Introduction

Pelvic fractures are arguably some of the most devastating traumatic injuries. During combat operations in Iraq and Afghanistan, pelvi-perineal penetrating trauma including pelvic fractures had an associated 48% mortality rate from the blast effects of improvised explosive device (IED) attacks. Each year, around 120,000 civilians suffer pelvic ring injuries from simple falls to high-energy vehicular blunt trauma that has similar mortality comparable to combat. A primary cause of death from pelvic fractures are the disrupted branches of the internal iliac arteries and sacral venous plexus.  

The objective for prehospital management is to stabilize a fractured pelvis, thereby providing some pain relief, and to slow or stop life-threatening hemorrhage. It is beyond our intent to discuss the pelvic girdle anatomy and types of fractures, but see an excellent review of pelvic trauma. Thus, our aim is to emphasize the importance of using either commercially available or an improvised pelvic binder to stabilize pelvic fractures and manage uncontrolled hemorrhage.

Background

In 2008, the Committee on Tactical Combat Casualty Care (CoTCCC) found insufficient evidence to include pelvic binder usage in the TCCC Guidelines. However, during a 2016 CoTCCC meeting, it was highly suggested that pelvic binders be reconsidered based on new evidence. Consequently, a CoTCCC working group was formed to review the literature and to make a recommendation. Their conclusion, as reported by Shackelford et al, found that 26% of service members who died during operations in Iraq and Afghanistan had a pelvic fracture. Of these, 76% resulted from IED blast injury, 15% by gunshot wounds, and 4.5% were the result of motor vehicle crashes. The working group recommended circumferential pelvic binders for initial pelvic fracture management. Of the several treatment options recommended for the stabilization and management of pelvic fractures, the only treatment available to prehospital providers is the pelvic binder. A podcast by Dr. Shackleford about the TCCC pelvic binder study is available.

For a pelvic binder device to be included in TCCC Guidelines, the CoTCCC working group had seven questions to address and were diligent in finding evidence-based answers:

Does a Pelvic Binder Stabilize the Pelvic Fracture?

Evidence in cadaver studies show that pelvic binders stabilize fracture motion most effectively when placed at the level of the pubic symphysis and greater trochanters. All commercial devices evaluated were found to provide near-anatomic fracture reduction with minimal overreduction. Level of evidence: B.

Does a Pelvic Binder Control Bleeding from a Fractured Pelvis?

Although selection bias was found in certain studies and there was a lack of prehospital application data, evidence exists that pelvic binder use reduces massive hemorrhage. It was anecdotally suggested that hemodynamics improve with pelvic binder use through decreased blood transfusion requirements, decreased length of stays in intensive care units, and shortened duration of hospital stay. Level of evidence: B.

Does a Pelvic Binder Improve Survival?

Very weak clinical evidence exists that pelvic binders increase survival after arrival to the emergency department. Survival data following prehospital application was found to be lacking. Level of evidence: C.

Is There Any Harm in Applying a Pelvic Binder?

Aside from possible pressure ulcerations due to prolonged application or overtightening, there is minimal risk of increased bleeding or injury in applying a pelvic binder. Level of evidence: C.

Who Should Receive a Pelvic Binder?

The accepted criteria for who should have a pelvic binder applied is listed in Table 1. Level of evidence: C

Where Does a Pelvic Binder Fit into Priorities?

Pelvic binders should be considered for hemorrhage control during the “Circulation” stage of the M-A-R-C-H mnemonic. This should occur after massive external hemorrhage control and addressing airway or respiratory concerns, but before tourniquet reassessment and/or conversion and IV/IO access. Similarly, Tactical Emergency Casualty Care (TECC) guidelines advocate the use of pelvic binder application during treatment rendered in the “Warm Zone” (i.e., indirect threat), and Advanced Trauma Life Support guidelines recommend pelvic stabilization during circulation assessment, “consider and intervene to stop hidden sources of bleeding.”

What is the Best Type of Pelvic Binder?

Of the three commercial pelvic binders evaluated in clinical and cadaver studies, none was identified as superior over another with respect to pelvic ring closure and motion of fractured bone fragments. These commercial devices are: 1) PelvicBinder®; 2) T-POD®; and 3) SAM Pelvic Sling®. (see Figures 1a-c). All devices tested were found to provide near-anatomic fracture reduction with minimal overreduction. Level of evidence: B

Figures 1a-c. Three CoTCCC recommended pelvic binder devices.


Of note, two CoTCCC recommended junctional tourniquets (the SAM Junctional Tourniquet and the Junctional Emergency Treatment Tool) have an additional function by incorporating a pelvic binder into their design to stabilize pelvic fractures along with hemorrhage control from junctional inguinal bleeding.   

It was reported that there was weak evidence suggesting that commercial devices were more effective than the use of an improvised pelvic sling, based on inconsistencies among users and variable tensions applied between single and multiple rescuers. Level of evidence: C.  

Improvised Pelvic Binder Techniques

For prehospital providers serving in remote environments, or personnel responding to mass casualty incidents, a commercial pelvic binder may be unavailable, demanding that improvised techniques be considered – see Table 2. Emergency Medical Service (EMS) providers have used a bed sheet to create a pelvic binder, but this approach is unable to reliably generate pressures approaching those of a commercial pelvic circumferential compression device. Some examples of effective improvised pelvic binders are shown in Figures 2a-d.

Figures 2a-d. Improvised pelvic binder methods as reported by Shackelford et al.

Recent Studies and Evidence

In a six-year retrospective study, Zingg et al found that type B1 (open book) and type C (vertically and rotationally unstable) pelvic ring fractures benefitted the most from the use of a prehospital pelvic binder. Similarly, Jarvis et al also found that despite widespread application, prehospital pelvic binders are not applied to all suspected pelvic fractures, primarily due to EMS protocol inconsistencies. Bailey et al evaluated compressive forces applied by commercial and improvised pelvic compression devices at the greater trochanters in male and female subjects with varying body fat percentages. Although these bony landmarks can be difficult to locate in obese populations, the study revealed no significant correlation between body fat percentage and applied compression force.  

Considerations in the Wilderness Setting

Pelvic injury assessment starts with an in-depth look at the mechanism of injury. In the wilderness, low energy accidents, such as a trip and fall on a trail, seldom produce serious injuries. However, falls from a height, mountain bike crashes, ski & snowboard crashes, and avalanche trauma can produce devastating pelvic fractures. There are solid evidence-based guidelines for pelvic fracture management as reported by Lee and Porter, and these guidelines have been previously modified for use in wilderness environments – see Table 3. A 2020 study found that multifunctional metallic survival blankets possess remarkable tensile strength showing that they too have the potential to be used as an improvised pelvic binder.