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 casualty’s 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)
“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.)
