title: Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary?
abstract: BACKGROUND
  In unstable pelvic ring fractures free abdominal fluid on ultrasound (US) may be caused by retroperitoneal hematoma that passes into the abdominal cavity or by an additional intraabdominal lesion. In this study a clinical pathway for the therapy of potentially combined lesions was analyzed.
  
  
  METHODS
  All patients treated in the ED for severe trauma underwent basic sonographical and radiologic diagnostics within 15 minutes. of admission. Data were prospectively documented. According to the treatment protocol unstable pelvic ring fractures with initial free fluid on US received laparotomy. Patients with stable vital conditions had abdominal CT-Scan before surgery.
  
  
  RESULTS
  1472 consecutive severely injured patients (ISS 20, age: 39 years) were included. Eighty subjects had sustained type B (47) or C (33) pelvic ring fracture. Early free abdominal fluid on US was absent in 49 cases. Three patients in this group required celiotomy later on, during ICU treatment. In 31 patients free fluid was present. All of them had laparotomy. Only one patient showed retroperitoneal hematoma alone, while all others had one or more significant lesions (rupture) that required surgical repair. Simultaneously with laparotomy pelvic stabilization was performed by external (19) or internal (6) fixation. In all cases with massive pelvic hemorrhage and free fluid in US bleeding was controlled by internal tamponade and external fixation.
  
  
  CONCLUSIONS
  The finding of intraperitoneal fluid on US in the emergency department strongly correlates with significant intraabdominal lesions requiring surgical intervention. Early laparotomy appears indicated in these cases. Shock control in pelvic bleeding can be sufficiently achieved by internal tamponade and external fixation.
authors.affiliation: Department of Trauma Surgery, University Hospital of Essen, Germany. steffen.ruchholtz@uni-essen.de
authors.forename: Steffen
authors.initials: S
authors.lastname: Ruchholtz
authors.forename: Christian
authors.initials: C
authors.lastname: Waydhas
authors.forename: Ulrike
authors.initials: U
authors.lastname: Lewan
authors.forename: Birte
authors.initials: B
authors.lastname: Pehle
authors.forename: Georg
authors.initials: G
authors.lastname: Taeger
authors.forename: Christian
authors.initials: C
authors.lastname: Kühne
authors.forename: Dieter
authors.initials: D
authors.lastname: Nast-Kolb
mesh_terms: D015998:Abbreviated Injury Scale; D000328:Adult; D000465:Algorithms; D019091:Critical Pathways / Q000592:standards; D003663:Decision Trees; D005260:Female; D005592:Fracture Fixation / Q000379:methods; D050723:Fractures, Bone / Q000145:classification / Q000150:complications* / Q000453:epidemiology / Q000601:surgery; D005858:Germany / Q000453:epidemiology; D006465:Hemoperitoneum / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000209:etiology; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D007813:Laparotomy; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D010384:Pelvic Bones / Q000293:injuries*; D011446:Prospective Studies; D012187:Retroperitoneal Space; D012680:Sensitivity and Specificity; D012771:Shock, Hemorrhagic / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography