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Three Part Question

In [patients with unstable pelvic fractures] are [pelvic compressions devices] effective at [reducing bleeding and mortality]?

Clinical Scenario

You are leading the team resuscitation of a cyclist who was hit by a car. From the injury pattern you suspect she may have an open book pelvic fracture, and decide to apply a pelvic binder. One of your colleagues suggests there is no point unless the injury is shown on x-ray, and another thinks they are entirely pointless. You get the binder applied, but resolve to check the evidence before next time.

Search Strategy

Medline 1950–Week 3 2013 via NHS Evidence.
(exp FRACTURES, BONE/ OR fractur*.ti,ab) AND (exp PELVIC BONES/ OR exp PELVIS/ or pelvi*.ti,ab)) AND (bind*.ti,ab OR t?pod.ti,ab OR wrap.ti,ab OR sling.ti,ab OR sheet.ti,ab OR SAM.ti,ab OR (circumferential AND compression).ti,ab)

Search Outcome

Seventy-nine results were obtained using the stated search. Of these, four provided the best evidence to answer the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tan et al, 2010 The Netherlands	15 patients with unstable pelvic fractures and evidence of hypovolaemic shock. All treated with T-POD pelvic binder.	Prospective, observational study	Increase in MAP two minutes after application	65.3mmHg to 81.2mmHg (p=0.03)	48 Patients excluded because of stabilisation pre-hospital. No comparison group. Surrogate measures used – no data on survival. Incomplete data (5/15 had no repeat BP/HR)
			Decrease in heart rate two minutes after application	107 to 94 (p=0.02)
			Improvement in haemodynamic parameters	7 sustained; 1 transient; 2 no improvement. These 2 plus a third patient died.
Croce et al, 2007 USA	186 Blunt pelvic fracture patients, 93 treated with a pelvic orthotic device (T-POD), 93 treated with a EPF	Retrospective observational study	24 h Transfusion requirement (U)	4.9 with T-POD, 17.1 with EPF (p<0.0001)	Ten-year period studied; likely other changes in management over this time. 3359 Patients with pelvic fractures, only 11% met inclusion criteria
			48 h Transfusion requirement (U)	6.0 with T-POD, 18.6 with EPF, (p<0.0001)
			Hospital length of stay (days)	16.5 with T-POD, 24.4 with EPF (p<0.03)
			Mortality	26% with T-POD, 37% with EPF (p=0.11)
Ghaemmaghami et al. 2007 USA	118 Patients with pelvic fracture and age over 55, unstable fracture pattern, or hypotension, treated with pelvic binder. Historical control group of 119 treated in the same centre in the previous year without a binder	Historical cohort study	In-hospital mortality	23% each group (p=0.92)	Control group occasionally treated with sheet wrap – no data on how frequent. 1258 Patients had pelvic fractures, only 237 met eligibility criteria. After introduction of pelvic binder, patients less likely to be eligible (118 in 3 years vs 119 in 1 year). Other methods of pelvic stabilisation not commented on
			Need for pelvic angioembolisation	11% with binder, 15% without (p=0.35)
			24 hour transfusion requirement	5.2 units with binder, 4.6 units without (p=0.64)
Nunn et al, 2007 UK	7 Patients with unstable pelvic fractures treated with a sheet-based pelvic binder before external fixation	Case series	HR, BP, transfusion requirement	5 Patients showed an almost immediate reduction in HR and increase in BP. All required at least 5 units of blood	Small case series. Duration of haemodynamic improvement not recorded, but 3 patients became hypotensive again while having a CT scan after application of the binder

Comment(s)

Bleeding associated with pelvic fractures can be directly from the fractured bone, from the pre-sacral venous plexus, and from the iliac vessels. Pelvic binders have been shown to restore normal bony anatomy effectively (Knops et al, 2011). In principle, this will directly tamponade the bleeding from bone, and by reducing pelvic volume and limiting movement should also reduce venous bleeding (Simpson et al, 2002). By preventing ongoing haemorrhage, they should confer benefits to mortality and transfusion requirements. In practice it is difficult to study this. The limited clinical research has involved historical cohort studies, which could have significant bias from the overall changes in trauma care that occur between the control and study groups. The results from those studies, which have been published, are heterogeneous and therefore difficult to interpret. While Croce et al found binders to be more effective than external fixators, Ghaemmaghami et al found no benefit from their use in the early stage of trauma resuscitation. Pelvic compression has also been shown to cause local tissue damage (Schaller et al, 2005; Jowett and Boyer, 2007), and it must be remembered that this is not an entirely benign intervention. Given the limited data to show any benefit, this demonstrates a need for further research into their role.

Editor Comment

BP, blood pressure; EPF, external pelvic fixator; HR, heart rate; MAP, mean arterial pressure; T-POD proprietary name.

Clinical Bottom Line

While widely advocated in trauma courses, there is no good quality evidence that the use of pelvic binders reduces mortality or bleeding in unstable pelvic fractures. Further research in this area is recommended.

References

1. Tan EC, van Stigt SF, van Vugt AB. Effect of a new pelvic stabilizer (T-POD) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures. Injury 2010;41:1239–43.
2. Croce MA, Magnotti LJ, Savage SA et al. Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg 2007;204:935–9.
3. Ghaemmaghami V, Sperry J, Gunst M et al. Effects of early use of external pelvic compression on transfusion requirements and mortality in pelvic fractures. Am J Surg 2007;194:720–3.
4. Schaller TM, Sims S, Maxian T Skin breakdown following circumferential pelvic antishock sheeting: a case report. J Orthop Trauma 2005;19:661–5.
5. Knops SP, Schep NW, Spoor CW, et al. Comparison of three different pelvic circumferential compression devices: a biomechanical cadaver study. J Bone Jt Surg Am 2011;93:230–40.
6. Jowett AJ, Bowyer GW. Pressure characteristics of pelvic binders. Injury 2007;38:118–21
7. Simpson T, Krieg JC, Heuer F et al. Stabilization of pelvic ring disruptions with a circumferential sheet. J Trauma 2002;52:158–61.
8. Nunn T, Cosker TD, Bose D, et al. Immediate application of improvised pelvic binder as first step in extended resuscitation from life-threatening hypovolaemic shock in conscious patients with unstable pelvic injuries. Injury 2007;38:125–8.