Session X - Pelvis
*Emergent Stabilization of Pelvic Ring Fractures by Controlled Circumferential Compression
Michael Bottlang, PhD1; James C. Krieg, MD2; Marcus Mohr, BS1; Britton Polzin, MD3;
Purpose: Early stabilization of pelvic ring fractures is of critical importance to reduce the risk of life-threatening hemorrhage. A noninvasive pelvic sling has recently been introduced to emergently stabilize pelvic ring fractures by application of defined circumferential compression. In a prospective clinical trial, we applied this pelvic sling to patients with pelvic ring fractures to quantify the amount of reduction for specific fracture patterns and to document its performance in a controlled environment.
Methods: After obtaining Institutional Review Board approval, a prospective clinical trial was conducted at two level I trauma centers during 2001 and 2002. Sixteen patients with pelvic ring fractures were enrolled and treated with a standard protocol. There were 10 male and 6 female patients with an average age of 48 ± 19 years. Partially stable (61-B) and unstable (61-C) pelvic ring fractures were present in 10 and 6 patients, respectively. Eight patients had "open-book" external rotation fractures (61-B1, C1, C2), and eight patients had internal rotation lateral compression fractures (61-B2, B3). The mechanisms of injury were a motor vehicle accident (3), pedestrian struck (3), motorcycle (1), fall from a height (4), crush by an object (4), and industrial (1).
At the emergency department, a pelvic sling was applied to each patient. This noninvasive device allowed for controlled circumferential compression to 140-N tension and was applied around the hip at the level of the greater trochanters. Anteroposterior radiographs were obtained directly before and after pelvic sling application to quantify the amount of reduction. Additional radiographs were obtained prior to pelvic sling removal to assess reduction over the duration of sling application.
Results: The pelvic sling controlled the circumferential tension to 143 ± 9 N. Pelvic sling application required on average less than 5 minutes (range, 4.6 ± 1.6). The pelvic sling remained on the patient for an average of 33 ± 22 hours until definitive treatment in the operating room was initiated. In case of "open-book" external rotation fractures, the pelvic sling reduced the symphysis diastasis by 19 ± 8 mm. This diastasis reduction did not significantly differ from the reduction induced by definitive stabilization at the operating room (21 ± 19 mm). Controlled circumferential compression to lateral compression fractures caused an 8 ± 5 mm decrease in pelvic width. This mild subsidence did not increase over the duration of pelvic sling application, and did not cause complications. For two patients the pelvic sling had to be released temporarily to allow access for angiography procedures.
Conclusion/Significance: Emergent stabilization of pelvic ring fractures can be a life-saving intervention to limit retroperitoneal hemorrhage. Although circumferential pelvic compression can be achieved with a simple sheet, the pelvic sling allowed for controlled compression to a predetermined sling tension. In a prior study on human cadavers, this pelvic sling was able to provide significant stabilization equivalent to that achieved with a pelvic C-clamp. This clinical trial documented effective reduction of open-book pelvic fractures with use of the pelvic sling. In cases of lateral compression fractures, no adverse effects of pelvic sling application were observed. Even in the emergency department, identification of the injury mechanism and fracture type proved difficult in some cases and may be impossible at the injury scene. However, since the pelvic sling application around the greater trochanters with 140-N tension did not cause adverse effects to lateral compression fractures, it may be safely applied at the accident scene upon suspicion of a pelvic fracture to stabilize the patient prior to transport.
* If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options and e-consultant or employee.