Trauma Registry, demographic and injury-associated characteristics as well as the outcome of pelvic fracture patients after sheet, binder, and c-clamp treatment was compared. Outcome parameters included transfusion requirement of packed red blood cells, length of hospital stay, mortality, and incidence of lethal pelvic bleeding.

RESULTS

Two hundred seven of 6137 (3.4%) patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets, binders, or c-clamps. In most cases, c-clamps (69%) were used, followed by sheets (16%), and binders (15%). The median age was significantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs. 47 vs. 42 years, p=0.01). Sheet wrapping was associated with a significantly higher incidence of lethal pelvic bleeding compared to binder or c-clamp stabilization (23% vs. 4% vs. 8%). No significant differences between the study groups were found in sex, fracture type, blood haemoglobin concentration, arterial blood pressure, Injury Severity Score, the incidence of additional pelvic packing and arterial embolization, need of red blood cell transfusion, length of hospitalisation, and mortality.

CONCLUSIONS

The data suggest that emergency stabilization of the pelvic ring by binders and c-clamps is associated with a lower incidence of lethal pelvic bleeding compared to sheet wrapping.

LEVEL OF EVIDENCE

Level III.

Does application position of the T-POD affect stability of pelvic fractures?

OBJECTIVE

Most trauma centers place pelvic binders on unstable pelvic fractures for acute management and control of hemorrhage. It has been proposed that the binders be placed at the level of the greater trochanters of the femur. Our hypothesis was that application of the T-POD at this site would provide better immobilization of an unstable pelvic injury than a more cephalad location.

METHODS

Unstable pelvic injuries (OTA type 61-C1) were surgically created in 9 fresh whole human cadavers. Electromagnetic sensors were affixed to the intact and injured sides of the pelvis. A Fastrak, three-dimensional electromagnetic motion analysis device was used to determine the angular motion occurring at the fractured sites. Maximum displacements for sagittal, coronal, and axial rotation were recorded during application of the binder, while performing bed transfers, while logrolling, and elevating the head of the bed. The T-POD device was placed either over the greater trochanters or at the level of the anterior superior iliac spine as per manufacturer's recommendations.

RESULTS

There were no significant differences in the amount of motion produced during application of the T-POD at either location. There was less motion observed in all planes of motion during all maneuvers when the T-POD was placed at the level of the greater trochanters versus anterior superior iliac spine. During bed transfers, this was statistically significant in all planes. This was statistically significant while logrolling in the axial plane and the coronal plane during head of bed elevation.

CONCLUSIONS

We advocate the placement of pelvic binder devices at the level of the greater trochanters for improved control of the fracture in an unstable pelvic injury. This may result in improved control of hemorrhage, better access to the abdomen, and greater patient comfort.

Management of traumatic spinopelvic dissociations: review of the literature

PURPOSE

Spinopelvic dissociation is a rare high-energy injury pattern in adults associated with high morbidity and an increased rate of neurological deficits. The purpose of this article is the conception of fracture type-associated treatment recommendations.

METHODS

This article is based on our own experience with spinopelvic dissociations and a review of the current literature.

RESULTS

Bilateral vertical plus an optional transverse fracture component configures spinopelvic dissociations as "U"- or "H"-shaped, with the result of a spinopelvic dissociation. "Y"-, "T"- or "II"-shaped fractures do not necessarily belong to this entity but can be subsumed to this entity in a wider sense. The surgical treatment of these injuries remains challenging. Initial haemodynamic stabilisation represents the main goal of primary care until definitive treatment can be performed. Anatomical reduction is demanding and even more complex in fracture areas with large comminution. Surgical treatment options depend on the fracture type, including transsacral screws, sacral banding and spinopelvic fixation, plus combinations of these procedures.

CONCLUSIONS

Spinopelvic dissociations remain highly complex injuries. "U"- and "H"-shaped fractures usually require triangular fixation, whereas "II"-, "Y"- and "T"-shaped fractures might be sufficiently stabilised with transsacral screws.

Comparison of external fixation versus the trauma pelvic orthotic device on unstable pelvic injuries: a cadaveric study of stability

BACKGROUND

Most institutions treating pelvic fractures use some method of acute mechanical stabilization. This typically involves use of pelvic binders or circumferential sheeting, and/or external fixation. The comparative value of these different modalities is controversial. We hypothesized that an external fixator would provide more stability to an unstable pelvic injury than a commercially available binder device (trauma pelvic orthotic device [T-POD]).

METHODS

Unstable pelvic injuries (Tile C) were surgically created in five fresh whole human cadavers. Electromagnetic sensors were placed on the same position of each hemipelvis. The amount of angular motion during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device. Maximum displacements were recorded during application of the stabilizing devices, bed transfer, logrolling, and head-of-bed elevation. External fixation frames were constructed by placing two 5.0-mm half pins into the iliac crest and then connected them with a 10-mm curved bar. The T-POD device was placed at the level of the greater trochanters as per manufacturer's recommendations.

RESULTS

While logrolling the patient and performing bed transfers, the T-POD conferred more stability in all planes of motion, although this did not reach statistical significance. During elevation of the head of the bed, the T-POD allowed less motion in the sagittal and coronal planes but permitted equivalent motion in axial rotation. These differences were not statistically significant.

CONCLUSION

There were no significant differences in stability conferred by an external fixator or a T-POD for unstable pelvic injuries. We advocate acute, temporary stabilization of pelvic injuries with a binder device and early conversion to internal fixation when the patient's medical condition allows.

Emergency medicine techniques and the forensic autopsy

Emergency medicine measures often have to be carried out under suboptimal conditions in emergency situations and require invasive patient treatment. In the case of a fatal outcome these measures have to be evaluated at autopsy, regarding indications, correct implementation and possible complications. As well, alongside the more familiar procedures--such as endotracheal intubation, insertion of chest drains, external cardiac massage and cannulation of central and peripheral veins--there are alternative techniques being increasingly applied, that include new tools for the management of hemorrhagic shock, drug delivery and alternative airway management devices. On the one hand, all of these measures are essential for the survival and appropriate treatment of the injured and/or sick patient, but on the other hand they can damage the patient and thus contain a significant risk of both medical and forensic relevance for the patient and the physician. In the following review we provide an overview of established, new and alternative techniques for emergency airway management, administration of drugs and management of hemorrhagic shock. The aim is to facilitate the understanding and autopsy evaluation of current emergency medicine techniques.

The early management of patients with multiple injuries: an evidence-based, practical guide for the orthopaedic surgeon

There have been many advances in the resuscitation and early management of patients with severe injuries during the last decade. These have come about as a result of the reorganisation of civilian trauma services in countries such as Germany, Australia and the United States, where the development of trauma systems has allowed a concentration of expertise and research. The continuing conflicts in the Middle East have also generated a significant increase in expertise in the management of severe injuries, and soldiers now survive injuries that would have been fatal in previous wars. This military experience is being translated into civilian practice. The aim of this paper is to give orthopaedic surgeons a practical, evidence-based guide to the current management of patients with severe, multiple injuries. It must be emphasised that this depends upon the expertise, experience and facilities available within the local health-care system, and that the proposed guidelines will inevitably have to be adapted to suit the local resources.