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AP pelvis radiograph is insufficient for diagnosis of U-type sacral fractures

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Abstract

Purpose

We investigated the sensitivity of a screening test for pelvic ring disruption, the AP pelvis radiograph, for clinically serious U-type sacral fractures which merit consultation with an orthopedic trauma specialist and may require transfer to a higher level of care.

Methods

Retrospective clinical cohort of 63 consecutive patients presenting with U-type sacral fractures at one level 1 trauma referral center from January 2006 through December 2019. The sensitivity of the first AP pelvis radiograph obtained on admission, interpreted without reference to antecedent or concomitant pelvis computed tomography (CT) by a radiologist and a panel of three blinded orthopedic traumatologists, was determined against a reference diagnosis made from review of all pelvis radiographs, CT images, operative reports, and clinical documentation.

Results

Sensitivity of AP pelvis radiograph for U-type sacral fractures was 2% as interpreted by a radiologist and mean 12% (range 5–27%) as interpreted by orthopedic traumatologists with poor inter-rater agreement (Fleiss’ κ = 0.11). 94% of sacra were at obscured by radiographic artifact.

Conclusion

The sensitivity of an AP pelvis radiograph is poor for U-type sacral fractures, whether interpreted by radiologists or orthopedic traumatologists. Pelvis CT should be considered as a screening test to rule out sacral fracture when the patient reports posterior pelvic pain, even if plain radiography demonstrates no injury or a minimally displaced pelvic ring disruption.

Level of evidence

Diagnostic level III

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Available upon request.

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References

  1. Pulley BR, Cotman SB, Fowler TT (2018) Surgical fixation of geriatric sacral U-type insufficiency fractures: a retrospective analysis. J Orthop Trauma 32(12):617–622

    Article  Google Scholar 

  2. Bellabarba C, Schroeder GD, Kepler CK et al (2016) The AOSpine sacral fracture classification. Glob Spine J 6(1S):S0036

    Google Scholar 

  3. DeRogatis MJ, Breceda AP, Lee P et al (2018) Sacral fractures with spondylopelvic dissociation. JBJS Rev 6(5):e3 1-10

    Article  Google Scholar 

  4. American College of Surgeons Committee on Trauma (2018) Advanced Trauma Life Support® student course manual, 10th edn. American College of Surgeons, Chicago

    Google Scholar 

  5. Bent C, Chicklore S, Newton A et al (2013) Do emergency physicians and radiologists reliably interpret pelvic radiographs obtained as part of a trauma series? Emerg Med J 30(2):106–111

    Article  Google Scholar 

  6. Kuklo TR, Potter BK, Ludwig SC et al (2006) Radiographic measurement techniques for sacral fractures consensus statement of the spine trauma study group. Spine 31(9):1047–1055

    Article  Google Scholar 

  7. Lunsjo K, Tadros A, Hauggaard A et al (2007) Acute plain anterioposterior radiograph of the pelvis is not useful in detecting fractures of iliac wing and os sacrum: a prospective study of 73 patients using CT as gold standard. Australas Radiol 51(2):147–149

    Article  CAS  Google Scholar 

  8. Hilty MP, Behrendt I, Benneker LM et al (2008) Pelvic radiography in ATLS algorithms: a diminishing role? World. J Emerg Surg 3(1):11

    Article  Google Scholar 

  9. Schicho A, Schmidt SA, Seeber K et al (2016) Pelvic X-ray misses out on detecting sacral fractures in the elderly – importance of CT imaging in blunt pelvic trauma. Injury 47(3):707–710

    Article  Google Scholar 

  10. Sauerland S, Bouillon B, Rixen D et al (2004) The reliability of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta-analysis. Arch Orthop Trauma Surg 124(2):123–128

    Article  Google Scholar 

  11. Vo NJ, Gash J, Browning J et al (2004) Pelvic imaging in the stable trauma patient: is the AP pelvic radiograph necessary when abdominopelvic CT shows no acute injury? Emerg Radiol 10(5):246–249

    Article  Google Scholar 

  12. Porrino JA Jr, Kohl CA, Holden D et al (2010) The importance of sagittal 2D reconstruction in pelvic and sacral trauma: avoiding oversight of U-shaped fractures of the sacrum. Am J Roentgenol 194(4):1065–1071

    Article  Google Scholar 

  13. Bishop JA, Dangelmajer S, Corcoran-Schwartz I et al (2017) Bilateral sacral ala fractures are strongly associated with lumbopelvic instability. J Orthop Trauma 31(12):636–639

    Article  Google Scholar 

  14. Strange-Vognsen HH, Lebech A (1991) An unusual type of fracture in the upper sacrum. J Orthop Trauma 5(2):200–203

    Article  CAS  Google Scholar 

  15. Roy-Camille R, Saillant G, Gagna G et al (1985) Transverse fracture of the upper sacrum Suicidal jumper’s fracture. Spine 10(9):838–845

    Article  CAS  Google Scholar 

  16. Meinberg E, Agel J, Roberts C et al (2018) Fracture and dislocation classification compendium—2018. J Orthop Trauma 32:S1–S10

    Article  Google Scholar 

  17. Kaiser SP, Gardner MJ, Liu J et al (2014) Anatomic determinants of sacral dysmorphism and implications for safe iliosacral screw placement. J Bone Joint Surg Am 96(14):e120 1–8

    Article  Google Scholar 

  18. Bossuyt PM, Reitsma JB, Bruns DE et al (2015) STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. Radiology 277(3):826–832

    Article  Google Scholar 

  19. Nork SE, Jones CB, Harding SP et al (2001) Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma 15(4):238–246

    Article  CAS  Google Scholar 

  20. Lemeshow S, Hosmer DW Jr (1982) A review of goodness of fit statistics for use in the development of logistic regression models. Am J Epidemiol 115(1):92–106

    Article  CAS  Google Scholar 

  21. Kim PK (2017) Radiology for trauma and the general surgeon. Surg Clin 97(5):1175–1183

    Google Scholar 

  22. Pfeifer R, Pape H-C (2008) Missed injuries in trauma patients: a literature review. Patient Saf Surg 2(1):20

    Article  Google Scholar 

  23. Natoli RM, Fogel HA, Holt D et al (2017) Advanced imaging lacks clinical utility in treating geriatric pelvic ring injuries caused by low-energy trauma. J Orthop Trauma 31(4):194–199

    Article  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Kenneth F. Linnau, MD, MS for his guidance on methods of distributing and reviewing radiographs.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, 90033-5322, USA

    Joseph T. Patterson

  2. Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA, USA

    William D. Lack, Julie Agel, Reza Firoozabadi, Michael F. Githens, Iain S. Elliott, Carlo Bellabarba & Conor P. Kleweno

  3. Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA

    Paul A. Toogood

  4. Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA

    Milton T. Little

  5. Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA

    Justin M. Haller

Authors
  1. Joseph T. Patterson
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  2. William D. Lack
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  3. Julie Agel
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  4. Paul A. Toogood
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  7. Reza Firoozabadi
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  8. Michael F. Githens
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  9. Iain S. Elliott
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  10. Carlo Bellabarba
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  11. Conor P. Kleweno
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Corresponding author

Correspondence to Joseph T. Patterson.

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Ethics approval

This study was approved by the Human Subjects Division of the University of Washington Institutional Review Board No. STUDY00008550.

Conflict of interest

JTP reports research support from AOTrauma North America. WDL reports membership of an editorial or governing board of the Journal of Orthopaedic Trauma. JA reports membership of a board or committee of the Orthopaedic Trauma Association. MTL reports paid consulting work for DePuy and Globus Medical. JMH reports membership of board or committee of the Orthopaedic Trauma Association and paid consulting work for NewClip Technics. RF reports teaching honoraria from AO North America Teaching Honorarium, royalties from Innomed, membership of a board or committee of the Orthopaedic Trauma Association, and paid consulting work for Smith & Nephew. MFG reports membership of an editorial or governing board of Techniques in Orthopaedics, membership of a board or committee of the Western Orthopaedic Association, speaker or presenter payments from DePuy Synthes, and publishing royalties from Wolters Kluwer Health—Lippincott Williams & Wilkins. CB reports membership of a board or committee of the Cervical Spine Research Society and membership of an editorial or governing board of Orthopedics Today. CPK reports membership of a board or committee of AOTrauma North America and the Orthopaedic Trauma Association; paid consulting work for Globus Medical, DePuy Synthes, and Stryker; and royalties from Globus Medical. PAG and IES report no relationships to disclose.

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Patterson, J.T., Lack, W.D., Agel, J. et al. AP pelvis radiograph is insufficient for diagnosis of U-type sacral fractures. Emerg Radiol 28, 1119–1126 (2021). https://doi.org/10.1007/s10140-021-01966-7

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  • DOI: https://doi.org/10.1007/s10140-021-01966-7

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