Pelvic Binder Placement

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We recently had a sim where only one person was confident in placing a pelvic binder. So this is basic but it should be reviewed, particularly for interns, in a trauma you may be asked to place one. So if you don't read anything, please watch the 2 very short videos below: a 1 minute video on pelvic binder placement - this I believe is the same binder we have in our ed, and a 3 min video on pelvic fractures. Afterward go find the pelvic binder on your next Northside shift and take a look at it.
 
1. Pelvic Binder Placement: https://www.emrap.org/episode/pelvicbinder/pelvicbinder
2. Pelvic Fractures: https://www.emrap.org/episode/pelvicfractures/pelvicfractures
 
For binders classically an open book fracture and an unstable patient will require a binder. A open book fracture results from Anteroposterior (AP) compression forces, which cause disruption near the symphysis pubis and sacroiliac joint opening resulting in the “open-book” pelvic injury. This injury can be diagnosed on an AP pelvic X-ray if the diastasis of the pubic symphysis is >2.5 cm. The high-forces from the injuries cause shearing and tearing of blood vessels leading to hemorrhagic shock. Examination of the pelvis will reveal gross instability. “Rocking” of the pelvis is discouraged as this force may dislodge clots that have formed. Instead, the greater trochanters should be grasped with both hands and gently squeezed together. Any movement with this procedure indicates an unstable pelvic fracture. Once an unstable pelvic fracture is recognized, it should immediately be stabilized with either a properly applied sheet and towel clamps or a commercial pelvic binder -over the greater trochanters not iliac crests. Patients who have immediate stabilization have been found to have lower transfusion requirements. Additionally, the AP injury pattern stands to benefit the most from external stabilization.
 
 
More on Pelvic Fractures, types, evaluation, and management:
 
Pelvic Fractures. There are 3 types based on mechanism. 
1. Lateral Compression
  • Most common
  • Often T-bone MVC/pedestrian hit from side
  • Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
  • Associated with the unstable wind-swept pelvis fracture
  • Severe cases usually associated with bladder rupture; consider CT or retrograde cystography
2. Anteroposterior Compression
  • Usually unstable as the iliac wings are forced outward, increasing pelvic volume
  • Often head on MVC
  • Often assocciated with pelvic and retroperitoneal hemorrhage
  • Coincident injuries of the thorax and the abdomen are the rule
  • Associated with the unstable open book fracture
  • Urethral disruption should also be considered
3. Vertical Shear
  • Result from vertically oriented force (fall) delivered to the pelvis via the extended femurs
  • Unstable; pelvic volume is increased
  • Associated with the unstable Malgaigne fracture or bucket handle fracture
 
Evaluation: 
XR, US, CT/MRI, Retrograde cystourethrogram
1. CXR: AP - Obtain in all unconscious blunt trauma patients
2. CT
  • Obtain in all hemodynamically stable blunt trauma patients with pelvic fracture on x-ray
  • Exceptions include isolated pubic rami fracture, avulsion fracture

3.Retrograde cystourethrogram

  • Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
 
Management: 
Inline image 1
Classify fracture pattern as "stable" or "unstable"
    • If unstable pelvis:
      • Wrap with sheet or pelvic binder: Place pelvic binder over greater trochanters
      • Do not over-reduce a lateral compression fracture (places increased strain on post pelvis)
      • Placing pelvic binder in vertical shear injury may worsen fracture
  • Anticipate hypotension: 80-90% Venous plexus bleeding, 10-20% Arterial bleeding
 
FAST Exam
    • If hemoperitoneum is present→ OR
    • If vital signs are unstable→ OR for damage control laparotomy, not CT
    • If vital signs are stable and no hemoperitoneum→ CTAP with IV contrast
      • Contact IR for possible pelvic angiographic embolization
  • Pre-peritoneal packing can rescue failed angiography (usually in venous bleeding)
    • Also an option for primary hemorrhage control
  • Look for vaginal or rectal bleeding, suggests open fracture (uncommon)
 
Specific Fractures
Open Book:
  • Disruption of pubic symphysis >2.5cm and the pelvis opens like a book and may be accompanied by sacroilial joint disruption
  • External rotation of the hemipelvis requires binding and likely surgical fixation
Straddle Pelvic Fracture: 
  • Unstable
  • Both rami fractured on both sides or both rami on one side with pubic symphysis diastasis
  • High rate of urinary tract and bowel injury
Pelvic Avulsion Fracture: 
  • Anterior superior iliac spine
    • Occurs from forceful sartorius muscle contraction (adolescent sprinters)
    • Bed rest for 3-4 wk with hip flexed and abducted, crutches, ortho follow up in 1-2wk
  • Anterior inferior iliac spine
    • Occurs from forceful rectus femoris muscle contraction (adolescent soccer players)
    • Bed rest for 3-4 wk with hip flexed, crutches, ortho follow up in 1-2wk
Sources: Rosh Review, Uptodate, EMRAP, Wikem
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