Binder use obscures traumatic pelvic injury in a 29-year-old man

We would like to thank the authors for their case presentation and images to highlight the importance of x-rays in the diagnosis of traumatic pelvic fractures (Seah & MacKay, 2021). It also provides an opportunity to highlight key principles of blunt trauma patient management.

As per the 10th edition Advanced Trauma Life Support (ATLS®) guidelines, any blunt trauma patient with hemodynamic instability, pelvic instability, or pelvic pain should undergo pelvic x-ray. This is consistent with many Canadian pre-hospital guidelines for binder application by Emergency Health Services. A pelvic binder is a core component of our University of Alberta protocol for shock and pelvis fractures (Menon et al, 2017). Thus, blunt trauma patients presenting to emergency departments in Canada with a pelvic binder in situ have an indication for a pelvic x-ray. This is also consistent with pelvic trauma guidelines from the Western Trauma Association (Tran et al, 2016), and the World Society of Emergency Surgery (Cocclioni et al, 2017).

The patient in the case presented was hemodynamically unstable, but there was no mention of a pelvic x-ray prior to CT scan. While the authors are using this case to highlight the potential to miss a ligamentous injury with a binder in situ, this example is still the vast minority of pelvic fracture cases (Clements et al, 2015). Thus, it is also a good case to highlight two key concepts:
1. a pelvic binder is a powerful resuscitative tool with a rotationally unstable pelvis, and
2. the importance of a pelvic x-ray as an adjunct to the primary survey.

Obtaining a pelvic x-ray prior to a planned CT scan can provide the trauma care provider(s) with important, timely, and actionable information if a pelvic fracture is identified (even with the binder in situ). Given the high morbidity (40-50%) and mortality (5-30%) of pelvic fractures in trauma patients, an x-ray confirmed pelvic fracture necessitates large bore intravenous access, availability of blood products, and appropriate personnel prior to transfer out of the trauma bay, including to CT scan; it also provides an opportunity for earlier orthopaedic consultation.

The authors appropriately note that trauma centres should have protocols for pelvic binder removal. They also note their patient was hemodynamically stable when the binder was removed. These are key reminders when planning for the post binder-removal x-ray.