Pelvic radiography in ATLS algorithms: A diminishing role?

Matthias P Hilty^*¹ , Isabelle Behrendt^*¹ , Lorin M Benneker² , Luca Martinolli^*¹ , Christoforos Stoupis^*³ , Donald J Buggy^*⁴ , Heinz Zimmermann^*¹ and Aristomenis K Exadaktylos^*¹

¹Department of Emergency Medicine, University Hospital of Berne, Switzerland

²Department of Orthopedic Surgery, University Hospital of Berne, Switzerland

³Institute of Diagnostic Radiology, University Hospital of Berne, Switzerland

⁴Department of Anaesthesia, Mater Misericordiae University Hospital, Dublin, Ireland

author email corresponding author email* Contributed equally

World Journal of Emergency Surgery 2008, 3:11doi:10.1186/1749-7922-3-11


Published:	4 March 2008

Abstract

Background

Pelvic x-ray is a routine part of the primary survey of polytraumatized patients according to Advanced Trauma Life Support (ATLS) guidelines. However, pelvic CT is the gold standard imaging technique in the diagnosis of pelvic fractures. This study was conducted to confirm the safety of a modified ATLS algorithm omitting pelvic x-ray in hemodynamically stable polytraumatized patients with clinically stable pelvis in favour of later pelvic examination by CT scan.

Methods

We conducted a retrospective analysis of all polytraumatized patients in our emergency room between 01.07.2004 and 31.01.2006. Inclusion criteria were blunt abdominal trauma, initial hemodynamic stability and a stable pelvis on clinical examination. We excluded patients requiring immediate intervention because of hemodynamic instability.

Results

We reviewed the records of n = 452 polytraumatized patients, of which n = 91 fulfilled inclusion criteria (56% male, mean age = 45 years). The mechanism of trauma included 43% road traffic accidents, 47% falls. In 68/91 (75%) patients, both a pelvic x-ray and a CT examination were performed; the remainder had only pelvic CT. In 6/68 (9%) patients, pelvic fracture was diagnosed by pelvic x-ray. None of these 6 patients was found having a false positive pelvic x-ray, i.e. there was no fracture on pelvic CT scan. In 3/68 (4%) cases a fracture was missed in the pelvic x-ray, but confirmed on CT (false negative on x-ray). None of the diagnosed fractures needed an immediate therapeutic intervention. 5 (56%) were classified type A fractures, and another 4 (44%) B 2.1 in computed tomography (AO classification). One A 2.1 fracture was found in a clinically stable patient who only received CT scan (1/23).

Conclusion

While pelvic x-ray is an integral part of ATLS assessment, this retrospective study suggests that in hemodynamically stable patients with clinically stable pevis, its sensitivity is only 67% and it may safely be omitted in favor of a pelvic CT examination if such is planned in adjunct assessment and available. The results support the safety and utility of our modified ATLS algorithm. A randomized controlled trial using the algorithm can safely be conducted to confirm the results.