Article, Traumatology

External contention for pelvic trauma: is 1 sheet enough?

A 58-year-old man was admitted in our hospital for pelvic trauma after a road traffic accident. At the injury scene, the arterial blood pressure was 90/55 mm Hg and the heart rate was 120 beats/min. The first physical examination showed lower- extremity external rotation and pelvic ring instability associated with a scrotal hematoma. A 23-cm-large pelvic circumferential compression (Bird & Cronin Inc, Eagan, MN) was placed immediately. At the admission in the trauma center (1 hour after trauma), the first anteroposterior pelvic x-ray showed a 2- cm symphyseal disruption, whereas the pelvic contention was in place (Fig. 1). An external rotation of the legs was also observed. A second contention (bed sheet) was placed around the patient’s knees to achieve the neutral position for the lower extremities. The scout view of computed tomographic scan showed a complete reduction of the pelvis disruption (Fig. 2). Bilateral sacral fractures and sacroiliac disruptions were also observed on computed tomographic scan with a small Retroperitoneal hematoma, associated with a vertebral fracture (12th thoracic vertebra). When both contentions were removed on surgeon demand, a new Pelvic radiography showed a pelvic disruption reaching 4 cm, with an important thighbone external rotation (Fig. 3). Both contentions were then handled again. Hemodynamically, the status remained stable. The patient underwent, in an emergency department, a surgical reduction with symphyseal fixation before being operated on in prone position the next day for the fixation of its vertebral fracture.

Several treatment options exist for early management of patients with pelvic trauma. External pelvic stabilization is an easy-to-use and effective method to reduce hemorrhage [12]. The use of a double contention aiming at reducing pelvic symphyseal disruption and lower-leg external rotation may be an attractive first-line technique in patients with pelvic trauma. Circumferential contentions with a bed sheet are effective but, because of their width, can render difficulty in the access to femoral vessels for catheterization and to the abdomen in case of laparoscopy or laparotomy. The use of a small belt such as the SAM Sling belt (SAM Medical Products, Newport, OR) as described by Knops et al [13] leaves more space for clinical diagnosis or vascular access, but corrects the difficulty in the external rotation of the legs. The risk of overcompression exists among skin sores, especially with

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442.e2 Case Report

Fig. 1 First pelvic anteroposterior x-ray with pelvic circumferential compression and lower-extremity external rotation, showing a symphyseal disruption of 2 cm.

pelvic circumferential compression devices, because of the difficulty to evaluate the closure pressure exercised on pelvis. Some authors used a bed sheet applied circumferentially around the pelvis and secured by a clamp [11]. The sheets have to be temporary placed to avoid Skin necrosis over the area of pelvic circumferential compression device application [14]. Adding a second contention surrounding the knees to limit the external rotation of the legs and to reduce pelvis symphyseal disruption without exerting excessive pressure across the hips could be of interest.

The antishock suit can be useful in case of retroperitoneal bleeding, but this technique had not shown any effect on mortality [4]. It can cause systemic complications, and its pressurization has been associated with compartmental syndromes in the lower extremities. Other authors recommend taping of uninjured lower extremities in an internally rotated position [15].

The double-contention technique presented here is simple, is noninvasive, and could be an effective external pelvic

contention in cases of open-book-type fractures, providing a temporary reduction of symphyseal disruption and, possibly, a reduction of the blood diffusion in the retroperitoneum space, before a complete surgical stabilization of the pelvic ring.

Fanny Vardon MD Elodie Brunel MD

Anesthesiology and Critical Care Department

University Hospital of Toulouse Equipe d’accueil Modelisation de l’agression

tissulaire et nociceptive University Paul Sabatier, Toulouse, France E-mail address: [email protected]

Mathieu Lecoq MD Orthopedic Surgery Department University Hospital of Toulouse

University Paul Sabatier, Toulouse, France

Fig. 2 Scout view of computed tomography with pelvic compression and second contention with a bed sheet around the knees, allowing neutral position of thighbones, showing a complete reduction of the symphyseal disruption.

Case Report 442.e3

Fig. 3 Pelvic anteroposterior x-ray without pelvic contention showing a 4-cm symphyseal disruption.

Olivier Fourcade MD, PhD Thomas Geeraerts MD, PhD

Anesthesiology and Critical Care Department

University Hospital of Toulouse Equipe d’accueil Modelisation de l’agression

tissulaire et nociceptive University Paul Sabatier, Toulouse, France

http://dx.doi.org/10.1016/j.ajem.2012.05.020

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