The Journal of TRAUMA威 Injury, Infection, and Critical Care

Accuracy of Trauma Ultrasound in Major Pelvic Injury

Vivek S. Tayal, MD, Amie Nielsen, MD, Alan E. Jones, MD, Michael H. Thomason, MD, James Kellam, MD,
and H. James Norton, PhD

Background: Trauma ultrasound (US)
utilizing the focused assessment with sonog-
raphy in trauma (FAST) is often performed
to detect traumatic free peritoneal fluid
(FPF). Yet its accuracy is unclear in certain
trauma subgroups such as those with major
pelvic fractures whose emergent diagnostic
and therapeutic needs are unique. We hy-
pothesized that in patients with major pelvic
injury (MPI) trauma ultrasound would per-
form with lower accuracy than has previ-
ously been reported.
Methods: Retrospective analysis of
adult trauma patients with pelvic frac-
tures seen at an urban Level I emergency
department and trauma center. Patients
were identified from the institutional
trauma registry and ultrasound database
from 1999 to 2003. All patients aged >16
years with MPI (Tile classification A2, all
type B and C pelvic fractures, and type C
acetabular fractures determined by a
blinded orthopedic traumatologist) and
who had a trauma US performed during
the initial emergency department evalua-
tion were included. All ultrasounds were
performed by emergency physicians or
surgeons using the four-quadrant FAST
evaluation. Results of US were compared
with one of three reference standards: ab-
dominal/pelvic computed tomography, di-
agnostic peritoneal tap, or exploratory
laparotomy. Two-by-two tables were con-
structed for diagnostic indices.
Results: In all, 96 patients were eli-
gible; 9 were excluded for indeterminate
ultrasound results. Of the remaining 87
patients, the pelvic fracture types were
distributed as follows: 9% type A2, 72%
type B, 16% type C, and 3% type C ace-
tabular fractures. Overall US sensitivity
for detection of FPF was 80.8%, specific-
ity was 86.9%, positive predictive value
was 72.4%, and negative predictive value
was 91.4%. Categorization of sensitivity
according to pelvic ring fracture type is as
follows: type A2 fractures: sensitivity and
specificity, 75.0%; type B fractures: sen-
sitivity, 73.3%, specificity, 85.1%; and
type C fractures (pelvis and acetabulum):
sensitivity and specificity, 100%. Of the
true-positive US results, blood was the
FPF in 16 of 21 (76%) and urine from
intraperitoneal bladder rupture in 4 in 21
(19%) patients.
Conclusion: US in the initial evalua-
tion of traumatic peritoneal fluid in major
pelvic injury patients has lower sensitivity
and specificity than previously reported
for blunt trauma patients. Additionally,
uroperitoneum comprises a substantial
proportion of traumatic free peritoneal
fluid in patients with MPI.
Key Words: Ultrasound, Trauma, In-
traperitoneal hemorrhage, Pelvic fracture,
FAST.
J Trauma. 2006;61:1453–1457.

U
ltrasound (US) has been shown to be an accurate diag-
nostic test in the setting of blunt abdominal trauma for
detecting clinically significant hemoperitoneum with
sensitivity of 72% to 93% and specificity of 90% to 100%.1– 4
Although the accuracy of abdominal ultrasound for free peri-
toneal fluid (FPF) in patients with major pelvic injury (MPI)
is not known, previous reports have suggested that the pres-
ence of pelvic injury creates potential difficulties with the use
of ultrasound for diagnosis and management of blunt abdom-
inal trauma.5 Distortion of the bony pelvis and its associated
vascular structures change the architecture of the pelvis and
retroperitoneum and theoretically impact the utility of previ-
Submitted for publication April 24, 2005.
Accepted for publication October 26, 2005.
Copyright © 2006 by Lippincott Williams & Wilkins, Inc.
From the Departments of Emergency Medicine (V.S.T., A.N., A.E.J.),
Surgery (M.H.T.), Orthopedic Surgery (J.K.), and Biostatistics (H.J.N.),
Carolinas Medical Center, Charlotte, NC.
Presented at the Society of Academic Emergency Medicine in Orlando,
Florida, May 2004 and the American Institute of Ultrasound in Medicine in
Phoenix, Arizona, June 2004.
Address for reprints: Vivek S. Tayal, MD, FACEP, Department of
Emergency Medicine, Carolinas Medical Center, Box 32861, Charlotte, NC
28232; email: vtayal@carolinas.org.
DOI: 10.1097/01.ta.0000197434.58433.88
ously accepted diagnostic modalities such as ultrasound. The
hypothesis of the present study states that ultrasound would
perform with a lower sensitivity and specificity in patients
with MPI compared with established values in a general
trauma population.
PATIENTS AND METHODS
This study was a retrospective analysis of all trauma
patients aged ⬎16 years at an urban regional Level I trauma
center with an annual emergency department volume of
greater than 100,000 patients/year and approximately 1,900
trauma admissions per year. The standard initial evaluation of
patients at our institution with multiple trauma or suspected
intra-abdominal or pelvic injuries include chest radiography,
pelvic radiography, and four-quadrant trauma ultrasound,
also known as the Focused Assessment with Sonography in
Trauma (FAST).6,7 FAST examinations are performed by
either attending or resident physicians from the emergency
medicine or trauma surgery service. All resident US are
supervised by credentialed attending physicians from one of
the services. As a part of routine care, trauma ultrasound are
interpreted in real time as positive (presence of anechoic
collection in known dependent peritoneal or pericardial
space), negative, or indeterminate. All ultrasounds performed
undergo quality assurance review for image quality and in-

Volume 61 • Number 6 1453

 The Journal of TRAUMA威 Injury, Infection, and Critical Care
Fig. 1. Major pelvic injury fracture types.
terpretation and are logged in an institutional ultrasound
database.
The trauma registry, which contains standard informa-
tion on all institutional trauma patients including demo-
graphics, mechanism of injury, all diagnostic tests performed,
hospital course and discharge diagnosis, and procedure codes
compiled by one of two data analysts, was searched for all
patients with pelvic fractures during the period March 1999 to
May 2003. The radiographs of these patients were reviewed
by one attending orthopedic traumatologist for the presence
of MPI as defined by the classification described by Tile.8
The following Tile subtypes were considered major injuries:
A2, direct injury to innominate bone or anterior pelvic arch;
B, rotational unstable pelvic injuries; C, completely unstable
pelvic ring injuries; and C acetabular fractures-associated
bone column acetabular fractures (Fig. 1).
The patients with MPI were cross-referenced to the in-
stitutional US database and those patients with US logged
were included in the study. Patients were excluded for inde-
terminate ultrasound results (as interpreted by the clinician at
the time the ultrasound was performed). All US results were
confirmed by one of three methods: abdominal/pelvic CT,
diagnostic peritoneal tap (DPT), or exploratory laparotomy.
In addition to pelvic injury and US data, demographics,
mechanism of injury, disposition, and length of stay were
obtained. The data were analyzed using descriptive statis-
tics including percentages and means with standard devia-
tions; two-by-two tables were constructed for US diagnostic
performance.
1454
RESULTS
A total of 96 patients were identified, 9 of which were
excluded for indeterminate ultrasound results, leaving a study
population of 87 patients. The average age was 42 ⫾ 19.4
years with 55% male. The mechanism of injury included
motor vehicle collision 57%, pedestrian struck 6%, motorcy-
cle collision 5%, fall from height 4%, and crush injury 2%.
The pelvic fracture types according to the Tile classification
were type A2 9%, type B1 7%, type B2 58%, type B3 7%,
type C 16%, and type C acetabular 3%.
US was performed for detection of FPF with a sensitivity
of 80.8% (95% CI 65.6% to 95.9%) and a specificity of
86.9% (CI 78.4% to 95.4%) as is shown in Table 1. When
subcategorized according to Tile fracture type, the sensitivi-
ties and specificities for free peritoneal fluid are as follows:
type A2 fractures: sensitivity 75.0% (CI 19.4% to 99.4%) and
specificity 75.0% (CI 19.4% to 99.4%); type B fractures:
Table 1 Overall Sensitivity and Specificity of Trauma
US in Major Pelvic Injury
Confirmatory Test Confirmatory Test
Positive Negative
US Positive 21 8 29
US Negative 5 53 58
26 61
Sensitivity (21/26) ⫽ 81% 95%CI (66 –96); Specificity (53/61) ⫽
61% 95%CI (78 –95); PPV (21/29) ⫽ 72% 95%CI (56 – 89); NPV (53/
58) ⫽ 91% 95%CI (84 –99).
December 2006

sensitivity 73.3% (CI 51% to 95%) and specificity 85.1%
(CI 74.9% to 95.3%); and type C fractures: sensitivity 100%
(CI 65.2% to 100%) and specificity 100% (CI 74.1% to
100%). Of the true-positive US results, blood was the FPF in
16 of 21 (76%), and urine from intraperitoneal bladder rup-
ture in 4 of 21 (19%) patients.
Of the eight false-positive ultrasound exams for FPF,
three of eight (38%) had extensive pelvic hematomas, two of
eight (25%) had extraperitoneal bladder rupture (one with
simultaneous pelvic hematoma), and four of eight had no fluid
seen on computed tomography. Of the false negatives for FPF,
three patients had splenic lacerations, one had a liver laceration,
and one had hemoperitoneum of unknown source. All false-
negative ultrasound patients had small collections of FPF.
Of the four patients with uroperitoneum, one patient was
hemodynamically unstable in the emergency department (ED)
with transfer to the operating room (OR) with only a bladder
rupture found at emergent laparotomy. This patient under-
went immediate angiographic embolization and stabilization
subsequent to the OR. The other three uroperitoneum patients
with positive FAST examinations in the ED had stable he-
modynamics with computerized tomography, angiography,
and laparotomy (in that order).
DISCUSSION
Ultrasound has become an accepted initial diagnostic
procedure for the detection of hemoperitoneum in trauma
patients in the United States during the last decade because of
its rapid, noninvasive, portable, nonionizing, and accurate
diagnostic ability.3,6,9,10 Most emergency medicine training
programs as well as Level I trauma centers report having
adopted ultrasound for the evaluation of the blunt trauma
patient.11 With the increased use of ultrasound, many new
issues have arisen regarding management of specific trauma
patient subtypes.5,12
Pelvic fractures, seen in 9% of blunt abdominal trauma
victims, are associated with a mortality rate approaching 50%
in hemodynamically unstable patients; in addition, the mor-
tality correlates with fracture severity.13 The injuries in the
pelvic trauma patient may not only be the typical abdominal
solid organ injuries but may also include retroperitoneal vas-
cular structures.14 The evaluation for intraperitoneal injury in
the patient with blunt abdominal trauma and a simultaneous
significant pelvic fracture often requires complicated deci-
sion-making and emergent actions. Bleeding within the ab-
domen usually demands surgical management; however,
simultaneous exsanguinating retroperitoneal bleeding re-
quires angiography and embolization.14 The decision in the
emergency department on how and where to proceed with
the patient for therapeutic intervention is critical in dictating
the proper sequence of therapeutic intervention and the ulti-
mate survival of the multitrauma patient with a significant
pelvic fracture.
Our data showed an overall sensitivity and specificity of
US in MPI of 81% and 87%, respectively, which are lower
Volume 61 • Number 6
Accuracy of Trauma Ultrasound in Major Pelvic Injury
than the generally accepted diagnostic abilities of US docu-
mented in previous prospective studies of general trauma
populations with sensitivities in the 90% to 100% range and
specificities in the 97% to 99% range.2,15,16 We theorize that
our lower specificity may be a result of the anatomic distor-
tions in the retroperitoneum of patients with MPI from both
fracture displacement and hematoma formation, resulting in
hypoechoic to anechoic collections that may mimic true peri-
toneal fluid. Additionally, with seepage of retroperitoneal
hematomas, some fluid collections can occur within the peri-
toneum that may not have true surgical significance.
When examining the data for ultrasound performance by
fracture type, we found that the highest sensitivity and spec-
ificity was in the subgroup with the most severe fractures
(Tile type C). Although we must be cautious because of the
overall small patient numbers, this high sensitivity is encour-
aging for the sickest of blunt abdominal and pelvic fracture
patients that may require emergent orthopedic stabilization,
angiographic embolization, and possible laparotomy.
The management of the patient with free peritoneal fluid
on trauma ultrasound has usually been stratified by hemody-
namic stability. Those patients with sonographic free perito-
neal fluid who are clinically stable receive computerized
tomography of the abdomen and pelvis for delineation of
potential injuries. Those with sonographic free peritoneal
fluid who are persistently unstable, however, usually receive
an emergent laparotomy. However, in the unstable trauma
patient with a major pelvic injury, the possibility of signifi-
cant blood loss in the retroperitoneum may require a different
therapeutic intervention based on the nature of the concomi-
tant peritoneal injuries. Peritoneal blood would suggest hemo-
dynamic compromise from an immediately correctable solid
organ or vascular injury, whereas urine (or bile) suggests an
injury requiring delayed therapeutic laparotomy and immediate
consideration of pelvic hemorrhage requiring embolization.
Other reports have documented the presence of uroperi-
toneum in the presence of pelvic fracture in the blunt abdom-
inal trauma victim.17–19 It is known that between 4% and 8%
of patients with pelvic fractures have an associated bladder
injury.20 In our study, uroperitoneum comprised an important
proportion of traumatic free peritoneal fluid (19%). This is
important because uroperitoneum may be mistaken for hemo-
peritoneum, prompting a nonemergent therapeutic laparotomy in
an unstable patient. Although uroperitoneum represents a true-
positive finding on US, it may lead the clinicians to employ the
wrong sequence of therapeutic interventions, as occurred in
one of our uroperitoneum patients and two patients in our
previous series.5 The presence of uroperitoneum, although
mandating therapeutic laparotomy, may not supercede the need
for emergent pelvic embolization therapy to reduce life-threat-
ening hemorrhage from disrupted pelvic vessels.
We provide a suggested algorithm (Fig. 2) for the use of
ultrasound in the unstable blunt abdominal trauma victim
with a positive FAST examination for peritoneal fluid and a
major pelvic fracture. We incorporate a diagnostic peritoneal
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 The Journal of TRAUMA威 Injury, Infection, and Critical Care
Fig. 2. Management of unstable blunt trauma victim with positive
FAST examination with pelvic fracture seen on anteroposterior
pelvis film.
tap (aspirate), which will separate hemoperitoneum (suggest-
ing immediate laparotomy) from uroperitonum (suggesting
retroperitoneal vascular exsanguination requiring immediate
embolization therapy and a delayed laparotomy).
The peritoneal sampling only requires an aspirate and not
necessarily a lavage as the information required is the type of
peritoneal fluid, not the concentrations in lavage fluid. In
addition, ultrasound may be used to guide the needle aspirate
around adjacent bowel. DPT done supraumbilically with a
Seldinger technique done within 5 minutes is preferable to a
minilaparotomy, in our experience, because of the perfor-
mance time and delay for transport and induction for any OR
procedure or even an open diagnostic peritoneal incision in
the ED to visualize the peritoneum, which would take typi-
cally 10 to 15 minutes. This sampling of peritoneal fluid, in
our opinion, is worth the few minutes to direct the patient to
the correct sequence of therapy.
Although some would advocate the avoidance of trauma
ultrasound in the unstable trauma patient with a pelvic frac-
ture, we would comment that the performance of trauma
ultrasound is routinely faster and less complicated than any
diagnostic peritoneal aspirate or lavage, which may have to
1456
be altered to a supraumbilical approach in the pelvic fracture
patient. In addition, alteration of typical protocol utilizing the
FAST examination may lead to inappropriate diagnostic de-
lays for those trauma patients whose injuries do not fit this
clinical situation.
Limitations
This report has several important limitations that require
discussion. First, this is a single-center, retrospective analysis
subject to incorporation bias, selection bias, and potentially
missed cases of pelvic injury. In addition, the results of this
study are limited because of the small sample size and the
relatively small number of each subtype of pelvic injury.
CONCLUSION
In the initial evaluation of traumatic peritoneal fluid in
patients with major pelvic injuries, ultrasound has a lower
sensitivity and specificity than previously reported for blunt
trauma patients. Uroperitoneum appears to comprise a sub-
stantial proportion of traumatic free peritoneal fluid in this
patient population. Further prospective evaluation is needed
to determine the appropriate role of ultrasound in the initial
management of patients with major pelvic trauma.
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