The value of 'binder-off' imaging to identify occult and unexpected pelvic ring injuries

Does a prehospital applied pelvic binder improve patient survival?

INTRODUCTION

Pelvic fractures are serious and oftentimes require immediate medical attention. Pelvic binders have become a critical tool in the management of pelvic injuries, especially in the prehospital setting. Proper application of the pelvic binder is essential to achieve the desired result. This study evaluates the effectiveness of prehospitally applied pelvic binders in improving outcomes for patients with pelvic fractures.

METHODS

This retrospective cohort study analyzed 66 patients with unstable pelvic ring fracture classified as AO61B or 61C, who were treated at a Level I hospital in the emergency room between January 2014 and December 2018. The ideal position for a pelvic binder was determined, and patients were divided into three sub-groups based on whether they received a pelvic binder in the ideal position, outside the optimal range, or not at all. The primary outcome measure was the survival rate of the patients.

RESULTS

66 trauma patients with unstable pelvic fractures were enrolled, with a mean age of 53.8 years, who presented to our ER between 2014 and 2018. The mean ISS score was 21.9, with 60.3 % of patients having a moderate to severe injury (ISS > 16 points). Pelvic binder usage did not differ significantly between patients with an ISS < or ≥ 16 points. A total of 9 patients (13.6 %) died during hospitalization, with a mean survival time of 8.1 days. The survival rate did not differ significantly between patients with or without a pelvic binder, or between those with an ideally placed pelvic binder versus those with a binder outside the ideal range. The ISS score, heart rate, blood pressure at admission, and hemoglobin level were significantly different between the group of patients who died and those who survived, indicating their importance in predicting outcomes.

CONCLUSION

Our study found that prehospital pelvic binders did not significantly impact patient outcomes for unstable pelvic fractures, with injury severity score (ISS) being the strongest predictor of survival. Assessing injury severity and managing blood loss remain crucial for these patients. While pelvic binders may not impact survival significantly, they still play a role in stabilizing pelvic fractures and managing blood loss.

Are Pelvic Binders an Effective Prehospital Intervention?

OBJECTIVE

Widespread adoption of prehospital pelvic circumferential compression devices (PCCDs) by emergency medical services (EMS) systems has been slow and variable across the United States. We sought to determine the frequency of prehospital PCCD use by EMS providers. Secondarily, we hypothesized that prehospital PCCD use would improve early hemorrhagic shock outcomes.

METHODS

We conducted a single-center retrospective cohort study of 162 unstable pelvic ring injuries transported directly to our center by EMS from 2011 to 2020. Included patients received a PCCD during their resuscitation (prehospital or emergency department). Prehospital treatment details were obtained from the EMS medical record. The primary outcome was the proportion of patients who received a PCCD by EMS before hospital arrival. Secondarily, we explored factors associated with receiving a prehospital PCCD, and its association with changes in vital signs, blood transfusion, and mortality.

RESULTS

EMS providers documented suspicion of a pelvic ring fracture in 85 (52.8%) patients and 52 patients in the cohort (32.2%) received a prehospital PCCD. Wide variation in prehospital PCCD use was observed based on patient characteristics, geographic location, and EMS provider level. Helicopter flight paramedics applied a prehospital PCCD in 46% of the patients they transported (38/83); in contrast, the EMS organizations geographically closest to our hospital applied a PCCD in ≤5% of cases (2/47). Other predictors associated with receiving a prehospital PCCD included lower body mass index (p = 0.005), longer prehospital duration (p = 0.001) and lower Injury Severity Score (p < 0.05). We were unable to identify any improvements in clinical outcomes associated with prehospital PCCD, including early vital signs, number of blood transfusions within 24 hours, or mortality during admission (p > 0.05).

CONCLUSION

Our results demonstrate wide practice variation in the application of prehospital PCCDs. Although disparate PCCD application across the state is likely explained by differences across EMS organizations and provider levels, our study was unable to identify any clinical benefits to the prehospital use of PCCDs. It is possible that the benefits of a prehospital PCCD can only be observed in the most displaced fracture patterns with the greatest early hemodynamic instability.

Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control

ABSTRACT

Major pelvic hemorrhage remains a considerable challenge of modern trauma care associated with mortality in over a third of patients. Efforts to improve outcomes demand continued research into the optimal employment of both traditional and newer hemostatic adjuncts across the full spectrum of emergent care environments. The purpose of this review is to provide a concise description of the rationale for and effective use of currently available adjuncts for the control of pelvic hemorrhage. In addition, the challenges of defining the optimal order and algorithm for employment of these adjuncts will be outlined.

LEVEL OF EVIDENCE

Review, level IV.

Medical and surgical devices in the emergency and trauma patient: what the radiologist should know, and how they can add value

A variety of different external and internal medical devices are used in the acute setting to maintain life support and manage severely injured and unstable trauma or emergency patients. These devices are inserted into the acutely ill patient with the specific purpose of improving outcome, but misplacement can cause additional morbidity and mortality. Consequently, meaningful interpretation of the position of devices can affect acute management. Some devices such as nasopharyngeal, nasogastric and endotracheal tubes and chest and surgical drains are well known to most clinicians, however, little formal training exists for radiologists in composing their report on the imaging of these devices. The novice radiologist often relies on tips and phrases handed down in an aural tradition or resorts to phrases such as: "position as shown". Furthermore, radiologists with limited experience in trauma might not be familiar with the radiological appearance of other more specific devices. This review will focus on the most common medical devices used in acute trauma patients, indications, radiological appearance and their correct and suboptimal positioning.

Intra- and interrater reliabilities and a method comparison of 2D and 3D techniques in cadavers to determine sacroiliac screw loosening

Sacroiliac (SI) screw loosening may indicate persistent instability, non-union and contribute to pain. Yet, there is no reliable objective measurement technique to detect and monitor SI screw loosening. In 9 cadaveric pelvises one of two SI screw was turned back approximately 20 mm and subsequently assessed by optical measurement, fluoroscopy and a 3D scan using an image intensifier. CTs were segmented and a contour-based registration of the 3D models and the fluoroscopies was performed to measure SI backing out (X-ray module). Three independent observers performed measurements with three repetitions. Deviation of the measurement techniques to the 3D scan, intra- and interrater reliabilities and method equivalence to the 3D scan were assessed. The X-ray module and two fluoroscopic measurement techniques yielded a difference less than 5 mm compared to the 3D scan and equivalence to the 3D scan. Intrarater reliability was for two observers and almost all techniques very good. Three fluoroscopic measurement techniques and optical measurements displayed a very good interrater reliability. The 3D scan and X-ray module yielded the most precise values for SI screw loosening but only the fluoroscopic measurement of the inlet lateral loosening displayed a good reliability and equivalence to the 3D scan.

Improved Intraoperative Fluoroscopy for Pelvic and Acetabular Surgery

Over the past 3 decades, the evolution of pelvic and acetabular surgery has been supported by the advances in intraoperative pelvic fluoroscopic imaging technology. The new Ziehm RFD 3D C-arm unit provides routine fluoroscopic pelvic imaging but also offers rapid and high-quality real-time axial, sagittal, and coronal intraoperative imaging. This technology allows the surgeon to accurately assess fracture reduction, loose body removal, and implant locations while the patient is still under anesthesia. In this way, any necessary corrections can be performed before the patient leaves the operating room. Essentially, this technology should eliminate the need for revision surgeries. In this report, we present our initial experience using this new device.