Yesterday, I detailed some pelvic binders commonly available
in the US.
Today, I’ll go through the (little) science there is regarding which are better
There are a number of factors to consider when choosing one
of these products. They are:
Does it work?
Does it hurt or cause skin damage?
Is it easy to use?
How much does it cost?
It’s difficult to determine how well binders work in the live,
clinical setting. But biomechanical studies can serve as a surrogate to try to answer
this question. One such cadaver study was carried out in the Netherlands a
few years ago. They created one of three different fracture types in pelvis
specimens. Special locator wires were placed initially so they could measure bone movement
before and after binder placement. All three of the previously discussed
commercial binders were used.
Here are the factoids:
In fracture patterns that were partially stable or unstable,
all binders successfully closed the pelvic ring.
None of the binders caused adverse displacements of fracture
Pulling force to achieve complete reduction was lowest with
the T-POD (40 Newtons) and highest with the SAM
pelvic sling (120 Newtons).
The SAM sling limits compression to 150 Newtons,
which was more than adequate to close the pelvis.
So what about harm? A healthy volunteer study was used to
test each binder for tissue pressure levels. The 80 volunteers were outfitted
with a pressure sensing mat around their pelvis, and readings were taken with
each binder in place.
Here are the additional factoids:
The tissue damage threshold was assumed to be 9.3 kPa
sustained for more than 2-3 hours based on the 1994 paper cited below.
All binders exceeded the tissue damage threshold at the
greater trochanters and sacrum while lying on a backboard. It was highest with
the Pelvic Binder and lowest with the SAM sling.
Pressures over the trochanters decreased significantly after
transfer to a hospital bed, but the Pelvic Binder pressures remained at the
tissue damage level.
Pressures over the sacrum far exceeded the tissue damage pressure
with all binders on a backboard and it remained at or above this level even
after transfer to a bed. Once again, the Pelvic Binder pressures were higher. The
other splints had similar pressures.
And finally, the price! Although your results may vary due to
your buying power, the SAM sling is about $50-$70, the Pelvic Binder $140, and
the T-POD $125.
Bottom line: The binder that performed the best (equivalent
biomechanical testing, better tissue pressure profile) was the SAM sling. It also happens to be the least expensive, although it takes a little more elbow grease to apply. In my mind, that’s a winning combo.
Plus, it’s narrow, which allows easy access to the abdomen and groins for
procedures. But remember, whichever one you choose, get them off as soon as
possible to avoid skin complications.
Several products for compressing the fractured pelvis are available. They range from free and simple (a sheet), to a bit more complicated and expensive. How to decide which product to use? Today, I’ll discuss the four commonly used products. Tomorrow, I’ll look at the science.
There are three commercial products that are commonly used. First is the Pelvic Binder from the company of the same name (www.pelvicbinder.com). It consists of a relatively wide belt with a tensioning mechanism that attaches to the belt using velcro. One size fits all, so you may have to cut down the belt for smaller patients. Proper tension is gauged by being able to insert two fingers under the binder.
Next is the SAM Pelvic Sling from SAM Medical Products (http://www.sammedical.com). This device is a bit fancier, is slimmer, and the inside is more padded. It uses a belt mechanism to tighten and secure the sling. This mechanism automatically limits the amount of force applied to avoid problems with excessive compression. It comes in three sizes, and the standard size fits 98% of the population, they say.
Finally, there is the T-POD from Pyng Medical (http://www.pyng.com/products/t-podresponder). This one looks similar to the Pelvic Binder in terms of width and tensioning. It is also a cut to fit, one size fits all device. It has a pull tab that uses a pulley system to apply tension. Again, two fingers must be inserted to gauge proper tension.
So those are the choices. Tomorrow, I’ll go over some of the data and pricing so you can make intelligent choices about selecting the right device for you.
I’m still not done reviewing abstracts from next month’s annual meeting of the Eastern Association for the Surgery of Trauma (EAST). There are yet more oral and poster abstracts that I want to pick apart. Here are some that are coming in the January issue:
On occasion (but not routinely) trauma patients need to have their stomach decompressed. The reflex maneuver is to insert a nasogastric (NG) tube. However, this may be a dangerous procedure in some patients.
Some patients may be at risk for a cribriform plate fracture, and blindly passing a tube into their nose may result in a nasocerebral (NC) tube (see picture). This is a neurosurgical catastrophe, and the outcome is uniformly dismal. It generally requires craniectomy to remove the tube.
The following patients are at risk:
Evidence of midface trauma (eyebrows to zygoma)
Evidence of basilar skull fracture (raccoon eyes, Battle’s sign, fluids leaking from ears or nose)
If you really need the tube, what can you do? If the patient is comatose, it’s easy: just insert an orogastric (OG) tube. However, that is not an option in awake patients; they will continuously gag on the tube. In that case, lubricate a curved nasal trumpet and gently insert it into the nose. The curve will safely move it past the cribriform plate area. Then lubricate a smaller gastric tube and pass it through the trumpet.
Over the past several days, I’ve been writing about updates to our solid organ injury protocol. It eliminates orders for bed rest and NPO diet status afterwards. After looking at our experience over the years, the number of early failures is practically zero. So how many days do you need to keep a patient in bed to make sure they have an empty stomach when they need to be whisked away to the OR. And does walking around really make your injured spleen fall apart?
The answers are none and no. So we’ve updated our protocol at Regions Hospital to reflect this. Feel free to download and modify to your heart’s content. If you want a copy of the Microsoft Publisher file, just email me!