What to do after a fall on the buttocks?

Assessment After a Fall on the Buttocks

After a fall on the buttocks, immediately assess for life-threatening conditions using the ABC approach (airway, breathing, circulation), then systematically evaluate for pelvic/hip fractures, neurological injury, and occult trauma before determining whether the patient requires emergency transport or can be managed with observation and follow-up.

Immediate Life-Threatening Assessment

• Check responsiveness and breathing status first - if the patient is unresponsive with absent or abnormal breathing, position them supine and initiate CPR immediately 1
• If the patient is unresponsive but breathing normally from a nontraumatic cause, place them in a lateral side-lying recovery position to maintain airway patency 1
• Do not move the patient if you suspect pelvic, hip, back, or spinal injury - leave them in the position found unless the airway is blocked or the area is unsafe 1

Critical Questions to Ask

Mechanism and Circumstances

• Exact location and surface where the fall occurred (indoor vs outdoor, stairs, height of fall) - falls on streets/sidewalks have comparable severity to indoor falls, with 5.2-5.9% requiring trauma center transport 2, 3
• Time spent on the floor/ground - prolonged time down indicates inability to self-rescue and suggests more severe injury 2
• Presence of loss of consciousness or altered mental status - this indicates potential head injury requiring immediate evaluation 2
• Symptoms of near-syncope, dizziness, or lightheadedness before or during the fall - suggests cardiac or orthostatic causes 2

Pain and Functional Status

• Location and severity of pain - specifically ask about buttock, hip, groin, and lower back pain 1
• Ability to bear weight - inability to bear weight suggests fracture 1
• Pain with hip rotation (internal and external) - this indicates potential hip or pelvic injury 1
• New onset groin pain - highly suspicious for hip fracture even with negative initial radiographs 1

Physical Examination Priorities

Immediate Inspection

• Perform head-to-toe examination to identify occult injuries, with particular attention to head trauma, fractures, and soft tissue injuries 2
• Examine the buttocks and sacral area for bruising, swelling, deformity, or open wounds 1
• Assess leg length and rotation - shortening and external rotation suggest hip fracture 1
• Check for tenderness over the greater sciatic notch - this may indicate piriformis syndrome or sciatic nerve involvement 4

Neurological Assessment

• Test lower extremity motor function and sensation - sciatic nerve injury can occur with buttock trauma 4
• Assess for saddle anesthesia or bowel/bladder dysfunction - indicates cauda equina syndrome requiring emergency intervention 2
• Evaluate gait and balance if the patient can safely stand - note any new deficits 2

Hemodynamic Assessment

• Measure orthostatic vital signs (supine, sitting, standing blood pressure and heart rate) - postural hypotension is a priority target for fall prevention 2
• Monitor for signs of shock - tachycardia, hypotension, pallor, or altered mental status may indicate occult pelvic bleeding 1

Red Flags Requiring Emergency Transport

• Hemodynamic instability (hypotension, tachycardia, signs of shock) - suggests severe pelvic injury with bleeding 1
• Inability to bear weight or severe pain with hip movement - high suspicion for hip or pelvic fracture 1
• Altered mental status or loss of consciousness - requires head CT evaluation 2
• Visible deformity or leg length discrepancy - indicates fracture 1
• Open wounds in the buttock or perineal area - open pelvic fractures have >50% mortality and require referral to trauma centers 1
• Neurological deficits in lower extremities - may indicate nerve injury or spinal involvement 2, 4

Imaging and Diagnostic Approach

Initial Radiographic Evaluation

• Obtain AP pelvis and lateral hip radiographs for any patient with buttock trauma and hip/groin pain 1
• If initial radiographs are negative but clinical suspicion remains high, obtain MRI within 2-3 days - occult hip fractures (particularly basicervical fractures) may not appear on plain films initially 1
• Order CT scan for suspected pelvic fractures - this provides comprehensive diagnosis of bone and soft tissue injuries 1

Additional Testing When Indicated

• EKG if cardiac symptoms, syncope, or unexplained fall are present 2
• Complete blood count and electrolyte panel to identify metabolic derangements 2
• Head CT for altered mental status or suspected head injury 2

Management Based on Findings

If No Fracture on Initial Evaluation

• Instruct the patient to use crutches and bear weight as tolerated 1
• Advise return for re-evaluation if discomfort worsens or does not improve within 2-3 days - delayed presentation of occult fractures is common 1
• Prescribe ice application and analgesics for soft tissue injury 2

If Fracture Suspected or Confirmed

• Activate EMS for transport to appropriate facility - severe pelvic trauma requires trauma center care 1
• Keep patient NPO in anticipation of surgical intervention 1
• Provide analgesia while awaiting transport 1

Post-Fall Assessment Protocol (Within 7 Days)

• Conduct comprehensive assessment within 7 days of the fall, including detailed fall circumstances, medical evaluation, and medication review - this reduces subsequent falls and hospital admissions 2, 1
• Develop individualized treatment plan addressing identified risk factors 2, 1
• Refer to primary physician for medical optimization and medication adjustment - education alone without referral does not reduce falls 2
• Educate staff (in institutional settings) on the specific treatment plan 2, 1

Common Pitfalls to Avoid

• Do not rely solely on initial negative radiographs - up to 10% of hip fractures are occult on plain films and require MRI for diagnosis 1
• Do not dismiss persistent groin or hip pain after buttock trauma - this warrants advanced imaging even with normal initial films 1
• Do not overlook posttraumatic piriformis syndrome - patients with buttock trauma who develop chronic pain, intolerance to sitting, and radicular symptoms may have this condition, which averages 32 months delay to diagnosis 4
• Do not assume outdoor falls are more severe - indoor and outdoor falls have comparable injury severity, with 27-28% rated as Emergent or Critical 3