Use of the trauma pelvic orthotic device (T-POD) for provisional stabilisation of anterior-posterior compression type pelvic fractures: a cadaveric study.
ABSTRACT To demonstrate that a commercially available pelvic binder the trauma pelvic orthotic device (T-POD) is an effective way to provisionally stabilise anterior-posterior compression type pelvic injuries.
Rotationally unstable pelvic injuries were created in 12 non-embalmed human cadaveric specimens. Each pelvis was then stabilised first with a standard bed sheet wrapped circumferentially around the pelvis and held in place with a clamp. After recreating the symphyseal diastasis, the pelvis was stabilised with the T-POD. Reduction of the symphyseal diastasis was assessed by comparing measurements obtained via pre- and post-stabilisation AP radiographs.
The mean symphyseal diastasis was reduced from 39.3mm (95% CI 30.95-47.55) to 17.4mm (95% CI -0.14 to 34.98) with the bed sheet, and to 7.1mm (95% CI -2.19 to 16.35) with the T-POD.
Although both a circumferential sheet and the T-POD were able to decrease symphyseal diastasis consistently, only the T-POD showed a statistically significant improvement in diastasis when compared to injury measurements. In 75% of the cadaveric specimens (9 of 12), the T-POD was able to reduce the symphysis to normal (<10mm diastasis). Both a circumferential sheet and the T-POD are effective in provisionally stabilising Burgess and Young anterior-posterior compression II type pelvic injuries, but the T-POD is more effective in reducing symphyseal diastasis.
[show abstract] [hide abstract]
ABSTRACT: The application of a pelvic clamp for provisional stability of unstable pelvic fractures has been advocated in the orthopaedic literature. Although the technique has gained some supporters, problems with placement and associated complications have prevented widespread acceptance. We have modified the pelvic clamp (ACE Pelvic Stabilizer) technique by applying the clamp to the trochanteric region of the femur and applying a reduction force similar to a pelvic binder or external fixator.Journal of Orthopaedic Trauma 02/2006; 20(1):47-51. · 2.13 Impact Factor
Article: Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures.[show abstract] [hide abstract]
ABSTRACT: To determine whether the evolution of the authors' clinical pathway for the treatment of hemodynamically compromised patients with pelvic fractures was associated with improved patient outcome. Hemodynamically compromised patients with pelvic fractures present a complex challenge. The multidisciplinary trauma team must control hemorrhage, restore hemodynamics, and rapidly identify and treat associated life-threatening injuries. The authors developed a clinical pathway consisting of five primary elements: immediate trauma attending surgeon's presence in the emergency department, early simultaneous transfusion of blood and coagulation factors, prompt diagnosis and management of associated life-threatening injuries, stabilization of the pelvic girdle, and timely insinuation of pelvic angiography and embolization. The addition of two orthopedic pelvic fracture specialists led to a revision of the pathway, emphasizing immediate emergency department presence of the orthopedic trauma attending to provide joint decision making with the trauma surgeon, closing the pelvic volume in the emergency department, and using alternatives to traditional external fixation devices. Using trauma registry and blood bank records, the authors identified pelvic fracture patients receiving blood transfusions in the emergency department. They analyzed patients treated before versus after the May 1998 revision of the clinical pathway. A higher proportion of patients in the late period had blood pressure less than 90 mmHg (52% vs. 35%). In the late period, diagnostic peritoneal lavage was phased out in favor of torso ultrasound as a primary triage tool, and pelvic binding and C-clamp application largely replaced traditional external fixation devices. The overall death rate decreased from 31% in the early period to 15% in the later period, as did the rate of deaths from exsanguination (9% to 1%), multiple organ failure (12% to 1%), and death within 24 hours (16% to 5%). The evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed by joint decision making between trauma surgeons and orthopedic traumatologists, has resulted in improved patient survival. The primary benefits appear to be in reducing early deaths from exsanguination and late deaths from multiple organ failure.Annals of Surgery 07/2001; 233(6):843-50. · 7.49 Impact Factor
The Journal of Bone and Joint Surgery 02/2002; 84-A Suppl 2:43-7. · 3.27 Impact Factor
Use of the trauma pelvic orthotic device
(T-POD) for provisional stabilisation of
anterior—posterior compression type pelvic
fractures: A cadaveric study
Nicola A. DeAngelisa,e, John J. Wixtedb,e, Jacob Drewc,e,
Mark S. Eskanderc,e,*, Jonathan P. Eskanderb,e, Bruce G. Frenchd
aUMass Memorial Medical Center, Orthopedic Surgery-Sports Medicine, 281 Lincoln Street,
Worcester, MA 01605, United States
bUMass Memorial Medical Center, University Campus, 55 Lake Avenue North, Worcester,
MA 01655, United States
cUMass Memorial Medical Center, The Arthritis and Total Joint Replacement Center,
119 Belmont Street, Worcester, MA 01605, United States
dGrant Medical Center, Orthopaedic Trauma Reconstructive Surgery (OTRS), 285 E State Street,
Suite 500, Columbus, OH 43215, United States
eUMass Medical School, Department of Orthopedics, 119 Belmont Street, Worcester,
MA 01605, United States
Accepted 3 December 2007
Injury, Int. J. Care Injured (2008) 39, 903—906
Objective: To demonstrate that a commercially available pelvic binder the trauma
pelvic orthotic device (T-POD) is an effective way to provisionally stabilise anterior—
posterior compression type pelvic injuries.
Methods: Rotationally unstable pelvic injuries were created in 12 non-embalmed
human cadaveric specimens. Each pelvis was then stabilised first with a standard bed
sheet wrapped circumferentially around the pelvis and held in place with a clamp.
After recreating the symphyseal diastasis, the pelvis was stabilised with the T-POD.
Reduction of the symphyseal diastasis was assessed by comparing measurements
obtained via pre- and post-stabilisation AP radiographs.
Results: The mean symphyseal diastasis was reduced from 39.3 mm (95% CI 30.95—
47.55) to 17.4 mm (95% CI ?0.14 to 34.98) with the bed sheet, and to 7.1 mm (95% CI
?2.19 to 16.35) with the T-POD.
* Corresponding author. Tel.: +1 508 334 9757; fax: +1 508 334 9762.
E-mail address: firstname.lastname@example.org (M.S. Eskander).
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved.
High energy forces are required to injure the pelvic
ring. As a result, patients with pelvic fractures often
have associated injuries and may be haemodynami-
cally unstable.7In the Burgess and Young classifica-
tion, anterior—posterior compression type (APC)
pelvic injuries are associated with large amounts of
the pelvis, patients presenting with hypotension
were significantly more likely to die than those
presenting with an unstable pelvic fracture pattern
reported.8Among all pelvic trauma patients, hae-
morrhage is the major reversible contribution to
mortality in 42%.9
Provisional control of APC pelvic injuries in the
emergency room can be an important component in
the resuscitation and treatment of a haemodynami-
cally unstable patient.9,10The AP pelvic radiograph
taken in the trauma bay, along with physical exam-
ination, can be used to assess pelvic stability and
initially classify pelvic fractures. Before patient
transfer, one of several techniques, including bed
sheets, pelvic binders, pelvic clamps, or external
fixation, should be employed to temporarily stabi-
lise pelvic injuries.1,6
Among these options, bed sheets and commer-
cially available pelvic binders such as the trauma
pelvic orthotic device (T-POD) each offer the advan-
tages of timely, simple, non-invasive application
while still allowingaccess to the abdomen and lower
extremities.6,14The T-POD has been shown to pro-
vide significant stabilisation of open-book pelvic
injury variants in human cadavers.4,5A clinical trial
by Kreig et al.11suggests that the device is able to
significantly reduce externally rotated pelvic frac-
tures in an emergency setting.12We hypothesise
that the T-POD is superior to simple bed sheet in
reducing symphysis diastasis.
Materials and methods
Rotationally unstable pelvic injuries (Burgess and
Young APC II, or Tile B1) were created in 12 non-
embalmed human cadaveric specimens by section-
ing the pubic symphysis and the anterior sacroiliac,
sacrospinous, and sacrotuberous ligaments on the
left side of the pelvis. Surgery was completed
through an anterior approach to the symphysis for
symphyseal sectioning and through the first window
of the ilioinguinal approach for sectioning of the
remaining ligamentous structures. All operations
were performed by the same orthopaedic surgeon.
Pre-operative X-rays were obtained and none of
the specimens had evidence of previous pelvic
trauma. Following surgery, an AP pelvic radiograph
was obtained and the symphyseal diastasis was
measured. A ruler was used to position and standar-
dise the X-ray bucky 40 cm from the pubic symphy-
sis. This was done to ensure no magnification,
thereby, producing radiographs exactly to scale. A
magnification marker was used to confirm the scale
and direct measurements were made from the AP
radiographs. After images were obtained, the pelvis
was stabilised in two manners. First, a standard bed
sheet folded to a width of approximately 8 in. was
wrapped circumferentially around the pelvis and
greater trochanters, the symphysis was reduced,
and the sheet was held in place with a clamp.
The sheet was then removed, the symphyseal dia-
stasis was recreated, and the symphysis was then
reduced using the T-POD according to the instruc-
tions provided by the manufacturer (Fig. 1).
Reduction with each technique was guided by
direct palpation of the symphysis. Each reduction
was evaluated with an AP pelvic radiograph and
The injury created in the cadaveric specimens
39.3 mm with a range of 33—46 mm (95% CI
30.95—47.55). On average, use of the bed sheet
reduced the symphyseal diastasis to 17.4 mm (range
3—38 mm, 95% CI ?0.14 to 34.98), while the T-POD
reduced the symphyseal diastasis to 7.1 mm (range
1—19 mm, 95%CI?2.19to 16.35) (Table1).In 75%of
the cadaveric specimens (9 of 12), the T-POD was
able to reduce the symphysis to normal (<10 mm
904N.A. DeAngelis et al.
Conclusions: Although both a circumferential sheet and the T-POD were able to
decrease symphyseal diastasis consistently, only the T-POD showed a statistically
significant improvement in diastasis when compared to injury measurements. In 75%
of the cadaveric specimens (9 of 12), the T-POD was able to reduce the symphysis to
normal (<10 mm diastasis). Both a circumferential sheet and the T-POD are effective
in provisionally stabilising Burgess and Young anterior—posterior compression II type
pelvic injuries, but the T-POD is more effective in reducing symphyseal diastasis.
# 2007 Elsevier Ltd. All rights reserved.
diastasis). The symphysis was reduced to normal in
17% of the cadaveric specimens (2 of 12) using the
The patient with an unstable pelvic fracture faces
serious risk of death via haemorrhage. As part of the
initial management of these patients, circumferen-
tial pelvic compression is typically applied to pro-
vide both tamponade and stabilisation of the bony
elements.1,6As a result of this manoeuvre, the rate
of haemorrhage from pelvic vessels is reduced, and
the risk of further vascular injury secondary to
mobile bony fragments is diminished. While the
benefits of provisional pelvic stabilisation are well
accepted, a consensus has yet to be agreed upon to
distinguish among non-invasive techniques.
Past researchers have touted anterior pelvic
external fixation as a routine intervention in even
stable patients with pelvic fractures.13
recent protocols now call for non-invasive means
of pelvic stabilisation to reduce the risks to
patients during the initial resuscitative period
and prior to operative stabilisation or angiogra-
phy.3As opposed to external fixation, non-invasive
pelvic stabilisation has been declared a safer,
more time-effective, technically simpler method
of effectively bridging the gap until definitive
A number of techniques of provisional pelvic
stabilisation have been proposed and attempted
with varying levels of acceptance. Pneumatic trou-
sers and other inflatable garments have been asso-
access to the abdomen and lower extremities.14,15
Commercially available bean bags, straps, and bin-
ders have been limited due to their high cost and
need for cleaning or replacement.14,15Because of
their technically difficult application, pelvic C-
clamps have been associated with numerous com-
plications including perforation of the ilium, frac-
ture fragment displacement, dislodgement of pins
into the greater sciatic notch, and haemorrhage
secondarytohaematomarelease, though amodified
technique may reduce the incidence of such com-
plications.2A standard bed sheet wrapped around
the trochanters and held in place with clamps has
been associated with necrosis of the underlying
The T-POD is a commercially available pelvic
circumferential compression device that has been
shown to provide pelvic stability comparable to the
pelvic C-clamp and closely reapproximate the sym-
T-POD for provisional stabilisation of APC905
sis in the setting of injury, treatment with a circumfer-
ential sheet, or T-POD
Average symphyseal displacement of diasta-
?0.14 to 34.98
?2.19 to 16.35
application of a sheet (C), and application of the T-POD (D).
A picture of the T-POD (A), and an example of AP pelvic radiographs after creation of an APC injury (B),
physeal diastasis.4,5Like the bed sheet, it can be
applied more rapidly than external fixators, and
requires no special training for proper place-
ment.4,13While not as readily available as the ubi-
quitous bed sheet, the T-POD is not prohibitively
expensive nor difficult to obtain. In the orthopaedic
trauma literature, no distinction has been drawn
between the two techniques.
Our results show that a commercially available
pelvic binder reduces the symphyseal diastasis in
APC type pelvic fractures more effectively than a
circumferential bed sheet. Since both techniques
are similarly easy to apply, inexpensive, and have
low complication rates, commercially available pel-
vic binders may be a better choice for temporary
pelvic stabilisation in the setting of an appropriate
pelvic fracture pattern.
Our methodology is limited in some respects. In
particular, it is possible that because we applied
the sheet first and the T-POD second in all cases,
the improvement in reduction seen with the T-POD
is because the previous attempt at reduction
facilitated symphyseal closure. In cadaveric speci-
mens, however, there would be no haematoma or
intervening soft tissue, which the first attempt
could displace. The deformity was recreated
and confirmed between attempts; furthermore,
in a static situation such as embalmed cadaveric
be that the force applied by the T-POD is
simply greater than can be applied with simple
Future work should clearly establish an associa-
tion between pelvic stabilisation and favourable
patient outcomes, such as decreased mortality
and transfusion rates. Furthermore, since force only
slightly in excess of that which is necessary to
provide adequate stabilisation of the pelvis may
induce skin breakdown,14close attention should
be paid to potential complications associated with
commercially available binders, such as pressure-
induced necrosis of the skin.
Although both a circumferential sheet and the T-
POD were able to reduce symphyseal diastasis con-
sistently, only the T-POD showed a statistically sig-
nificant improvement in diastasis when compared to
Both a circumferential sheet and the T-POD are
effective in provisionally stabilising Burgess and
Young anterior—posterior compression II type pelvic
injuries; however, the T-POD is more effective in
reducing symphyseal diastasis.
Conflict of interest statement
There are no conflicts of interest in this study and
none of the authors received any financial contri-
The authors would like to thank Allison Brailey, for
her help with the statistics, the technicians in the
Department of Radiology at UMASS, for their help
with the radiographs and Tristan McKenna, for his
help in obtaining the cadavers.
1. American College of Surgeons. ATLS student course manual,
6th ed., Chicago: American College of Surgeons; 1997 . p. 251.
2. Archdeacon MT, Hiratzka J. The trochanteric c-clamp for
provisional pelvic stability. J Orthop Trauma 2006;20(1):
3. Biffl WL, Smith WR, Moore EE, et al. Evolution of a multi-
disciplinary clinical pathway for the management of unstable
pelvic ring fractures with use of circumferential compres-
sion. JBJS Am 2002;84:S43—7.
5. Bottlang M, Simpson T, Sigg J, et al. Noninvasive reduction of
Orthop Trauma 2002;16(6):367—73.
6. ColePA.What’s new in orthopaedic trauma.JBJS Am 2003;85-
7. Dickson KF. The acute management of pelvic ringinjuries. In:
Kellam JF, et al., editors. Orthopedic knowledge update:
trauma 2. Rosemont, IL: AAOS; 2000.
8. Eastridge BJ, Starr A, Minei JP, et al. The importance of
fracture pattern in guiding therapeutic decision-making in
patients with hemorrhagic shock and pelvic ring disruptions.
J Trauma 2002;53(3):446—51.
9. Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for
the management of haemodynamically unstable pelvic frac-
ture patients. ANZ J Surg 2004;74(7):520—9.
10. Kellam JF, Browner BD. Fractures of the pelvic ring.
Browner BD, et al., editors. Skeletal trauma. 2nd ed., Phi-
ladelphia: Saunders; 1998.
compression in the presence of soft-tissue injuries: a case
report. J Orthop Trauma 2005;59(2):468—70.
12. Krieg JC, Mohr M, Ellis TJ, et al. Emergent stabilization
of pelvic ring injuries by controlled circumferential com-
pression: a clinical trial. J Orthop Trauma 2005;59(3):
13. Poka A, Libby EP. Indications and techniques for external
fixation of the pelvis. Clin Orthop 1996;329:54—9.
14. Routt Jr CML, Falicov A, Woodhouse E, Schildhauer TA.
Circumferential pelvic antishock sheeting: a temporary
resuscitation aid. J Orthop Trauma 2002;16(1):45—8.
15. Schaller TM, Sims S, Maxian T. Skin breakdown following
circumferential pelvic antishock sheeting: a case report. J
Orthop Trauma 2005;19(9):661—5.
906N.A. DeAngelis et al.