What is the recommended imaging and initial management for a patient who has fallen and is suspected of having a pelvic fracture?

Imaging and Initial Management for Suspected Pelvic Fracture After Fall

For a patient who has fallen with suspected pelvic fracture, immediately assess hemodynamic stability—if unstable, obtain portable pelvic X-ray and E-FAST during resuscitation; if stable, proceed directly to CT abdomen/pelvis with IV contrast without obtaining X-ray first. 1

Immediate Assessment

Check vital signs first to categorize the patient as hemodynamically stable or unstable, as this determines the entire imaging and management pathway. 2

• Hemodynamic instability (persistent hypotension, tachycardia, shock) suggests possible pelvic fracture with active arterial bleeding requiring urgent intervention 1
• Obtain serum lactate and base deficit as sensitive markers of hemorrhagic shock extent and resuscitation response 1
• Perform physical examination looking for pelvic ring deformity, pelvic or perineal hematoma, rectal/urethral bleeding 1
• Before attempting urinary catheterization (especially in men), check specifically for blood at urethral meatus, inability to void, gross hematuria, or suprapubic tenderness—these indicate urethral injury requiring specialized imaging first 1, 2

Imaging Algorithm for Hemodynamically Unstable Patients

Obtain portable pelvic X-ray immediately alongside chest X-ray and E-FAST during ongoing resuscitation. 1

• E-FAST combined with chest X-ray enables appropriate urgent intervention decisions with 98% accuracy in unstable patients 1, 3
• E-FAST has 97% positive predictive value for detecting intra-abdominal bleeding in pelvic trauma 3, 2
• Pelvic X-ray identifies unstable fractures requiring immediate pelvic stabilization and helps determine need for angiography or laparotomy 1
• When chest X-ray and E-FAST rule out extra-pelvic causes of hemorrhagic shock, the patient should undergo angiography/embolization for pelvic bleeding control 1, 3
• If E-FAST shows significant hemoperitoneum (3 positive sites correlates with 61% need for laparotomy), proceed to immediate exploratory laparotomy with concomitant pelvic stabilization 3, 4

Imaging Algorithm for Hemodynamically Stable Patients

Proceed directly to CT scan of abdomen/pelvis with IV contrast without obtaining pelvic X-ray first. 1, 2

• CT identifies 35.6% more pelvic fractures than X-ray and has 93.9% positive predictive value for detecting active arterial bleeding 1, 2
• CT provides complete injury inventory including bladder, urethral, bowel, and vascular injuries 1, 2
• Pelvic X-ray does not influence management in stable patients since normal images only exclude pelvic injuries as bleeding sources 1
• CT with 3D bone reconstructions reduces tissue damage during procedures, operative time, and required expertise 1

Urethral and Bladder Imaging

Perform retrograde urethrography (ideally with CT) before catheterization in men with blood at meatus, inability to void, gross hematuria, or suprapubic tenderness. 1, 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 1, 2
• Never attempt urinary catheterization in men with blood at meatus without first performing retrograde urethrography—this can convert partial urethral tear to complete disruption 2

Initial Management Based on Hemodynamic Status

For Unstable Patients:

Time between hospital arrival and bleeding control should not exceed 60 minutes—mortality increases by 1% for every additional 3 minutes delay. 1

• Apply immediate external pelvic compression/binder around greater trochanters for unstable fractures 2
• If intra-abdominal bleeding is absent on E-FAST, transfer to angiography within 45 minutes of arrival 4
• Perform non-selective bilateral embolization of internal iliac arteries in unstable patients with multiple bilateral bleeding targets 1
• If patient cannot be transferred to CT or angiography cannot be performed within 60 minutes, perform surgical pre-peritoneal pelvic packing with external fixation 1

For Stable Patients:

• Obtain CT with contrast to exclude pelvic hemorrhage and identify fracture pattern 1
• If CT shows contrast extravasation, proceed to angiography with selective embolization 1, 2
• Provide multimodal analgesia including peripheral nerve blocks (iliofascial block) for pain control 2

Critical Pitfalls to Avoid

• Do not delay CT scanning to obtain pelvic X-rays in stable patients 2
• Do not accept E-FAST as definitive—it can have false positives from hemoretroperitoneum or intraperitoneal bladder rupture 3, 2
• Do not perform laparotomy in unstable patients with positive FAST if pelvic fracture is the only injury—proceed to angioembolization instead 1
• Recognize that FAST has high false-negative rate in patients with pelvic fractures 1
• Be aware that 20% of intestinal injuries are missed on initial CT and may require serial examinations 2