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The American College of Surgeons
Advanced Trauma Life Support advocates the routine
use of the antero-posterior pelvic X-ray as an adjunct
to the primary survey.
Some authors suggest that this is
not cost effective and that clinical criteria may
be used to screen for the presence of a pelvic injury.
Examination of the pelvis is notoriously unreliable,
especially in obtunded, intoxicated or obese patients.
In addition, repeated 'springing' of the pelvis may
result in disruption of any clot that has formed and
lead to further exsanguination.
The antero-posterior pelvic X-ray
should still be routinely used to determine the presence
of pelvic injury in multiply injured trauma patients.
Clinical examination, especially repeated 'springing'
of the pelvis, should be kept to an absolute minimum.
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Evidence
There is no Level I evidence regarding
the use of a routine antero-posterior pelvic X-ray.
There is no Level II evidence regarding
the use of a routine antero-posterior pelvic X-ray.
Gillott A, Rhodes M and Lucke J (1988).
“Utility of routine pelvic X-ray during blunt trauma resuscitation.”
J Trauma 28(11): 1570-1574.
Abstract: To assess the utility
of a routine pelvic X-ray in resuscitation of blunt trauma
patients, 669 patients were studied prospectively over a
2-year period. One hundred twelve patients (16.7% ) had
positive pelvic X-rays (PPX). When compared with the negative
pelvic X-ray group (NPX), the PPX group had a significantly
higher mean Injury Severity Score, 24-hour mean requirement
for blood and component therapy, and higher incidence of
associated injury of chest and abdomen. Despite the higher
injury parameters, the mortality between the groups was
not significantly different. When compared with five standard
resuscitative assessment variables, a pelvic X-ray performed
as an additional predictor of injury severity and 24-hour
blood requirement. A pelvic X-ray should be performed routinely
in victims of blunt trauma as part of the early resuscitation
X-ray protocol since a positive finding has immediate prognostic
and therapeutic implications.
Kaneriya PP, Schweitzer ME, Spettell
C, Cohen MJ, et al. (1999). “The cost-effectiveness of routine
pelvic radiography in the evaluation of blunt trauma patients.”
Skeletal Radiol 28(5): 271-273.
Abstract: OBJECTIVE:. To determine
the cost-effectiveness of routine protocol-driven pelvic
radiography in the evaluation of blunt trauma patients.
DESIGN AND PATIENTS: A retrospective review was performed
on 319 blunt trauma patients who underwent protocol-driven
pelvic radiography to record the frequency of pelvic fracture.
Medical records of the patients in whom fractures were identified
radiographically were then examined to determine the clinical
suspicion of injury prior to radiography. Using Medicare
reimbursement data, the cost-effectiveness of routine pelvic
radiography was calculated in terms cost per pelvic radiograph
with evidence of fracture. These values were then compared
with literature values of other screening studies, namely
mammography and colonoscopy. RESULTS: Thirty-eight of 319
patients (11. 9%) were found to have fractures identified
on routine pelvic radiography. Using the 1997 Medicare reimbursement
charge of $27.79 for a single anteroposterior radiograph
of the pelvis, the total cost of performing these 319 trauma
protocol-driven studies was calculated as $8865.01. The
cost per protocol-driven pelvic radiograph with evidence
of pelvic fracture was subsequently determined to be $233.
29. Only 18 (47.4%) of these 38 patients were suspected
to have pelvic fracture on the basis of the clinical findings
alone. CONCLUSIONS: Trauma protocol-driven pelvic radiography
is a necessary and cost-effective means of identifying acute
pelvic injury in all trauma patients regardless of clinical
presentation.
Mackersie RC, Shackford SR, Garfin
SR and Hoyt DB (1988). “Major skeletal injuries in the obtunded
blunt trauma patient: a case for routine radiologic survey.”
J Trauma 28(10): 1450-1454.
Abstract: Trauma patients obtunded
as a result of head injury, hypotension, alcohol, or drugs
have an unreliable physical examination which may lead to
errors or delays in diagnosis. To define the extent of routine
radiologic survey needed in patients with a depressed level
of consciousness, the records of 789 adults with blunt injuries
and a Glasgow Coma Score (GCS) of 10 or less on admission
were reviewed. Major skeletal injury (MSI), was defined
as one or more fractures or dislocations of the axial spine,
pelvis, hip, or long bones of the lower extremity. The overall
incidence of MSI was 31%. Injuries to the axial spine were
present in 14% of patients, while 10% sustained pelvic fractures
or hip dislocations and 15% sustained femur or tibia-fibula
fractures. Patients who sustained MSI had lower admission
CRAMS, Trauma Score, GCS, and admission blood pressure compared
to non-MSI patients (p less than 0.002). An analysis of
mechanisms of injury showed that pedestrians struck by a
motor vehicle (57%) , and victims of motorcycle accidents
(40%) had increased incidences of MSI (p less than 0.05).
Patients suffering falls (18%) and assaults (2%) had a decreased
incidence of MSI (p less than 0.01). The high incidence
of potentially occult MSI in obtunded patients after blunt
trauma demonstrated by this data suggests the need for routine
radiologic survey including the axial spine, pelvis and
long bones of the lower extremity. Mechanism of injury,
CRAMS, TS, and GCS may be useful in the early identification
of a particularly high-risk group.
Civil ID, Ross SE, Botehlo G and Schwab
CW (1988). “Routine pelvic radiography in severe blunt trauma:
is it necessary?” Ann Emerg Med 17(5): 488-490.
Abstract: To evaluate the hypothesis
that all victims of severe blunt trauma require a pelvic
radiograph, we prospectively studied all such patients admitted
to the Southern New Jersey Regional Trauma Center during
a seven-month period. All patients were classified as unconscious;
impaired; awake, alert, and symptomatic; or alert, oriented,
and asymptomatic for pelvic fracture on admission. All underwent
a plain anterior- posterior radiograph of the pelvis. A
total of 265 patients were studied and 26 pelvic fractures
were identified. These occurred in seven of 36 unconscious
patients, 11 of 96 impaired patients, and eight of 23 symptomatic
patients. No fractures were identified in 110 awake, alert,
oriented, and asymptomatic patients (P less than .0001).
We conclude that pelvic radiographs are required in unconscious
or impaired victims of severe blunt trauma and those with
signs or symptoms of pelvic fractures but are not required
in the awake, alert, and asymptomatic patient.
Koury HI, Peschiera JL and Welling
RE (1993) “Selective use of pelvic roentgenograms in blunt
trauma patients.” J Trauma 34(2): 236-237.
Abstract: This study was initiated
to investigate the need for routine pelvic roentgenograms
for all blunt trauma victims. Over a 2-year period, we prospectively
studied patients referred to the trauma service in the level
I trauma center at our institution who met the inclusion
criteria. The patients were evaluated by physical examination
and, if mentally alert and reliable, were included in the
study. After inclusion into the study, a routine pelvic
roentgenogram was performed to substantiate the results
of our physical examination. All 125 patients included in
the study were found to have normal results on pelvic roentgenograms.
We conclude that alert, oriented and reliable patients involved
in blunt trauma do not need a routine pelvic roentgenogram
if the findings on physical examination are negative.
Salvino CK, Esposito TJ, Smith D, Dries
D, et al. (1992). “Routine pelvic x-ray studies in awake
blunt trauma patients: a sensible policy?” J Trauma 33(3):
413-416.
Abstract: To evaluate the usefulness
of routine pelvic x-ray films in the resuscitation of blunt
trauma victims, 1395 patients were prospectively evaluated
over a 13-month period. Of these, 810 (58%) were awake with
Glasgow Coma Scale scores greater than or equal to 13 and
were enrolled into the study. A history, with directed questions
regarding pelvic pain, a clinical examination of the pelvis,
and an anterior- posterior pelvic x-ray film (APPX) were
obtained for each patient. Thirty-nine patients (5%) had
fractures identified on the x-ray films. Of these patients
with radiographically identified fractures, 34 (87%) complained
of pain and had positive results on clinical examination,
two (5%) either complained of pain or had positive results
on examination and three (8%) had neither complaint of pain
nor positive examination results. Of the 771 patients without
fractures 743 (96%) lacked pain complaints or positive examination
results. The likelihood of fracture was greatest in patients
with complaints of pain and positive examination results
(65%) followed by patients with either complaint of pain
or positive examination results (16%). Only three (0.4%
) of the 743 patients having no complaints of pain and a
negative clinical examination had fractures diagnosed roentgenographically.
These were minor fractures that did not affect the clinical
course. Total charges incurred to diagnose pelvic fractures
in this low-yield patient group were $88,028. We conclude
that the practice of obtaining a screening APPX is not necessary
or cost-effective in the management of awake blunt trauma
patients who do not complain of pain and who have normal
pelvic physical examination results.
Guide to Evidence Appraisals
The definitions of the types of evidence
and the grading of recommendations used originate from the
US Agency for Health Care Policy and Research
| Evidence
obtained from meta-analysis of randomised controlled
trials |
| Evidence
obtained from at least one randomised controlled trial |
| Evidence
obtained from at least one well-designed controlled
study without randomisation |
| Evidence
obtained from at least one other type of well-designed
quasi-experimental study |
| Evidence
obtained from well-designed non-experimental descriptive
studies, such as comparative studies, correlation studies
and case control studies |
| Evidence
obtained from expert committee reports or opinions and/or
clinical experience of respected authorities |
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