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.

Full text

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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
www.elsevier.com/locate/injury
KEYWORDS
Pelvic fracture;
T-POD;
Pelvic binder;
Provisional stabilisation
Summary
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: eskanm01@ummhc.org (M.S. Eskander).
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2007.12.008

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Introduction
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
bloodloss.10Inthesettingofaverticalshearinjuryto
the pelvis, patients presenting with hypotension
were significantly more likely to die than those
whowerenormotensive(44%versus17%).7Inpatients
presenting with an unstable pelvic fracture pattern
andhaemorrhagicshock,mortalityover50%hasbeen
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
measurementoftheremainingsymphysealdiastasis.
Results
The injury created in the cadaveric specimens
resultedinameansymphyseal
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
diastasisof
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.

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diastasis). The symphysis was reduced to normal in
17% of the cadaveric specimens (2 of 12) using the
bed sheet.
Discussion
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
More
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
stabilisation.9
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-
ciatedwithcompartmentsyndromeandalsorestrict
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
skin.14,15,11
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
Table 1
sis in the setting of injury, treatment with a circumfer-
ential sheet, or T-POD
Average symphyseal displacement of diasta-
Average
symphyseal
diastasis (mm)
Range
(mm)
95% Confidence
intervals
Injury
Sheet
T-POD
39.3
17.4
7.1
33—46
3—38
1—19
30.95—47.55
?0.14 to 34.98
?2.19 to 16.35
Figure 1
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),

Page 4

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
specimensthe mostlikely
be that the force applied by the T-POD is
simply greater than can be applied with simple
sheeting.
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.
conclusion would
Conclusions
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
injury measurements.
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-
butions.
Acknowledgements
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.
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