Page 161 - Journal of Special Operations Medicine - Spring 2017

binders. The results of retrospective studies are mixed. The radiologic signs of open book pelvic fracture may
A German-language publication reported 104 severely be masked after pelvic binder is applied, and cases of
injured (Injury Severity Score [ISS] >16) patients with missed injury due to near-perfect bony alignment after
isolated pelvic fracture and hemodynamic instability. pelvic binder placement have been reported. 55
Those who did receive external pelvic stabilization af-
ter hospital arrival had a mortality rate of 19%, while Conclusion: applying a pelvic binder is unlikely to in-
those treated without external stabilization had a 33% crease injury or bleeding. Prolonged use or overtighten-
mortality rate. 45 ing may cause pressure ulcerations. Level of evidence: C

In contrast, a retrospective historical control study in Who Should Receive a Pelvic Binder?
the United States showed that external mechanical com-
pression, when applied after arrival to the hospital, had Strategies to identify pelvic fracture in the prehospital
no effect on mortality, need for angioembolization, or environment include identification of risk factors for
transfusion in a center that emphasized early treatment pelvic fracture and physical examination findings.
with angiography. 46
An analysis of 77 consecutive patients with traumatic
Of 135 patients with unstable pelvic fractures trans- lower limb amputation due to a dismounted IED from
ferred to a trauma center, three deaths occurred among the United Kingdom Joint Theater Trauma Registry
those who did not receive a pelvic binder before transfer demonstrated a high incidence of pelvic fractures in
and none occurred among those who did. 39 patients with lower limb amputations: overall, 22% of
these casualties had a pelvic fracture; if bilateral above
Conclusion: There is very weak clinical evidence that knee amputations were present, 39% had a pelvic frac-
pelvic binders may improve survival when applied after ture. The authors concluded that routine application of
3
hospital arrival. Evidence in regard to survival follow- pelvic binders was indicated for this injury pattern.
ing prehospital application of pelvic binders is lacking.
Level of evidence: C Further analysis of bilateral lower extremity amputa-
tions in UK servicemen showed that 14% also had an
open pelvic fracture. Of patients who sustained a
56
Is There Any Harm perineal injury from IED blast, 53% also had a pelvic
in Applying a Pelvic Binder?
fracture; the combination of pelvic fracture and perineal
In theory, pelvic compression could worsen displacement injury had a high mortality rate—41%. 57
of certain fracture patterns, particularly lateral com-
pression injuries, or cause injury to internal structures A large study assessing the sensitivity of prehospital
through fracture fragment motion; however, there is no physical examination for pelvic fracture showed that
actual clinical evidence that significant harm occurs. about one-third of severe pelvic fractures were not sus-
pected in the prehospital environment, with brain injury
In a series of 115 patients with high-energy Tile B and and low Glasgow Coma Scale (GCS) score indepen-
C pelvic ring injuries, bony alignment of the pelvis im- dently associated with missed injury. Hypotension and
47
proved in 68% after application of a pelvic binder, was high ISS (≥ 25) decreased the risk of missing a pelvic
unchanged in 11%, and worsened in 11%. The authors injury. 58
noted that in some lateral compression fractures, the ra-
diologic deformity increased with pelvic binder place- The Royal London Hospital published their standard
ment; however, any association between a pelvic binder criteria for application of a pelvic binder, which included
and femoral artery, bladder, or rectal injury was deter- obvious pelvic disruption, severe trauma with pain in
mined to be unlikely. 48 the pelvis, pain in lower back, pain in the hip, pelvic
deformity on visual inspection, and unconscious patient
A clinical series of 16 pelvic fracture patients showed with high-energy blunt mechanism. They reported that
59
that open book fractures were effectively reduced with a 25% of all prehospital missed injuries were pelvic frac-
controlled tension pelvic binder, while overreduction of tures (eight pelvic fractures were missed on prehospital
compression type fractures was minimal and no compli- assessment, two of which were severe); however, none
cation observed even with prolonged application (mean of the missed pelvic fractures were associated with hy-
59 hours). 49 potension. The majority of those that were missed also
had distracting injuries to the head or limbs.
Pressure injury to the skin is a known complication of
pelvic binder; such skin break down may interfere with The London Faculty of Pre-Hospital Care (FPHC) con-
operative fixation of the pelvis. 50–54 sensus meeting on prehospital management of pelvic

Pelvic Binders TCCC Guidelines Change 137