Source: Gonzales RP. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Amer Coll Surg 2002;194:121-125.
The purpose of this study was to prospectively evaluate the sensitivity of clinical examination as a screening modality for pelvic fractures in awake, alert blunt trauma patients. Only patients with a Glasgow Coma Score (GCS) of 14-15 were included. An elevated serum ethanol level was not an exclusion criterion. A detailed clinical evaluation was performed before radiography. This included inspection of the pelvis (i.e., abrasions over bony prominences; ecchymosis about the pubis, perineum and scrotum; blood at the urethral meatus); posterior and inward compression of the iliac wings; compression of the symphysis pubis; inspection for limb length discrepancy; hip flexion; inward and outward hip rotation; rectal examination with assessment for gross blood; and assessment for neurologic deficit. The clinical examination was documented on a study form and sealed in an envelope. A single anterior-posterior (AP) x-ray of the pelvis then was performed. All patients were admitted for a minimum 23-hour observation period and re-evaluated prior to discharge.
During a 32-month period, 2176 consecutive blunt trauma patients older than age 14 were evaluated. Ninety-seven (4.5%) of these had pelvic fractures. Two hundred fifty-five patients (12%) had positive clinical examinations, 89 (35%) of which had pelvic fractures. There were seven injuries missed on clinical examination (sensitivity 93%). None of these injuries required surgical intervention, and only two of seven had a change in weight-bearing status following the diagnosis. There were 463 patients who had ethanol levels greater than 100 mg/dL (range 100-480 mg/dL). In this subgroup, 20 fractures were identified, with only one missed on clinical examination (sensitivity 95%). The sensitivity of a single AP radiograph was 87%, with 13 missed injuries. All of these were identified by abdominopelvic computed tomography.
Commentary by Michael A. Gibbs, MD, FACEP
Pelvic ring fractures are the third most common cause of injury-related death, following traumatic brain injury and aortic disruption. Despite advances in care, the mortality in this patient population remains between 5% and 10%.1 So, the underlying message should always be rapid identification and characterization of the pelvic injury and concern with aggressive stabilization.
On the flip side, the results of this trial are consistent with four prior studies demonstrating that a good physical examination can exclude pelvic injury in the majority of alert patients.1-4 In this study, the sensitivity of the clinical examination was actually better than radiography (p < 0.05). Of interest, elevated ethanol levels did not impact clinical diagnosis.
In 1998, the American College of Surgeons recommended pelvic radiography in "all patients suffering major blunt torso trauma."5 While this approach is effective at excluding injury, it comes at the expense of a large number of negative radiographs. In addition to the obvious financial implications, this approach results in unnecessary exposure to radiation, and potential delays in trauma patient evaluation and stabilization. While this trial supplements the current literature suggesting that low-risk criteria can be employed successfully, all studies to date (including this one) suffer from a relatively small sample size. A large, multicenter trial (such as with NEXUS) should be the next goal.
Dr. Gibbs, Residency Program Director, Medical Director, Medcenter Air, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, is on the Editorial Board of Emergency Medicine Alert.
References
1. Yugueros P. Unnecessary use of pelvic x-ray in blunt trauma. J Trauma 1995;39:722.
2. Civil ID. Routine pelvic radiography in severe blunt trauma: Is it necessary? Ann Emerg Med 1988;17:488.
3. Kouri JI. Selective use of pelvic roentgenograms in blunt trauma patients. J Trauma 1993;236:34.
4. Salvino CK. Routine pelvic x-ray in awake blunt trauma patients: A sensible policy? J Trauma 1992;33:413.
5. American College of Surgeons, Committee on Trauma: ATLS instructor manual. Chicago; American College of Surgeons:1998.
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