Pelvis and Lower Extremity Reduction

Overview

• 1.

  Application of a pelvic binder is a key step in the initial management of an unstable pelvic fracture.

• 2.

  Commercial pelvic binders are available, or a simple bedsheet may be used as a pelvic binder.

• 3.

  Venous bleeding is the most common cause of hemorrhage in a patient with hemodynamic instability and an unstable pelvic fracture.

• 4.

  By applying a binder, stability is provided to the fracture, allowing tamponade and organization of the hematoma.

Indications for Use

An unstable “open-book” pelvic injury (Tile B injury or anterior-posterior compression (APC) II or III injuries)

• 1.

  Note that placement of a pelvic binder is not contraindicated in a patient with a lateral compression-type injury.

• 2.

  The benefit of using a pelvic binder for a lateral compression-type injury is not likely to be as great as for an open-book pelvic injury.

Precautions

• 1.

  Close coordination with the trauma team and trauma anesthesiologist is mandatory.

• 2.

  Perform a careful physical examination before applying a binder. Determine whether the fracture is open or closed.

• 3.

  Correct placement of a pelvic binder is vital for it to function properly.

  • a.

    The binder should be centered around the greater trochanters.

  • b.

    The binder should “not” be centered at the patient’s waist.

Pearls

• 1.

  Although commercial binders are easier to apply than a bedsheet, not all emergency departments are equipped with commercial binders, so it is important to know how to use both a commercial binder and a bedsheet.

• 2.

  Place a towel over the perineal area to protect the structures therein.

• 3.

  After a commercial binder or a bedsheet is placed, postreduction radiographs are mandatory.

• 4.

  If the sheet will be used for more than emergent stabilization, then use two to four towel clips rather than tying the sheet to prevent loosening and pressure necrosis.

Equipment

• 1.

  Two people are required to reduce the pelvis and apply a binder appropriately (not shown).

• 2.

  A commercial pelvic binder ( Fig. 11.1 ) or a bedsheet

  

• 3.

  Towel clamps, Kelly forceps, or other large clamps

Basic Technique

• 1.

  Patient positioning:

  • a.

    Supine on a stretcher

• 2.

  Landmarks:

  • a.

    Greater trochanters

  • b.

    Anterior superior iliac spine (ASIS)

• 3.

  Steps:

  • a.

    Position the patient.

  • b.

    Palpate the landmarks.

  • c.

    Roll the patient.

  • d.

    Reduce the pelvis.

  • e.

    Place the commercial binder or bedsheet.

Detailed Technique

• 1.

  Position the patient.

• 2.

  Palpate the landmarks; feel both greater trochanters and ASIS ( Fig. 11.2 ).

  

• 3.

  Roll the patient. A standard trauma log roll technique should be used to place the commercial binder or bedsheet under the patient ( Fig. 11.3 ), with additional people at the legs and the head.

  

• 4.

  If a bedsheet is being used, place it as widely as possible over the greater trochanter and ASIS.

  • a.

    Reduce the pelvis by applying an inward force.

  • b.

    Use towel clips if available; if not, tie an extremely tight knot around the pelvis and add a second square knot ( Fig. 11.4 ).

    

• 5.

  Procedure for placing a commercial binder:

  • a.

    Wrap the binder around the patient ( Fig. 11.5 ).

    

  • b.

    Ensure correct placement. The binder must be centered on the greater trochanters.

  • c.

    Trim any excess ( Fig. 11.6 ).

    

  • d.

    Reduce the pelvis by applying an inward force.

  • e.

    Pull the cords to tighten the binder ( Fig. 11.7 ).

    

Overview

• 1.

  Numerous maneuvers have been described for reduction of dislocated hips.

• 2.

  All maneuvers basically function to recreate the deforming force.

  • a.

    Posterior dislocations ( Fig. 11.8 ): flexion, adduction, and internal rotation

    

  • b.

    Anterior dislocations: abduction and external rotation in extension

• 3.

  The incidence of dislocated hips is much higher in patients who have undergone hip arthroplasty compared with patients who have not.

• 4.

  The vast majority of hip dislocations are posteriorly directed.

• 5.

  Relocation of hips can be difficult because of the significant muscular and ligamentous impediments inherent to the joint.

• 6.

  In patients with traumatic dislocations, relocation is easier because of the associated posterior wall acetabular fracture.

Indications for Use

Posterior hip dislocations using the modified Bigelow technique.

Precautions

An assistant is required for the modified Bigelow technique to apply countertraction.

Pearls

Conscious sedation is virtually mandatory in most patients. The typical exception to this rule is a patient with a total hip arthroplasty whose hip becomes dislocated on a chronic basis.