Journal of Ultrasound (2021) 24:423–428

https://doi.org/10.1007/s40477-020-00483-6

ORIGINAL PAPER

Diagnostic accuracy of pubic symphysis ultrasound in the detection

of unstable pelvis in polytrauma patients during e‑FAST: the value
of FAST–PLUS protocol. A preliminary experience
Stefania Ianniello1 · Paola Conte1 · Marco Di Serafino2 · Vittorio Miele3 · Margherita Trinci1 ·
Gianfranco Vallone4 · Michele Galluzzo1

Received: 15 April 2020 / Accepted: 19 May 2020 / Published online: 9 June 2020
© Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2020

Abstract
Background Extended focused abdominal sonography for trauma (e-FAST) is part of the primary survey in patients with
high-energy trauma. However, it does not identify patients with retroperitoneal haemorrhage associated with significant
pelvic trauma. A traumatic diastasis of pubic symphysis, as well as an ‘open book’ (OB) pelvic injury, is a diagnostic clue to
recognize unstable pelvis with higher risk of bleeding. FAST–PLUS (FAST–PL pleural –US ultrasound of symphysis) pro-
tocol is an addendum to the e-FAST, which takes into account the study of the pubic symphysis in a single transverse scan
after the traditional focused evaluation of the abdomen and thorax.
Objectives The aim of this study is to determine the value of FAST–PLUS protocol in the evaluation of pubic symphysis
injuries and the identification of ‘open book’ (OB) unstable pelvic fractures.
Methods Between January 2018 and December 2019, we retrospectively reviewed 67 polytraumatised patients with clinical
suspicion of pelvic instability and with known anteroposterior pelvis compression injuries who underwent e-FAST with an
additional transverse scan of the pubic symphysis, named the FAST–PLUS protocol and computed tomography (CT) exam
in order to assess the correlation between them in defining the presence or absence of pubic symphyseal widening (SW).
A cutoff value of 2.5 cm in transverse diameter was used to diagnose OB unstable pelvic injury. The results were analysed
using Cohen’s test, which uses the Kappa value as the reference index.
Results The analysis carried out to assess the degree of agreement between FAST–PLUS and CT showed 5/67 patients
(7.5%) with a critical pubic SW (> 2.5 cm transverse diameter) suggestive of unstable OB pelvic injury and 62/67 (92,5%)
without any signs of SW at FAST–PLUS. At CT, findings of unstable OB pelvic fracture were confirmed in all patients with
positive results at FAST–PLUS. Similarly, all patients with negative results for critical pubic SW (< 2.5 cm in transverse
diameter) at FAST–PLUS were found to be negative at CT exam. The level of correlation between the two methods was
high (Kappa value = 1)
Conclusion The FAST–PLUS protocol shows a high correlation with CT exam, which is the gold standard for the detection
of unstable pubic SW, as well as OB pelvic injury, in polytraumatised patients. Inclusion of FAST–PLUS in patient manage-
ment in the shock room may lead to a quicker identification of patients with unstable pelvis and to faster therapeutic work-up.

Keywords Trauma imaging · Ultrasound · e-FAST · FAST–PLUS · Pelvic fractures · Symphyseal widening · Open book
pelvic fracture

Background and objectives

Pelvic ring fractures occur in 9.3% of patients with blunt

trauma [1], although their incidence is increasing due to the
high number of motor vehicle accidents, falls from a height,
* Stefania Ianniello crush injuries and extreme sports [2–4]. These fractures are
stefianni66@gmail.com often associated with damage to the abdominal and pelvic
Extended author information available on the last page of the article organs, with a reported prevalence ranging from 11 to 20.3%

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424 Journal of Ultrasound (2021) 24:423–428

[5]. According to the Young and Burgess classification, the

anteroposterior compression, lateral compres-

Complex fracture, including a combination of
biomechanics of pelvic ring disruption include 3 mechanisms
(Table 1): anteroposterior compression, lateral compression
and vertical shear [3, 6].
Due to the ring constitution of the pelvis, for each injury
caused by a high-energy force vector in one area, another bone

sion and/or vertical shear

or ligamentous lesion must correspond on the opposite side [7,
8]. Exceptions include insufficiency fractures, caused by ‘low-
energy’ force vectors, as occur in osteoporotic patients, or in
avulsion fractures typical of juvenile sport injuries. Mortality
in patients affected by pelvic fractures has been reported to

Combined
be 4–15% [9, 10], and pelvic haemorrhage, multiple organ
failure and sepsis are the most common causes of death [2,
3, 9, 10]. The early identification of patients at risk of pelvic
haemorrhage who might benefit from operative management

Vertical displacement of hemipelvis, pubic

may reduce blood loss, prevent late complications and improve
outcomes [1].
In unstable patients, pelvic ring evaluation is usually per-
formed during the primary survey, with anteroposterior pelvic

and sacroiliac joint fractures

X-ray. In stable patients, CT is performed during the secondary
survey and allows for a more precise evaluation of pelvic ring
stability [11]. Contrast-enhanced ultrasound (CEUS) is limited
to cases of low-energy isolated abdominal trauma, particularly

Vertical shear
in children or in the follow-up of low-grade traumatic lesions,
thus avoiding or lowering levels of ionizing radiation [12, 13].
Focused Assessment with Sonography for Trauma (FAST)
with extended FAST (e-FAST) is part of the primary survey in
polytrauma patients [14–16]. It is a non-invasive, repeatable,

diastasis of the anterior part of the sacroiliac posterior fracture with dislocation of the ipsi-
lateral anterior compression fracture of the
I: Stable oblique fracture of pubic rami ipsi-

contralateral anteroposterior compression

III: Equates to a complete hemipelvis separa- III: Unstable ipsilateral lateral compression
safe, non-irradiating, cheap and quick technique that aims to II: Rotationally unstable, vertically stable
exclude immediate life-threatening conditions such as pericar-
dial tamponade, hemothorax, pneumothorax and hemoperito- lateral iliac wing (crescent fracture)
neum [17, 18]. However, FAST (or e-FAST) cannot evaluate
retroperitoneal haemorrhages, and cannot distinguish between
blood and urine in severe unstable pelvic trauma [18, 19]. At
fracture of pubic rami

the same time, the presence of the pubic symphyseal widening

Lateral compression

(SW) is a diagnostic clue to recognize unstable ‘open book’

(OB) pelvic fractures with higher risk of retroperitoneal bleed-
sacral ala

ing [19]. FAST–PLUS (FAST—PL pleural—US ultrasound

of symphysis) is an addendum to the e-FAST protocol which
takes into account the study of the pubic symphysis in a single
transverse scan after the traditional focused evaluation of the
unstable pubic diastasis > 2.5 cm disruption-

sacroiliac joint ligaments with dislocation

abdomen and thorax. The aim of this study is to determine the

joint, with intact posterior sacroiliac joint

tion (but without vertical displacement);

Table 1  Young and Burgess classification

II: Rotationally unstable, vertically stable

pubic diastasis > 2.5 cm disruption and

diastasis of both anterior and posterior

value of the FAST–PLUS protocol in the evaluation of pubic

symphysis injuries and more particularly in the identification
I: Stable pubic diastasis < 2.5 cm

of unstable OB pelvic fractures.[1, 18, 19].

Anteroposterior compression

Materials and methods

Patients selection and study design

ligaments

Between January 2018 and December 2019, 497 polytrau-

matised patients were admitted to our emergency department

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Journal of Ultrasound (2021) 24:423–428
and underwent e-FAST during the primary survey. In 67/497
of them (43 males and 24 females; mean age 47 years;
range 40–70 years) with abdominopelvic trauma and with
a clinical suspicion of pelvic instability and the known
injury mechanism of anteroposterior compression, an addi-
tional transverse scan of the pubic symphysis, called the
FAST–PLUS protocol, was performed in order to evaluate
the presence of symphyseal widening (SW). A cutoff value
of 2.5 cm in transverse diameter was used to define the pres-
ence or absence of pubic SW suggestive of unstable pelvic
OB fractures, according to the Young and Burgess classifica-
tion [20]. All 67 patients underwent computed tomography
(CT) scans after FAST–PLUS. We retrospectively reviewed
all 67 patients who underwent FAST–PLUS and CT scans
in order to assess the correlation between these exams in
detecting critical SW (> 2.5 cm). The results were analysed
using Cohen’s test, which uses the Kappa value as the ref-
erence index. The CT technique was considered the gold-
standard reference for the detection of pelvic ring fractures.
Patients under 18 years of age and pregnant women were
excluded, as they may have atraumatic symphyseal widen-
ing. Obese patients (body mass index–BMI > 30 kg/m2)
were also excluded from the study, since the morphotype
is a well-known limiting factor for US examination in gen-
eral. Furthermore, patients with certain clinical evidence of
pelvic instability and known injury mechanisms of lateral
compression or vertical shear compression, or those who
did not have FAST–PLUS performed, were excluded from
the study.
Image acquisition
The FAST–PLUS exam was first carried out with a low-
frequency probe (3.5–5 MHz convex transducer) for better
penetration of tissues in the abdominal cavity, to exclude
hemoperitoneum, according to the well-known FAST pro-
tocol (pericardial view; right and left flank view; pelvic
view). It was subsequently performed again with a high-
frequency probe (15–4 MHz linear transducer) for the
evaluation of both hemithorax (i.e. the pleura) to exclude
pneumothorax or hemothorax, according to the extended-
FAST version and finally with the same high-resolution
linear probe, the pubic symphysis was scanned with a trans-
verse section (Table 2). Both probes are ready to use in the
Table 2  FAST–PLUS protocol FAST–PLUS protocol
FAST protocol
e-FAST protocol
Transverse scan on the
pubic symphysis
425
same US machine ­(MyLab™25, Esaote SpA, IT) without
time-consuming adjustments. Measurements of pubic SW
were made between the pubic tubercles on the transverse
scan (Fig. 1). A pubic SW > 2.5 cm in transverse diameter
was considered positive for unstable OB pelvic fracture. CT
images were obtained with a multidetector row CT scanner
with 64 detector rows (Somatom Sensation, Siemens Medi-
cal Systems, Erlangen, Germany) after intravenous contrast
media administration to exclude active bleeding.
Results
The analysis carried out to assess the degree of agreement
between FAST–PLUS and CT showed 5/67 patients (7.5%)
with a critical pubic SW (> 2.5 cm in transverse diameter)
suggestive of unstable OB pelvic fracture and 62/67 (92.5%)
without any signs of SW at FAST–PLUS. At CT, findings of
unstable OB pelvic fracture were confirmed in all patients
with positive results at FAST–PLUS. Similarly, all patients
with negative results for critical pubic SW (< 2.5 cm in
transverse diameter) at FAST–PLUS were found to be nega-
tive at CT exam too (Figs. 2, 3, 4). The level of correlation
between the two methods was high (Kappa value = 1).
Discussion
Similar to the results obtained by Bauman et al. [21], our
study demonstrates that US evaluation of pubic symphy-
sis during FAST–PLUS, may help to identify patients with
unstable pelvic fractures presenting with pubic SW > 2.5 cm
transverse diameter. Evaluation of pelvic ring anatomy and
stability is usually performed with CT or X-ray. The X-ray
anteroposterior projection, usually performed during the
primary survey, provides a huge amount of information
about the mechanism of injury. Additional projections (i.e.
inlet view, outlet view and oblique projections) are useful
for the evaluation of cranial dislocation of hemipelvis and
for posterior sacroiliac joint or pubic branches dislocation.
CT remains the gold-standard technique for the diagnosis
and characterisation of pelvic ring fractures, allowing for
panoramic exploration and greater anatomical detail [3].
US shows a high correlation with CT findings in detecting
Pericardial view; right and left To exclude hemoperitoneum
flank view; pelvic view
Pleural view To exclude pneumothorax or hemothorax
Pubic symphysis view To exclude unstable pelvic fractures
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Fig. 1  a Example of a transverse scan of the pubic symphysis per- the pelvis (c) with evidence of branched (b, c, arrows) and not dia-
formed with a high-frequency linear probe; b, c anatomical represen- stased symphysis (b, c, dotted line) in patient with femoral right neck
tation of the pubis at US transverse scans (b) and at CT axial scan of fracture (c, arrowheads)

Fig. 2  a US shows the normal aspect of pubic symphysis and b CT demonstrates the lack of diastasis of the pubic branches

Fig. 3  a US shows pubic symphysis widening; the distance between the two pubic tubercles (arrows) is < 2.5 cm. b CT confirms the diastasis of
the pubic branches, less than 2.5 cm

critical SW and OB unstable pelvic fractures. However, US at US exam. Moreover, as regards anteroposterior pelvis
has no accuracy in the detection of lateral compression and compression injuries, the FAST–PLUS protocol does not
vertical shear injuries, because in these types of fractures, allow for identification of the different degrees of the Young
the symphysis usually remains intact, without any alteration and Burgess classification, but it is a reliable diagnostic clue

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Journal of Ultrasound (2021) 24:423–428
Fig. 4  a US shows large diastasis of the pubic symphysis, greater
than 2.5 cm. The right pubic branch is clearly visible (arrow), while
only a detached fragment of the left branch is visible (arrowhead): b,
to detect unstable OB pelvic fractures with a pubic SW over
2.5 cm in transverse diameter. According to these results,
an additional single transverse scan on the pubic symphy-
sis during the FAST–PLUS protocol is not time consuming
and may provide a quick evaluation of the degree of critical
SW, with a high diagnostic indication of pelvic ring insta-
bility and urgent operative management. Nevertheless, CT
remains the gold-standard technique for the entire evaluation
of pelvic anatomy and the detection of the type and degree
of pelvic ring fractures and the associated injuries (such as
vascular, urogenital and nerve lesions).
Conclusions
US evaluation of pubic symphysis with FAST–PLUS proto-
col shows a high correlation with CT findings in detection
of pubic critical SW, as well as OB unstable pelvic fractures
in patients with anteroposterior mechanism of injury. The
FAST–PLUS protocol is not time-consuming and may pro-
vide a quick evaluation of the degree of critical SW, with
a high diagnostic indication of pelvic ring instability and
urgent operative management. Of course, further prospective
studies on large case series are needed to verify this possible
systematic use of US in traumatised patients.
427
c axial CT scan and d 3D reconstruction confirm the large widening
of the pubic symphysis and the ‘open book’ fracture of the pelvis
Funding The Authors declare that they do not receive any funding for
the publication of this article.
Compliance with ethical standards
Conflict of interest The Authors declare that they have no conflict of
interest related to the publication of this article.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and national research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was acquired.
Research involving human participants and/or animals This article
does not contain any studies with animals performed by any of the
authors.
References
1. Demetriades D, Karaiskakis M, Toutouzas K et al (2002) Pelvic
fractures: epidemiology and predictors of associated abdominal
injuries and outcomes. J Am Coll Surg 195:1–10
2. Flint L, Cryer HG (2010) Pelvic fracture: the last 50 years. J
Trauma 69:483–488
3. McCormak R, Strauss EJ, Alwatter BJ et al (2010) Diagnosis
and management of pelvic fractures. Bull NYU Hosp Jt Dis
68:281–291
13
428
4. Trainham L, Rizzolo D, Diwan A et al (2015) Emergency manage-
ment of high-energy pelvic trauma. JAAPA 28:28–33
5. Yoon W, Kim JK, Jeong YY et al (2004) Pelvic arterial hemor-
rhage in patients with pelvic fractures: detection with contrast-
enhanced CT. RadioGraphics 24:1591–1605
6. Pennal GF, Tile M, Waddell JP et al (1980) Pelvic disruption:
assessment and classification. Clin Orthop Relat Res 151:12–21
7. Gertzbein SD, Chenoweth DR (1977) Occult injuries of the pelvic
ring. Clin Orthop Relat Res 128:202–207
8. Stahel PF, Hammerberg EM (2016) History of pelvic fracture
management: a review. World J Emerg Surg 11:18
9. Vaidya R, Scott AN, Tonnos F et al (2016) Patients with pelvic
fractures from blunt trauma. What is the cause of mortality and
when? Am J Surg 211:495–500
10. Chong KH, DeCoster T, Osler T et al (1997) Pelvic fractures and
mortality. Iowa Orthop J 17:110–114
11. Sampson MA, Colquhoun KBM, Hennessy NLM (2006) Com-
puted tomography whole body imaging in multi-trauma: 7 years
experience. Clin Radiol 61:365–369
12. Trinci M, Piccolo CL, Ferrari R et al (2019) Contrast-enhanced
ultrasound (CEUS) in pediatric blunt abdominal trauma. J Ultra-
sound 22:27–40
13. Piccolo CL, Trinci M, Pinto A (2018) Role of contrast-enhanced
ultrasound (CEUS) in the diagnosis and management of traumatic
splenic injuries. J Ultrasound 21:315–327
14. Moylan M, Newgard CD, Ma OJ et al (2007) Association between
a positive ED FAST examination and therapeutic laparotomy in
normotensive blunt trauma patients. J Emerg Med. 33:265–271
Affiliations
Stefania Ianniello1 · Paola Conte1 · Marco Di Serafino2
Gianfranco Vallone4 · Michele Galluzzo1
1 3
Department of Emergency Radiology, S. Camillo Hospital,
C.ne Gianicolense, 87, 00152 Rome, Italy
2 4
Department of General and Emergency Radiology, “Antonio
Cardarelli” Hospital, Naples, Italy
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Journal of Ultrasound (2021) 24:423–428
15. Ianniello S, Di Giacomo V, Sessa B et al (2014) First-line sono-
graphic diagnosis of pneumothorax in major trauma: accuracy of
e-FAST and comparison with multidetector computed tomogra-
phy. Radiol Med 119:674–680
16. Ianniello S, Piccolo CL, Trinci M (2019) Extended-FAST plus
MDCT in pneumothorax diagnosis of major trauma: time to revisit
ATLS imaging approach? J Ultrasound 22:461–469
17. Stengel D, Bauwens K, Sehouli J et al (2005) Emergency ultra-
sound-based algorithms for diagnosing blunt abdominal trauma.
Cochrane Database Syst Rev 2015(9):004446
18. Kirkpatrick AW, Sirois M, Laupland KB et al (2005) Prospective
evaluation of hand-held focused abdominal sonography for trauma
(FAST) in blunt abdominal trauma. Can J Surg 48:453–460
19. Poletti PA, Wintermark M, Schnyder P et al (2002) Traumatic
injuries: role of imaging in the management of the polytrauma
victim (conservative expectation). Eur Radiol 12:969–978
20. Becker I, Woodley SJ, Stringer MD (2010) The adult human pubic
symphysis: a systematic review. J Anat 217:475–487
21. Bauman M, Marinaro J, Tawil I et al (2011) Ultrasonographic
determination of pubic symphyseal widening in trauma: the
FAST-PS Study. J Emerg Med 40:528–533
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
· Vittorio Miele3 · Margherita Trinci1 ·
Department of Radiology, Careggi University Hospital,
Florence, Italy
Department of Life and Health, “Vincenzo Tiberio”
University of Molise, Campobasso, Italy