Prehospital pelvic compression

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Ron
SInce you asked... :-)
This list is a little out of date now - there's some new stuff out there,
but the basic experiments on the effect of "closing the pelvis" are in
there.  (Remember we're looking for CLINICALLY RELEVANT effect).  Look at
the graph in the Grimm/Vrahas paper.  The data points are all over the place
and if you believe the lines, the fixator increases pressure in the pelvis
by less than 5mmHg at the volumes that we are talking about.

Karim

Level I

*Waikakul S; Harnroongroj T; Vanadurongwan V
'Immediate stabilization of unstable pelvic fractures versus delayed
stabilization.'
J Med Assoc Thai, 1999 Jul, 82:7, 637-42*

To compare the immediate and long term outcome of immediate stabilization of
the unstable pelvic fractures to delayed stabilization with simple external
fixation, the study was carried out as a paralell trial with 2 year
follow-up. There were 112 patients with 69 males and 43 females who had
unstable pelvic fractures. They were allocated randomly into 2 groups. In
group 1, 40 patients, conventional management was performed while in group
2, 72 patients, reduction and anterior stabilization of pelvic fractures
with a simple external fixator were carried out immediately just after the
unstable fractures were detected. Blood transfusion, post operative pain,
need of reconstructive surgery of the pelvic fractures and late deformities
were less in the group 2. Immediate anterior reduction and stabilization of
the unstable pelvic fractures gave encouraging results.

Level IIa

*Bassam, D., G. A. Cephas, et al
A protocol for the initial management of unstable pelvic fractures.
Am Surg 1998 64(9): 862-7*

*Design:* Prospective Cohort Study
*Fracture Type:* Tile B,C, Young & Burgess APC2 & 3, LC2 & 3, VS
*Study Population:* 15
*Methods:* Patients with anteriorly unstable inguries underwent emergent
external fixation, while primarilyu posterior injuries underwen emergent
angiography.
*Results:* Blood product & hospital stay similar in the two groups.
Complication rate higher in external fixation group, due to failure to
adequately control haemorrhage.
*Conclusions:* APC 2&3, LC 2&3 and VS injuries who are unstable due to their
pelvic injuries should undergo immediate angiography if laparotomy is not
indicated.

*Comments:* Non-randomised, small study. However no patient undergoing
emergent angiography required a second intervention to control bleeding,
compared to 50% of the external fixation group, who went on to angiography.
Also massive thigh/buttock/flank haematomas seen in the ex-fix group.

Level IIb

*Grimm MR, Vrahas MS, Thomas KA
Pressure-volume characteristics of the intact and disrupted pelvic
retroperitoneum.
J Trauma 1998 Mar; 44(3):454-9*

*Design:* Cadaveric Model
*Fracture Type:* Open book
*Study Population:* 6
*Methods:* External iliac vein cannulated & ruptured. Fluid transfused into
the intact retroperitoneum. Pressure measurements taken before and after
external fixation, and after laparotomy.
*Results:* Intact pelvis - pressure 30mmHg after 5 litres. After fracture -
35 mmHg after 20 litres. External fixation increased pressure by 3mmHg at
low volumes to a maxium of 11mmHg at high volumes. Laparotomy decreased
retroperitoneal pressure from 35mmHg to 15mmHg.
*Conclusions:* low-pressure venous hemorrhage may be tamponaded by an
external fixator, given that enough fluid volume is present in the pelvic
retroperitoneum. External fixation may not generate sufficient pressure to
stop arterial bleeding. A large volume of fluid must be lost into the pelvis
before an external fixator can have much effect on retroperitoneal
pressures.

*Ghanayem AJ, Wilber JH, Lieberman JM, Motta AO
The effect of laparotomy and external fixator stabilization on pelvic volume
in an unstable pelvic injury.
J Trauma 1995 Mar; 38(3):396-400*

*Design:* Cadaveric Model
*Fracture Type:* Tile B, APC II
*Study Population:* 5
*Methods:* Pelvic volume measured by CT scanning. With/without external
fixator. With/without laparotomy.
*Results:* Opening the abdomen increases pelvic volume by around 15%
(400mls). Internal fixation reduces the volume of the pelvis (with or
without laparotomy wound) by around 25% (700mls).
*Conclusion:* Supports reduction and temporary stabilization of unstable
pelvic injuries before or concomitantly with laparotomy.

*Comment:* Advocates closing the pelvic volume without determining the
effect this has on haemorrhage. Does not support the external fixator over
other methods of pelvic fixation.

*Simonian PT, Routt ML Jr, Harrington RM, Tencer AF
Anterior versus posterior provisional fixation in the unstable pelvis. A
biomechanical comparison.
Clin Orthop 1995 Jan; (310):245-51*

*Design:* Cadaveric Model
*Fracture Type:* Tile C
*Study Population:* 6
*Methods:* Movement at superior raums fracture and sacroiliac joint measured
before and after injury, with anterior external fixator and with posterior
(Ganz) clamp
*Results:* Motions were significantly greater than the intact specimen with
both the external fixator and the posterior clamp. There was no significant
difference between the Ganz clamp and the external fixator.

*Moss MC; Bircher M
Volume changes within the true pelvis during disruption of the pelvic ring -
where does the haemorrhage go?
Injury 1996;27 Suppl 1:S-A21*

Fractures of the pelvis are not only common but are very varied in their
complexity. They represent 3% of all fractures (1), they account for 1 in
every 1000 surgical admissions and are the third most commonly encountered
injury in motor vehicle accident fatalities (2). However, only a small
percentage of all pelvic fractures are associated with major disruption of
the pelvic ring (3). Life threatening haemorrhage is a frequent complication
of major pelvic fractures (1, 4) and haemorrhage is the leading cause of
death in these patients (5, 6). It was believed that fracture and subsequent
displacement of the ring greatly increased pelvic volume. However, clinical
practice seemed to indicate that this might not be true. This study aimed to
assess the change in pelvic volume which occurs in severely displaced pelvic
fractures. A model of the bony pelvis was designed to permit extreme
displacements of the symphyseal and sacroiliac joints. The volume of a
polythene balloon placed within the true pelvis was measured as an
indication of true pelvic volume.*Our finding was that the increase in the
volume of the true pelvis which occurs in a fracture with massive diastasis
is much smaller than previously assumed.*

*Ghanayem AJ; Stover MD; Goldstein JA; Bellon E; Wilber JH
Emergent treatment of pelvic fractures. Comparison of methods for
stabilization.
Clin Orthop 1995 318:75-80*

The emergent care of an unstable pelvic ring disruption in the patient who
is hemodynamically unstable includes rapid application of military antishock
trousers or an external fixator in an attempt to control bleeding and
hemodynamically stabilize the patient. However, use of the military
antishock trousers is limited in that it restricts access to the abdomen and
lower extremities. The external fixator is limited at many institutions by
the need to apply it in the operating room. Two experimental devices have
been developed to provide emergent pelvic fracture reduction and temporary
stabilization in the trauma room, while maintaining access to the abdomen
and lower extremities. This study compared the efficacy of pelvic fracture
reduction and stabilization in a cadaveric model using an external fixator
with the efficacy of 2 experimental devices, the pelvic stabilizer and the
pelvic c-clamp. *Based on their ability to restore pelvic volume and reduce
pubic diastasis and their application time, the 3 devices performed
similarly.* Complications in applying each device were noted but were of
less clinical significance for the external fixator. Surgeon practice on
cadavera before clinical use will help ensure safe application of either
experimental device in the trauma room.

*Kyle F. Dickson; Joel M. Matta, MD
Skeletal Deformity Following External Fixation of the Pelvis
American Academy of Orthopaedic Surgeons 1998 Annual Meeting - Scientific
Program Paper No: 075*

The clinical observation of a flexed and internally rotated hemipelvis in
patients with an unstable pelvis who were treated with an anterior external
fixator prompted this study. Using three-dimensional measuring techniques,
the authors reviewed the radiographs of pre- and post-external fixator
placement in the referred patients with an initial hemodynamic and
mechanically unstable pelvis. *The authors found 67% of the patients had
worsening of the deformity posteriorly.* The most frequent deformities of
the hemipelvis were cephalad and posterior translation, internal rotation,
and flexion. An equal number of abduction and adduction deformities existed.
Worsening of the external fixation deformity occurred in 73% of the
patients. All cases had a maximum measurement of displacement greater than 1
cm (average 3 cm; range: 1.5 cm to 5.4 cm) after placement of an external
fixator.

Level III

*Riemer B, Butterfield SL, Diamond DL, Young JC et al
Acute mortality associated with injuries to the pelvic ring: The role of
early patient mobilization and external fixation.
J Trauma 1993 35(5): 671-677*

*Design:* Retrospective Review
*Fracture Type:* Tile B,C
*Study Population:* 605
*Methods:* Protocl employing external fixation and early mobilization
introduced to the unit in 1982. Three groups of patient studied.
Pre-protocol, transitional and post-protocol introduction.
*Results:* Mortality rates fell from 26% to 6%. Mortality for patients
hypotensive on admission fell from 41% to 21%. Proportion of patients
undergoing external fixation rose from 3% to 31% (52% for hypotensive
patients).

Comments: There is no indication about how often the application of an
external fixator restored blood pressure. Also no indication as to the use
of angiographic embolization over this time period.

*Moreno C, Moore EE, Rosenberger A, Cleveland HC
Hemorrhage associated with major pelvic fracture: A multispecialty
challenge.
J Trauma 1986 26(11): 987-994*

*Design:* Retrospective Review
*Fracture Type:* All pelvic fractures
*Study Population:* 92
*Methods:* Selected patients requiring > 6 units of blood transfusion on
first post-injury day.
*Results:* Overall mortality 26.1%. 10 deaths from haemorrhage (10.8%). PASG
applied in 47patients, controlled haemorrhage in 12 (25.5%). External
fixator applied in 19, controlled haemorrhage in 10 (52.6%). Angiography
controlled haemorrhage in 5/7.

*Comments:* Retrospective study that fails to adequately describe management
of injury according to fracture pattern. Management protocol does not
utilise angiography after laparotomy to control retroperitoneal haematoma.

*Hupel TM, McKee MD, Waddell JP, Schemitsch EH
Primary external fixation of rotationally unstable pelvic fractures in obese
patients.
J Trauma 1998 Jul; 45(1):111-5*

*Design:* Retrospective Review
*Fracture Type:* Tile B, APC II
*Study Population:* 42
*Methods:* Achievement or maintenance of reduction by external fixator
assessed from radiographs and clinical data
*Results:* Overall external fixator was unable to control 6.25% of non-obese
pelvic injuries and 50% of those in obese patients. With pure open book
fractures, anterior external fixation did not control 12.5% of nonobese
patients and 100% of obese patients
*Conclusion:* Higher incidence of inability to obtain or maintain pelvic
stabilization using external fixation.

*Comment:* Overall there was a 16.7% failure rate with external fixation,
rising to 46% when studying pure open-book injuries.

*Gylling SF, WR, Holcroft JW, Bray TJ, Chapman MW
Immediate External Fixation of Unstable Pelvic Fractures.
Am J Surg 1985 150(12): 721-724*

*Design:* Retrospective Review
*Fracture Type:* Tile B,C, APC II-III
*Study Population:* 66
*Methods:* Compares two groups, patients with mechanically unstable
fractures treated with external fixation, and those with mechanically stable
fractures treated with bed rest, regardless of haemodynamic instability.
*Results:* Overall mortality 12%. Haemodynamic parameters similar in the two
groups, but mean 16 units of blood given to mechanically unstable group
compared to 6 in the unstable group. Mortality in the two groups was
similar.
*Conclusion:* 'Any patient with multiple trauma who has an unstable major
pelvic fracture should undergo immediated external fixation.'

*Comments:* Although mortality in the two groups was similar, the results do
not adequately support the conclusion. Authors themselves comment in the
discussion: 'The avergae high transfusion requirement in the unstable group
suggests that the external fixator did not limit haemorrhage'.

2009/3/10 Ronald Simon <Traumamd at nyc.rr.com>:
> I understand there is no data to support closing down the pelvic volume
thus
> reducing bleeding but I wonder is there data to support what you wrote?
> Thanks
> Ronald Simon
> Dir of Trauma
> Bellevue Hosp Center
> NYC
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:
trauma-list-bounces at trauma.org]
> On Behalf Of Karim Brohi
> Sent: Tuesday, March 10, 2009 6:24 PM
> To: Trauma &amp, Critical Care mailing list
> Subject: Re: Prehospital pelvic compression
>
> Unfortunately this is one of those orthopaedic myths that continues to
> be propagated despite excellent animal data to the contrary.  The
> bleeding pelvis does not fill up like water in a bucket.  The volume
> of a cone or any other geometrical construct is irrelevant.  Blood
> tracks through the retroperitoneum along tissue planes, which are
> partially disrupted in trauma. There is no lid on the pelvis.  The
> blood tracks posteriorly up the retroperitoneum, through the posterior
> abdomen and sometimes even up into the chest.  It also extends
> anteriorly up the abdominal wall and out through the sciatic foramina
> into the gluteal planes.    If not breached the peritoneum, even that
> within the pelvis, remains empty.  Applying a pelvic belt does not
> significantly increase pressure within the pelvis  (if properly
> applied it's going around bone after all!!)  PLUS pressure can escape
> into the abdomen and out into the buttocks
>
> Remember that a vertical shear fracture is essentially an internal
> hemipelvectomy.  All tissue planes are disrupted.   Any movement of
> the pelvis (and there is a lot with transfers/scoops etc) is totally
> without any internal stabililty, and clot is persistently dislodged
> and further bleeding & injury insues.  The same is true to a lesser
> extent with less severe fracture patterns.
>
> The belt stops bleeding just like any splint does - by holding the
> fracture in place so allowing stable clot to form.
>
> Karim
>
>
>
> 2009/3/10 Rajesh <rajesh84 at asianetindia.com>:
>> My impression was that they allow one to prevent the pelvis opening
>> up(increasing the volume as it is proportional to the diameter) and help
>> control the volume of space available for blood to flow into, thus
leading
>> to a tamponade effect.It is not to actively control bleeding per se.
>>
>> K.R.Rajesh FRCS,FRCS(Orth)
>> Staff Specialist (Ortho)
>> Bega
>> NSW
>> ----- Original Message ----- From: "McSwain, Norman E Jr."
>> <nmcswai at tulane.edu>
>> To: <trauma-list at trauma.org>
>> Sent: Wednesday, March 11, 2009 4:24 AM
>> Subject: Re: Prehospital pelvic compression
>>
>>
>>> First understand the data
>>> These devices close the pelvic fracture, however there is NO data that
>>> shows that they control hemorrhage. The answer to your question is based
> on
>>> your need.
>>> Why were they applied?
>>> Is  that outcome needed and
>>> beneficial for the patient
>>> Does the data support it's use?
>>>
>>> Typed by the thumbs of
>>> Norman on his BlackBerry
>>>
>>> Norman McSwain, MD
>>> Tulane Univ Surgery
>>> 504 988-5111
>>>
>>> ----- Original Message -----
>>> From: trauma-list-bounces at trauma.org <trauma-list-bounces at trauma.org>
>>> To: trauma-list at trauma.org <trauma-list at trauma.org>
>>> Sent: Tue Mar 10 12:03:18 2009
>>> Subject: Prehospital pelvic compression
>>>
>>>
>>> Hello!
>>> I have a question to all of you regarding the use of prehospital pelvic
>>> binders. I work at a small hospital where we dont have access to x-ray
of
>>> the pelvis in the traumaroom. Currently the prehospital personel applies
> the
>>> TPOD (pelvic binder) in the prehospital setting whenever they suspects a
>>> pelvic fracture. The TPOD is often placed before removing the patients
>>> cloths. This approach interferes the examination of the patient in the
>>> traumaroom because when the pelvic divice is applied prehospital every
> one
>>> is afraid of removing it with the fear of bleeding. Since we dont have
> acces
>>> to plain x-ray in the traumaroom we often leave the TPOD until the
> trauma-ct
>>> is done and we have  pictures. The tpod also makes it difficult to
remove
>>> the patients clothes and sometimes makes it impossible to make a good
>>> examination of the lower back, perineum/rectum. How would yo approach
> this
>>> matter?
>>>
>>> Johan
>>>
>>>
>>>
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>>
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