Page 160 - Journal of Special Operations Medicine - Spring 2017

binder, pelvic sling, pelvic orthotic device, pelvic circum- often disrupted, allowing free bleeding into the perito-
4
ferential compression device, hemorrhage, and prehospi- neal cavity. Therefore, it is more likely that splinting of
tal. A total of 1,984 articles were identified; 114 abstracts pathologic fracture motion to allow clot formation is
were reviewed; 60 articles were identified for full review, the mechanism that aids in hemostasis.
and 53 articles selected for final inclusion. The references
of selected articles were also reviewed as potential addi- Hemorrhage with stable fracture patterns is unlikely to
tional sources, identifying an additional 7 articles. be controlled with a pelvic binder. However, since it is
not possible to differentiate a stable from an unstable
fracture pattern in the prehospital environment, all sus-
Does a Pelvic Binder Stabilize the Pelvic Fracture?
pected pelvic fractures should have a binder applied.
The effectiveness of a pelvic binder to stabilize frac-
ture fragments has been assessed in human cadaver Several clinical studies have attempted to assess the effect
studies where various unstable fracture patterns were of pelvic binder placement on hemorrhage control. A ret-
created and the fracture motion measured after pelvic rospective review of 585 patients with pelvic fractures
™
binder application. Commercial devices (Pelvic Binder requiring transfer to a trauma center showed that those
®
[Pelvic Binder Inc.; http://www.pelvicbinder.com/], T-POD who received a pretransfer pelvic binder required fewer
[Pyng Medical; http://www.pyng.com/products/t-pod blood transfusions and had a shorter length of stay. 39
combat/], and SAM Pelvic Sling [SAM Medical Prod-
®
ucts; www.sammedical.com/]) and circumferential sheet- In a retrospective study of 183 patients treated with ex-
ing were compared in various combinations in five sepa- ternal fixation or pelvic binder after hospital arrival, the
rate studies. 32–36 All devices tested were found to provide binder was associated with lower 24-hour transfusion
near- anatomic fracture reduction with minimal overre- and shorter length of stay, and with a nonsignificant
duction. Angular motion was controlled during simu- decrease in mortality (26% versus 37%). The authors
33
lated patient care maneuvers in one study. In general, noted that the binder could be applied more quickly
no significant difference was detected between the vari- compared to external fixation. 40
ous commercial devices and circumferential sheet.
A retrospective comparison of 192 civilian trauma pa-
Placement of the binder at the level of the pubic sym- tients treated with pelvic compression after hospital ar-
physis and greater trochanters was shown to reduce the rival showed that lethal hemorrhage was higher when a
unstable pelvic fracture most effectively with the least circumferential sheet was used (23%) compared with a
amount of force. 35–37 binder or C-clamp (4% and 8%) respectively, although
the authors acknowledged that sheets may have been
Conclusion: There is evidence in cadaver studies that used at the more inexperienced trauma centers, while
fracture motion is stabilized with a pelvic binder. The the experienced centers had binders available. 41
binder should be placed at the level of the pubic sym-
physis/greater trochanters. Level of evidence: B In several case reports, a properly applied binder along
with ongoing resuscitation effectively improved hemo-
dynamics for patients with pelvic fracture and hypoten-
Does a Pelvic Binder Control Bleeding sion. 42–44 In a case-series of 15 hemodynamically unstable
From a Fractured Pelvis?
patients with unstable pelvic fractures, hemodynamics
The primary source of hemorrhage from pelvic fractures were assessed before and immediately after placement of
is the posterior pelvic venous plexus and bleeding cancel- a T-POD device; mean arterial pressure increased and
®
lous bone surfaces; however, 10–15% of the time, hemor- heart rate declined after the binder was placed.
rhage is arterial and arises from branches of the internal
iliac, pudendal, and superior gluteal arteries. Exsangui- Conclusion: There is weak clinical evidence that pelvic
nating hemorrhage may occur in all fracture patterns, binder may reduce blood transfusion and lethal hem-
even simple rami fractures, and may be independent of orrhage compared to other methods. There is likely to
the bony injury pattern to the pelvis altogether. 4 have been selection bias in these studies and no studies
of prehospital application were identified. Anecdotally,
Conventional teaching indicated that pelvic binders con- hemodynamics often improve after pelvic binder appli-
trol bleeding by reducing the volume of the pelvis and cation. Level of evidence: B
inducing tamponade. However, the reduction in volume
of the true pelvis is much less than expected: a large pubic Does a Pelvic Binder Improve Survival?
diastasis of 10 cm corresponds to only a 35% increase
38
in pelvic volume, or 480 cm. Additionally, a tampon- No high-quality evidence was found that documented
ade effect may not occur since the retroperitoneum is improved survival associated with the use of pelvic

136 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017