Pelvic Fracture in Emergency Medicine Workup

  • Author: C Crawford Mechem, MD, MS, FACEP; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: May 12, 2010
 

Laboratory Studies

  • Serial hemoglobin and hematocrit measurements monitor ongoing blood loss.
  • Urinalysis may reveal gross or microscopic hematuria.
  • Pregnancy test is indicated in females of childbearing age to detect pregnancy as well as potential bleeding sources (eg, miscarriage, abruptio placentae).
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Imaging Studies

  • Radiography
    • Anteroposterior pelvic radiograph is the basic screening test and uncovers 90% of pelvic injuries. However, as severely injured trauma patients often routinely undergo CT scans of the abdomen and pelvis, plain pelvic radiographs in this patient population are most appropriate for hemodynamically unstable patients to allow for rapid diagnosis of pelvic fractures and early notification of interventional radiology. Anteroposterior (AP) compression injury as seen onAnteroposterior (AP) compression injury as seen on an AP radiograph of the pelvis. Characteristic features of an AP compression injury include symphyseal and sacroiliac joint diastasis. In this patient, the pubic symphysis and right sacroiliac joint are widened.
    • Plain radiographs may also be used in patients who otherwise would not have a CT scan of the abdomen and pelvis performed.
  • Computed tomography
    • CT scan is the best imaging study for evaluation of pelvic anatomy and degree of pelvic, retroperitoneal, and intraperitoneal bleeding. CT scan also confirms hip dislocation associated with an acetabular fracture.
    • CT scanning has largely replaced plain radiographs except for screening, and it has virtually eliminated the use of auxiliary views. Windswept pelvis (lateral compression injury) as sWindswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The patient sustained a left lateral compression injury with internal rotation of the left hemipelvis and a characteristic sacral buckle fracture. Note the concomitant left sacroiliac joint diastasis. The lateral force vector continued across the pelvis to produce external rotation of the right hemipelvis and diastasis of the right sacroiliac joint. The combination of injuries resulted in a windswept pelvis.
  • MRI may provide more definitive identification of pelvic fractures when compared to plain radiographs, thereby prompting patients to more timely and appropriate therapy. In one retrospective study, a large number of false positives and false negatives were noted when comparing plain films to MRI.[11]
  • Ultrasonography
    • As part of the Focused Assessment with Sonography for Trauma (FAST) examination, the pelvis should be visualized for intrapelvic bleeding/fluid.
    • In addition, the FAST examination may identify intraperitoneal bleeding to explain shock. However, recent studies suggest that ultrasonography has a lower sensitivity for identifying hemoperitoneum in patients with pelvic fractures than previously reported.[12] Therefore, keep in mind that, although the positive predictive value of noting hemoperitoneum as part of a FAST examination is good, therapeutic decisions using FAST as a screening examination may be limited.
  • Urethrography
    • Retrograde urethrography is necessary for males with a displaced or boggy prostate or blood at the urethral meatus and for females in whom a Foley catheter cannot easily pass on gentle attempts.
    • This study should also be used in females with a vaginal tear or palpable fracture fragments adjacent to the urethra.
  • Arteriography
    • Consider this study in hemodynamically unstable patients when CT scanning or other appropriate diagnostic studies exclude significant intraperitoneal bleeding and after the external pelvis is stabilized.
    • Arteriography allows for determination of the bleeding site. In addition, embolization may be very effective for hemorrhage control.
  • Cystography: Consider this study in any patient with hematuria and an intact urethra.
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Procedures

  • Use a suprapubic catheter for patients in whom urethral injuries are suspected but a urethrogram cannot be obtained.
  • Early application of an external pelvic fixator may be necessary to control hemorrhage.
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Contributor Information and Disclosures
Author

C Crawford Mechem, MD, MS, FACEP  Associate Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Emergency Medical Services Medical Director, Philadelphia Fire Department

C Crawford Mechem, MD, MS, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Michelle Ervin, MD  Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

David B Levy, DO, FACEP, FAAEM  Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

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Anterior-posterior (AP) compression pelvic fracture.
Vertical shear (VS) fracture pattern.
Anteroposterior (AP) compression injury as seen on an AP radiograph of the pelvis. Characteristic features of an AP compression injury include symphyseal and sacroiliac joint diastasis. In this patient, the pubic symphysis and right sacroiliac joint are widened.
Windswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The patient sustained a left lateral compression injury with internal rotation of the left hemipelvis and a characteristic sacral buckle fracture. Note the concomitant left sacroiliac joint diastasis. The lateral force vector continued across the pelvis to produce external rotation of the right hemipelvis and diastasis of the right sacroiliac joint. The combination of injuries resulted in a windswept pelvis.
 
 
 
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