This is the second in series of short, case-based learning posts for trauma team leaders (TTL). These tips, based on our real-world experience with injured patients, will help you get the best out of your team when it matters most.
An eighty-two year old man has just arrived in Resus. He was brought to hospital by ambulance after falling down some stairs. It is his birthday today, and he has been celebrating over a few pints at the Virchester Arms.
As the patient is transferred onto the trolley, the paramedics inform you that he is currently hypotensive, and has become increasingly confused over the last few minutes.
You see that a pelvic binder has been applied. One of your nursing colleagues is frowning, however, and you wonder if the binder been placed correctly…
Does this patient really need a pelvic binder?
Yes! Pelvic binders should be used on all patients with a suspected unstable pelvis. Often, they will be placed before the patient gets to hospital… but “often” is not always, so you need to know how they work.
Here are a few tips to help you get the best outcomes in pelvic trauma. If you would rather read these on a PDF and if you want to share that PDF with colleagues, then click here.
Get a binder on the bed
If you receive a standby for blunt trauma, and you are unsure whether a binder has been applied, get one ready.
Lie the open binder across the bed before the ambulance arrives. Then when you move the patient off the trolley, the binder will be underneath them and ready to fasten.
Also, get a bandage out that you canuse to tie the feet together. If a binder is working the toes should be pointing to the celing. A bandage tied in a figure of 8 can facilitate this. I pack a bandage in the same place as a carry my pelvic binder when working prehospitally for exactly this reason.
Check the binder is on right
Pelvic binders need to be at the level of the greater trochanters — not the iliac bones. Make sure the binder has not been placed too high. We think that the world would have been a much better place if Pelvic binders were called ‘Hip Binders’ as that would give people a much better clue as to where to put them. You should be able to feel the trochanters and ensure the ‘pull’ of the binder is over the trochanters. An alternative method is to put the patient’s arms by their side. You will usually find that the wrist crease is at the level of the trochanters – try this for yourself.
Once you are sure the binder is in the right position, check it is on tightly. Different binders have different mechanisms, so make sure you know how to do this. The type we used to use at St Emlyn’s “clicks” when it is tight enough, now we have one that fixes with velcro and it’s more subjective, but what it is is ‘tight’.
Be careful when you take the binder off
When you take the binder off, make sure you request a plain X-ray to be taken soon after release. This should be done in ED, before your patient goes to the ward. This is to ensure that you don’t miss an unstable open book pattern. If the pubic symphysis is disrupted the binder may be holding everything nicely in position and your CT may look normal, but when you release it the pelvis may open up. This is also the case when you have identified a pelvic fracture on CT but decide it’s stable and the binder can come off. It can, but always check with a post binder removal X-ray. It is technically possible to do measure the pubic symphysis distance with ultrasound before and after binder removal, but we do not recommend this as a definitive test.
The trauma CT will (usually) rule out bony injury, but until the binder is off, you have not ruled out an unstable pelvic ligament injury. Check that pubic symphysis, for example: it should be 6mm or less.
Download the PDF version here.
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Greg Yates and Simon Carley
Further reading
- https://www.rcemlearning.co.uk/modules/pelvic-injuries/lessons/management-for-pelvic-trauma/topic/use-of-pelvic-binder/
