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The pelvic binder is now the initial stabilization of choice for the immediate management of pelvic ring injuries and is used acutely in the management of exsanguinating pelvic trauma. There are several versions of the binder available on the market. Most have been developed with a single purpose - to apply a large amount of compressive force to the pelvic ring in order to 'reduce the volume of the pelvis'. However this is neither the primary role of the binder, nor is it sufficient to design a binder solely for this purpose. This article discusses the functions and indications for the binder, and then presents the features of the ideal binder to meet these requirements.
Functions of the pelvic binder
- To splint the bony pelvis to reduce haemorrhage from bone ends and venous disruption.
- To reduce pain and movement during transfers.
- To provide some integrity to the pelvis when operative packing of the pelvis is necessary.
- To provide stabilization of the pelvis until definitive stabilization can be achieved.
- The haemodynamically unstable patient with a mechanically unstable pelvis.
- The haemodynamically unstable patient with a suspected pelvic fracture.
- Haemodynamically normal patients with unstable pelvic fractures, for pain control and reducing movement during transfers.
Practical aspects of the pelvic binder
Much as the cervical spine collar is used to protect the cervical spine from further injury prior to definitive identification and characterization of an injury, the pelvic binder should be used where a pelvic injury is suspected before definitive imaging is available.
The pelvis does not fill with blood like water poured into a cone-shaped bucket. Pelvic haemorrhage spreads through disrupted tissue planes, extending through the retroperitoneum vertically out of the pelvis into the abdominal retroperitoneum up into the thorax, and anteriorly around the bladder the anterior abdominal wall. 'Closing the pelvis' does not prevent this and the binder is not used to reduce the volume of the pelvis or achieve perfect anatomical alignment. .
The pelvic binder is used to splint the bony pelvis. The binder splints the bony fracture, approximating bone ends and reducing low-pressure bleeding from bone ends and disrupted veins. As the fracture pattern is often unknown at this stage, it is possible to exacerbate certain injury patterns if excessive force is applied. This is particularly true of severe lateral compression or vertical shear injuries.
Before & after application of a pelvic binder
The binder should be placed over the greater trochanters, not over the iliac crests. This provides the best mechanical stability of the pelvic ring structures. A misplaced binder may exacerbate a pelvic fracture if there is an injury through the iliac crest. When placed too high it will also obstruct access for laparotomy.
The binder will not control arterial haemorrhage. Patients who do not improve haemodynamically following application of the pelvic binder may require urgent angio-embolization or operative intervention. As such the binder should allow easy access to the groins or abdomen without having to remove or reposition the belt.
The binder should remain in place until the definitive stabilization procedure. This may not be for 24 hours or so until the patient becomes haemodynamically normal and all imaging has been completed. As such the belt needs to be of such material and construction that it does not induce pressure necrosis and allows for ease of nursing. The binder should be removed as soon as possible, but not before the fracture has been fully characterized and the patient is able to tolerate operative fixation.
Emergency external fixation has no benefit over the pelvic binder, and the binder should not be removed only to be replaced by an emergency fixator. The anterior external fixator may be used as definitive management of a rotationally unstable fracture. In some cases, after careful specialist consultation it may be used as a bridge to definitive internal fixation where this is not readily available. The external fixator may compromise the approaches for definitive stabilization and should not be used lightly. There is now a very limited role, if any, for the external fixator as an emergency stabilization device.
Characteristics of the ideal binder
The ideal pelvic binder therefore should have the following characteristics:
- It should be suitable for use in the prehospital arena and emergency department. It should therefore be light and easily applied, ideally by one person.
- It must allow access to the abdomen for laparotomy, and to the groins for angioembolization
- It may need to stay on for 24 hours or more and thus should be of a soft material that will be comfortable and not induce pressure ulceration.
- Should not limit access to the perineum and anus for examination.
- Must fit various sizes of patients (including children), or different sizes be available.
- Should be washable or cheap enough to be disposable.