Monday, August 5, 2013

"Springing the Pelvis" - An evidence-based assessment of first aid practices

ASPA Medical Advisory Committee – Briefing Paper re “Springing of the Pelvis”
July 2013

The Medical Advisory Committee (“MAC”) has been asked to provide a recommendation as to whether the practice of “springing the pelvis” as part of the Secondary Survey should be continued as part of Ski Patrol first aid teaching and practice.

It has been anecdotally reported that some (un-named) first aid training organisations are no recommending or teaching “springing the pelvis”.

As well as making a recommendation with regard to “springing the pelvis”, it would also be worthwhile for the MAC to consider whether the section on Pelvic Fractures should be revised to amplify the information describing when to suspect a pelvic fracture and management and specifically mention application of a pelvic binder.

Based on available publications, there would appear to be fairly persuasive evidence that the practice of “springing the pelvis” in the pre-hospital setting should be discontinued. It would also appear that there is scope for improving the information in the ASPA Manual regarding suspicion and management of pelvic fractures.

(Copies of the individual articles and guidelines referred to in this paper are available on request.)

Index:
1.         Summary of evidence and opinions regarding the practice of “springing the pelvis”.
2.         Sections of the ASPA Advanced Emergency Care Manual which refer to the pelvis.
3.         Published recommendations regarding “springing the pelvis”.
4.         Opinions regarding “springing the pelvis”.

1.         Summary of evidence and opinions regarding the practice of “springing the pelvis”.

Not Recommended
Recommended
Publications
Publications
ABC of Prehospital Medicine
2007 – MJ Heetveld (NSW Trauma Guidelines) (*heavily qualified endorsement)
1990 – PT Grant (Archives of Emergency Medicine)
Opinions
2004 – MJ Heetveld et al (World Journal of Surgery)
MICA Flight Paramedic
2007 – Lee and Porter (Emergency Medicine Journal)
Orthopaedic Surgeon
2009 – White, Hsu and Holcomb (Injury)

2009 – Trauma Emergencies

2010 – Ambulance Victoria

2012 - Royal Melbourne Hospital Trauma Guidelines – Pelvic Fracture

2013 – J Brun et al (Injury)


 2.         Sections of the ASPA Advanced Emergency Care Manual which refer to the pelvis and/or “springing the pelvis”.

2.5.3.6             Pelvis
The pelvis is composed of two pelvic bones that are held together at the front, and connected to the sacrum at the back, by very strong ligaments. It provides attachment for back, abdominal and leg muscles supports the body weight and protects major organs, e.g. bladder or pregnant uterus. The pelvic bones are very vascular and bleed profusely if badly fractured.

2.5.3.7             Lower Extremities
The upper leg contains the longest bone in the body (the femur). At its top end the head of the femur fits into a socket in the pelvis (hip joint). The shaft of the bone is strong and surrounded by heavy muscles while the lower end of the femur is broadened to form the upper part of the knee joint.

2.9                   Reproductive System
The reproductive system includes the organs necessary for natural conception and childbirth.

The female organs, including the ovaries, fallopian tubes, uterus, and vagina are protected by the bony pelvis, which also protects the developing foetus for the first fourteen weeks.

In the male, the testes and penis are exterior to the bony pelvis and more prone to injury.

The process of conception, gestation, and childbirth, though apparently simple, requires a balanced interaction of male and female endocrine and reproductive systems.

3.3.3.1             Principles of Examination
(…)
·         Be systematic: use the same process every time to avoid omitting any part of the examination. Start with the head, then the spinal column (neck, spine), upper torso (shoulders, chest), lower torso (abdomen, pelvis), and limbs. Be consistent in examining limbs, always working from the trunk to the periphery or vice versa.
(…)

3.3.3.2             Specific Examination
(…)
The Lower Torso
·                Feel the abdomen systematically, in all four quadrants, gently checking for pain, distension, or rigidity of the muscles, each of which may indicate intra-abdominal trauma.
·                Gently spring the pelvis by applying lateral pressure. Pain may indicate possible fractures.
·                Note any urinary or faecal incontinence, which may indicate internal injury to the pelvic cavity.

(Figure 30 Springing the pelvis – lateral recovery position)

3.5                   Approach to the Casualty – Summary Flowchart
(…)
Secondary Survey
(…)
·         Examination must include whole body: head, neck, back, chest, abdomen, pelvis and limbs.
Lower Torso
o Check the 4 quadrants for signs or symptoms of injury
o Spring the pelvis (once only)
o Check the groin for wetness, bleeding.
(…)

6.1.5                Internal Bleeding
Internal bleeding may result from the tearing of an organ such as the spleen or the lung, or from a closed fracture. Internal bleeding may manifest itself externally from the:
·         Lungs: blood may be coughed up; it will be bright red and frothy.
·         Stomach: blood may be vomited; fresh blood will be bright red but blood which has been sitting in the stomach for some time will be black, like coffee grounds. The longer the blood has been in the stomach, the darker it will be.
·         Bowel: fresh red blood may be mixed with the faeces; blood which has spent some time in the digestive tract will produce black, tarry bowel motions with a very strong odour.
·         Rectum: bright blood is mixed with the faeces.
·         Kidneys and bladder: blood escapes with the urine, which may be smoky or red in appearance.
·         Female genital tract: bright blood or clots appear at the opening of the vagina.
·         Muscles: swelling will be present over the site of injury; the swelling may be coloured, as in a bruise, and may have a fluid ‘feel’ when palpated.

At other times, internal bleeding may not be evident. Bleeding from the liver, spleen, and aorta, or in association with fractures of the femur or pelvis will be hidden. Bleeding may take place into the abdominal cavity; this will not appear outside the body. Hidden internal bleeding can be life threatening and should be suspected after trauma to the abdomen with signs and symptoms of shock but without obvious bleeding.

6.1.6                Internal Bleeding at Fracture Sites
Fractures of large bones may bleed significantly, but examination of the fracture site may not always reveal the presence of swelling that signifies internal blood loss. One or two litres of blood may escape into the thigh from a fractured shaft of femur, and two or more litres may be lost with severe pelvic fractures. Treat these casualties as for internal bleeding. Bleeding from fractures of the tibia and other long bones is less severe, but can still present a problem.

6.2.3.2             Severity of Shock
When assessing hypovolaemic (or haemorrhagic) shock, consider that:
·                A normal healthy person easily compensates completely for acute blood loss of up to 10% of the blood volume (i.e. 500 to 700 mL in an average adult; as in a blood donation).
·                The normal blood volume is 5 to 6 litres.
·                Signs of shock appear when blood loss exceeds 15% to 30% of blood volume in a short period of time (i.e. 800 mL to 1500 mL blood).
·                Life cannot be sustained with an acute blood loss of 2 to 2.5 litres (i.e. 40–50% of blood volume).
·                Closed fractures of the femur or pelvis can cause substantial blood loss into the tissues, however not all victims with these fractures will develop shock. Bleeding usually slows after an initial ‘torrent’ (i.e. when the tissue pressure reaches blood pressure levels).

8.1.3                Principles of Management
In managing fractures, the patroller should:
·         examine for:
o   nerve function, by checking for sensation and movement below the injury before commencing treatment;
o   vascular function, by checking distal pulse and capillary return below the injury before commencing treatment;
o   signs of hypovolaemic shock, especially with open fractures (remember however that major closed fractures such as pelvic or femoral can also cause hypovolaemic shock);
(…)

9.3                   Lower Limbs
9.3.1                Pelvic Fractures
Pelvic fractures usually result from a direct blow or crushing injury but can also occur when landing upright on the leg(s) after a fall from a height (e.g. over 3 metres). This injury can shear the pelvis through the pubic symphysis and sacral joints or force the femur up through the pelvis.

·         Signs: a simple fracture of a pubic ramus may produce minimal pain; extensive crush fractures will produce early bruising and severe diffuse pain, not focused on the site of injury; blood loss may be significant and result in hypovolaemic shock; there may be pain on leg movement; tenderness and crepitus may be elicited when the pelvis is compressed or sprung.

·         Management: expect and prepare to treat for hypovolaemic shock; immobilise the casualty and transport urgently to medical care in a scoop stretcher; notify medical care (a doctor) early so that fluid resuscitation can be commenced as soon as possible.

·         Complications: primarily arise from hypovolaemic shock. Other complications arise if the bladder or urethra (male) is damaged, especially if it is full at the time of injury; any urine passed by the casualty should be kept for later evaluation by a medical practitioner.

(Figure 132: Fractured pubic ramus.)

9.3.3                Dislocated Hip
(…)
·         Complications: generally arise through associated fractures of the pelvis or femoral head complicating dislocations. Avascular necrosis of the head of the femur with subsequent early arthritis is a disabling complication.


10.3.6              The Scoop Stretcher
(…)
Uses
The scoop is ideal for use in: casualties with suspected spinal injuries (including all unconscious casualties); casualties with pelvic fractures or hip injuries where lifting may be very painful;
(…)

10.3.7              Spine Board (Supine Position)
(…)
6.         Secure the casualty to the spine board using the straps. Apply strap 1 from the shoulder, across the chest, to the opposite pelvic region, strap 2 across the other shoulder, as per strap 1. strap 3 across the pelvis and strap 4 across the upper legs above the knees. (Alternatively, strap 3 &4 can be crossed from pelvis to opposite knee area).

10.3.10            The Kendrick Extraction Device (KED)
Use
The KED is mainly used for spinal injuries but can be used as a splint for other injuries, e.g. neck of femur, pelvis injuries. It can be washed with soap and water. Originally the KED was developed to extract people with spinal injuries from car seats. It is particularly useful for extracting casualties from tight situations. The instructions below are a summary of the full Ferno™ training manual for this device. Click on the Ferno symbol above to open that manual.
(…)
3.         Apply the upper thigh system by sliding the male buckle under the leg, at the knee, and see-saw upward until positioned in the crotch area. Engage the buckle. A click signals that the buckle is locked. Cinch the strap until the traction pole receptacle is positioned at the belt line or pelvic crest. (Note: assure that male genitals are clear of the strap).
(…)
11.       The leg straps secure the pelvis to the lower portion of the KED to stabilise the lumbar area. Whether using either of the configurations for leg straps shown below, you must position the straps as close as possible to the casualtys body midline.
(…)

10.3.11            The Hare Traction Splint
(…)
When traction is applied to the leg through the ankle hitch, counter-traction is applied by the padded half-ring against the ischial tuberosity of the casualty’s pelvis. Proper counter-traction is essential to the correct functioning of the splint.
(…)

3.         Published recommendations regarding “springing the pelvis”.
ABC of Prehospital Medicine, edited by Tim Nutbeam and Matthew Moylan.
Published by John Wiley & Sons (Google eBook, July 2013).

Chapter 16. Trauma: Pelvic Injury
Matt O’Meara, Keith Porter and Tim Nutbeam.
(Pages 85-86)
(…)
Pelvic binders
Pelvic binders should be applied at an early stage (as part of the ‘C’ assessment) and not removed until significant pelvic injury has been excluded (Figures 16.4 and 16.5). The binder performs two roles:
1. Anatomical reduction of the pelvis – reducing pelvic volume; and
2. Stabilising all forms of pelvic fracture – limiting movement through mechanical splinting.

·         Application: First correct shear by drawing feet level and binding feet/ankles and knees together. Then reduce A-P rotation through application of circumferential compression with binder at greater trochanter.
·         Indications: All patients with a mechanism of injury which may have caused pelvic injury and are either (a) unevaluable (e.g., head injury, intoxication, intubated) or (b) complaining of back, pelvic or lower abdominal pain.
·         Combined fractures: With suspected combined femoral and pelvic fractures, first apply manual traction to the legs drawing feet and ankles level. Next apply a pelvic binder before applying Kendrick or equivalent (see Chapter 17 on extremity injury) traction splint to each leg suspected of having a femoral fracture. Apply traction aiming for anatomical reduction. Bind feet together to prevent external rotation.

Avoiding iatrogenic injury
Pelvic fractures should be assumed to be unstable – additional iatrogenic injury may be caused by the movement of bone fragments and movement causing changes in pelvic volume and/or architecture.

Do not spring the pelvis – it adds little relevant clinical information but can cause significant damage.

Care must be taken when removing patient clothing e.g., motor bike leathers. These clothes may be holding fractures in a reduced position – on removal significant damage may be caused by changes in pelvic volume/architecture.

Log roll is not recommended and should be minimized (10-15 degrees maximum). A split scoop-style stretcher is ideal for lifting and transporting patients.

Tips from the Field:
·         Avoid iatrogenic injury by minimal handling techniques, avoidance of log roll and not springing the pelvis.
·         Have a high index of suspicion: if in doubt apply a pelvic binder.
·         PR or PV bleeding may represent an ‘open’ fracture into a hollow viscus, these have a mortality of > 50%.
·         Pelvic binders need to be applied at the level of the greater trochanters (even though they may look better around the waist!).
·         Do not allow anyone to mistake a pelvic binder for a board strap and accidentally unclip it!


Further Reading
Joint Royal College Ambulance Liaison Committee (IRCALC) Prehospital Guidelines 2006. Warwick: University of Warwick, 2006.
Lee C, Porter K. The prehospital management of pelvic fractures. Emergency Medicine Journal 2007; 24: 130-133.

(1990)
[This is a key paper which many of the other references refer back to.]
Grant PT. The diagnosis of pelvic fractures by 'springing'. Archives of Emergency Medicine, 1990; 7: 178-182

SUMMARY
Thirty-six patients were studied prospectively to assess the benefit of 'springing' the pelvis in traumatized patients, to confirrn or refute a fracture of the pelvis. None of the patients was multiply injured and half of those with fractures were elderly, sustaining their injuries in simple falls. Springing the pelvis was a poor predictor of the presence or absence of a pelvic fracture, at best it yielded a specificity of 71% and sensitivity of 59%. Its routine use in clinical examination should be abandoned.

Discussion
(…)
I would suggest that there is no easy answer to the best method of detecting these fractures clinically and one must resort to the use of X-rays liberally, not just in major injury but also in the more minor, especially elderly patient who may only have vague groin discomfort or a mild limp following relatively trivial trauma. I feel that 'springing' the pelvis should no longer be taught to medical students and junior doctors alike, and should be completely discarded from our clinical practice.

(2004)
Heetveld MJ, Harris I, Sclaphoff G, Balogh Z, D’Amours SK, Sugrue M. Hemodynamically Unstable Pelvic Fractures: Recent Care and New Guidelines. World Journal of Surgery 2004; 28: 904–909.

“Clinically, a suprapubic hematoma may be palpable, suggesting pelvic arterial and/or venous hemorrhage. The sensitivity of pelvic springing to detect pelvic ring instability is only 59%, and we do not advocate springing, which is also painful in conscious patients.” [34 - Grant PT. The diagnosis of pelvic fractures by ‘springing’. Arch. Emerg. Med. 1990;7:178–182].

(2007)
Lee C, Porter K. The prehospital management of pelvic fractures. Emergency Medicine Journal 2007; 24:130–133.
(Abstract)
Pelvic fractures are one of the potentially life-threatening injuries that should be identified during the primary survey in patients sustaining major trauma. Early suspicion, identification and management of a pelvic fracture at the prehospital stage is essential to reduce the risk of death as a result of Hypovolaemia and to allow appropriate triage of the patient. The assessment and management of pelvic fractures in the prehospital environment is reviewed here. It is advocated that the pelvis should not be examined by palpation or springing, and that the patient should not be log rolled. Pelvic immobilisation should be used routinely if there is any suspicion of pelvic fracture based on the mechanism of injury, symptoms and clinical findings.
(…)
This paper aimed to review the literature and analyse current practices in order to identify the
optimum management for a patient with a suspected pelvic fracture in the prehospital environment.

PREHOSPITAL ASSESSMENT
The most common mechanism of injury resulting in pelvic fracture is road traffic collisions (20–66%), with an increased likelihood if the patient is sitting in the front of the vehicle in head on collisions, on the struck side or with near intrusion. Pelvic fractures resulting from pedestrian collisions (14–59%) and motorcyclist collisions (5–9.3%) are also common.10 12 14 16 Falls from heights, or from a low level by elderly patients with osteoporosis are also implicated in the aetiology and, more rarely, crush injuries.

Pelvic fractures should be identified by the circulatory assessment of the CAcBCDE assessment following resuscitation of catastrophic haemorrhage, airway and breathing problems.

Traditional teaching encourages the practice of ‘‘springing’’ the pelvis as part of this assessment to identify tenderness or instability as an indicator of pelvic fracture and therefore a source of internal haemorrhage.17 A variety of methods of springing have been described: most involve compression or distraction of the fracture site.18 However, the current belief is that this is an unreliable test, which will only detect major pelvic disruption and is dangerous in dislodging clots and promoting further blood loss.

In 1990, a level three prospective study first dealt with concerns about examining the pelvis, looking at 36 patients with blunt trauma (excluding multiple injuries). The results found that springing the pelvis had a specificity of 71% and a sensitivity of 59%, suggesting that routine use of this examination should be abandoned.19

Several studies have looked at the likelihood of a pelvic fracture being present depending on
whether a patient has symptoms of pain or suspicion on clinical examination, as a means of
reducing the use of routine pelvic x rays in a patient sustaining blunt trauma (table 1).

The limitations of most of these studies are that they were performed on patients with a Glasgow Coma Scale (GCS) of >13 who were co-operative and alert. The examiners could, therefore, only verify the reliability of examination in these circumstances and the studies were thus not applicable to patients with severe multiple injuries and reduced consciousness
levels due to intracranial injury, shock or the influence of alcohol or drugs. In cases where injuries were missed, the authors of these studies suggest that painful distracting injuries at other sites may also have been a contributing factor.

In the meta-analysis, the diagnostic accuracy was confirmed as being much lower in those
studies which included patients regardless of GCS (three of these studies were on children).20
(…)
In the Gonzalez et al’s9 study of patients with GCS 14 or 15, the most common positive finding in patients with pelvic fractures was of the patient complaining of pelvic pain (67% of
97 patients) whereas only 32% had pain on iliac compression and 37% had pain on palpation of the pubic symphysis.

In summary, the prehospital practitioner first needs to assess the mechanism of injury to be able to predict a potential pelvic fracture.

Alerting features suggestive of significant pelvic injury during examination include deformity, bruising or swelling over the bony prominences, pubis, perineum or scrotum. Leg-length discrepancy or rotational deformity of a lower limb (without fracture in that extremity) may be evident. Wounds over the pelvis or bleeding from the patient’s rectum, vagina or urethra may indicate an open pelvic fracture. Neurological abnormalities may also rarely be present in the lower limbs after a pelvic fracture. Discrete rectal or vaginal bleeding or a high-riding prostate will not be detected in the prehospital environment.

In the alert, orientated, cooperative patient with no distracting injury, it will be possible for the prehospital practitioner to ask the patient about the presence of pain in the pelvic area,
including the lower back (assessing the sacroiliac joint), groin and hips. Any positive reply should call for routine immobilization of the pelvis. In the absence of any symptoms or signs of pelvic fracture as described above, discharge from scene is an option, provided there are no other injuries requiring transfer to a hospital.

In the case of the unresponsive trauma patient, the pelvis should not be palpated for tenderness or instability. A pelvic fracture should be assumed to be present and routinely
immobilised as described below.

HAEMORRHAGE CONTROL
Traditional teaching advises that the emergency management of pelvic fractures includes internal rotation of the lower limbs to reduce the pelvic volume and circumferential wrapping of a sheet around the pelvis as a sling.17 Reduction and stabilization of pelvic ring injuries should occur as soon as possible after injury,23 while clotting mechanisms are still intact, before irretrievable haemorrhage has occurred and before the patient’s movement and transport.
(…)
CONCLUSIONS
Prehospital management of a suspected pelvic fracture should adhere to the following principles:
·         Read the mechanism of injury.
·         Ask the alert patient about the presence of pain in the pelvic, back or groin regions and routinely immobilise the pelvis if there is any positive reply.
·         Examination is unreliable (especially if reduced GCS, or distracting injuries) and the pelvis should not be palpated, to avoid further internal haemorrhage.
·         If there is any suspicion of fracture, immobilise the pelvis using an external compression splint (commercial or modified eg, sheet).
·         Do not fully log roll the patient.
·         Use a scoop stretcher to facilitate the patient’s movement on to a spinal board or vacuum mattress for transport. In the emergency department, this process should be reversed.
·         Fluid resuscitation to maintain a radial pulse only.
·         Do not remove a pelvic splint in the presence of a suspected unstable pelvic injury until it is radiologically confirmed that there is no fracture or the patient is in a theatre.

(2007)
NSW Health. Adult Trauma Clinical Practice Guidelines. Management of haemodynamically unstable patients with a Pelvic Fracture.
Citation: Dr Martin Heetveld 2007, The Management of Haemodynamically Unstable Patients with a Pelvic Fracture, NSW Institute of Trauma and Injury Management.
(…)
(Page 9) Physical assessment is highly sensitive in determining the presence of fracture of the pelvis in a conscious and orientated patient. Findings warranting a plain pelvic X-ray are hip pain, groin pain, low back pain, tenderness to palpation over the pelvic girdle, obvious deformities and ecchymosis or abrasions around the pelvic area.21 To detect an unstable
fracture pattern of the pelvic bones at physical examination springing of the pelvis is advocated, but unless one is experienced in pelvic fracture surgery, the sensitivity of pelvic springing is only 59% and is painful in the awake patient.22 [Grant P 1990, The diagnosis of pelvic fractures by springing, Archives of Emergency Medicine 1990;7(3):178-82.]

The most common mechanisms of pelvic fractures are motor vehicle accidents (57%), pedestrians hit by motor vehicles (18%), motorcycle accidents (9%), falls (9%) and crush injuries (4%).23

[Note: This appears to be a heavily qualified endorsement of “springing the pelvis” and it is strange that the author cites an article which categorically states that “springing” should not be used. It also undermines the author’s credibility that in 2004 he was part of a team of authors stating that “we do not advocate springing”, citing the same article by PT Grant.]

(Page 25)
6.         How to optimally mechanically stabilise the pelvis?
Rotationally unstable APC types II and III, LC type III pelvic fractures benefit most from external stabilisation. If vertical instability is also present, such as in VS and combination type pelvic fractures, rotational stabilisation needs to be supplemented by skeletal traction on the injured side. (Level of Evidence: III-3)

The optimal time-effective and safe pelvic external stabilisation device in the haemodynamically unstable patient is non-invasive. A bed sheet wrapped and clamped tightly around the pelvis is a good option. There are a variety of non-invasive proprietary devices available. The device should be applied so that it allows both laparotomy access and femoral artery access for angiography. (Level of Evidence: IV)
(…)

(Page 26)
Approach in the emergency setting
In the situation of haemodynamic instability, stabilisation of the pelvis in APC type II and III,
LC type III, VS and combinations of these fractures, must be performed in the shortest possible time. Two kinds of pelvic stabilisation can be considered: non-invasive techniques and invasive fixation.

Non-invasive techniques have advantages: they are safe, time-effective, do not require the presence of an orthopaedic surgeon in the resuscitation room and do not interfere with further resuscitation efforts.88 Simple, popular options include the use of a bed sheet wrapped and clamped tightly around the pelvis or a vacuum beanbag to provide emergent pelvic stability. (36;78;88) There are also a number of more expensive proprietary devices specifically
designed and marketed for such use. These non-invasive options should be considered as
temporising measures bridging the gap from injury to more definitive stabilisation.75 Pelvic stability promotes venous bleeding tamponade and protects the soft tissues from further injury.70;87

Appendix A contains photographs of a step-by-step pelvic sheeting technique. (It was not possible to reproduce this here.)

(2009)
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury 2009; 40:1023–1030.
(…)
Pelvic fractures account for approximately 3% of all skeletal injury after blunt trauma. In large series, most result from motor vehicle crashes.12,27,43,76,81,105 Though injuries combining mechanically unstable pelvic fractures with haemodynamic instability are rare, comprising less than 10% of all pelvic fractures presenting to Level I centres, they represent the bulk of mortality of this group.39,43,56 To disrupt the integrity of the pelvic ring requires an instantaneous deceleration of approximately 30 miles per hour and as this energy dissipates, it often causes trauma to the head, chest, abdomen or extremities which adds to the over-all physiological burden of injury.54,96,105 In fact, more than 80% of patients with unstable pelvic fractures will be found to have additional musculoskeletal injuries.25,54,80 Injury severity score (ISS) is indicative of the degree of destructive energy applied to the body as a whole, and ISS, not type of pelvic instability, appears to be the most important factor in predicting mortality in patients with pelvic fractures.3,39,76,80,96,114,118 Only a small proportion of deaths are directly attributable to the pelvic fracture alone.31,90,95
(…)

Focus should then be turned to reduction of venous bleeding by stabilisation of pelvic ring injuries. This is most expeditiously accomplished with a longitudinally folded bed sheet wrapped circumferentially around the pelvis, placed between the iliac crests and greater trochanters, and secured anteriorly by clamping97,100,110 (Fig. 2), or with simple commercially available devices which also provide circumferential pelvic stabilisation
and may permit the applied reduction force to be controlled to a pre-determined level.27,100 Both the improvised and commercially available binders stabilise the pelvis and allow for clot formation. While binders and external fixators may decrease the pelvic volume of ‘‘open-book’’ injuries,9 it is controversial whether they can create a tamponade effect, since the retroperitoneum is disrupted.47,53 The ‘‘splinting’’ of pathological pelvic motion is more likely to be the mechanism that aids in haemostasis. Moreover, the reduction in volume of the true pelvis is much less than expected. A large pubic diastasis of 10 cm only corresponds to a 35% increase in pelvic volume or 479 cm3.120

Pelvic binders also assure continued access to the abdomen, pelvis and lower extremities, do not require special training to place and are generally free from complications with short-term
use. As such, ATLS guidelines recommend their placement by pre-hospital personnel and providers in rural settings before transport of these patients. In fact, the use of pelvic binders
results in significantly lower transfusion amounts and length of hospital stay compared to external fixation.27 Long periods of tight immobilisation may cause tissue necrosis, nerve injury and/or abdominal or extremity compartment syndrome(s) although this time course is not well defined.75,100,108,126 There is a case report of skin breakdown affecting patient management secondary to circumferential anti-shock sheeting.106 A recent study raised concerns about prolonged use of binders due to pressure over bony prominences.70 Pelvic sheeting or compressive devices usually remain in place until the patient is haemodynamically stable and transfusion requirements have ceased, usually in one to two days, or if the patient continues to bleed and another intervention is necessary.11,123 Military antishock trousers (MAST) trousers limit access to the traumatised regions and have also been associated with these complications with no evidence of benefit and should not be used for this purpose.32,43

Clinically, a palpable haematoma above the inguinal ligament, on the proximal thigh, and/or over the perineum (Destot sign) may indicate pelvic fracture with associated bleeding; ecchymosis about the flank (Grey Turner sign) is associated with retroperitoneal haemorrhage. Pelvic springing involves applying alternating compression and distortion over the iliac wings to detect pelvic ring instability and is a poor predictor of the presence or
absence of pelvic fracture. Additionally, it may dislodge adherent clot further exacerbating haemorrhage, is painful to the conscious patient and should therefore be avoided.52,59 [Grant PT. The diagnosis of pelvic fractures by ‘springing’. Arch Emerg Med 1990; 7:178–82.; 59. Heetveld MJ, Harris I, Schlaphoff G, et al. Hemodynamically unstable pelvic
fractures: recent care and new guidelines. World J Surg 2004; 28:904–9.]

(2009)
Major Pelvic Trauma – New Guidance. Trauma Emergencies, May 2009. (8 pages)
(…)
5. ASSESSMENT
Assess:
·         AIRWAY
·         BREATHING
·         CIRCULATION
·         DISABILITY (mini neurological examination).

Evaluate whether patient is TIME CRITICAL or NON-TIME CRITICAL following criteria as per trauma emergencies guideline. If patient is TIME CRITICAL, correct A and B problems, stabilise the pelvis on scene, and rapidly transport to nearest suitable receiving hospital. Send a Hospital Alert Message. Enroute, continue patient management of pelvic trauma (see below).

In NON-TIME CRITICAL patients perform a more thorough patient assessment with a brief Secondary Survey.

5.1 Specifically consider
Pelvic fracture should be considered based upon the mechanism of injury.67

Clinical assessment of the pelvis includes observation for physical injury such as bruising, bleeding, deformity or swelling to the pelvis. Shortening of a lower limb may be present (see also limb trauma guideline).68 Assessment by compression or distraction (e.g. springing) of the pelvis is unreliable and may both dislodge clots and exacerbate any injury and should not be performed.69-71
[Relevant footnotes:
69. MacLeod M, Powell JN, MacLeod M, Powell JN. Evaluation of pelvic fractures. Clinical
and radiologic. Orthopedic Clinics of North America 1997;28(3):299-319.
70. Fox MA, Mangiante EC, Fabian TC, Voeller GR, Kudsk KA. Pelvic fractures: an analysis of factors affecting prehospital triage and patient outcome. Southern Medical Journal 1990;83(7):785-8.
71. Sauerland S, Bouillon B, Rixen D, Raum MR, Koy T, Neugebauer EAM. The reliability
of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta-analysis.
Archives of Orthopaedic & Trauma Surgery 2004; 124(2):123-8.]

Any patient with a relevant mechanism of injury and concomitant hypotension MUST be
managed as having a time critical pelvic injury until proven otherwise.

Reduction and stabilisation of the pelvic ring should occur as soon as is practicable whilst still on scene, as stabilisation helps to reduce blood loss by realigning fracture surfaces, thereby limiting active bleeding and additionally helping to stabilise clots.67 72 Reduction of the pelvis may have a tamponade affect, particularly for venous bleeding; however there is little evidence to support this belief.73

Log rolling of the patient with possible pelvic fracture should be avoided as this may
exacerbate any pelvic injury;67 where possible utilise an orthopaedic scoop stretcher to lift
patients off the ground and limit movement to a 15º tilt.

6. MANAGEMENT
6.1 Oxygen Therapy
Major pelvic injury falls into the category of critical illness and requires high levels of
supplemental oxygen regardless of initial oxygen saturation reading (SpO2). Maintain high flow oxygen (15 litres per minute) until vital signs are normal; thereafter reduce flow rate, titrating to maintain oxygen saturations (SpO2) in the 94- 98% range (refer to oxygen guideline).

6.2 Pelvic Stabilisation
There is currently no evidence to suggest that any particular pelvic immobilisation device or
approach is superior in terms of outcome in pelvic trauma and a number of methods have
been reported.32 74-86 Effective stabilisation of the pelvic ring should be instigated at the earliest possible opportunity, preferably before moving the patient, and may be achieved by:
·         use of an appropriate pelvic splint 32 74-78
·         application of circumferential support, however care must be taken to ensure that over-compression does not occur.79-82

Expert consensus suggests the use of an appropriate pelvic splint is preferable to improvised immobilisation techniques. In all methods, circumferential pressure is applied over the greater trochanters87 and not the iliac crests. Care must be exercised so as to ensure that the pelvis is not reduced beyond its normal anatomical position.

Pressure sores and soft tissue injuries may occur when immobilisation devices are incorrectly fitted.88


6.3 Fluid Therapy
There is little evidence to support the routine use of IV fluids in adult trauma patients; please refer to the fluid therapy guideline for specific guidance.

6.4 Pain Management
Patients’ pain should be managed appropriately (refer to pain management guidelines);
analgesia in the form of Entonox (refer to Entonox drug protocol for administration and
information) or morphine sulphate may be appropriate (refer to morphine drug protocol
for dosages and information).

(Five pages of relevant references are supplied with this article.)

(2010)
Notes from the office of Operational Quality and Improvement (Ambulance Victoria)
Topic: Pelvic and Femur Fractures

Hello All,

The coming 2010 CPE has a session on major trauma with a part devoted to Pelvic fracture management. This was visited only a couple of years ago but will be repeated for a few reasons. Firstly, the amalgamation has meant that the SAM pelvic splint as used in AAV and rural shall be introduced for use into metro.

In metro, the major option for pelvic fracture management has been the Pelvic Wrap 'big nappy' technique. This works pretty well and should not be discarded out of hand. It has a couple of limitations though. The compressive force applied is variable and dependent on operator application. It is also possible to loosen as the patient is moved and transported. The other thing creative ambos do is use the KED as a pelvic splint. Invert it so that the larger chest part sits over the pelvic area and pull the straps tight. The lower part can be used to grab the legs and tied off with a bandage etc. This isn't specified as a use by the manufacturer but seems to work okay. Again though, you cannot govern the pressure applied and there is no evidence that it really does work. Also, it can be a bit harder to get the force in just the
right place which can count for a lot.

Pelvic traction should be applied to the lower part of the pelvis in the area of the femur trochanters. This is a bit lower than many would first guess. The SAM splint is a great device designed just for binding up the truly stuffed pelvis. It applies just the right amount of force and doesnt let go in transit.

Why splint a pelvic fracture? Like all fractures, movement allows for further soft tissue damage and increased pain so splinting is usually good. In the case of the pelvis, there are a lot of fairly important blood vessels travelling through. If these are damaged, outcomes are often bad. Further, the pelvis itself is fairly vascular (you can even stick intra-osseous needles into it). When a pelvis is broken clean through and loses its shape ('open book fracture') two things can happen. The smaller vessels in the bone itself bleed more and the larger vessels passing through have a bigger space to bleed into. Splinting increases the tamponade effect within a reduced pelvic space reducing both sorts of bleeding. Also, by returning bones to the right place, the smaller bleeding bone vessels can be better controlled.

How do you pick a pelvic fracture? The mechanism and pattern of injury are the first clues. Patients fallen from a height, in a head on (your knees ramming your femurs back into your pelvis by the dashboard will do it pretty well) or a good T-bone into the victims door are good. Signs and symptoms are not perfect for detection. It can be hard to pick a pelvic fracture without X-ray or CT. Hip/groin/lower back pain, pelvic tenderness, hematuria or vaginal bleeding are all clues. Lower back injuries and upper femur fractures can be very hard to distinguish from a pelvis. The open book fracture is only a small percent of all fractures but is the bad one. This will likely involve more severe pain, evidence of pelvic deformity, shortening or leg rotation, crepitus, bruising to the groin area and poor perfusion. If the hips and upper thigh(s) look a bit stuffed, assume the pelvis is broken. Though perfusion can be attacked by other injuries, a hip/pelvis injury and poor perfusion is a good chance to be an open book fracture.

Though it says crepitus, you shouldn't go looking for this. Springing the pelvis is not a great idea. Not only might it hurt, we don't normally wiggle other fractures around just to check if anything really is broken. You can worsen the injury. Many fractures won't be revealed by this technique anyway so it isn't really diagnostic. Gather all the evidence as described above. If you are in any doubt, treat as if it is an open book pelvic fracture. A SAM splint may not be much help for a fracture that isn't open book but it will do a lot for it when it is.

What about if there is a femur fracture(s) as well? Well, you can die from a broken pelvis. You don't usually die from a femur or even two (though you would probably look and be pretty crook with two). The pelvis gets priority. It takes a lot of trauma to break a pelvis or a couple of femurs. When you splint a pelvis, the pressure is across the body and doesn't really impact on the lower limb. So a pelvis shouldn't upset the femur fracture. The femur pushes up into the pelvis when traction is applied. The amount of push is usually not enough to upset the pelvis; it is more against the ischial tuberosity. So you can apply a Donway splint on a fractured pelvis even though some traction splint manufacturers advise against it. The SAM splint when properly placed over the trochanters still shouldn't interfere with the ischial ring of the Donway; the latter sits a tad lower. You shouldn't use a traction splint if a knee or ankle joint is cactus. Advice from the Alfred Trauma centre is that if in any doubt, splint up the pelvis. Then rotate and pull the legs into as best as normal alignment as you can (this helps pull the pelvis back into shape and a fair bet might hurt without a good dose of analgesia first). Finally use basic techniques like figure of 8 on the ankles and broad bandage to truss the legs together. It is arguable how much benefit can be gained from traction in the pre-hospital setting but there is no question as to the value of immobilisation. I can hear the dinosaurs moaning 'MAST suit' in their agonised sleep from here.....

And remember, once applied, no pelvic splint should be removed by us once applied. It should be removed slowly and only with an emergency physician in attendance as dramatic deterioration can follow.

Jeff Kenneally, Acting Manager Clinical Effectiveness & Research
Operational Quality and Improvement
Ambulance Victoria, 375 Manningham Road Doncaster Vic 3108


(2012)
Royal Melbourne Hospital Trauma Service. Trauma Service Guidelines - Haemodynamically Unstable Pelvic Fracture Guideline.
Developed by: K. Gumm, R. Judson, P. Page, M. Richardson & ACT
Created: February 2005; Version 1.0
Revised: July 2012 Version 2.0
Revised By: K. Gumm, R. Judson, A. Bucknill, A. Oppy, M. Walsh, D. Pascoe
(…)
Pelvic fractures are relatively uncommon and account for only 3% of all skeletal injuries after blunt trauma, most result from high velocity injuries such as motor vehicles, pedestrians, motor bike, falls and crush injuries. They occur in 20% of multi-trauma cases and most commonly in 15 to 30 year olds and in the over 60’s, with 75% of all injuries occurring in men 2-8.
(…)
Assessment
Patients who present with or develop haemodynamic instability with a suspected or known pelvic fracture will require a primary and secondary survey.

Initial inspection should be for signs of external blood loss and for blood loss from long bone fractures. A chest x-ray will rule out a large haemothorax.

If a fracture is seen on pelvic x-ray there is a 32% probability of arterial bleeding in the pelvic retroperitoneum 11-13. Signs and symptoms of a significant pelvic fracture include: 2
·         Deformity
·         Bruising and swelling over bony prominences, pubis perineum, and/or scrotum
·         Leg length discrepancy or rotation deformity of a lower limb
·         Wounds over the pelvis or bleeding from rectum vagina or urethra
·         Neurological abnormality.

Springing the pelvis is an unreliable test in detecting major pelvic disruption and is dangerous as it may dislodge a clot promoting further bleeding in the unstable patient.

Disruption of the pelvic ring requires a high energy decelerative force of approximately 50 km/hr 2, 3, 6, 9. These forces cause multiple other organ injuries up to 90% of patients with an unstable pelvic fracture have other associates injuries and 50% have sources of haemorrhage other than the pelvic fracture 3, 8, 13, 14. Including long bones (40%), intrathoracic (29%), spleen (32%), liver (20%), bladder (15%), bowel (10%), kidney (7%)11, 13. Therefore it is crucial to exclude other causes of shock including tension pneumothorax, pericardial tamponade and neurogenic shock. Whilst continuing with fluid resuscitation a rapid systematic evaluation of the whole body is needed to manage patients with pelvic fractures.
(…)
Pelvic Sling 3, 7, 8, 15, 16.
The pelvic sling is a non-invasive external pelvic stabilisation device. It is easy to apply and readily available in the trauma bays in emergency department. The sling when applied to the greater trochanters will affect pressure and cause the legs to internally rotate, assist in decreasing pelvic volume, improving mechanical stability and prevent disruption of haemostatic clots. A pelvic sling should be considered as early as possible in patients with suspected pelvic fractures, the sling should not be removed until the patient is haemodynamically stable, normothermic and not coagulopathic (see the RMH Pelvic Sling Guidelines for full use instructions: http://intranet.mh.org.au/w2/i1013938)17.
(…)
(A page of references is supplied with this Guideline.)

 (2013)
(Article in press): Brun J, et al. Detecting active pelvic arterial haemorrhage on admission following serious pelvic fracture in multiple trauma patients. Injury (2013), http://dx.doi.org/10.1016/j.injury.2013.06.011

“During the pre-hospital phase, it was recommended to place pelvic belt for patients with suspected displaced pelvic fracture or ongoing haemorrhage originated from the pelvis.”

4.         Opinions regarding “springing the pelvis”.
Subject: Re: medical query for ASPA procedures - springing of pelvis

My immediate thoughts on out-of-hospital recognition of the fractured pelvis;

Physical and historical assessment (with associative indicator confidence)
·         Unable to raise legs or straighten bent legs due to 'clear' pelvic-area pain (moderate to
·         high)
·         Pelvic pain on 'springing' pelvis, that is, palms on iliac crests progressively pushing
·         down, then lateral inwards pressure (high)
·         Painful/rigid/firm lower abdomen (low to moderate)
·         The unconscious trauma patient (Suspect it and you won't miss it)
·         Blood in urine (not an appropriate out-of-hospital exam. Blood can be present in urine,
·         but requires urinalysis to confirm)
·         Failed attempt to ambulate from pelvic pain (low to moderate)
·         Direct pelvic impact described, that is, mechanism (low)

How do you increase the likelihood of ensuring correct identification? Combine these all
together. The more positives you get in the above, the more likely a fractured pelvis is present.

I respectfully disagree with the assertion about 'unwanted' transports and radiography. If you
think it's there with reasonable evidence, THEN IT IS! COMMIT TO EARLY OFF MOUNTAIN EVACUATION. This is a fundamental of pre-hospital medicine, and indeed a trauma centre would not hesitate to conduct x-rays with a modicum of suspicion. However I do reinforce the point of 'reasonable' evidence. Mechanism alone is usually not sufficient evidence, unless the patient have other significant injuries or is unconscious.

(MICA Flight Paramedic)
*   *   *   *   *
The word springing in the pelvis means different things to different people.

The test that orthopaedic surgeons usually use for suspected pelvic injury is to put a hand on either side of the pelvis just above the greater trochanter of the thighs and push the iliums together.  If this does not cause any pain then it is unlikely that there is any significant injury to the pelvic ring which includes the sacroiliac joints, the iliums and the pubic rami.

If the patient is supine then pressing on the pubis may cause pain if there are fractures to the pelvic ring and/or a disruption of the symphysis pubis.

 Once again doing this test cannot cause any new damage.

I believe that ASPA should be careful not to be over conservative which may result in the following:

1.         An unnecessary trip by ambulance from the snowfield to the  nearest hospital.
2.         Completely unnecessary investigations such as x-rays and CT scans all of which are harmful.
3.         Unnecessarily increasing the anxiety of the injured skier and/or the accompanying persons.

If the ski patroller seriously believes that the patient may have a significantly nasty pelvic injury then the patroller should get the patient to pass urine. If they cannot then that is not a good sign and if they can and there is no blood in the urine that is a good sign.

(Orthopaedic Surgeon)
 *   *   *   *   *
(Note: Research and document collation was undertaken  26-29 July 2013.)

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