What is the recommended positioning for a patient with a pelvic fracture?

Positioning for Pelvic Fractures

For patients with pelvic fractures, the recommended positioning includes application of a pelvic binder around the greater trochanters and symphysis pubis, with adduction of the lower limbs to reduce pelvic volume and control hemorrhage. 1

Initial Positioning and Stabilization

• Commercial pelvic binders should be positioned around the great trochanters and symphysis pubis to apply pressure that reduces the pelvic fracture and adducts the lower limbs, decreasing pelvic internal volume 1
• If commercial binders are unavailable, "home-made" binders (such as bed sheets) can be effectively used in resource-limited settings, though commercial binders are more effective for hemorrhage control 1
• Pelvic binders should be applied as an early strategy to stabilize the pelvic ring and decrease hemorrhage in the resuscitation phase 1
• When using a pelvic binder, early transfer from the spine board is essential to significantly reduce the risk of skin pressure lesions 1

Timing and Duration Considerations

• Pelvic binders should not be kept in place for more than 24-48 hours to avoid complications 1
• Continuous application of pressure above 9.3 kPa for more than 2-3 hours can lead to skin necrosis and pressure ulcerations 1
• Pelvic binders should be removed as soon as physiologically justifiable and replaced by external pelvic fixation or definitive pelvic stabilization when indicated 1

Special Patient Populations

• In elderly patients, pelvic binders should be positioned with extra caution due to bone fragility 1
• For pregnant women, the pelvis can be stabilized with internal rotation of the legs and cautious pelvic binder positioning 1
• In patients with lateral compression fracture patterns (common in elderly), angiography may have more hemostatic effect than pelvic binding alone 1

Progression to Definitive Management

• Pelvic binders serve as a bridge to definitive mechanical stabilization in hemodynamically stable patients with mechanical instability 1
• For unstable pelvic ring injuries (APC-II, LC-II, APC-III, LC-III, VS, CM patterns), progression to definitive internal fixation is indicated after initial stabilization 1
• In cases of severe hemodynamic instability where transfer to CT scan or angioembolization cannot be performed within 60 minutes, pre-peritoneal pelvic packing may be considered as a complementary method for temporary hemostasis 1

Positioning for Specific Procedures

• For retrograde urethrogram in patients with suspected urethral injuries, position the patient obliquely with the bottom leg flexed at the knee and the top leg kept straight 1
• If severe pelvic fractures are present, leave the patient supine and place the penis on stretch to acquire the image 1
• For patients requiring external fixation, the fixator must be placed anteriorly and inferiorly to allow for potential laparotomy 1

Complications to Avoid

• Avoid repeated attempts at urethral catheter placement in patients with pelvic fracture associated urethral injury to prevent increasing injury extent 1
• Avoid over-tightening of pelvic binders as this can lead to skin necrosis and pressure ulcerations 1
• Monitor for potential soft tissue complications from prolonged compression with pelvic binders 1
• Ensure early transfer from spine boards when pelvic binders are in place to reduce pressure-related complications 1