Chapter 11 Pelvis and Lower Extremity Reduction

Pelvis reduction

Overview

1. Application of a pelvic binder is a key step in the initial management of an unstable pelvic fracture.

2. Commercial pelvic binders are available, or a simple bed sheet may be used as a pelvic binder.

3. Venous bleeding is the most common cause of hemorrhage in a patient with hemodynamic instability and an unstable pelvic fracture.

4. By applying a binder, stability is provided to the fracture, allowing tamponade and organization of the hematoma.

Indications for Use

Unstable “open book” pelvic injury (Tile B injury or anterior-posterior compression [APC] II or III injuries)

1. Note that placement of a pelvic binder is not contraindicated in a patient with a lateral compression–type injury.

2. The benefit of using a pelvic binder for a lateral compression–type injury is not likely to be as great as for an open book pelvic injury.

Precautions

1. Close coordination with the trauma team and trauma anesthesiologist is mandatory.

2. Perform a careful physical examination before applying a binder. Determine if the fracture is open or closed.

3. Correct placement of a pelvic binder is vital for it to function properly.

a. The binder should be centered around the greater trochanters.

b. The binder should not be centered at the patient’s waist.

Pearls

1. Although commercial binders are easier to apply than a bed sheet, not all emergency departments are equipped with commercial binders, so it is important to know how to use both a commercial binder and a bed sheet.

2. Place a towel over the perineal area to protect the structures therein.

3. After a commercial binder or a bed sheet is placed, postreduction radiographs are mandatory.

4. If the sheet will be used for more than emergent stabilization, use two to four towel clips rather than tying the sheet to prevent loosening and pressure necrosis.

Equipment

1. Two people are required to reduce the pelvis and apply a binder appropriately (not shown).

2. Commercial pelvic binder (Figure 11-1) or a bed sheet

3. Towel clamps, Kelly forceps, or other large clamps

Figure 11-1

Basic Technique

1. Patient positioning:

a. Supine on stretcher

2. Landmarks:

a. Greater trochanters

b. Anterior superior iliac spines (ASIS)

3. Steps:

a. Position the patient.

b. Palpate landmarks.

c. Roll the patient.

d. Reduce the pelvis.

e. Place the commercial binder or bed sheet.

Detailed Technique

1. Position the patient.

2. Palpate landmarks; feel both greater trochanters and ASIS (Figure 11-2).

3. Roll the patient. A standard trauma log-roll technique should be used to place the commercial binder or bed sheet under the patient (Figure 11-3), with additional people at the legs and the head.

4. If a bed sheet is being used, place it as widely as possible over the greater trochanter and ASIS.

a. Reduce the pelvis by applying an inward force.

b. Use towel clips if available, If not, tie a very tight knot around the pelvis and add a second square knot (Figure 11-4).

5. Procedure for placing a commercial binder:

a. Wrap the binder around the patient (Figure 11-5).

b. Ensure correct placement. The binder must be centered on the greater trochanters.

c. Trim any excess (Figure 11-6).

d. Reduce the pelvis by applying an inward force.

e. Pull the cords to tighten the binder (Figure 11-7).

Figure 11-2

Figure 11-3

Figure 11-4

Figure 11-5

Figure 11-6

Figure 11-7

Hip reduction

Overview

1. Numerous maneuvers have been described for reduction of dislocated hips.

2. All maneuvers basically function to recreate the deforming force.

a. Posterior dislocations (Figure 11-8): flexion, adduction, and internal rotation

b. Anterior dislocations: abduction and external rotation in extension

3. The incidence of dislocated hips is much higher in patients with hip arthroplasty compared with patients who do not have hip arthroplasty.

4. The vast majority of hip dislocations are directed posteriorly.

5. Relocation of hips can be difficult because of the significant muscular and ligamentous impediments inherent to the joint.

6. In patients with traumatic dislocations, relocation is easier because of the associated posterior wall acetabular fracture.

Figure 11-8

Indications for Use

Posterior hip dislocation using the modified Bigelow technique

Precautions

An assistant is required for the modified Bigelow to apply countertraction.

Pearls

Conscious sedation is virtually mandatory in most patients. The typical exception to this rule is a patient with a total hip arthroplasty whose hip becomes dislocated on a chronic basis.

Equipment

Bed sheet

Basic Technique

1. Patient positioning:

a. Supine on stretcher

2. Landmarks:

a. Anterior superior iliac spine

b. Greater trochanters

3. Steps:

a. Obtain conscious sedation.

b. Position the patient.

c. Perform a reduction maneuver.

d. Apply an abduction pillow.

Detailed Technique

1. Obtain conscious sedation.

2. Position the patient. The patient should be completely supine.

3. Tie a bed sheet loosely around your waist (Figure 11-9).

4. Perform a reduction maneuver:

a. The surgeon mounts the stretcher and straddles the affected extremity between his or her legs (Figure 11-10).

b. The patient’s knee is flexed to 90 degrees, and the hip is also flexed to 90 degrees.

c. The surgeon’s arms are locked together under the knee.

d. An assistant applies countertraction via the ASIS (Figure 11-11).

e. The surgeon applies an upwardly directed force.

f. The hip is then adducted.

g. The hip is then internally rotated (Figure 11-12).

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