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Pelvic binder in fracture pelvis
Общие вопросы/General questions Отправлено T.J.George 15 Апрель 2009, 21:52
Group,
We had some discussion on this topic couple of years ago. ( http://hwbf.org/hwb/conf/georg17/pbelt.htm ).
I would be happy to get the groups view on the use of sheets vs Ex fix as an emergency measure to stabilise patients with pelvic fractures. Is the trend towards moving away from Ex fix in pelvic fractures? Any recent accepted protocols on early management of haemodynamically unstable patients with pelvic fractures?

Dr. T. I. George,
(Dr George T Ittoop)
Sr Specialist, Orthopaedics,
Ibra Regional Hospital,
PO Box no: 3,
Postal code 413.
North Sharquia Region,
Sultanate of Oman.

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    Re: Pelvic binder in fracture pelvis
    Milton L. Routt 15 Апрель 2009, 22:09
    We use circumferential sheets positioned and adjusted for each patient’s pelvic ring injury...if a frame is indicated for the specific pelvic injury pattern and the reduction is excellent in the sheet, then holes are cut in the sheet to allow for pin insertions and frame application-assembly before the sheet is then removed....iliosacral screws can similarly be inserted using the sheet’s “working portals” when the reductions are valid.

    Commercial binders are expensive and not always available....so we use sheets.

    Acute pelvic frame use as a resuscitation adjunct is very rare in our institution.

    Posterior pelvic C-clamps or other such posterior pelvic external devices are not used....instead, iliosacral screws are used.

    But some physicians sell binders and therefore recommend them...others use them because they are attracted to such medical gear...some like binders because they are marketed very well in the USA...binders just seem like a huge waste of money to me.

    Frames are difficult to apply unless you are familiar with them...many pins are mis-inserted, some not even in bone...the pin site incisions often are extensive and can negatively affect potential surgical sites...over the years, it’s become obvious to me that pelvic frame application in acute clinical situations is unpredictable and random, at best.

    Many physicians are now tinkering around with low anterior pelvic frames applied using pins inserted at the AIIS and along the pelvic brim above the acetabulum...these frames were initially popular in the late-80s (maybe even before then) and have made a recent comeback under the guise of their “power and strength”...as people have grown more obese, manufacturers have made very long pins so now we can use these again if we choose to...they are quite effective for pelvic manipulative reductions in the OR while internal fixation is assembled around them...but definitively (despite some small series advocating them) we’ve seen hip infections from these pins, the low pins also obstruct medullary ramus screw use, and if inserted deeply they will obstruct even routine iliosacral screw use...most low frame patients have a very difficult time trying to sit or move around with such frames in their anterior hip regions...they are deeper from skin to bone so the dripping is as expected...some physicians even use them after anterior iliac exposures with resultant deep iliac abscess formation...symptomatic ectopic bone formation is also common around the AIIS pins.

    I like the low frames best as an operative manipulative device, and occasionally as an “activity restrictor” if we anticipate significant non-compliant behaviour from our patient.

    Maybe that’s what we wrote before...I didn’t read the old discussion...so if this is the same as back when, then we’re at least consistent!!!!!!!

    chip

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    Re: Pelvic binder in fracture pelvis
    Roger C. Sohn 18 Апрель 2009, 12:42
    George,
    We recently revisited our hospital's protocol. It's attached (PDF 1.1 Mb). We use a non-invasive pelvic binder (TPOD), with Ex-fix added after initial stabilization.

    We incorporated Balogh's practice guidelines (PDF 215 Kb) with time limits on non-invasic pelvic binding, Abd clearance, and pelvic angio (they showed a 28% decrease in mortality after adopting these standards). Also, a good algorithm can be found at http://www.trauma.org/index.php/main/article/668/
    I'm sure there are many others with good algorithms here. I'm looking forward to seeing them.

    Roger Sohn



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    Re: Pelvic binder in fracture pelvis
    T.I. George 18 Апрель 2009, 12:49
    Chip and Roger,

    Thank you very much for the input.

    The previous discussion I referred to took place in 2003 ( http://hwbf.org/hwb/conf/georg17/pbelt.htm ). Very interesting to note that Chip's views and practices have not changed in almost six years.

    The traum.org alogrithm is a very recent one(2008).

    I tried to find something from OTA but could find only the one of 2000. Are there any more recent OTA debates/ alogrithms on pelvic injury?

    Looking forward to further inputs.
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    • Re: Pelvic binder in fracture pelvis
      Отправитель: Milton L. Routt 18 Апрель 2009, 12:55
      It’s important to not be led astray by algorithms...they are appropriate as conceptual guides, but each individual patient is unique and likewise has a unique injury pattern and primary organ system injuries and response to their traumatic event...the treating team must be efficient, communicative, aware, skilled, dynamic, cooperative, and adaptable.

      Simple techniques that gather together an unstable pelvic ring while allowing the resuscitation efforts to proceed without negatively impacting further definitive procedures are optimal.... accurate reduction and stable internal fixation rule the eventual clinical result.

      It’s not that we haven’t tried to push the edge, but if you keep working long enough at some point the clinical realities and individual diversities become apparent.

      Wrap, warm, fill, (squirt and/or divert if necessary), reduce, and fix expeditiously.

      chip

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      • Re: Pelvic binder in fracture pelvis
        Отправитель: Adam J. Starr, M.D. 18 Апрель 2009, 12:57
        I think what Chip said is right on the money.

        Although it's hard to prove statistically, most of us believe that stabilizing the pelvis provisionally - with sheet, binder, etc. - helps the patient.

        You can find people who argue - strenuously - that provisional pelvic stabilization does nothing at all to help. However, given the fact that you can apply a binder quickly, with very little risk, I have a hard time seeing why you wouldn't want to do it.

        Different centers will make different choices on how to provisionally stabilize the pelvis. At our place we use binders. Others are happy with sheets.

        I think speed counts, so a method that is simple to teach and simple to apply is best. The people on the front lines of care are the ones who should be taking early steps to help the pelvic fracture patient.

        We have tendencies at Parkland, and have outlined them in a flowchart to help guide our thinking, or to remind us of things when people get excited. But we also stray from the chart if the situation demands it.

        Good luck,

        Adam

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