Comparison of skin pressure measurements with the use of pelvic circumferential compression devices on pelvic ring injuries

Abstract

Objectives

Pelvic circumferential compression devices are commonly used in the acute treatment of pelvic fractures for reduction of pelvic volume and initial stabilisation of the pelvic ring. There have been reports of catastrophic soft-tissue breakdown with their use. The aim of the current investigation was to determine whether various pelvic circumferential compression devices exert different amounts of pressure on the skin when applied with the force necessary to reduce the injury. The study hypothesis was that the device with the greatest surface area would have the lowest pressures on the soft-tissue.

Methods

Rotationally unstable pelvic injuries (OTA type 61-B) were surgically created in five fresh, whole human cadavers. The amount of displacement at the pubic symphysis was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). The T-POD, Pelvic Binder, Sam Sling, and circumferential sheet were applied in random order for testing. The devices were applied with enough force to obtain a reduction of less than 10 mm of diastasis at the pubic symphysis. Pressure measurements, force required, and contact surface area were recorded with a Tekscan pressure mapping system.

Results

The mean skin pressures observed ranged from 23 to 31 kPa (173 to 233 mm of Hg). The highest pressures were observed with the Sam Sling, but no statistically significant skin pressure differences were observed with any of the four devices (p > 0.05). The Sam Sling also had the least mean contact area (590 cm²). In greater than 70% of the trials, including all four devices tested, skin pressures exceeded what has been shown to be pressure high enough to cause skin breakdown (9.3 kPa or 70 mm of Hg).

Conclusions

Application of commercially available pelvic binders as well as circumferential sheeting commonly results in mean skin pressures that are considered to be above the threshold for skin breakdown. We therefore recommend that these devices only be used acutely, and definitive fixation or external fixation should be performed early as patient physiology allows. There may be some advantage of use of a simple sheet given its low cost, versatility, and ability to alter contact surface area.

Introduction

The mortality rate of pelvic ring injuries varies from 5–36%.[1], [2], [3], [4], [5], [6], [7], [8], [9] Early mortality is usually due to exsanguination or head injury, and reduction of pelvic volume and stabilisation of the pelvic fracture should be part of the initial resuscitation. The severe bleeding associated with these injuries may arise from vascular injury, rupture of the sacral venous plexus, or soft-tissue and fracture bleeding.[10], 11, 12, [13], 14, 15 There are several commercially available binder devices for the treatment of unstable pelvic injuries in the acutely injured patient. In addition, some authors have simply advocated the use of a circumferentially applied sheet.16, 17, 18, 19

There have been several reports of catastrophic skin breakdown following the application of pelvic circumferential compression devices.20, 21, 22, 23 Some have proposed that this complication is due to pressure under the device, while others maintain that this may be the consequence of the initial soft-tissue trauma. In response to these reports, there have been studies performed examining the pressure exerted by commercially available binder devices.22, 24 Neither of these studies specifically examined the pressures imparted on the patient when adequate force to reduce the fracture was applied. Another recent study looked at the force necessary to obtain reduction of a pelvic fracture but did not examine skin pressure.²⁵

The purpose of the current investigation was to record and compare the skin pressures exerted by various commercially available pelvic binders as well as a circumferentially applied sheet when applied with enough force to adequately reduce an experimentally produced pelvic fracture. Our hypothesis was that the device with the greatest surface area would produce the least amount of skin pressure underneath it.