The Utility of Obtaining Postmobilization Imaging in Nonsurgical Pelvic Ring Injuries

Abstract

Introduction: Pelvic fractures are diverse injuries with varying degrees of severity. Treatment recommendations are determined by the associated instability. For likely stable patterns, postmobilization imaging is used to assess for occult instability. This study assesses the utility of postmobilization images and determines how often they alter the recommendations for treatment. Methods: Records at a single level 1 trauma center from January 2007 through December 2014 were reviewed, and patients with Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision codes for pelvic and acetabular fractures were identified. For those chosen for nonsurgical treatment at presentation, a detailed chart review was performed to identify patients who had postmobilization radiographs and to determine whether this imaging led to a change in treatment recommendations. Results: Inclusion criteria were met by 762 patients whose average age was 50 years. Of 331 patients planned for nonsurgical treatment at presentation, 168 (51%) had postmobilization images. The postmobilization radiographs did not alter treatment recommendations in any of these patients; however, three of these patients underwent surgical stabilization based on the patients' report of pain with attempted mobilization. Discussion: Routine postmobilization imaging has limited value for patients with pelvic injuries and a low likelihood for instability, such as those with incomplete sacral fractures. Eliminating this step would reduce cost and decrease radiation exposure. The need for change in treatment plan or further imaging should be based on the patient's clinical progress with weight bearing. Level of Evidence: Level 4

Post Post-Mobilization Films for LC1 Pelvic Ring Injuries: Follow up Stress Imaging Demonstrates Minimal Utility

“…Similar to prior studies, we found that injuries with complete sacral fractures and bilateral rami fracturs have a higher risk of displacing greater than 10 mm than those with incomplete sacral fractures and unilateral rami fractures. 10,18 Combining our results with those of Winston et al 9 would suggest that widespread follow-up imaging on successfully mobilized LC1 pelvic ring injuries is not necessary outside of social or specific patient considerations in the inpatient or outpatient settings…”

“…Similar to prior studies, we found that injuries with complete sacral fractures and bilateral rami fracturs have a higher risk of displacing greater than 10 mm than those with incomplete sacral fractures and unilateral rami fractures. 10,18 Combining our results with those of Winston et al 9 would suggest that widespread follow-up imaging on successfully mobilized LC1 pelvic ring injuries is not necessary outside of social or specific patient considerations in the inpatient or outpatient settings Because there is minimal risk of stable LC1 pelvic ring injuries displacing enough to necessitate operative intervention, obtaining multiple outpatient radiographs increases radiation exposure, raises health care costs, and does not add to patient care. The radiation from a single pelvis radiograph is estimated at 20 dGy per cm.…”

“…Previous literature has also called into question the utility of postmobilization radiographs and suggest that they do not change treatment plans. 9,13,14 More recent literature has suggested that a better assessment of pelvic stability might be obtained by intraoperative examination under anesthesia, 15 emergency department manual stress examination, 16 or lateral stress radiographs. 17 Our study adds to this vein of thought that classical postmobilization radiographs (AP/inlet/outlet) provide poor utility and that the field should look to other methods of assessing pelvic stability.…”

“…Lateral compression type 1 fractures that are shown to be stable based on inpatient postmobilization films 9 are likely stable and unlikely to displace over time. This finding can be combined with prior research to reconsider follow-up plans for nonoperatively managed stable LC1 pelvic ring injuries.…”

“…Recently, these postmobilization films have been shown to rarely change treatment recommendations in patients with pelvic ring injuries, suggesting that they are of limited utility. 9 Although Winston et al provide good evidence against the routine use of in-hospital postmobilization radiographs, they did not investigate whether these fractures displace over the course of outpatient follow-up, and therefore, whether further surveillance is warranted.…”