Page 37 - Journal of Special Operations Medicine - Fall 2017

Combat Trousers as Effective Improvised Pelvic Binders

A Comparative Cadaveric Study

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Andrew Loftus, MB BCh, MChem, MPhil *; Rhys Morris, MBBS, BSc, MSc, MRCS ;
Yasmin Friedmann, PhD ; Ian Pallister, MBBS, MMed Sci (Trauma), FRCS, MD ;
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Paul Parker, FIMC, FRCSEd (Orth) 5

ABSTRACT
Background: Improvised explosive devices and landmines improvised explosive devices (IEDs) have been widely used to
can cause pelvic fractures, which, in turn, can produce cata- devastating effect. IEDs most often cause lower limb injury
strophic hemorrhage. This cadaveric study compared the in- and amputation, with blast damage directed upward to the
trapelvic pressure changes that occurred with the application perineum and pelvis. The injury pattern caused by IEDs means
of an improvised pelvic binder adapted from the combat trou- pelvic fractures are now more common in military patients. In
sers worn by British military personnel with the commercially a recent retrospective analysis of 77 military personnel with
available trauma pelvic orthotic device (TPOD). Methods: Six traumatic lower limb amputations, 22% had an associated
unembalmed cadavers (three male, three female) were used pelvic fracture, of which 50% of this subset had unstable ring
to simulate an unstable pelvic fracture with complete disrup- fractures. 2,3
tion of the posterior arch (AO/OTA 61-C1) by dividing the
pelvic ring anteriorly and posteriorly. A 3–4cm manometric Pelvic fractures have a high associated mortality. The main
balloon filled with water was placed in the retropubic space cause of death is hemorrhage, which is venous in origin in
4,5
and connected to a 50mL syringe and water manometer via 85% of cases. Other sources of bleeding include fractured
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a three-way tap. A baseline pressure of 8cmH O (average bone ends and ruptured iliac vessels. Prompt reduction and
7–9
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central venous pressure) was set. The combat trouser binder stabilization of pelvic ring injuries are crucial in managing the
(CTB) and TPOD were applied to each cadaver in a random substantial hemorrhage associated with these injuries. 7,10 Pre-
sequence and the steady intrapelvic pressure changes were re- vention of this hemorrhage fits within the concept of dam-
corded. Statistical analysis was performed using the Wilcoxon age control resuscitation to prevent the loss of clotting factors
rank-sum test and a paired t test depending on the normality contributing to coagulopathy, hypothermia, and acidosis—the
of the data to determine impact on the intrapelvic pressure of “lethal triad.” Early identification and management of a pel-
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each intervention compared with baseline. Results: The me- vic fracture at the prehospital stage are essential to reduce the
dian steady intrapelvic pressure achieved after application of mortality resulting from hemorrhage into the intrapelvic space
the CTB was 16cmH O and after application of the TPOD and has recently been included into the hemorrhage compo-
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binder was 18cmH O, both of which were significantly greater nent of the Tactical Combat Casualty Care algorithm.
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than the baseline pressure (p < .01 and .036, respectively) but
not significantly different from each other (p > .05). Con- This cadaveric study assessed the changes in intrapelvic pres-
clusion: Pelvic injuries are increasingly common in modern sure after application of a pelvic binder adapted from the
theaters of war. The CTB is a novel, rapidly deployable, yet combat trousers that British soldiers wear. We have termed
effective, method of pelvic binding adapted from the clothes this the combat trouser binder (CTB). The intrapelvic pres-
the casualty is already wearing. This technique may be used sure changes after application of the trauma pelvic orthotic
in austere environments to tamponade and control intrapelvic device (TPOD) were measured and, finally, the two interven-
hemorrhage. tions were compared via statistical analysis. The methodology
was adapted from previous pilot study performed at Swansea
Keywords: pelvic fracture; pelvic binder; trauma; hemor- University Medical school and further developed in a study
rhage; coagulopathy; military; combat; prehospital emer- performed at the Royal College of Surgeons, which mea-
gency care sured the actual change in intrapelvic pressure 11,12 rather than
use surrogate markers such as symphyseal diastasis or pelvic
circumference. 7,15,16
Introduction
Materials and Methods
Pelvic fractures are life-threatening injuries that should be
suspected in all major trauma patients; their overall inci- Ethical approval was sought from the local ethics governing
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dence is 8%, with high mortality. In recent military conflicts, body, which found the research was within the scope of the

*Correspondence to Andrew.Loftus.RN@gmail.com
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1 Surg Lt Loftus is with the Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK. Dr Morris is a junior trauma
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fellow, University Hospital of Wales, Heath Park, Cardiff, UK. Dr Friedmann is at Cellnovo Limited, Pencoed Technology Centre, UK, and
formerly Swansea University, Singleton Park, Swansea, UK. Prof Pallister is with the Department of Trauma and Orthopaedics, Morriston Hos-
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pital, Swansea, UK. Col Parker is with the Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK, and is senior
lecturer in SOF medicine at University College Cork.
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