Pelvic Fracture in Emergency Medicine Workup
- Author: C Crawford Mechem, MD, MS, FACEP; Chief Editor: Trevor John Mills, MD, MPH more...
Lab studies include the following:
- 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).
Workup includes the following:
- 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.
- 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 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.
- 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. 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.
- Retrograde urethrography is necessary for males with 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.
- 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.
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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