title: Pre-hospital pelvic girdle injury: Improving diagnostic accuracy in a physician-led trauma service.
abstract: BACKGROUND
  Examination of missed injuries in our physician-led pre-hospital trauma service indicated that the significant injuries missed were often pelvic fractures. We therefore conducted a study whose aim was to evaluate the pre-hospital diagnostic accuracy of pelvic girdle injuries, and how this would be affected by implementing the pelvic injury treatment guidelines recently published by the Faculty of Pre-Hospital Care.
  
  
  METHODS
  All blunt trauma patients attended in a 5-month period were included in the study. The presence or absence of pelvic girdle injury on computed tomography (CT) or, if unavailable, pelvic X-ray was used as a primary outcome measure. A retrospective database and case note review was conducted to identify patients who had pelvic binder applied in the study period. For the purposes of the study, pelvic ring and acetabular fractures were grouped together as patients with suspected pelvic girdle injury that should be fitted with a pelvic binder in the pre-hospital setting. The sensitivity and specificity, relating to the presence of pelvic girdle injury in patients with pelvic binders, was calculated in order to determine pre-hospital diagnostic accuracy.
  
  
  RESULTS
  785 patients were attended during the study period. 170 met the study inclusion criteria. 26 (15.3%) sustained a pelvic girdle injury. 45 (26.5%) had a pelvic binder applied. There were eight missed fractures (31%), of which the majority (six) sustained less severe injuries that were managed non-operatively. Two patients required operative fixation. Radiological images and/or reports were available on 169 (99.4%) patients. As a test of the presence of pelvic fracture, pelvic binder application had a sensitivity of 0.69 (95% CI 0.50-0.85) and a specificity of 0.81 (95% CI 0.74-0.87).
  
  
  CONCLUSIONS
  Even with a careful clinical assessment and a low threshold for binder application, this study highlights the problems of distracting injury when trying to diagnose and manage pelvic fractures. By implementing the pelvic treatment guidelines published by the Faculty of Pre-hospital Care, the missed injury rate could be reduced from 31% to 8%.
authors.affiliation: Foundation Doctor, Institute of Pre-Hospital Care, Royal London Hospital, London E1 1BB, UK.
authors.forename: E
authors.initials: E
authors.lastname: Yong
authors.affiliation: Trauma & Orthopaedics Specialty Registrar (ST8) & Pre-Hospital Care Doctor, Institute of Pre-Hospital Care, Royal London Hospital, London E1 1BB, UK. Electronic address: avasireddy@nhs.net.
authors.forename: A
authors.initials: A
authors.lastname: Vasireddy
authors.affiliation: Foundation Doctor, Institute of Pre-Hospital Care, Royal London Hospital, London E1 1BB, UK.
authors.forename: A
authors.initials: A
authors.lastname: Pavitt
authors.affiliation: Consultant in Emergency Medicine and Pre-Hospital Care, Institute of Pre-Hospital Care, Royal London Hospital, London E1 1BB, UK.
authors.forename: G E
authors.initials: GE
authors.lastname: Davies
authors.affiliation: Consultant in Intensive Care Medicine, Anaesthesia and Pre-hospital Care, Institute of Pre-Hospital Care, Royal London Hospital, London E1 1BB, UK.
authors.forename: D J
authors.initials: DJ
authors.lastname: Lockey
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D004638:Emergency Treatment; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis* / Q000601:surgery; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010384:Pelvic Bones / Q000000981:diagnostic imaging* / Q000293:injuries; D010808:Physical Examination; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed; D006113:United Kingdom; D014949:Wounds, Nonpenetrating / Q000175:diagnosis* / Q000601:surgery; D055815:Young Adult
keywords: Diagnostic accuracy; Pelvic fracture; Pre-hospital care; Sensitivity; Specificity; Trauma