Pelvic Fracture in Emergency Medicine Workup

Updated: Oct 10, 2017
  • Author: Nicholas Moore, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Workup

Laboratory Studies

Lab studies include the following:

  • Serial hemoglobin and hematocrit measurements to monitor ongoing blood loss.
  • Blood type and screen in setting of hemodynamic instability to prepare for possible transfusion.

  • 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 radiography is a basic screening test for pelvic fracture and has historically been indicated in all blunt trauma patients according to ATLS protocols. Plain pelvic radiographs should be performed in all hemodynamically unstable blunt trauma patients to uncover significant fractures and to allow early notification of interventional radiology and other consulting services. Studies of pelvic plain films in trauma patients have found them to be only 64-78% sensitive for identification of pelvic fractures. Therefore, in patients who are hemodynamically stable, it may be reasonable to forego pelvic plain films and rely on CT, as it will likely not change their management or outcome. [12, 13, 14]   

Anterior-posterior (AP) compression pelvic fractur Anterior-posterior (AP) compression pelvic fracture.

Computed tomography

CT scan is the best imaging study for evaluation of pelvic anatomy and degree of pelvic, retroperitoneal, and intraperitoneal bleeding (see the image below). 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. [40, 41, 42]

Windswept pelvis (lateral compression injury) as s 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

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. [43]

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, some studies suggest that ultrasonography has a lower sensitivity for identifying hemoperitoneum in patients with pelvic fractures than previously reported. [44]   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 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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