What is the appropriate workup and treatment for pelvic pain in a patient after a fall on ice into a split position?

Workup and Treatment for Pelvic Pain After Fall on Ice into Split Position

For a patient with pelvic pain after falling into a split position on ice, immediately assess hemodynamic stability and obtain pelvic X-ray plus E-FAST if unstable, or proceed directly to CT pelvis with IV contrast if stable, while evaluating for urethral injury before catheterization if blood at meatus or inability to void is present. 1

Initial Assessment

Hemodynamic Status Determination

• Assess vital signs immediately to categorize the patient as hemodynamically stable or unstable, as this determines the entire imaging and management pathway 1
• Hemodynamic instability (hypotension, tachycardia, signs of shock) suggests possible pelvic fracture with active bleeding requiring urgent intervention 2

Clinical Examination Priorities

• Inspect for perineal ecchymosis, asymmetry, or deformity suggesting pelvic ring disruption 3
• Check specifically for blood at the urethral meatus, inability to void, gross hematuria, or suprapubic tenderness before attempting urinary catheterization, particularly in men, as these indicate potential urethral injury requiring specialized imaging first 2
• Palpate for pelvic instability (though avoid repeated manipulation if fracture suspected) 3
• Perform rectal examination to assess for bony fragments, sphincter tone, and blood 3

Imaging Algorithm

For Hemodynamically Unstable Patients

• Obtain pelvic X-ray immediately alongside E-FAST during resuscitation to detect unstable pelvic fractures requiring urgent intervention 1
• E-FAST has 97% positive predictive value for intra-abdominal bleeding in pelvic trauma patients 4
• If E-FAST and chest X-ray rule out extra-pelvic bleeding sources, proceed directly to pelvic angiography for embolization 1

For Hemodynamically Stable Patients

• Proceed directly to CT scan of abdomen/pelvis with IV contrast without obtaining pelvic X-ray first, as CT identifies 35.6% more pelvic fractures than X-ray and has 93.9% positive predictive value for detecting active bleeding 1
• CT provides complete injury inventory including bladder, urethral, bowel, and vascular injuries 2
• Pelvic X-ray adds no clinical value in stable patients and only delays definitive imaging 1

Urethral and Bladder Imaging

• Do not perform routine urethral/bladder opacification in all pelvic trauma patients 2
• Perform retrograde urethrography (ideally with CT) before catheterization in men with blood at meatus, inability to void, gross hematuria, or suprapubic tenderness 2
• Posterior urethral injuries occur in 4-19% of pelvic fractures, particularly with unstable fracture patterns involving bilateral pubic rami and sacroiliac disruption 2
• Bladder injuries occur in 3.5% of pelvic fractures, with higher risk if trauma occurred with full bladder 2

Treatment Based on Findings

If Pelvic Fracture Identified

Stable Fractures (minimally displaced, intact pelvic ring):

• Conservative management with analgesia and protected weight-bearing 3
• Multimodal analgesia including peripheral nerve blocks (iliofascial block) for pain control 2

Unstable Fractures (displaced, disrupted pelvic ring):

• Immediate external pelvic compression/binder placement around greater trochanters 5
• Surgical stabilization with external fixation or internal fixation depending on fracture pattern 3
• Consider angiography with embolization if contrast extravasation seen on CT 2

If No Fracture but Persistent Pain

Musculoskeletal Injury (most likely in split-position fall without fracture):

• Evaluate for myofascial pelvic floor dysfunction, adductor muscle strain, or symphysis pubis injury 6
• Pelvic floor physical therapy targeting muscle impairments and fascial restrictions 6
• NSAIDs for anti-inflammatory effect 7
• Consider gabapentin if neuropathic component present 7

Soft Tissue Injuries:

• Assess for adductor tendon avulsion or pubic symphysis disruption on CT/MRI if high clinical suspicion 3
• Conservative management with rest, ice, NSAIDs, and progressive physical therapy 6

Critical Pitfalls to Avoid

• Never attempt urinary catheterization in men with blood at meatus or inability to void without first performing retrograde urethrography, as this can convert partial urethral tear to complete disruption 2
• Do not delay CT scanning to obtain pelvic X-rays in stable patients 1
• Do not miss associated injuries—over 80% of patients with unstable pelvic fractures have additional musculoskeletal injuries 3
• Recognize that E-FAST can have false positives from hemoretroperitoneum or intraperitoneal bladder rupture 4
• Be aware that 20% of intestinal injuries are missed on initial CT and may require serial examinations 5

Disposition and Follow-up

• Admit patients with pelvic fractures for observation, pain control, and surgical planning 3
• Discharge stable patients without fracture with close orthopedic or sports medicine follow-up 6
• Arrange pelvic floor physical therapy referral for persistent pain without fracture 6
• Consider behavioral therapy integration for chronic pain management if symptoms persist beyond 6 months 7