Pelvic Radiography in Evaluating Blunt Trauma Patients
Pelvic Radiography in Evaluating Blunt Trauma Patients
This was a prospective cross-sectional study being performed in Shahid Rajaee trauma centre (our level I trauma centre) affiliated with Shiraz University of Medical Sciences during a 5-month period (from May to September 2010). We included all the conscious patients with high-energy blunt trauma who were haemodynamically stable and had negative pelvic physical examination. The study protocol was approved by both the institutional review board and the ethics committee of Shiraz University of Medical Sciences, and all the participants gave their informed written consents.
Patient care was in concordance with the ATLS protocol, including primary survey, followed by resuscitation and the secondary survey. Data was collected by means of a standard questionnaire, including demographic information (age, sex, area of residence), vital signs, injury mechanism and thorough history and physical examination findings. High-energy blunt trauma was defined as those mechanisms of injury transferring high energy to the patient, including motor vehicle accidents with more than a speed of 20 mph, or those in which the patient is ejected, auto–pedestrian accidents, motorcycle accidents and falls from heights greater than 20 feet. We also included those motor vehicle accidents in which one or more of the vehicle occupants were dead, and those which had an extrication time of more than 20 min. We also included those patients suffering from multiple traumas following assault. Haemodynamically unstable patients, those with positive pelvic physical examination, those less than 18 years of age, those with penetrating trauma, unreliable physical examination, isolated head trauma, and Glasgow Coma Scale (GCS) score less than 14 were all excluded from the study. Considering the importance of effective relationship with patients in history taking and physical examination, we also excluded individuals who could not communicate due to language or mental barrier. Stable haemodynamic condition was defined as systolic blood pressure >90 mm Hg and heart rate<100 beat per minute. Positive pelvic physical examination was considered if any of the following criteria were met: (1) hip pain, (2) tenderness on compression of the iliac wings or bilateral inversion and eversion of anterior superior iliac spine, (3) pubic symphysis tenderness, (4) presence of limb length inequalities, and (5) tenderness in hip flexion, internal and external rotations. The examinations were performed in the order mentioned above in order to avoid further pelvic damage. The pelvic examination was discontinued if any of these steps were found to be positive. All physical examinations and history takings were performed by the junior and senior surgical residents. However, the final judgment was adjudicated by the attending trauma surgeon.
A standard anterior–posterior pelvic radiography was performed for all the included patients. Other views including oblique views and obturator views were additionally ordered with the decision of the orthopaedic surgeon or the senior attending trauma surgeon. In those who had negative pelvic physical examination and the radiography was not revealing enough, CT imaging was requested. We also requested pelvic CT imaging in those whose pelvic radiographies had positive findings. The trauma surgery team has completed their clinical judgment and data collection before viewing the pelvic radiography. Patients were followed for a period of 24 h, and they were ambulated before discharge if they had no pelvic fractures.
All the pelvic radiographies were interpreted by an attending radiologist unaware of the clinical findings of the patients. The pelvic radiography findings were recorded in a separate questionnaire identified by the patients' admission code. The results of the study, including both the clinical findings (determined by trauma surgery team) and radiology findings (determined by attending radiologist) were prospectively entered into a computer-based database, and were further analysed by a statistician.
Methods
This was a prospective cross-sectional study being performed in Shahid Rajaee trauma centre (our level I trauma centre) affiliated with Shiraz University of Medical Sciences during a 5-month period (from May to September 2010). We included all the conscious patients with high-energy blunt trauma who were haemodynamically stable and had negative pelvic physical examination. The study protocol was approved by both the institutional review board and the ethics committee of Shiraz University of Medical Sciences, and all the participants gave their informed written consents.
Patient care was in concordance with the ATLS protocol, including primary survey, followed by resuscitation and the secondary survey. Data was collected by means of a standard questionnaire, including demographic information (age, sex, area of residence), vital signs, injury mechanism and thorough history and physical examination findings. High-energy blunt trauma was defined as those mechanisms of injury transferring high energy to the patient, including motor vehicle accidents with more than a speed of 20 mph, or those in which the patient is ejected, auto–pedestrian accidents, motorcycle accidents and falls from heights greater than 20 feet. We also included those motor vehicle accidents in which one or more of the vehicle occupants were dead, and those which had an extrication time of more than 20 min. We also included those patients suffering from multiple traumas following assault. Haemodynamically unstable patients, those with positive pelvic physical examination, those less than 18 years of age, those with penetrating trauma, unreliable physical examination, isolated head trauma, and Glasgow Coma Scale (GCS) score less than 14 were all excluded from the study. Considering the importance of effective relationship with patients in history taking and physical examination, we also excluded individuals who could not communicate due to language or mental barrier. Stable haemodynamic condition was defined as systolic blood pressure >90 mm Hg and heart rate<100 beat per minute. Positive pelvic physical examination was considered if any of the following criteria were met: (1) hip pain, (2) tenderness on compression of the iliac wings or bilateral inversion and eversion of anterior superior iliac spine, (3) pubic symphysis tenderness, (4) presence of limb length inequalities, and (5) tenderness in hip flexion, internal and external rotations. The examinations were performed in the order mentioned above in order to avoid further pelvic damage. The pelvic examination was discontinued if any of these steps were found to be positive. All physical examinations and history takings were performed by the junior and senior surgical residents. However, the final judgment was adjudicated by the attending trauma surgeon.
A standard anterior–posterior pelvic radiography was performed for all the included patients. Other views including oblique views and obturator views were additionally ordered with the decision of the orthopaedic surgeon or the senior attending trauma surgeon. In those who had negative pelvic physical examination and the radiography was not revealing enough, CT imaging was requested. We also requested pelvic CT imaging in those whose pelvic radiographies had positive findings. The trauma surgery team has completed their clinical judgment and data collection before viewing the pelvic radiography. Patients were followed for a period of 24 h, and they were ambulated before discharge if they had no pelvic fractures.
All the pelvic radiographies were interpreted by an attending radiologist unaware of the clinical findings of the patients. The pelvic radiography findings were recorded in a separate questionnaire identified by the patients' admission code. The results of the study, including both the clinical findings (determined by trauma surgery team) and radiology findings (determined by attending radiologist) were prospectively entered into a computer-based database, and were further analysed by a statistician.
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