Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable

Abstract

Background: Occult instability of lateral compression type-1 (LC1) pelvic ring injuries may be determined with a fluoroscopic stress examination under anesthesia (EUA) performed in the operating room. We hypothesized that LC1 injuries, similar to some fractures of the extremities, could be radiographically stressed for stability in the emergency department (ED). Our primary objective was to determine if stress examination of LC1 fractures could be safely and accurately performed in the ED and could be tolerated by patients.Methods: A prospective, consecutive series of 70 patients with minimally displaced LC1 pelvic injuries (<10-mm displacement on presentation) underwent stress examinations performed by the on-call orthopaedic resident in the ED radiology suite. The stress examination series included static 40°inlet, internal rotation stress inlet, and external rotation stress inlet views. Pelvic fractures that had positive stress results ( ‡10 mm of overlap of the rami) were indicated for a surgical procedure. These fractures also underwent EUA in order for the 2 techniques to be compared.Results: All patients tolerated the ED stress examination without general anesthetic or hemodynamic instability. Fiftyseven patients (81%) had negative stress results and were allowed to bear weight. All patients with negative stress results who had 3-month follow-up went on to radiographic union without substantial displacement. For the patients with a positive stress result in the ED, the mean displacement was 15.15 mm (95% confidence interval [CI], 10.8 to 19.4 mm) for the ED stress test and 15.60 mm (95% CI, 11.7 to 19.4 mm) for the EUA (p = 0.86). Two patients with a negative ED stress test did not mobilize during their hospitalization and underwent EUA and conversion to a surgical procedure. Thus, a total of 11 patients underwent both stress testing in the ED and EUA; no patient had a positive result on one test but a negative result on the other.Conclusions: ED stress examination of LC1 injuries is a safe and reliable method to determine pelvic ring stability. The displacement measured in the ED stress examination is similar to the displacement measured under general anesthesia. Furthermore, a negative ED stress examination predicts successful nonoperative treatment. Given the results of this study, we encourage the use of stress examination in the ED for LC1-type injuries involving complete sacral fractures only. Widescale adoption of this streamlined protocol may substantially diminish cost, anesthetic risk, and potential operations for patients.Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence. Lateral compression type-1 (LC1) fractures are common injuries, accounting for approximately 50% of all pelvic ring injuries 1-3 . They occur secondary to a lateral compressive force on the pelvis causing medialization and internal rotation of the hemipelvis 1,3,4 . These injuries have historically been treated nonoperatively, but current surgical indications a...

Combined Anterior–Posterior versus Posterior-Only Fixation of Stress-Positive Minimally Displaced Lateral Compression Type 1 (LC1) Pelvic Ring Injuries

“…9,27,28 It has been demonstrated in multiple studies that operative management in appropriately selected patients, seems to improve the early outcomes of stress positive patients in pain and mobility. 2,7,8,10–12 The current study suggests that the cited goals of operative management of these controversial injuries may be more likely achieved with a combined anterior–posterior fixation construct.…”

“…1–6 Proponents of operative management of these injuries cite potential benefits in pain control, mobilization, hospital length of stay, and ability to discharge home. 2,7–13 However, it has been repeatedly shown that the long-term outcomes of these injuries are similar, regardless of operative management. 13–20…”

“…[1][2][3][4][5][6] Proponents of operative management of these injuries cite potential benefits in pain control, mobilization, hospital length of stay, and ability to discharge home. 2,[7][8][9][10][11][12][13] However, it has been repeatedly shown that the long-term outcomes of these injuries are similar, regardless of operative management. [13][14][15][16][17][18][19][20] Percutaneous screw fixation of the posterior ring followed by repeat stress examination to determine the necessity of anterior ring fixation has been previously demonstrated to be a successful management strategy in preventing late fracture displacement.…”

“…[13][14][15][16][17][18][19][20] Percutaneous screw fixation of the posterior ring followed by repeat stress examination to determine the necessity of anterior ring fixation has been previously demonstrated to be a successful management strategy in preventing late fracture displacement. 11,12 Because the main proposed benefit of fixation is believed to be an improved early recovery, a strategy that maximizes pelvis stability may be more beneficial. However, in our practice, we have observed patients who do not appear to benefit significantly from posterior-only fixation-prompting us to evaluate the early hospital course of patients treated with posterior-only versus combined anterior-posterior fixation.…”

Comparing Emergency Department Stress of Lateral Compression Type 1 Pelvis Fractures With a Validated Instability Scoring System

“…Early reports of pelvic stress examination in awake patients, similar to stress examination on Weber-B fibula fractures, have shown promise. 16,17 In June 2018, our institution enacted a protocol where all minimally displaced LC1 pelvic fractures underwent a radiographic stress examination in the emergency department (ED) to determine pelvic ring stability. This protocol showed excellent (100%) agreement with exam under anesthesia in the operating room (OR-EUA) and also predicted successful nonsurgical treatment of stress-negative patients.…”