Is a pelvic binder required in patients with an inferior pubic ramus fracture?

Pelvic Binder Use in Inferior Pubic Ramus Fractures

A pelvic binder is not routinely required for isolated inferior pubic ramus fractures unless there is hemodynamic instability or evidence of posterior pelvic ring involvement. 1, 2

Assessment of Pelvic Stability and Fracture Pattern

• Inferior pubic ramus fractures rarely occur in isolation and often indicate additional pelvic ring disruption that may not be apparent on initial radiographs 3
• 68% of patients with displaced inferior pubic ramus fractures have associated posterior ring injuries, with 60% of these being unstable injuries requiring intervention 3
• Patients with concurrent superior ramus fractures have a higher likelihood of posterior ring injury and pelvic instability 3
• Parasymphyseal involvement in unilateral inferior ramus fractures is associated with higher incidence of posterior ring injury and pelvic instability 3

Indications for Pelvic Binder Application

• Pelvic binders are primarily indicated for hemodynamically unstable pelvic fractures to stabilize the pelvic ring and decrease hemorrhage in the early resuscitation phase 1, 2
• The World Journal of Emergency Surgery recommends external pelvic compression as an early strategy only for unstable pelvic fractures with hemodynamic compromise 1
• Most fractures of the pubic rami do not require stabilization by internal or external fixation if the posterior ring is stable 4
• Thorough investigation including CT scan of the pelvis is necessary to exclude acetabular extension or posterior ring involvement before mobilization, especially in patients with hip arthroplasty 5

Proper Technique When Binder Is Indicated

• If a pelvic binder is required, it should be positioned around the great trochanters and symphysis pubis to apply pressure that reduces the pelvic fracture and adducts lower limbs 1, 2
• Commercial pelvic binders are more effective for hemorrhage control than "home-made" ones, though the latter can be used effectively in resource-limited settings 1, 2
• Pelvic binders should be removed as soon as physiologically justifiable and replaced by external pelvic fixation or definitive stabilization when indicated 1, 2
• Early transfer from the spine board is essential when a pelvic binder is in place to significantly reduce the risk of skin pressure lesions 1, 2

Special Considerations

• Pelvic binders should be positioned with extra caution in elderly patients due to bone fragility 2
• In pregnant women, pelvic binders require cautious positioning 1, 2
• Continuous application of pressure above 9.3 kPa for more than 2-3 hours can lead to skin necrosis and pressure ulcerations 2
• Pelvic binders should not be kept in place for more than 24-48 hours to avoid complications 2

Diagnostic Algorithm for Inferior Pubic Ramus Fractures

1. Initial assessment with AP pelvic radiograph to identify inferior pubic ramus fracture 3
2. CT scan of the pelvis to evaluate for posterior ring involvement, which is present in nearly 97% of cases with pubic rami fractures 6
3. If posterior ring injury is identified or patient is hemodynamically unstable, consider pelvic binder application 1
4. If isolated inferior pubic ramus fracture with no posterior involvement and patient is hemodynamically stable, pelvic binder is not required 1, 4

Management Approach

• Early mobilization is advocated for stable inferior pubic ramus fractures without posterior involvement 5
• For unstable fractures or those with posterior involvement, appropriate stabilization (including possible pelvic binder use) should be considered before mobilization 1, 3
• In patients with prolonged pain following pubic rami fractures, further diagnostic work-up is warranted as they likely represent an undiagnosed pelvic ring injury 6
• Internal fixation of the anterior pelvic ring should be reserved for symphysis pubis dislocations and only a minority of pubic ramus fractures 4