Pelvic ring injuries have a high mortality and morbidity rate [11]. Shearing of pelvic vessels, as well as bleeding from fractured bone ends, can result in life-threatening retroperitoneal hemorrhage, adding to morbidity [12]. In cases of suspected pelvic fracture, one time pelvic compression test may be performed to identify laxity and instability, but this should be done with caution because a formed blood clot may dislodge, resulting in further hemorrhage [13]. Shlamovitz et al. discovered that the sensitivity of this test was only 8%, implying that it may be unreliable for detecting instability [14]. As a result, in the early stages of major trauma care, the presence of pelvic disruption should be suspected after considering the mechanism of injury rather than confirmed by physical examination [15].
Because of its efficiency in lowering pelvic volume for the tamponade effect [16], the use of a PCCD has become a standard part of Advanced Trauma Life Support protocol. Bakhshayesh et al. supported the use of the PCCD in the initial care of patients with suspected pelvic bleeding in their systematic review [17]. Despite the fact that Pap et al.’s recent study revealed that the PCCD is not clearly connected to improved clinical outcomes and may cause iatrogenic harm, the clinical advantages appear to exceed the hazards [17, 18].
Regarding the time to apply the PCCD, Vaidya et al. found that most of the PCCD were performed after imaging [19]. The sooner the bleeding is stopped, the better the chances of lowering the mortality rate. Our study discovered that the time to apply a PCCD in the early pelvic sling group compared to the conventional stepwise group was 16.40 and 40.40 min, respectively. Fu et al. demonstrated that employing a PCCD in patients with a pelvic ring injury who were transferred to another institution resulted in considerably lower transfusion requirements, regardless of whether they were hemodynamically stable or unstable prior to transfer [4]. In their retrospective cohort study, Hsu et al. demonstrated that patients receiving pelvic sling before definitive imaging had a significantly lower transfusion requirement [7]. Our findings were comparable in that the need for packed red blood cell transfusions was statistically lower in the early pelvic sling group (0.80 unit) than in the conventional group (2.40 units). However, the Hct change does not differ significantly between groups. According to Ryan et al., the admission Hct linked with hemorrhage in trauma patients requiring emergency surgery, but the Hct change did not [20]. This could be because the Hct change contains various confounders that are difficult to assess, such as IV hydration, blood transfusion, and continuous hemorrhage.
According to Ghaemmaghami et al., early application of PCCD may have limited utility in centers with quick access to angioembolization [6]. They did not, however, specify the number of each type of fracture. Our study attempted to address this issue by categorizing the types of pelvic fractures. Moreover, they also excluded patients with LC1 fractures and those with isolated ileal wing fractures. Although stable pelvic fractures are frequently regarded as minor injuries and are typically treated conservatively, 7–13.9% of patients with stable pelvic fractures require embolization for hemostasis [21, 22]. Takeda et al. reported a patient with stable pelvic ring fractures, hemorrhagic shock, and acute traumatic coagulopathy. The SAM Sling® was used to stop the hemorrhaging, and she was eventually rescued [23]. Early application of PCCD, in our opinion, would benefit the population with these types of fractures in terms of transfusion requirements because the associated hemorrhage from the fracture surface could be reduced with the compression force of the PCCD.
The PCCD can be used in both lateral compression (LC) and anterior posterior compression (APC) pelvic fractures [24], but there may be some debate in the vertical shear (VS) type. Despite the fact that we only had one patient with VS type in the early pelvic sling group, there was no consequence from the PCCD in this patient. Our findings matched those of Hsu et al., who conducted a retrospective investigation on 204 pelvic ring injuries [7]. The PCCD was used in various types of fractures with no complications from over-reduction. However, key drawbacks of the PCCD include the fact that they do not control VS fractures and do not stop arterial bleeding; thus, access to administer embolization is critical.
Although the use of the PCCD has been deemed safe due to its noninvasive nature, clinicians should be aware of the possibility of adverse consequences. Hsu et al. reported three patients who experienced complications because of wearing the pelvic binder for an extended period of time [7]. To reduce the risk of developing pressure sores, skin necrosis and nerve palsy, Knopps et al. suggested removing the pelvic sling once hemodynamic resuscitation was established [25]. The 24-h protocol for the early pelvic sling group in our study not only reduced packed red blood cell transfusion requirements statistically significantly compared to the conventional approach, but also revealed no complications due to soft tissue and skin necrosis. Suzuki et al. [26] and Toth et al. [5] also described major adverse effects from PCCD use, such as bladder rupture or external iliac vein compression. Because all complications were discovered after the PCCD was applied, it was difficult to distinguish between those caused by the original injury and those caused by the PCCD. Nevertheless, doctors should be aware of all of these complications, especially when treating patients with suspected acetabular fractures.
Our paper’s strength is its use of a force-controlled circumferential pelvic sling, which has been scientifically demonstrated to decrease and stabilize pelvic fractures safely and successfully [27]. It has a fastener with an auto-stop buckle that limits circumferential compression when tensional force exceeds 150 N. There are a few potential limitations to our study. It was a single-institution event that may have reflected local patient characteristics. As with most retrospective assessments, unmeasured or unknown confounding variables may be to blame for the effects observed and the conclusions reached. The sample size was small, with only 15 patients in each group. This may result in a failure to capture the full statistical significance of these factors. Finally, despite the fact that patients in both groups had similar demographic data, case allocation heterogeneity between the two arms was possible due to the recruitment method.
