The Pelvic Sling
Pelvic injuries can be life threatening, especially in a remote environment where we are far from help. To safely manage a casualty with a pelvic injury requires particular understanding of the cause, recognition and treatment.
This article also looks at how we can stabilise a pelvis with minimal equipment.
Your pelvis is a large, stable and strong ring-like structure. Each illium is joined to either side of the sacrum - the base of the spineThe 'ring' is completed at the front by a cartilage bridge called the symphisis pubis. This flexible joint is necessary for the pelvis to flex and expand during childbirth. Because all eggs carry the female X chromosome all foetuses start off as females which is why men also have a symphisis pubis. And nipples, but that's irrelevant.
To complicate the situation, a fractured pelvis can become unstable and will require support to stabilise it, especially if the casualty is to be moved. This is essential as the femoral arteries run across the front of the pelvis. Movement of broken bone ends can cause catastrophic internal bleeding. Femoral arteries shown in orange.
Mechanism of Injury
To break a pelvis requires a significant force; typically impact. If we think about the type of incidents which can create such forces we think of:
- Falls from Height
- Anything involving a vehicle - driver, occupant, pedestrian, cyclist etc.
- High speed sports impact - skiing, snowboaridng or mountain biking etc.
exactly the same as those for a spinal injury.
Anything under tension of compression will break at the weakest points; in the pelvis these likely weak points are:
- The joint between the illium and the sacrum - the sacroilliac joint
- Where the pelvis is thinnest, such as the ramus - the thin bridges at the front of the pelvis.
- The symphisis pubis
- The acetabulum - the socket the hip sits in
Any damage to these parts can cause instability, as such we do not move the pelvis
Moving the pelvis can cause further damage, trap nerves or blood vessels or even collapse the pelvic ring.
So how do we assess a casualty for a pelvic injury if we cannot move it?
We are not going to physically assess for a pelvic injury in the field, we are going to assume: As the incidents which could reasonably cause a pelvic injury are the same as those that could have caused a spinal injury, we ask ourselves:
- Fall from height or vehicular impact? Assume it is broken.
- Not a fall from height or impact? Assume it is fine.
Do not press, rock or flex the pelvis!
If you are treating a casualty for a spinal injury, treat them for pelvic injury as well.
Conventional treatment requires a purpose made 'pelvic sling'. There are several brands such as the Sam Pelvic Sling.
Whilst all commercially available pelvic slings are effective and in many ways superior to anything improvised, they are expensive and bulky. Given that they are only to be removed by a clinician once the casualty reaches the hospital, it is unlikely you will ever see your sling again.
We are going to improvise and to do so you will need:
- A foil 'space blanket'
- A triangular bandage or alternative
- An assistant, ideally.
- Using a triangular bandage or alternative (tape, cord, belt etc) tie the casualty's ankles together; this is most comfortably and stably achieved applying a 'figure of eight' around the back of the casualty's ankles, across their shoe laces and tied off underneath their feet.
- Tying the ankles together bring in the feet which prevents outwards rotational forces on the pelvis.
- Completely unfold a space blanket and while grasping the top edge with hands wide apart, gather up the entire blanket into pleats into your hands.
- Pass the gathered space blanket under the natural hollows behind the casualty's knees to minimise movement. Pull the blanket through until it is central.
- Have an assistant stand astride of the casualty, above their waist and lift the casualty's bottom off the ground (only an inch or so) by grabbing them by their belt or waist band. if they are wearing tracksuit trousers or something stretchy without a stable belt, have them reach under their bottom and lift them up by pulling the seat of their trousers taut.
- Quickly, slide the blanket under their bottom and unfurl the pleats so that the blanket is spread out from their waist down to the crease between their buttocks and the top of their thighs.
- Gently lower the casualty only the blanket.
- Bring either side of the blanket around the casualty's hips, bring the ends together and start twisting to 'wind in' the blanket. This will bring the hips in and stabilise the pelvis without applying direct pressure to the pelvis itself.
- Twist the ends until it feels snug; it must be tight enough to feel as though it is doing something but not so tight that you are 'crushing' the pelvis. Remember, you want to stabilise, not compress!
Combined with the ankles tied together, you have effectively stabilised you spinal / pelvic casualty ready for transport.
Related articles: Spinal injury in remote environments