Pelvic Radiography in Evaluating Blunt Trauma Patients
Pelvic Radiography in Evaluating Blunt Trauma Patients
Pelvic fractures are accompanied by high morbidity and mortality which can be up to 60%. This is because pelvic fractures are mostly the result of severe motor vehicle accidents and, thus, are accompanied by multiple trauma of head, limbs and other parts. In addition, these fractures are associated with massive internal bleeding leading to haemodynamic instability and haemorrhagic shock if remaining undetected. Thus, early diagnosis of pelvic fractures is important for preventing consequences. In this regard, the ATLS recommends performing routine pelvic radiographies in all major blunt trauma patients. This approach has been questioned by many studies believing that pelvic fractures can easily be ruled out by pelvic physical examination in alert haemodynamically stable blunt trauma patients. On the other hand, it was shown that the sensitivity of pelvic radiography is about 50%–60% in recognising significant pelvic fractures. In this study, we observed that pelvic physical examination in haemodynamically stable, high-energy, blunt trauma patients would rule out the pelvic fracture. Thus, eliminating the routine pelvic radiography in trauma practice would not change the therapeutic approach and will save healthcare resources. This is consistent with previous studies questioning the role of routine pelvic radiography in initial evaluation of all blunt trauma patients. A single shot of pelvic radiography exposes the patient to low doses of ionising radiation. However, we should take into consideration the point that high-energy blunt trauma patients should undergo several other radiographies including chest and cross-table cervical spine radiographies, and probably further CT imaging. Thus, eliminating each of these radiographies would be beneficial both for the patients and the healthcare system.
Duane et al included 1961 blunt trauma patients who were divided into protocol (n=520) and non-protocol (n=1441) groups. The pelvic radiographies were performed if there was a positive pelvic physical examination and if the GCS was less than 13 in the protocol group. However, all the patients in the non-protocol group underwent a pelvic radiography. Pelvic physical examination detected all the pelvic fractures in the protocol group and decreased the hospital charges significantly. In another study by Gonzalez et al, it was shown that pelvic physical examination had a sensitivity of 93% (with seven missed cases) in detecting pelvic fractures, while pelvic radiography had a sensitivity of 87% with 13 missed injuries. All these studies, including ours, have used the same criteria for pelvic physical examination, including pelvic pain, pelvic girdle tenderness (including symphysis pubic, inner and outer pelvic wings and pelvic promontories), pelvic deformities (rotation and flexion deformities), limb inequalities and signs of bleeding (in rectal examination). This clinical protocol can be easily used in trauma emergency rooms for detecting pelvic fractures in alert haemodynamically stable blunt trauma patients.
All these studies and protocols are applicable to adult trauma patients. The clinical indicators of pelvic fractures in paediatric blunt trauma patients are a bit different. It was shown by Romirez et al that the following clinical indicators would be beneficial in recognising pelvic fractures in awake, alert haemodynamically stable, paediatric, blunt trauma patients: presence of hip or pelvic pain, pelvic contusions or abrasions, abdominal pain or distension and/or femur deformity/pain. They showed that these four indicators have a negative predictive value of 87%.
One other issue that has hastened the diminishing of routine pelvic radiography in trauma practice is the increasing use of CT imaging in trauma practice. Now, many studies recommend using CT imaging in all blunt trauma patients especially in those suffering from multiple trauma or severe injuries. It is shown that multidetector CT scanners have a sensitivity and specificity of 100% in detecting pelvic fractures. CT imaging was even introduced as the modality of choice in multiple blunt trauma patients. CT imaging has some advantages and some disadvantages just like any other modality. It is quick, efficient and available in many trauma centres. The most important disadvantage of CT imaging is exposure to high doses of radiation leading to future side effects. It is also more expensive and is not accessible everywhere especially in developing countries like ours. In this study, only three (0.77%) patients needed CT imaging and only one (0.25%) had pelvic fracture. Thus, CT imaging did not add anything to our findings. Consequently, the role of CT imaging in awake, haemodynamically stable, blunt trauma patients should also be questioned.
We note some limitations to our study. First, our study period (5 months) was limited; however, because of the high rate of trauma in our region, 1679 patients referred to our centre out of which 389 fulfilled the inclusion criteria. Larger studies are now being undertaken in our centre to elucidate the role of routine radiographies in initial evaluation of trauma patients. Second, the study may be underpowered due to the low incidence of positive pelvic radiography (0.25%) in haemodynamically stable blunt trauma patients which may lead to type II error; however, this is consistent with our hypothesis, questioning the role of cervical spine radiography in initial evaluation of trauma patients. The third limitation was the variability in the examiners and decision makers. During the study period, five junior and three senior residents attended the trauma centre, besides an attending trauma surgeon, on their rotation of duty. Thus, interobserver variability was inevitable.
In conclusion, pelvic radiography could be eliminated from the primary survey protocol of the patients with high-energy blunt trauma who are haemodynamically stable and have negative pelvic physical examination (deformity of the bony prominences, tenderness while gently compressing the iliac wings and pubic symphysis, bilateral inversion and eversion of anterior superior iliac spine and hip flexion/rotation). This approach will save healthcare resources and prevent patients from receiving unnecessary radiation.
Discussion
Pelvic fractures are accompanied by high morbidity and mortality which can be up to 60%. This is because pelvic fractures are mostly the result of severe motor vehicle accidents and, thus, are accompanied by multiple trauma of head, limbs and other parts. In addition, these fractures are associated with massive internal bleeding leading to haemodynamic instability and haemorrhagic shock if remaining undetected. Thus, early diagnosis of pelvic fractures is important for preventing consequences. In this regard, the ATLS recommends performing routine pelvic radiographies in all major blunt trauma patients. This approach has been questioned by many studies believing that pelvic fractures can easily be ruled out by pelvic physical examination in alert haemodynamically stable blunt trauma patients. On the other hand, it was shown that the sensitivity of pelvic radiography is about 50%–60% in recognising significant pelvic fractures. In this study, we observed that pelvic physical examination in haemodynamically stable, high-energy, blunt trauma patients would rule out the pelvic fracture. Thus, eliminating the routine pelvic radiography in trauma practice would not change the therapeutic approach and will save healthcare resources. This is consistent with previous studies questioning the role of routine pelvic radiography in initial evaluation of all blunt trauma patients. A single shot of pelvic radiography exposes the patient to low doses of ionising radiation. However, we should take into consideration the point that high-energy blunt trauma patients should undergo several other radiographies including chest and cross-table cervical spine radiographies, and probably further CT imaging. Thus, eliminating each of these radiographies would be beneficial both for the patients and the healthcare system.
Duane et al included 1961 blunt trauma patients who were divided into protocol (n=520) and non-protocol (n=1441) groups. The pelvic radiographies were performed if there was a positive pelvic physical examination and if the GCS was less than 13 in the protocol group. However, all the patients in the non-protocol group underwent a pelvic radiography. Pelvic physical examination detected all the pelvic fractures in the protocol group and decreased the hospital charges significantly. In another study by Gonzalez et al, it was shown that pelvic physical examination had a sensitivity of 93% (with seven missed cases) in detecting pelvic fractures, while pelvic radiography had a sensitivity of 87% with 13 missed injuries. All these studies, including ours, have used the same criteria for pelvic physical examination, including pelvic pain, pelvic girdle tenderness (including symphysis pubic, inner and outer pelvic wings and pelvic promontories), pelvic deformities (rotation and flexion deformities), limb inequalities and signs of bleeding (in rectal examination). This clinical protocol can be easily used in trauma emergency rooms for detecting pelvic fractures in alert haemodynamically stable blunt trauma patients.
All these studies and protocols are applicable to adult trauma patients. The clinical indicators of pelvic fractures in paediatric blunt trauma patients are a bit different. It was shown by Romirez et al that the following clinical indicators would be beneficial in recognising pelvic fractures in awake, alert haemodynamically stable, paediatric, blunt trauma patients: presence of hip or pelvic pain, pelvic contusions or abrasions, abdominal pain or distension and/or femur deformity/pain. They showed that these four indicators have a negative predictive value of 87%.
One other issue that has hastened the diminishing of routine pelvic radiography in trauma practice is the increasing use of CT imaging in trauma practice. Now, many studies recommend using CT imaging in all blunt trauma patients especially in those suffering from multiple trauma or severe injuries. It is shown that multidetector CT scanners have a sensitivity and specificity of 100% in detecting pelvic fractures. CT imaging was even introduced as the modality of choice in multiple blunt trauma patients. CT imaging has some advantages and some disadvantages just like any other modality. It is quick, efficient and available in many trauma centres. The most important disadvantage of CT imaging is exposure to high doses of radiation leading to future side effects. It is also more expensive and is not accessible everywhere especially in developing countries like ours. In this study, only three (0.77%) patients needed CT imaging and only one (0.25%) had pelvic fracture. Thus, CT imaging did not add anything to our findings. Consequently, the role of CT imaging in awake, haemodynamically stable, blunt trauma patients should also be questioned.
We note some limitations to our study. First, our study period (5 months) was limited; however, because of the high rate of trauma in our region, 1679 patients referred to our centre out of which 389 fulfilled the inclusion criteria. Larger studies are now being undertaken in our centre to elucidate the role of routine radiographies in initial evaluation of trauma patients. Second, the study may be underpowered due to the low incidence of positive pelvic radiography (0.25%) in haemodynamically stable blunt trauma patients which may lead to type II error; however, this is consistent with our hypothesis, questioning the role of cervical spine radiography in initial evaluation of trauma patients. The third limitation was the variability in the examiners and decision makers. During the study period, five junior and three senior residents attended the trauma centre, besides an attending trauma surgeon, on their rotation of duty. Thus, interobserver variability was inevitable.
In conclusion, pelvic radiography could be eliminated from the primary survey protocol of the patients with high-energy blunt trauma who are haemodynamically stable and have negative pelvic physical examination (deformity of the bony prominences, tenderness while gently compressing the iliac wings and pubic symphysis, bilateral inversion and eversion of anterior superior iliac spine and hip flexion/rotation). This approach will save healthcare resources and prevent patients from receiving unnecessary radiation.