Pressure characteristics of pelvic binders

Pressure characteristics of pelvic binders

Injury, Int. J. Care Injured (2007) 38, 118—121 www.elsevier.com/locate/injury Pressure characteristics of pelvic binders A.J.L. Jowett a,*, G.W. Bo...

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Injury, Int. J. Care Injured (2007) 38, 118—121

www.elsevier.com/locate/injury

Pressure characteristics of pelvic binders A.J.L. Jowett a,*, G.W. Bowyer b a

Department of Trauma and Orthopaedics, Poole Hospital NHS Trust, Longfleet Road, Poole, Dorset BH15 2JB, United Kingdom b Department of Trauma and Orthopaedics, Southampton General Hospital, United Kingdom Accepted 15 March 2006

KEYWORDS Pelvic binder; Pressure sores; Pelvic fractures; Haemorrhage

Summary We present a study of the pressures developed at the bony prominences (greater trochanter, iliac crest and sacrum) when a pelvic binder was applied to 10 healthy individuals. The pressures developed between the pelvic binder and the skin over the prominences were all greater than the pressure recommended at interfaces to avoid the development of pressure sores. This suggests that patients with pelvic fractures who are treated with temporary pelvic binders are at risk of developing pressure sores. This should be recognised and the skin inspected if the binder is to be in place for a prolonged period. # 2006 Elsevier Ltd. All rights reserved.

Introduction Pelvic binders are being increasingly used in the initial stabilisation of pelvic fractures. They can be quickly and easily applied in the accident and emergency department. They allow assessment of the patient for other injuries, while providing temporary effective stabilisation for the potentially life-threatening pelvic injury.1 A more permanent fixation of the pelvis can be achieved in a controlled fashion in due course (external or internal fixation). Prolonged high pressure at interfaces between skin and an overlying material can lead to pressure sores. The development of pressure sores requires high pressure at an interface for a long period. This * Corresponding author. Tel.: +44 1202 665511; fax: +44 1202 740696. E-mail address: [email protected] (A.J.L. Jowett).

is most commonly seen in the elderly, resulting in pressure sores over the sacrum and heels, but there is also potential for their development over bony prominences when a pelvic binder is in place. No data are available on the prevalence or incidence of pressure sores after pelvic binder application. Neither are there any data available for the pressures developed at the skin/pelvic binder interface. The aim of this study was to quantify the pressures and pressure distribution when a pelvic binder is applied, and to see if this is affected by the patient’s body habitus (Table 1).

Methods In all, 10 healthy individuals, of varying body habitus, were recruited from the orthopaedic workforce

0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.03.018

Pressure characteristics of pelvic binders

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Table 1 Pressures obtained over bony prominences in the 10 participants, with BMI tabulated for reference Participant

BMI

Trochanter pressure (kPa)

Sacrum pressure (kPa)

Iliac crest pressure (kPa)

A B C D E F G H I J

22.5 25 25 25 27 27 27 30 32 32

33 15 24 17 5 26 16 13 12 9

25

14 10 19 10 6 17 8 12 10

17 10 14 11 9 8

at our hospital. They were dressed in theatre clothing, and an ultra-thin (0.007 in./0.15 mm) flexible pressure-sensitive sensor, as used in shoe pressure measurement (Tekscan, Boston, MA), was applied over the skin covering the bony prominences (anterior superior iliac spine, greater trochanter and sacrum). The standard pelvic binder as used in our hospital (Pelvic Binders Inc., Dallas, TX) was then applied and tightened following the manufacturers’ instructions (Figs. 1—3). The pressure sensor consisted of 960 sensing locations distributed uniformly. Once the binder had been applied and allowed to stabilise for 10 min, the pressures generated in the affected area were recorded. The pressures achieved were found to be reproducible on repeat application. No

attempt was made to examine the pressure/time profile of the device.

Figure 1 tion.

Figure 2 Sensor held in position in preparation for binder application.

Bony anatomy in relation to binder applica-

Results The body mass index (BMI) of the subjects ranged from 22.5 to 32.0. The pressure over the trochanter ranged from 5.0 to 33.0 kPa (mean 17.0), over the sacrum from 8.0 to 25.0 kPa (mean 13.4) and over

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A.J.L. Jowett, G.W. Bowyer

Figure 5

Figure 3 Binder applied to subject with sensors over iliac crests.

the iliac crest from 8.0 to 17.0 kPa (mean 11.1). The pressures obtained appeared to demonstrate an inverse correlation with BMI, as shown in Figs. 4—6.

Discussion Pressure sores arise from peripheral circulatory failure which leads to tissue hypoxia and necrosis.2 Risk factors for their development are both local (pressure, shearing force, capillary occlusion, increased temperature and moisture) and systemic (aging, decreased mobility, poor nutrition, arterial disease and hypotension).6 It is recommended that the pressure at the interface is kept below 4.66 kPa,3 i.e. below capillary blood pressure, allowing circulation to the skin to be maintained. Tissue damage is thought to occur when pressures of more then 9.3 kPa are sustained for more than 2—3 h.4 Local and systemic aetiological factors for pressure sores are present in a pelvic injury. The pressure at the interface is controlled by the tightening

Figure 4

BMI vs. trochanter pressures.

BMI vs. sacral pressures.

of the pelvic binder. Large shearing forces are potentially developed at the time of applying the binder, and hypotension and decreased mobility may follow pelvic injury. The control of the pressure at the interface is therefore important if pressure sores are to be avoided. The tightening of the pelvic binder is not directly measured, and there are no specific directions in the instructions. We contacted the company directly, who replied that the Parkland Memorial Hospital (Parkland, TX) trauma surgeons who developed the binder recommend that it should be possible to fit two fingers between the patient and the appropriately tightened binder. This advice was followed in all cases in our study. The data obtained from our study indicate that in all cases the pressure interface was greater than the limit recommended to prevent pressure sores. This was particularly so in the thinner patient. Whilst we appreciate that our study involved healthy individuals without pelvic fractures, it would be reasonable to assume that similar pressures might be obtained in patients with such injuries. We also are aware that the pressures generated may alter with time, but this change seems unlikely to take the pressures below the critical levels quoted.

Figure 6

BMI vs. Iliac crest pressures.

Pressure characteristics of pelvic binders These limitations should be considered in conjunction with other potential risks associated with pelvic binders, such as nerve injury.5

Conclusion Whilst we recognise that it is likely that a pelvic binder is not going to be in place for a long period, we would recommend that the applying team takes heed of these pressure figures, does not overtighten the binder, does not keep it in place longer than absolutely necessary and checks the pressure areas if extended use is planned.

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References 1. Biffl WL, Smith WR, Moore EE, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg 2001;233:843—50. 2. Bliss M, Simmi B. When are the seeds of postoperative pressure sores sown? BMJ 1999;319:863—4. 3. Vohra R, McCollum C. Fortnightly review: pressure sores. BMJ 1994;309:853—7. 4. Hedrick-Thompson JK. A review of pressure reduction device studies. J Vasc Nurs 1992;X:3—5. 5. Kosiak M. Etiology of decubitus ulcers. Arch Phys Med Rehab 1961;42:19—29. 6. Shank JR, Morgan SJ, Smith WR, et al. Bilateral peroneal nerve palsy following emergent stabilization of a pelvic ring injury. J Orthop Trauma 2003;17:67—70.