Why the Pelvic Binder Sits at the Trochanters
Hemorrhage from an unstable pelvic ring fracture can kill within hours, and a binder placed at the right level closes the bleeding pelvis while the patient waits for the OR or angiography.
Key terminology
- Pubic symphysis
- This cartilage joint links the 2 pubic bones at the front of the pelvis. A widened gap here on the AP film marks an anterior ring injury.
- Sacroiliac (SI) joint
- This joint links the sacrum to the ilium on each side at the back of the pelvis. It anchors the posterior ring, which holds most of the stability.
- Open-book injury
- This anteroposterior compression injury springs the pubic symphysis apart and opens the pelvis like a book. It enlarges pelvic volume and can bleed heavily.
- Pelvic binder
- This wide belt wraps the hips and squeezes the pelvic ring closed. It shrinks pelvic volume to slow bleeding until definitive care.
- Greater trochanter
- This bony knob sits at the outer top of the femur, just below the hip joint. It is the landmark for binder placement and can be felt on the side of the hip.
- Retrograde urethrogram
- This X-ray study fills the urethra with contrast from the tip of the penis. It shows a urethral tear before anyone passes a catheter.
- Preperitoneal pelvic packing
- This surgery packs gauze into the space beside the bladder, outside the peritoneum, through a low incision. It tamponades venous bleeding that embolization cannot reach.
Takeaways
- The pelvis is a ring, so one break usually comes with a second injury. The anterior ring is the pubic symphysis and the pubic rami. The posterior ring is the sacrum and both sacroiliac (SI) joints, and it holds most of the weight-bearing stability. SI joint disruption and symphysis diastasis both predict major pelvic bleeding, so check both on every AP pelvis (Coccolini et al, World J Emerg Surg 2017;12:5, PMID 28115984).
- Most pelvic fracture bleeding is venous and comes from the fracture surfaces. In unstable pelvic ring disruptions, 80-90% of hemorrhage arises from the presacral and paravesical venous plexus and from raw bone surfaces at sacral, iliac and SI joint injuries. Only 10-20% is arterial, and arterial bleeding almost always comes with venous bleeding too (Coccolini et al, World J Emerg Surg 2017;12:5, PMID 28115984).
- An open-book injury enlarges the pelvis and lets blood pool without tamponade. Anteroposterior compression (APC) springs the symphysis apart, so pelvic volume rises and the retroperitoneum can hold a few liters of blood. In Burgess's series, APC injuries averaged 14.8 units of blood vs 3.6 units for lateral compression, with mortality of 20% vs 7% (Burgess et al, J Trauma 1990;30:848-856, PMID 2381002; Coccolini et al, World J Emerg Surg 2017;12:5, PMID 28115984).
- Center the pelvic binder over the greater trochanters. Of 167 binder radiographs, only 50% sat at the trochanters and 39% sat too high (the most common error). In open-book injuries the symphysis gap was 2.8 times wider with a high binder (mean 22 mm more). A cadaver study found less pelvic motion at the trochanters than at the ASIS (Bonner et al, J Bone Joint Surg Br 2011;93:1524-1528, PMID 22058306; Prasarn et al, J Orthop Trauma 2013;27:262-266, PMID 22810548).
- Blood at the meatus after a pelvic fracture calls for a retrograde urethrogram before any Foley. Posterior urethral injury occurs in 1.5-10% of pelvic fractures. Blood at the meatus is the most common sign, along with inability to void, perineal bruising and a high-riding prostate. AUA advises against blind catheter passage before the urethrogram (Morey et al, J Urol 2014;192:327-335, PMID 24857651).
- Posterior ring injuries tear the superior gluteal artery, and anterior injuries tear the pudendal or obturator. All 3 are internal iliac branches. In 1 angiography series the pudendal artery was injured most often overall, and the superior gluteal artery led in posterior fractures (O'Neill et al, Clin Orthop Relat Res 1996;329:60-67, PMID 8769437; Coccolini et al, World J Emerg Surg 2017;12:5, PMID 28115984).
- A binder cuts transfusion needs and has no proven mortality benefit. In 186 exsanguinating pelvic fractures, a binder in place of emergent external fixation cut 24-hour transfusion from 17.1 to 4.9 units, and mortality was 26% vs 37% (not significant). WSES advises removal as soon as physiology allows, ideally within 24-48 h, to avoid pressure sores (Croce et al, J Am Coll Surg 2007;204:935-939, PMID 17481514; Coccolini et al, World J Emerg Surg 2017;12:5, PMID 28115984).
- Guidelines differ on how hard to lean on packing vs angioembolization in the unstable pelvis. WSES rates preperitoneal pelvic packing as effective early bleeding control (Grade 1B) and pairs it with angiography. It cites mortality above 40% with angioembolization-only care, since embolization does not treat venous bleeding. EAST 2011 left packing for further study (Coccolini et al, World J Emerg Surg 2017;12:5, PMID 28115984; Cullinane et al, J Trauma 2011;71:1850-1868, PMID 22182895).