Pelvic Radiography Unnecessary in Children if CT Is Planned

Ricki Lewis, PhD

August 12, 2014

Plain pelvic radiography to detect fracture or dislocation among children with blunt torso trauma is only 78% sensitive, according to a study published online July 29 in the Annals of Emergency Medicine.

Anteroposterior pelvic X-ray has been the gold standard to evaluate children who have undergone blunt force trauma, but it may not identify all cases. Therefore, it may not be necessary and may even add to radiologic risk in children who are scheduled to have an abdominal/pelvic computed tomography (CT) scan.

Plain pelvic X-rays are typically used for patients with hypotension and for hemodynamically stable patients to confirm a clinical diagnosis of a fracture or dislocation in those for whom CT scanning is not planned. Injuries sustained in motor vehicle accidents are the ones most likely to include fracture, particularly among pedestrians and bicycle riders.

Previous studies have shown that pelvic X-rays have poor sensitivity among adults with blunt torso trauma. In the current study, Maria Y. Kwok, MD, MPH, from the Department of Pediatrics at Columbia University Medical Center in New York City, and colleagues evaluated their sensitivity in a pediatric population. They conducted a prospective multicenter observational study of patients in the Pediatric Emergency Care Applied Research Network who were younger than 18 years who had blunt torso trauma, comparing pelvic X-rays with the final diagnosis by an orthopedist.

Of 12,044 patients in the study, 451 (3.7%; 95% confidence interval [CI], 3.4% - 4.1%) had pelvic fractures or dislocations. Of those, 65 (14%; 95% CI, 11% - 18%) underwent surgery and 21 (4.7%; 95% CI, 2.9% - 7.0%) had age-adjusted hypotension. In the emergency department, 382 of the 451 patients had pelvic X-rays, which detected 297 (78% sensitivity; 95% CI, 73% - 82%) of 382 for those with fractures or dislocations, 55 (92% sensitivity; 95% CI, 82% - 97%) of 60 for patients undergoing surgery, and 14 (82% sensitivity; 95% CI, 57% - 96%) of 17 for patients with hypotension.

The researchers suggest revision of the recommendation from the Advanced Trauma Life Support program for pediatric blunt force trauma patients to have X-rays, based on the finding of 78% sensitivity. Of the 85 patients not correctly identified as having pelvic fractures or dislocations from X-ray, 84 underwent CT scans, which identified fractures in 82 (98% sensitivity; 95% CI, 92% - 100%). However, the researchers caution that CT scanning should only follow findings from a physical exam that indicate a patient has a pelvic fracture or dislocation.

Limitations of the study include inability to detect minor fractures, exclusion of radiographs with inconclusive interpretations, and exclusion of patients who died from their injuries.

The researchers have disclosed no relevant financial relationships.

Ann Emerg Med. Published online July 29, 2014. Abstract

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