What areas of the body should be X-rayed in a 60-year-old female who fell on her bottom?

Imaging for a 60-Year-Old Female After Fall on Bottom

For a 60-year-old female who fell on her bottom, obtain X-rays of the pelvis and lumbar spine as initial imaging, with a low threshold to proceed directly to CT if there is significant pain, inability to bear weight, or high clinical suspicion for fracture. 1

Initial Imaging Approach

Pelvis X-ray (Essential)

• Pelvic X-ray is the primary initial study for patients with falls on the bottom, as pelvic fractures are common in this mechanism and age group 1
• Pelvic fractures occur in approximately 20% of older adults sustaining low-energy falls, making this a high-yield examination 2
• Standard anteroposterior (AP) view of the pelvis should be obtained 1

Lumbar Spine X-ray (Strongly Recommended)

• Lumbar spine imaging should be included because thoracolumbar fractures are challenging to identify clinically, with only 48-75% detected on physical examination 1
• Any patient over 60 years of age with a fall mechanism is considered high-risk and warrants thoracolumbar spine imaging 1
• Obtain AP and lateral views of the lumbar spine 1

Sacrum Evaluation

• The sacrum is evaluated on both pelvis and lumbar spine films, as sacral insufficiency fractures are common in this demographic and mechanism 1
• Sacral fractures are frequently missed on plain radiographs and may require advanced imaging if clinical suspicion remains high 1

When to Proceed Directly to CT

High-Risk Indicators Requiring CT

• CT of the pelvis and lumbar spine without contrast is the gold standard for identifying fractures in this region, with 94-100% sensitivity compared to 49-82% for plain radiographs 1
• Consider direct CT imaging if the patient has: midline tenderness, high-energy mechanism features, inability to ambulate, or is unexaminable due to pain or altered mental status 1
• In older adults with low-energy falls, plain radiography has only 49.7% sensitivity for detecting fractures, with a negative likelihood ratio of 0.5, meaning negative X-rays do not reliably exclude fractures 2

CT Protocol

• CT pelvis and lumbar spine without IV contrast is appropriate for fracture detection 1
• Multiplanar reconstructions significantly improve fracture detection 1
• IV contrast is not needed unless there is concern for vascular injury or active bleeding 1

Critical Considerations for This Age Group

Osteoporosis Risk

• At age 60, this patient is in a high-risk category for osteoporotic fractures, particularly insufficiency fractures of the pelvis and spine 1, 3
• Vertebral fractures account for 39% of all fractures in women over 50 and frequently remain unrecognized 4
• If fractures are identified, DXA scanning of the lumbar spine and bilateral hips should be obtained to assess for underlying osteoporosis 5, 6

Screening for Additional Injuries

• Screen the entire spine when any spinal injury is identified, as 20% of spine trauma patients have noncontiguous spinal injuries 1
• If thoracic spine tenderness is present, add thoracic spine imaging 1

Common Pitfalls to Avoid

Do Not Rely Solely on Clinical Examination

• Physical examination has poor sensitivity (48-75%) for thoracolumbar injuries in this population, so imaging should not be withheld based on benign examination alone 1
• Pain may be minimal initially due to age-related decreased pain perception or analgesic use 2

Do Not Miss Sacral Fractures

• Sacral insufficiency fractures are easily missed on plain films and may require MRI or bone scan if clinical suspicion persists despite negative X-rays 1
• MRI pelvis without contrast is the most sensitive test for sacral insufficiency fractures when X-rays are negative 1

Do Not Delay Advanced Imaging in High-Risk Patients

• If the patient cannot bear weight, has severe pain, or X-rays are equivocal, proceed directly to CT rather than repeating plain films in 10-14 days 1, 2
• The 10-14 day repeat X-ray strategy is less sensitive than MRI and delays definitive diagnosis 1

Follow-Up Imaging Strategy

If Initial X-rays Are Negative But Suspicion Remains High

• MRI of the pelvis and lumbar spine without IV contrast is the next appropriate study, with superior sensitivity for occult fractures, bone marrow edema, and soft tissue injury 1
• MRI should be obtained within days rather than waiting 2 weeks for repeat X-rays 1
• Bone scan with SPECT is an alternative but less specific than MRI 1

If Fractures Are Identified

• Obtain DXA of lumbar spine and bilateral hips to diagnose osteoporosis and guide treatment decisions 5, 6
• Consider vertebral fracture assessment (VFA) if T-score is less than -1.0, as this patient would meet age criteria (≥60 years) 6