I was in the crosswalk! He hit me!

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It was cold and pouring.

We found the patient in the middle of the roadway, writhing in pain. Nearby there was a stopped van with a very distraught-appearing middle-aged man. The dent on the front of the van was suspiciously human-shaped…

"What happened?" I asked.

"I was in the crosswalk! He hit me!"

I was internally working through my assessment, 'No major bleeding. Airway intact. Good chest movement. I don't feel anything obvious [on the chest]...

"Deep breath, sir," I listen to lung sounds. "Good."

... 'lungs clear. Belly seems okay.'

"What hurts?"

"My back... My leg," he said, wincing.

It was then I lightly grazed his pelvis…

"AHHH! Don't do that!"

I suspected a pelvic injury from the start, just by how he was lying, but that settled it. He also had a muckled left leg and a broken arm/clavicle. We used a scoop stretcher to get him off the ground and onto the stretcher, removed the scoop, and loaded him in the ambulance to get a better look.

There we did the full assessment and got some vitals.

He had a large area of ecchymosis on his left hip. I applied a gentle inward force to his pelvis - He did not like it and neither did I. I had never felt a true "mushy pelvis" before then but boy did I recognize it as soon as I felt it. I didn't let go.

My partner had just finished taking a BP, "HR is 120 and BP is 100/62."

"Grab the binder," I nodded over to the cabinet, "I'm not letting go."

True pelvic ring injuries happen in two distinct groups of people: Gam Gam with osteoporosis who took a tumble and dude getting smoked by a car - and not a ton in between. The high-energy injuries are caused overwhelmingly by MVAs, people getting hit by cars, and falls from height. True hemodynamically significant, unstable pelvic injuries are rare and are often associated with other significant injuries. But while rare, they account for around 20% of deaths due to trauma per year.

I assume you've seen diagrams and stuff of the pelvis before, right? If not, look them up.
The pelvis is a ring-like structure made of right and left innominate bones (each comprised of three separate bones: The ischium, ilium, and pubis) joined posteriorly by the sacrum and anteriorly by the pubis synthesis and held together by a really, really strong network of ligaments - which is actually what makes it all so strong.

Lots of stuff lives inside the pelvis including the pelvic organs (bladder, rectum, reproductive organs (females), and the prostate (males)) as well as lots of blood vessels and nerves. The pelvis has a robust collateral blood supply. A lot of that blood supply is concentrated towards the back, near the sacrum.

The big risk of pelvic fractures is bleeding.

Contrary to popular belief, the vast majority of bleeding associated with pelvic fractures is venous or bony. Like, 85% or so. NOT arterial. The jam is that these veins all sit really close to the bones (or are in the bones) and are thin-walled and easily damaged. Veins, unlike arteries, don't vasoconstrict and clamp themselves off - they just bleed. They need to be tamponaded somehow. Turns out, the pelvis can hold a lot of blood... Like 3-4 L worth. So you get this massive venous bleeding (usually) into an essentially open space.

There are several ways to classify pelvic fractures. The most common two ways are the Tile classification and the Young-Burgess classification. Feel free to look both of those up... For the sake of brevity, I can't talk about all that here. The important summary points are that not all fractures are unstable, but many are, and that depending on how the pelvis is broken, some patients benefit more than others from things like pelvic binders.

The jam? In EMS we don't have X-rays, so we either need to rely on a mechanistic approach or blindly bind anyone we think has a significant pelvic fracture. Some hospitals don't like EMS placing pelvic binders because of this. In fact, the hospital system I currently work in does not want their EMS services placing them in the field. Granted, I tend to agree with this, so don't shoot the messenger. However, most systems I have worked in are far more "pro" binder than "anti" - so most of you are safe.

So let's talk pelvic binding.

I think the big takeaway here is that this is an imperfect, temporizing measure that may or may not work, but probably doesn't do harm IF done correctly.

The thought behind binding the pelvis is that an open pelvis has more room to bleed into and has bones shifting around near important stuff. Placing a binder reduces the pelvic volume which can reduce the amount of bleeding (in theory), stabilize fractured segments, and prevent clot dislodgement.

Honestly, it probably doesn't do a ton for reducing the amount of bleeding from broken vessels. It may or may not help by reducing the amount of blood needed to tamponade, but 3-4 L is still a lot... The is very minimal evidence that this is how a binder actually works, however, placement of a binder in specific types of fractures (open book style) has been shown to reduce the amount of blood transfusions. This is a grand oversimplification of the evidence, but, eh, this is a Facebook post. I'll put references in the comments for you to read beyond my summary. Where the binder probably does help more is fracture stabilization. The evidence here is almost all from cadaver studies, however. This can help by reducing bony bleeding and reducing further chance of injury.

So there is a theoretical benefit... Is there any risk? The short answer is, maybe.

In theory, misplacement and overtightening can lead to worsening injury. Also, in specific types of fractures, like a "windswept pelvis" where there is lateral rotation, tightening can cause further worsening of that injury. With that said, this is all theoretical. No studies have shown increased complications or harm with binder placement.

This patient, at least for me, is a slam-dunk case for a binder. Generally, you can justify placing a binder on any patient with a suspected pelvic ring fracture in the setting of hemodynamic instability, pelvic pain, or signs/symptoms of pelvic injury instability on exam. Obviously, follow your local protocols/guidelines…

So this patient got a binder.

Granted, we probably should have placed it before moving him (that is generally the recommendation) however we wanted to get him off the cold street and out of the rain. We removed his clothing (already, during the assessment) and slid the binder under his knees and then up his thigh to the level of the greater trochanters (the prominent top of the femur that people generally call their "hip"). We then secured the device here, across the pubic symphysis - which is where you want it to lie.

PLACEMENT HERE IS IMPORTANT. EMS kinda sucks at it... Some sources say we misplace this 40 - 50 % of the time. Anecdotally, as a flight paramedic, I have to fix these on-scene calls probably 50% of the time they are placed PTA. Greater trochanters. NOT iliac crests. The key is snug, but not super tight. The goal isn't REDUCTION - you aren't trying to minimize pelvic volume - it's STABILIZATION. You want it roughly anatomic. You don't need to yank down on the thing. Then, and everyone forgets this part, you should bind the feet together so they are rotated medially, helping keep the pelvic inline. If you don't have a commercial binder, that's cool too. Turns out you don't need one. A standard hospital sheet works just as well.

Once the binder was applied we initiated transport. His pressures came down... 90s, 80s. Ultimately he got some fluid to temporize him which he responded favorably too. Beyond the binder, this is a hemorrhagic patient and should be treated as such. Avoid crystalloid, MAP >65, SBP >90, etc. We also gave him some analgesia VERY carefully - turns out a mushed-up pelvis hurts a lot.

We took him to the local level III center who then flew him to a level I center (an hour away). I'm not sure how he did... Pelvic fractures with hemodynamic instability have a 30-50% mortality. They are very sick patients.

Does your company have binders? Have you used them? Let me know below!

Thanks for reading! Check out below for references and YouTube links demonstrating placement!


-Dean Stockley


References:
Abraham, MK. Ch. 18: Pelvic Trauma. The Emergency Medicine Trauma Handbook. Cambridge University Press, 2020.

Bond, MC & MK Abraham. Ch. 46: Pelvic Injuries. Rosen's Emergency Medicine: Concepts and Clinical Practice, 10th ed. Elsevier, 2023.

Nassar, A, L Knowlton & DS Spain. Ch. 39: Pelvis. Trauma, 9th ed. McGraw-Hill, 2021.

Shakelford, S, R Hammeshahr, D Morissette, H Montgomery, et. Al. The Use of Pelvic Binders in Tactical Combat Casualty Care: TCCC Guidelines Change 1602. 7 Nov 2016. J Spec Oper Med. 2017 Spring;17(1):135-147. doi: 10.55460/1WLZ-MKW4. PMID: 28285493.

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