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Abstract: Background: Emergency devices for pelvic ring stabilization include circumferential sheets, pelvic binders, and c-clamps. Our knowledge of the outcome of these techniques is currently based on limited information. Methods: Using the dataset of the German Pelvic Trauma Registry, demographic and injury-associated characteristics as well as the outcome of pelvic fracture patients after sheet, binder, and c-clamp treatment was compared. Outcome parameters included transfusion requirement of packed red blood cells, length of hospital stay, mortality, and incidence of lethal pelvic bleeding. Results: Two hundred seven of 6137 (3.4%) patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets, binders, or c-clamps. In most cases, c-clamps (69%) were used, followed by sheets (16%), and binders (15%). The median age was significantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs. 47 vs. 42years, p =0.01). Sheet wrapping was associated with a significantly higher incidence of lethal pelvic bleeding compared to binder or c-clamp stabilization (23% vs. 4% vs. 8%). No significant differences between the study groups were found in sex, fracture type, blood haemoglobin concentration, arterial blood pressure, Injury Severity Score, the incidence of additional pelvic packing and arterial embolization, need of red blood cell transfusion, length of hospitalisation, and mortality. Conclusions: The data suggest that emergency stabilization of the pelvic ring by binders and c-clamps is associated with a lower incidence of lethal pelvic bleeding compared to sheet wrapping. Level of evidence: Level III. [Copyright &y& Elsevier]

Abstract: Background: Unstable pelvic fractures with associated haemodynamic instability are major contributors of mortality and morbidity after blunt trauma. The pelvic C-clamp is one of the methods for emergency skeletal stabilization for pelvic ring injuries with posterior instability. The application of this device is taught on courses, but it is seldom used. The safety and efficiency of C-clamp application by trained first time users is unknown. We hypothesised that the pelvic C-clamp cannot be safely positioned on a training model after one training session. Methods and materials: A theoretical and a practical session on the application of the pelvic C-clamp was held within an interval of 11.2±4.4. Twenty-seven participants of various levels of training were assessed on accuracy and efficacy of the application of the pelvic C-clamp was applied to a pelvic model (Pelvic Trainer™). Results: 70.4% of all participants were able to place both pins inside the safe zone, whilst 81.5% of all pins were positioned safe. 18.5% were considered to be in unsafe position. The distance to optimal target point was 9.6±7.8mm on the left (injured) hemipelvis and 8.7±7.8mm on the right (uninjured). The time needed for assembly was 99.7±39.7s, for placement it averaged at 133.9±74s. Conclusions: The majority of pins were placed into the safe zone on a training model within 4min after one training session. 18.5% dangerous pin placement within 11 days of the training requires careful consideration (risk/benefit) in the context of a critically injured dying patient. [Copyright &y& Elsevier]

Abstract: Bleeding pelvic fractures that result in haemodynamic instability have a reported mortality rate as high as 40%. Because of the extreme force needed to disrupt the pelvic ring, associated injuries are common and mortality is usually from uncontrolled haemorrhage from extra-pelvic sources. Identifying and controlling all sources of bleeding is a complex challenge and is best managed by a multi-disciplinary team, which include trauma surgeons, orthopaedic surgeons and interventional radiologists. Once the pelvis is identified as the major source of haemorrhage, component therapy reconstituting whole blood should be used and the pelvic region wrapped circumferentially with a sheet or pelvic binder. Patients at risk for arterial bleeding who continue to show haemodynamic instability despite resuscitative efforts should undergo immediate arteriography and embolisation of bleeding pelvic vessels. If this is unavailable or delayed, or the patient has other injuries (i.e., head, chest, intra-abdominal, long bone), external fixation and pelvic packing, performed concomitantly with other life-saving procedures, may be used to further reduce pelvic venous bleeding. If however, the patient remains haemodynamically labile without apparent source of blood loss, transcatheter angiographic embolisation should be attempted to locate and stop pelvic arterial bleeding. Institutional practice guidelines have been shown to reduce mortality and should be developed by all centres treating pelvic fractures. [Copyright &y& Elsevier]

Abstract: Pelvic angiography is an established technique that has evolved into a highly effective means of controlling arterial pelvic haemorrhage. The current dominant paradigm for haemodynamically unstable patients with pelvic fractures is angiographic management combined with mechanical stabilisation of the pelvis. However, an effective rapid screening tool for arterial bleeding in pelvic fracture patients has yet to be identified. There is also no precise way to determine the major source of bleeding responsible for haemodynamic instability. In many pelvic fracture patients, bleeding is from venous lacerations which are not effectively treated with angiography to fractured bony surfaces. Modern pelvic packing consists of time-saving and minimally invasive techniques which appear to result in effective control of the haemorrhage via tamponade. This review article focuses on the recent body of knowledge on angiography and pelvic packing. We propose the optimal role for each modality in trauma centres. [Copyright &y& Elsevier]