PEDIATRICS/ORIGINAL RESEARCH
Sensitivity of Plain Pelvis Radiography in Children With Blunt Torso Trauma Maria Y. Kwok, MD, MPH*; Ken Yen, MD, MS; Shireen Atabaki, MD, MPH; Kathleen Adelgais, MD, MPH; Madelyn Garcia, MD, MPH; Kimberly Quayle, MD; Joshua Kooistra, DO; Bema K. Bonsu, MD; Kent Page, MStat; Dominic Borgialli, DO, MPH; Nathan Kuppermann, MD, MPH; James F. Holmes, MD, MPH† *Corresponding Author. E-mail: [email protected].
Study objective: Plain anteroposterior pelvic radiographs are commonly used to screen children for pelvic fractures or dislocations after blunt torso trauma. The test sensitivity and utility, however, are unclear. We assessed the sensitivity of anteroposterior pelvic radiographs for identifying children with pelvic fractures or dislocations after blunt torso trauma. We hypothesized that anteroposterior pelvic radiographs fail to identify all children with pelvic fractures or dislocations, including patients undergoing operative intervention and those with hypotension. Methods: We conducted a prospective multicenter observational study of children (20 mph MVC
3
Additional Thoracoabdominal Injuries
Pelvic Bone Fractures
Death Arterial Bleeding Within From a Pelvic 30 Days Fracture of Injury
Femur fracture
Ilium*
No
No
Liver, kidney, adrenal gland, hemoperitoneum, pulmonary contusion, pneumothorax, hemothorax, rib fracture None Pulmonary contusion, pneumothorax, hemothorax, rib fracture Liver, adrenal gland, hemoperitoneum, pulmonary contusion, rib fracture, cardiac contusion None
Pubis, ilium
No
No
Ilium Pubis, ilium
No No
No Yes
Pubis, acetabulum involvement
No
No
Pubis
No
No
Pubis, ilium, ischium
No
Yes
No
Yes
Gastrointestinal, pancreas, vascular, hemoperitoneum, femur fracture, pulmonary contusion Femur fracture, pulmonary contusion, pneumothorax, rib fracture
No
No
5 15
Pubis, sacrum, open-book disruption, SI joint disruption Liver, spleen, hemoperitoneum, pulmonary Pubis, sacrum* contusion, pneumothorax, rib fracture None Pubis, sacrum None Pubis, sacrum
No No
No No
15
Urinary bladder, hemoperitoneum
3 15 3 15 3 15
15
Pedestrian or bicyclist struck by moving vehicle
3
16
MVC, >40 mph
3
16
MVC
3
Spleen, hemoperitoneum, pulmonary contusion, hemothorax, rib fracture Pulmonary contusion Pulmonary contusion, pneumothorax, rib fracture None Hemothorax
Pubis, ilium, sacrum, acetabulum involvement Pubis
No
No
No
Yes
Sacrum Pubis, sacrum
No No
No Yes
Pubis, Acetabulum Involvement* Pubis, sacrum, SI joint disruption Sacrum, acetabulum involvement
No
No
No
Yes
No
No
No
No
No
Yes
Yes
No
Liver, hemoperitoneum, femur fracture, pulmonary contusion, pneumothorax, hemothorax Liver, spleen, kidney, hemoperitoneum, Pubis, ischium, sacrum pulmonary contusion, pneumothorax, hemothorax, rib fracture, pneumomediastinum Liver, spleen, hemoperitoneum, Ilium pneumothorax, hemothorax, rib fracture, diaphragm Liver, spleen, hemoperitoneum, pulmonary Pubis, ilium, sacrum, contusion, pneumothorax, hemothorax, acetabulum involvement rib fracture
MVC, Motor vehicle crash; mph, miles per hour. *The patient had normal plain pelvis radiograph results.
radiographs in patients already scheduled to undergo abdominal or pelvic CT. CT scanning, however, should not be used as a primary screening test if no clinical evidence of pelvic fracture or dislocation exists. Although normal plain anteroposterior pelvic radiographs do not absolutely exclude the possibility of fracture, the patient is 68 Annals of Emergency Medicine
at substantially lower risk if the plain anteroposterior pelvic radiograph result is normal. These patients may be allowed to ambulate, and if concern still exists for pelvic fractures or dislocations (ie, inability to ambulate), then CT should be considered (see Figure 2 for a suggested algorithm). Volume 65, no. 1 : January 2015
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Table 5. Patients with normal plain anteroposterior pelvic radiograph results who underwent operative intervention.* Age, Years
Mechanism of Injury
Pelvic Bone Fractures or Dislocations
GCS Score
Additional Thoracoabdominal Injuries None Splenic laceration (hemoperitoneum), pulmonary contusion, pneumothorax, rib fracture Rib fracture
10 13
MVC MVC, >40 mph
15 3
15
15
15
Pedestrian or bicyclist struck by moving vehicle MVC
15
16
MVC
15
Splenic laceration (hemoperitoneum), pulmonary contusion, pneumothorax, hemothorax, rib fracture None
Acetabulum Sacrum Ilium, pubis, sacroiliac joint Pubis, sacroiliac joint
Pubis, sacroiliac joint
*All fractures identified by pelvic CT scanning. None of these 5 patients were hypotensive on presentation.
Limited data exist about the importance of assessing for pelvic instability in injured patients. Adult studies suggest it is not useful because it has low reliability, sensitivity, and specificity.15,16 Yen et al17 examined the cohort of patients reported in this study and also found poor interrater reliability in the assessment of pelvic instability. Furthermore, concern exists for further dislodging fractured pelvic bones by applying direct pressure. More concerning, however, was the poor sensitivity in a subset of patients with unstable pelvic fractures or dislocations (those with open-book pelvic fractures). These findings indicate that the clinical assessment of children with blunt trauma for pelvic instability has limited utility. In an era in which cost-effectiveness and the mutagenic effects of cumulative lifetime exposure to ionizing radiation are major
concerns,18,19 appropriate use of radiography is important. Previous investigations have advocated the use of clinical findings to guide the decision on obtaining plain anteroposterior pelvic radiographs.20-22 One study suggested that children are at low risk for pelvic fractures if they have the following: lack of lower extremity injury, lack of an abnormal physical examination result of the pelvis, and no indication for abdominopelvic CT. That study, however, was limited by its retrospective nature, selection of only subjects with Glasgow Coma Scale scores 14 and 15, and the lack of information on distracting injury or alcohol intoxication that may make examinations difficult.7 Adult studies suggest that pelvic radiographs can be avoided in patients who are alert, are hemodynamically stable, and have no pelvic bone tenderness. Although these variables do not identify all patients
Figure 2. Suggested algorithm for the initial evaluation of children considered at risk for pelvic fractures or dislocations by the treating physician. Volume 65, no. 1 : January 2015
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Kwok et al
Sensitivity of Plain Pelvis Radiography in Children with pelvic fractures, they have excellent sensitivity for adult patients with pelvic fractures undergoing operative intervention.4,23 This study demonstrates that high-risk mechanisms of injury for pelvic fractures or dislocations include pedestrians or bicyclists struck by moving vehicles and injuries involving motor vehicle crashes. Victims of low-level falls or bicycle collisions, or a fall from bicycles, rarely received a diagnosis of pelvic fractures or dislocations. Furthermore, none of the 281 patients in this study who fell down stairs received a diagnosis of pelvic fractures or dislocations. Physicians may use this information when determining the need for pelvic radiography. The pubis was the most commonly injured pelvic bone, results similar to those of previous studies.12,16 Hip joint dislocations and open-book pelvic fractures were rare, results that were also similar to those of previous studies.12 Surgery was rare; however, among patients undergoing surgery, the most common injury was to the pubis bones. Pelvic fractures or dislocations were rare in patients younger than 2 years and were most likely to the ilium and pubis bones. In summary, plain anteroposterior pelvic radiograph has a limited sensitivity for identifying children with pelvic fractures or dislocations after blunt trauma, including a significant proportion of children with hypotension and those who undergo operative intervention. Plain anteroposterior pelvic radiographs should not be relied on as the sole diagnostic test in patients considered at high risk of pelvic fractures or dislocations. Furthermore, plain anteroposterior pelvic radiograph is unnecessary in patients for whom abdominal or pelvic CT scanning is otherwise planned.
Author contributions: NK and JFH conceived and designed the study. JFH obtained grant funding for the project. MYK, KY, SA, KA, MG, KQ, JK, BKB, DB, NK, and JFH supervised the study at their respective sites and acquired data for the study. KP, NK, and JFH had full access to the data in the study and take responsibility for the accuracy of the data analysis. MYK, KP, NK, and JFH participated in the data analysis and interpreted the data. MYK, KP, and JFH created the figures. MYK and JFH performed the literature search. MYK drafted the article. KY, SA, KA, MG, KQ, JK, BKB, KP, DB, NK, and JFH critically revised the article. MYK takes responsibility for the paper as a whole.
The authors acknowledge the research coordinators in PECARN, without whose dedication and hard work this study would not have been possible; and all the clinicians around the PECARN who enrolled children in this study.
REFERENCES
Supervising editor: Steven M. Green, MD Author affiliations: From the Department of Pediatrics, Columbia University Medical Center, New York, NY (Kwok); the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (Yen); the Department of Pediatrics, Children’s National Medical Center, Washington, DC (Atabaki); the Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO (Adelgais); the Department of Pediatrics, University of Rochester Medical Center, Rochester, NY (Garcia); the Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO (Quayle); the Department of Pediatrics, Helen DeVos Children’s Hospital, Grand Rapids, MI (Kooistra); the Department of Pediatrics, Nationwide Children’s Hospital, Columbia, OH (Bonsu); the Department of Pediatrics, University of Utah, Salt Lake City, UT (Page); the Department of Emergency Medicine, Hurley Medical Center, Flint, MI, and Department of Emergency Medicine, University of Michigan, Ann Arbor, MI (Borgialli); and the Department of Emergency Medicine (Kuppermann, Holmes) and Department of Pediatrics (Kuppermann), University of California, Davis, Sacramento, CA.
70 Annals of Emergency Medicine
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and provided the following details: This work was supported by a grant from the Centers for Disease Control and Prevention (1 R49CE00100201). PECARN is supported by the Health Resources and Services Administration, Maternal and Child Health Bureau, Emergency Medical Services for Children Program through the following cooperative agreements: U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC00008, U03MC22684, and U03MC22685. Publication dates: Received for publication February 6, 2014. Revision received June 10, 2014. Accepted for publication June 16, 2014. Available online July 30, 2014. Presented at the Pediatric Academic Society, May 2013, Washington, DC; and the Society of Academic Emergency Medicine, May 2013, Atlanta, GA.
1. Committee on Trauma, American College of Surgeons (2012). ATLS: Advanced Trauma Life Support Program for Doctors (9th ed.). Chicago: American College of Surgeons. 2. Demetriades D, Karaiskakis M, Velmahos GC, et al. Pelvic fractures in pediatric and adult trauma patients: are they different injuries? J Trauma. 2003;54:1146-1151. 3. Rees MJ, Aickin R, Kolbe A, et al. The screening pelvic radiograph in pediatric trauma. Pediatr Radiol. 2001;31:497-500. 4. Holmes JF, Wisner DH. Indications and performance of pelvic radiography in patients with blunt trauma. Am J Emerg Med. 2012;30:1129-1133. 5. The Pediatric Emergency Care Applied Research Network (PECARN): rationale, development, and first steps. Acad Emerg Med. 2003;10:661-668. 6. Holmes JF, Lillis K, Monroe D, et al. Identifying patients at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013;62:107-116.e2. 7. US Department of Health and Human Services NIH; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Bethesda, MD: National Heart, Lung, & Blood Institute; 2005:8-15. 8. Bent C, Chicklore S, Newton A, et al. Do emergency physicians and radiologists reliably interpret pelvic radiographs obtained as part of a trauma series? Emerg Med J. 2013;30:106-111. 9. Berry GE, Adams S, Harris MB, et al. Are plain radiographs of the spine necessary during evaluation after blunt trauma? accuracy of screening torso computed tomography in thoracic/lumbar spine fracture diagnosis. J Trauma. 2005;59:1410-1413.
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Sensitivity of Plain Pelvis Radiography in Children
10. Cain G, Shepherdson J, Elliott V, et al. Imaging suspected cervical spine injury: plain radiography or computed tomography? systematic review. Radiography. 2010;16:68-77. 11. Guillamondegui OD, Mahboubi S, Stafford PW, et al. The utility of the pelvic radiograph in the assessment of pediatric pelvic fractures. J Trauma. 2003;55:236-239. 12. Wong AT, Brady KB, Caldwell AM, et al. Low-risk criteria for pelvic radiography in pediatric blunt trauma patients. Pediatr Emerg Care. 2011;27:92-96. 13. Barleben A, Jafari F, Rose J Jr, et al. Implementation of a cost-saving algorithm for pelvic radiographs in blunt trauma patients. J Trauma. 2011;71:582-584. 14. Kessel B, Sevi R, Jeroukhimov I, et al. Is routine portable pelvic x-ray in stable multiple trauma patients always justified in a high technology era? Injury. 2007;38:559-563. 15. Poole GV, Ward EF, Muakkassa FF, et al. Pelvic fracture from major blunt trauma: outcome is determined by associated injuries. Ann Surg. 1991;231:532-539. 16. Lunsjo K, Tadros A, Hauggaard A, et al. Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients. J Trauma. 2008;62:687-691.
17. Yen K, Kuppermann N, Lillis K, et al. Interobserver agreement in the clinical assessment of children with blunt abdominal trauma. Acad Emerg Med. 2013;20:426-432. 18. Brenner DJ, Elliston CD, Hall EJ, et al. Estimated risks of radiationinduced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001;176:289-296. 19. International Commission on Radiological Protection. 1990 Recommendations of the International Commission on Radiological Protection Publication 60. International Commission on Radiological Protection. Oxford, England: Pergamon; 1991. 20. Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg. 2002;194:121-125. 21. Yugeros P, Sarmiento J, Garcia A, et al. Unnecessary use of pelvic x-ray in blunt trauma. J Trauma. 1995;3:722-725. 22. Kevel K, Wong A, Goldman HS, et al. Is a complete trauma series indicated for all pediatric trauma victims? Pediatr Emerg Care. 2002;18:75-77. 23. Sauerland S, Bouillon B, Rixen D, et al. The reliability of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta-analysis. Arch Orthop Trauma Surg. 2004;124:123-128.
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Volume 65, no. 1 : January 2015
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Sensitivity of Plain Pelvis Radiography in Children
APPENDIX Participating centers and site investigators are listed below in alphabetical order: Bellevue Hospital Center (M. Tunik); Children’s Hospital Boston (L. Lee); Children’s Hospital of Michigan (P. Mahajan); Children’s Hospital of New YorkPresbyterian (M. Kwok); Children’s Hospital of Philadelphia (F. Nadel); Children’s National Medical Center (S. Atabaki); Cincinnati Children’s Hospital Medical Center (B. Kerrey); DeVos Children’s Hospital (J. Kooistra); Howard County Medical Center (D. Monroe); Hurley Medical Center (D. Borgialli); Jacobi Medical Center (S. Blumberg); Medical College of Wisconsin/Children’s Hospital of Wisconsin (K. Yen); Nationwide Children’s Hospital (B. Bonsu); University of California Davis Medical Center (J. Holmes, N. Kuppermann); University of Maryland (J. Menaker); University of Michigan (A. Rodgers); University of Rochester (M. Garcia); University of Utah/Primary Children’s Medical Center (K. Adelgais); Washington University/St. Louis Children’s Hospital (K. Quayle); Women and Children’s Hospital of Buffalo (K. Lillis). We acknowledge the efforts of the following individuals participating in PECARN when this study was initiated. PECARN Steering Committee: N. Kuppermann, Chair; E. Alpern, D. Borgialli, J. Callahan, J. Chamberlain, P. Dayan, J. M. Dean, M. Gerardi, M. Gorelick, J. Hoyle, E. Jacobs, D. Jaffe, R. Lichenstein, K. Lillis, P. Mahajan, R. Maio, F. Moler, D. Monroe, R. Ruddy, R. Stanley, M. Tunik, A. Walker. MCHB/EMSC liaisons: D. Kavanaugh, H. Park. PECARN Central Data Management and Coordinating Center (CDMCC): M. Dean, R. Holubkov, S. Knight, A. Donaldson, S. Zuspan, M. Miskin, J. Wade, A. Jones, M. Fjelstad.
71.e1 Annals of Emergency Medicine
Feasibility and Budget Subcommittee: T. Singh, Chair; A. Drongowski, L. Fukushima, E. Kim, D. Monroe, G. O’Gara, H. Rincon, M. Tunik, S. Zuspan. Grants and Publications Subcommittee: M. Gorelick, Chair; E. Alpern, D. Borgialli, K. Brown, L. Cimpello, A. Donaldson, G. Foltin, F. Moler, S. Teach. Protocol Concept Review and Development Subcommittee: D. Jaffe, Chair; J. Chamberlain, A. Cooper, P. Dayan, J. M. Dean, R. Holubkov, P. Mahajan, R. Maio, N. C. Mann, K. Shaw, A. Walker. Quality Assurance Subcommittee: R. Stanley, Chair; P. Ehrlich, R. Enriquez, M. Gerardi, R. Holubkov, E. Jacobs, R. Lichenstein, K. Lillis, B. Millar, R. Ruddy, M. Shults. Safety and Regulatory Affairs Subcommittee (SRAS): W. Schalick, J. Callahan, Cochairs; S. Atabaki, J. Burr, K. Call, J. Hoyle, R. Ruddy, J. Suhajda, N. Schamban.
Table E1. Pelvic instability among patients with or without pelvic fractures or dislocations.
Pelvic Instability Presence of pelvis instability Absence of pelvis instability Pelvis instability marked as “unknown” Missing value for pelvis instability Total
Presence of Absence of Pelvic Fractures Pelvic Fracture/ or Dislocations Dislocations Total* 38 376 27
89 10,999 194
127 11,375 221
10
311
321
451
11,593
12,044
*The total number of subjects is based on the cohort in the parent study.
Volume 65, no. 1 : January 2015
Sensitivity of Plain Pelvis Radiography in Children With Blunt Torso Trauma Maria Y. Kwok, MD, MPH*; Ken Yen, MD, MS; Shireen Atabaki, MD, MPH; Kathleen Adelgais, MD, MPH; Madelyn Garcia, MD, MPH; Kimberly Quayle, MD; Joshua Kooistra, DO; Bema K. Bonsu, MD; Kent Page, MStat; Dominic Borgialli, DO, MPH; Nathan Kuppermann, MD, MPH; James F. Holmes, MD, MPH† *Corresponding Author. E-mail: [email protected].
Study objective: Plain anteroposterior pelvic radiographs are commonly used to screen children for pelvic fractures or dislocations after blunt torso trauma. The test sensitivity and utility, however, are unclear. We assessed the sensitivity of anteroposterior pelvic radiographs for identifying children with pelvic fractures or dislocations after blunt torso trauma. We hypothesized that anteroposterior pelvic radiographs fail to identify all children with pelvic fractures or dislocations, including patients undergoing operative intervention and those with hypotension. Methods: We conducted a prospective multicenter observational study of children (20 mph MVC
3
Additional Thoracoabdominal Injuries
Pelvic Bone Fractures
Death Arterial Bleeding Within From a Pelvic 30 Days Fracture of Injury
Femur fracture
Ilium*
No
No
Liver, kidney, adrenal gland, hemoperitoneum, pulmonary contusion, pneumothorax, hemothorax, rib fracture None Pulmonary contusion, pneumothorax, hemothorax, rib fracture Liver, adrenal gland, hemoperitoneum, pulmonary contusion, rib fracture, cardiac contusion None
Pubis, ilium
No
No
Ilium Pubis, ilium
No No
No Yes
Pubis, acetabulum involvement
No
No
Pubis
No
No
Pubis, ilium, ischium
No
Yes
No
Yes
Gastrointestinal, pancreas, vascular, hemoperitoneum, femur fracture, pulmonary contusion Femur fracture, pulmonary contusion, pneumothorax, rib fracture
No
No
5 15
Pubis, sacrum, open-book disruption, SI joint disruption Liver, spleen, hemoperitoneum, pulmonary Pubis, sacrum* contusion, pneumothorax, rib fracture None Pubis, sacrum None Pubis, sacrum
No No
No No
15
Urinary bladder, hemoperitoneum
3 15 3 15 3 15
15
Pedestrian or bicyclist struck by moving vehicle
3
16
MVC, >40 mph
3
16
MVC
3
Spleen, hemoperitoneum, pulmonary contusion, hemothorax, rib fracture Pulmonary contusion Pulmonary contusion, pneumothorax, rib fracture None Hemothorax
Pubis, ilium, sacrum, acetabulum involvement Pubis
No
No
No
Yes
Sacrum Pubis, sacrum
No No
No Yes
Pubis, Acetabulum Involvement* Pubis, sacrum, SI joint disruption Sacrum, acetabulum involvement
No
No
No
Yes
No
No
No
No
No
Yes
Yes
No
Liver, hemoperitoneum, femur fracture, pulmonary contusion, pneumothorax, hemothorax Liver, spleen, kidney, hemoperitoneum, Pubis, ischium, sacrum pulmonary contusion, pneumothorax, hemothorax, rib fracture, pneumomediastinum Liver, spleen, hemoperitoneum, Ilium pneumothorax, hemothorax, rib fracture, diaphragm Liver, spleen, hemoperitoneum, pulmonary Pubis, ilium, sacrum, contusion, pneumothorax, hemothorax, acetabulum involvement rib fracture
MVC, Motor vehicle crash; mph, miles per hour. *The patient had normal plain pelvis radiograph results.
radiographs in patients already scheduled to undergo abdominal or pelvic CT. CT scanning, however, should not be used as a primary screening test if no clinical evidence of pelvic fracture or dislocation exists. Although normal plain anteroposterior pelvic radiographs do not absolutely exclude the possibility of fracture, the patient is 68 Annals of Emergency Medicine
at substantially lower risk if the plain anteroposterior pelvic radiograph result is normal. These patients may be allowed to ambulate, and if concern still exists for pelvic fractures or dislocations (ie, inability to ambulate), then CT should be considered (see Figure 2 for a suggested algorithm). Volume 65, no. 1 : January 2015
Kwok et al
Sensitivity of Plain Pelvis Radiography in Children
Table 5. Patients with normal plain anteroposterior pelvic radiograph results who underwent operative intervention.* Age, Years
Mechanism of Injury
Pelvic Bone Fractures or Dislocations
GCS Score
Additional Thoracoabdominal Injuries None Splenic laceration (hemoperitoneum), pulmonary contusion, pneumothorax, rib fracture Rib fracture
10 13
MVC MVC, >40 mph
15 3
15
15
15
Pedestrian or bicyclist struck by moving vehicle MVC
15
16
MVC
15
Splenic laceration (hemoperitoneum), pulmonary contusion, pneumothorax, hemothorax, rib fracture None
Acetabulum Sacrum Ilium, pubis, sacroiliac joint Pubis, sacroiliac joint
Pubis, sacroiliac joint
*All fractures identified by pelvic CT scanning. None of these 5 patients were hypotensive on presentation.
Limited data exist about the importance of assessing for pelvic instability in injured patients. Adult studies suggest it is not useful because it has low reliability, sensitivity, and specificity.15,16 Yen et al17 examined the cohort of patients reported in this study and also found poor interrater reliability in the assessment of pelvic instability. Furthermore, concern exists for further dislodging fractured pelvic bones by applying direct pressure. More concerning, however, was the poor sensitivity in a subset of patients with unstable pelvic fractures or dislocations (those with open-book pelvic fractures). These findings indicate that the clinical assessment of children with blunt trauma for pelvic instability has limited utility. In an era in which cost-effectiveness and the mutagenic effects of cumulative lifetime exposure to ionizing radiation are major
concerns,18,19 appropriate use of radiography is important. Previous investigations have advocated the use of clinical findings to guide the decision on obtaining plain anteroposterior pelvic radiographs.20-22 One study suggested that children are at low risk for pelvic fractures if they have the following: lack of lower extremity injury, lack of an abnormal physical examination result of the pelvis, and no indication for abdominopelvic CT. That study, however, was limited by its retrospective nature, selection of only subjects with Glasgow Coma Scale scores 14 and 15, and the lack of information on distracting injury or alcohol intoxication that may make examinations difficult.7 Adult studies suggest that pelvic radiographs can be avoided in patients who are alert, are hemodynamically stable, and have no pelvic bone tenderness. Although these variables do not identify all patients
Figure 2. Suggested algorithm for the initial evaluation of children considered at risk for pelvic fractures or dislocations by the treating physician. Volume 65, no. 1 : January 2015
Annals of Emergency Medicine 69
Kwok et al
Sensitivity of Plain Pelvis Radiography in Children with pelvic fractures, they have excellent sensitivity for adult patients with pelvic fractures undergoing operative intervention.4,23 This study demonstrates that high-risk mechanisms of injury for pelvic fractures or dislocations include pedestrians or bicyclists struck by moving vehicles and injuries involving motor vehicle crashes. Victims of low-level falls or bicycle collisions, or a fall from bicycles, rarely received a diagnosis of pelvic fractures or dislocations. Furthermore, none of the 281 patients in this study who fell down stairs received a diagnosis of pelvic fractures or dislocations. Physicians may use this information when determining the need for pelvic radiography. The pubis was the most commonly injured pelvic bone, results similar to those of previous studies.12,16 Hip joint dislocations and open-book pelvic fractures were rare, results that were also similar to those of previous studies.12 Surgery was rare; however, among patients undergoing surgery, the most common injury was to the pubis bones. Pelvic fractures or dislocations were rare in patients younger than 2 years and were most likely to the ilium and pubis bones. In summary, plain anteroposterior pelvic radiograph has a limited sensitivity for identifying children with pelvic fractures or dislocations after blunt trauma, including a significant proportion of children with hypotension and those who undergo operative intervention. Plain anteroposterior pelvic radiographs should not be relied on as the sole diagnostic test in patients considered at high risk of pelvic fractures or dislocations. Furthermore, plain anteroposterior pelvic radiograph is unnecessary in patients for whom abdominal or pelvic CT scanning is otherwise planned.
Author contributions: NK and JFH conceived and designed the study. JFH obtained grant funding for the project. MYK, KY, SA, KA, MG, KQ, JK, BKB, DB, NK, and JFH supervised the study at their respective sites and acquired data for the study. KP, NK, and JFH had full access to the data in the study and take responsibility for the accuracy of the data analysis. MYK, KP, NK, and JFH participated in the data analysis and interpreted the data. MYK, KP, and JFH created the figures. MYK and JFH performed the literature search. MYK drafted the article. KY, SA, KA, MG, KQ, JK, BKB, KP, DB, NK, and JFH critically revised the article. MYK takes responsibility for the paper as a whole.
The authors acknowledge the research coordinators in PECARN, without whose dedication and hard work this study would not have been possible; and all the clinicians around the PECARN who enrolled children in this study.
REFERENCES
Supervising editor: Steven M. Green, MD Author affiliations: From the Department of Pediatrics, Columbia University Medical Center, New York, NY (Kwok); the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (Yen); the Department of Pediatrics, Children’s National Medical Center, Washington, DC (Atabaki); the Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO (Adelgais); the Department of Pediatrics, University of Rochester Medical Center, Rochester, NY (Garcia); the Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO (Quayle); the Department of Pediatrics, Helen DeVos Children’s Hospital, Grand Rapids, MI (Kooistra); the Department of Pediatrics, Nationwide Children’s Hospital, Columbia, OH (Bonsu); the Department of Pediatrics, University of Utah, Salt Lake City, UT (Page); the Department of Emergency Medicine, Hurley Medical Center, Flint, MI, and Department of Emergency Medicine, University of Michigan, Ann Arbor, MI (Borgialli); and the Department of Emergency Medicine (Kuppermann, Holmes) and Department of Pediatrics (Kuppermann), University of California, Davis, Sacramento, CA.
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Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and provided the following details: This work was supported by a grant from the Centers for Disease Control and Prevention (1 R49CE00100201). PECARN is supported by the Health Resources and Services Administration, Maternal and Child Health Bureau, Emergency Medical Services for Children Program through the following cooperative agreements: U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC00008, U03MC22684, and U03MC22685. Publication dates: Received for publication February 6, 2014. Revision received June 10, 2014. Accepted for publication June 16, 2014. Available online July 30, 2014. Presented at the Pediatric Academic Society, May 2013, Washington, DC; and the Society of Academic Emergency Medicine, May 2013, Atlanta, GA.
1. Committee on Trauma, American College of Surgeons (2012). ATLS: Advanced Trauma Life Support Program for Doctors (9th ed.). Chicago: American College of Surgeons. 2. Demetriades D, Karaiskakis M, Velmahos GC, et al. Pelvic fractures in pediatric and adult trauma patients: are they different injuries? J Trauma. 2003;54:1146-1151. 3. Rees MJ, Aickin R, Kolbe A, et al. The screening pelvic radiograph in pediatric trauma. Pediatr Radiol. 2001;31:497-500. 4. Holmes JF, Wisner DH. Indications and performance of pelvic radiography in patients with blunt trauma. Am J Emerg Med. 2012;30:1129-1133. 5. The Pediatric Emergency Care Applied Research Network (PECARN): rationale, development, and first steps. Acad Emerg Med. 2003;10:661-668. 6. Holmes JF, Lillis K, Monroe D, et al. Identifying patients at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013;62:107-116.e2. 7. US Department of Health and Human Services NIH; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Bethesda, MD: National Heart, Lung, & Blood Institute; 2005:8-15. 8. Bent C, Chicklore S, Newton A, et al. Do emergency physicians and radiologists reliably interpret pelvic radiographs obtained as part of a trauma series? Emerg Med J. 2013;30:106-111. 9. Berry GE, Adams S, Harris MB, et al. Are plain radiographs of the spine necessary during evaluation after blunt trauma? accuracy of screening torso computed tomography in thoracic/lumbar spine fracture diagnosis. J Trauma. 2005;59:1410-1413.
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10. Cain G, Shepherdson J, Elliott V, et al. Imaging suspected cervical spine injury: plain radiography or computed tomography? systematic review. Radiography. 2010;16:68-77. 11. Guillamondegui OD, Mahboubi S, Stafford PW, et al. The utility of the pelvic radiograph in the assessment of pediatric pelvic fractures. J Trauma. 2003;55:236-239. 12. Wong AT, Brady KB, Caldwell AM, et al. Low-risk criteria for pelvic radiography in pediatric blunt trauma patients. Pediatr Emerg Care. 2011;27:92-96. 13. Barleben A, Jafari F, Rose J Jr, et al. Implementation of a cost-saving algorithm for pelvic radiographs in blunt trauma patients. J Trauma. 2011;71:582-584. 14. Kessel B, Sevi R, Jeroukhimov I, et al. Is routine portable pelvic x-ray in stable multiple trauma patients always justified in a high technology era? Injury. 2007;38:559-563. 15. Poole GV, Ward EF, Muakkassa FF, et al. Pelvic fracture from major blunt trauma: outcome is determined by associated injuries. Ann Surg. 1991;231:532-539. 16. Lunsjo K, Tadros A, Hauggaard A, et al. Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients. J Trauma. 2008;62:687-691.
17. Yen K, Kuppermann N, Lillis K, et al. Interobserver agreement in the clinical assessment of children with blunt abdominal trauma. Acad Emerg Med. 2013;20:426-432. 18. Brenner DJ, Elliston CD, Hall EJ, et al. Estimated risks of radiationinduced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001;176:289-296. 19. International Commission on Radiological Protection. 1990 Recommendations of the International Commission on Radiological Protection Publication 60. International Commission on Radiological Protection. Oxford, England: Pergamon; 1991. 20. Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg. 2002;194:121-125. 21. Yugeros P, Sarmiento J, Garcia A, et al. Unnecessary use of pelvic x-ray in blunt trauma. J Trauma. 1995;3:722-725. 22. Kevel K, Wong A, Goldman HS, et al. Is a complete trauma series indicated for all pediatric trauma victims? Pediatr Emerg Care. 2002;18:75-77. 23. Sauerland S, Bouillon B, Rixen D, et al. The reliability of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta-analysis. Arch Orthop Trauma Surg. 2004;124:123-128.
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APPENDIX Participating centers and site investigators are listed below in alphabetical order: Bellevue Hospital Center (M. Tunik); Children’s Hospital Boston (L. Lee); Children’s Hospital of Michigan (P. Mahajan); Children’s Hospital of New YorkPresbyterian (M. Kwok); Children’s Hospital of Philadelphia (F. Nadel); Children’s National Medical Center (S. Atabaki); Cincinnati Children’s Hospital Medical Center (B. Kerrey); DeVos Children’s Hospital (J. Kooistra); Howard County Medical Center (D. Monroe); Hurley Medical Center (D. Borgialli); Jacobi Medical Center (S. Blumberg); Medical College of Wisconsin/Children’s Hospital of Wisconsin (K. Yen); Nationwide Children’s Hospital (B. Bonsu); University of California Davis Medical Center (J. Holmes, N. Kuppermann); University of Maryland (J. Menaker); University of Michigan (A. Rodgers); University of Rochester (M. Garcia); University of Utah/Primary Children’s Medical Center (K. Adelgais); Washington University/St. Louis Children’s Hospital (K. Quayle); Women and Children’s Hospital of Buffalo (K. Lillis). We acknowledge the efforts of the following individuals participating in PECARN when this study was initiated. PECARN Steering Committee: N. Kuppermann, Chair; E. Alpern, D. Borgialli, J. Callahan, J. Chamberlain, P. Dayan, J. M. Dean, M. Gerardi, M. Gorelick, J. Hoyle, E. Jacobs, D. Jaffe, R. Lichenstein, K. Lillis, P. Mahajan, R. Maio, F. Moler, D. Monroe, R. Ruddy, R. Stanley, M. Tunik, A. Walker. MCHB/EMSC liaisons: D. Kavanaugh, H. Park. PECARN Central Data Management and Coordinating Center (CDMCC): M. Dean, R. Holubkov, S. Knight, A. Donaldson, S. Zuspan, M. Miskin, J. Wade, A. Jones, M. Fjelstad.
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Feasibility and Budget Subcommittee: T. Singh, Chair; A. Drongowski, L. Fukushima, E. Kim, D. Monroe, G. O’Gara, H. Rincon, M. Tunik, S. Zuspan. Grants and Publications Subcommittee: M. Gorelick, Chair; E. Alpern, D. Borgialli, K. Brown, L. Cimpello, A. Donaldson, G. Foltin, F. Moler, S. Teach. Protocol Concept Review and Development Subcommittee: D. Jaffe, Chair; J. Chamberlain, A. Cooper, P. Dayan, J. M. Dean, R. Holubkov, P. Mahajan, R. Maio, N. C. Mann, K. Shaw, A. Walker. Quality Assurance Subcommittee: R. Stanley, Chair; P. Ehrlich, R. Enriquez, M. Gerardi, R. Holubkov, E. Jacobs, R. Lichenstein, K. Lillis, B. Millar, R. Ruddy, M. Shults. Safety and Regulatory Affairs Subcommittee (SRAS): W. Schalick, J. Callahan, Cochairs; S. Atabaki, J. Burr, K. Call, J. Hoyle, R. Ruddy, J. Suhajda, N. Schamban.
Table E1. Pelvic instability among patients with or without pelvic fractures or dislocations.
Pelvic Instability Presence of pelvis instability Absence of pelvis instability Pelvis instability marked as “unknown” Missing value for pelvis instability Total
Presence of Absence of Pelvic Fractures Pelvic Fracture/ or Dislocations Dislocations Total* 38 376 27
89 10,999 194
127 11,375 221
10
311
321
451
11,593
12,044
*The total number of subjects is based on the cohort in the parent study.
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