Skip and save: utility of pelvic x-rays in the initial evaluation of blunt trauma patients

Abstract

Background: The cost of medical care is an area of major emphasis in the current healthcare environment. Medical providers have a significant role in reducing costs. One way to achieve this goal is to eliminate practices that add little value to patient care. The pelvic x-ray (PXR) obtained during the initial evaluation of blunt trauma may be an example. The objective of this study was to explore the utility of the pelvic x-ray in the initial evaluation of blunt trauma patients.

Methods: Blunt trauma patients with pelvic fractures of any type admitted to our urban trauma center from January 2012 to December 2013 were reviewed. Demographics including age, sex, race, mechanism of injury, and outcomes were collected. Findings on PXR and computed tomography (CT) were compared for correlation. Patients requiring surgery for their pelvic fractures were identified.

Results: Of the 3,217 trauma admissions over the 2-year period, 153 patients sustained a pelvic fracture. Mean age was 50 years (15 to 97), male 54%, and Caucasian 46%, Hispanic 31%, African American 22%, and Asian 1%. The average injury severity score was 12.9. The main mechanism of injury was motor vehicle collisions 45%, followed by fall from standing 22% and auto and/or pedestrian accidents 12%. There were 22 patients that did not have both CT and pelvic imaging for comparison. Of the 131 patients with both CT and pelvic films, findings were the same in 43 (33%). CT identified one or more additional pelvic fractures in 88 (67%) patients compared with the PXR. In 29 patients (22%), pelvic fractures were not evident on PXR with fractures only identified by CT. The most common missed fractures on PXR were sacral and iliac injuries. Of the 153 patients with pelvic fractures, 24% required surgery for their pelvic injuries. Mortality was 4% for nonpelvic fracture-related causes. The PXR findings did not change management provided by trauma team in the emergency department.

Conclusions: As expected, CT is more sensitive in identifying pelvic fractures compared with PXR. Most blunt trauma patients are undergoing further evaluation with CT. We therefore propose that in patients that are normotensive with no pelvic instability or hip dislocation on physical examination who are to undergo further imaging with CT, the pelvic film should be avoided as it adds little value to patient management. The Advanced Trauma Life Support (ATLS) guidelines should be revised to reflect a diminishing role of the PXR in blunt trauma patients.

Keywords: Blunt trauma; Pelvic fractures; Pelvic x-rays.