This retrospective data suggests that pelvic x-ray can safely be avoided in hemodynamically stable patients with clinically stable pelvis. Firstly, patients who received both a pelvic x-ray and a CT scan and those who received a CT scan only, had identical outcome. Secondly, none of the patients who received a subsequent CT scan only, had any acute complications. One case with an A 2.1 pelvic fracture, which was clinically stable and not bleeding, was missed in the clinical examination during the primary survey and might have been detected earlier using conventional radiography after the primary survey.
Even though conventional pelvic x-ray in Emergency Departments was shown to have a specifity of 100% compared with CT, 33% of all pelvic fractures are missed by pelvic x-ray. Our present study suggests that pelvic x-ray may be of limited value in this context. It could be studied if the missed fractures are of minor importance compared to the ones detected. Patients who suffer pelvic fractures are usually the victims of trauma and often have other trauma-related injuries. Up to 52% of emergency department patients with pelvic fractures develop shock due to hemorrhage and despite the escalating role of computed tomography in trauma, conventional radiography remains important in the acute management of trauma patients . Current ATLS guidelines recommend that only chest, pelvis and lateral cervical spine are x-rayed immediately. Inherent delays, relatively high radiation dose and practical difficulties in acquiring radiographs in the multi-injured patient can adversely affect management, bearing in mind the critical importance of physician access to badly injured patients during the "golden hour".
Conventional pelvic radiography has a radiation of up to 20% of that of a spiral CT of the region , so radiation reduction by omission of conventional studies is significant. The potential cost reduction of omitting pelvic x-rays routinely is also significant.
Abdominal injuries influence the diagnostic procedures in blunt trauma. Focused assessment with sonography in trauma (FAST), introduced a decade ago, is non invasive and has high sensitivity but low specificity for the detection of free fluid and visceral damage . This may have an impact on treatment and outcome in trauma patients. CT remains the diagnostic study of choice at most institutions even in the evaluation of hemodynamically stable, blunt abdominal trauma. It is highly specific and sensitive in the detection and definition of the extent of most intra-abdominal and also pelvic injuries but requires the patient to be hemodynamically stable according to ATLS principles.
A trend towards the avoidance of multiple radiographic studies and to early utilisation of CT instead is occurring [13, 14], partly because of the ability of CT to define the extent of injury better than any other immediately available radiographic tool and because CT scanners have become much faster and integrated into many modern emergency rooms. In our population group, all potentially hemorrhagic pelvic fractures (AO classification B1 and C) could be ruled out by clinical examination and the other inclusion criteria. The remaining fractures have little potential for acutely life-threatening complications and resulted from direct anterior (A2.1) or lateral (B2.1) compression instead of rotational forces in the vertical plane. Recent studies with similar hypothesis and different patient population support our results [7–9, 15].
In conclusion, this retrospective study suggests that pelvic x-ray has limited value for detecting pelvic fractures compared with CT scanning. The clinical examination of the abdomen and pelvis remains a key factor in the decision making regarding further radiological examinations. Hemodynamically stable patients who undergo CT scanning after immediate resuscitation and have a stable pelvis on clinical examination seem not to benefit from a routine pelvic x-ray. Pelvic x-ray remains important in the management of hemodynamically unstable patients and patients with suspect clinical examination of the pelvis. The results support the safety and utility of our modified ATLS algorithm described above (Figure 1). A randomized controlled trial using the algorithm can safely be conducted to confirm the results.