The utility of clinical examination in screening for pelvic fractures in blunt trauma

BACKGROUND: Current recommendations of the American College of Surgeons Advanced Trauma Life Support course is routine radiographic screening of the pelvis for all patients who suffer blunt torso trauma. The purpose of this study is to evaluate in a prospective manner the sensitivity of clinical examination as a screening modality for pelvic fractures in awake and alert blunt trauma patients. STUDY DESIGN: During a 32-month period, 2,176 consecutive blunt trauma patients who presented with Glasgow Coma Scores of 14 or 15 were evaluated at an urban Level I trauma center. Clinical examination of all patients was prospectively performed by trauma resident housestaff. The clinical examination of each patient was documented in a study form before performance of a standard anterior-posterior (A-P) pelvic x-ray. RESULTS: We evaluated 2,176 blunt trauma patients, 97 (4.5%) of whom were diagnosed with pelvic fracture. There were seven missed injuries on clinical examination (sensitivity 93%). None of the missed injuries on clinical examination required surgical intervention. The sensitivity of A-P pelvic x-ray was 87%, with 13 missed injuries. There were 463 patients who entered with ethanol levels equal or greater than 100 mg/dL (range 100 to 480 mg/dL). There were 20 pelvic fractures diagnosed in this group, with only 1 missed injury on clinical examination (sensitivity 95%). CONCLUSIONS: 1) Clinical examination of the pelvis can reliably rule out significant pelvic fracture in the awake and alert blunt trauma patient. 2) The addition of routine A-P pelvic x-ray does not improve the sensitivity in diagnosis of surgically significant pelvic fractures nor does it have significant impact on outcomes of pelvic fracture patients. 3) Elevated ethanol level is not a contraindication to use of clinical examination as a screening modality for pelvic fractures in the awake and alert blunt trauma patient. (J Am Coll Surg 2002;194:121-125. (C) 2002 by the American College of Surgeons).