title: Emergency radiological examination of the externally stabilized pelvis--there is a catch to it: lessons learned from two cases with symphyseal disruption despite initial inconspicuous computed tomography.
abstract: BACKGROUND
  Preclinical and early clinical external pelvic stabilization using commercially available devices has become common in trauma patient care. Thus, in the emergency department an increasing number of patients will undergo radiographic evaluation of the externally stabilized pelvis to exclude injuries. While reports exist where injuries to the pelvis were elusive to radiological examination due to the pelvic immobilization we elaborate on an algorithm to remove an external pelvic stabilizing device, prevent delayed diagnosis of pelvic disruption and thus increase patient safety.
  
  
  METHODS
  We report on two patients with external pelvic stabilization presenting with an inconspicuous pubic symphysis on initial pelvic computed tomography scans. The first patient was an otherwise healthy 51-year old male being run over by his own car. He received external pelvic stabilization in the emergency department. The second patient was a 36-year old male falling from a ladder. In this patient external pelvic stabilization was performed at the scene. In the first patient no pelvic injury was obvious on computed tomography. In the second patient pelvic fractures were diagnosed, yet the presentation of the pubic symphysis appeared normal. Nevertheless, complete symphyseal disruption was diagnosed in both of them upon removal of the external pelvic stabilization and consequently required internal fixation.
  
  
  CONCLUSIONS
  Based on our experience we propose an algorithm to "clear the initially immobilized pelvis" in an effort to minimize the risk of missing a serious pelvic injury and increase patient safety. This is of significant importance to orthopedic trauma surgeons and emergency physicians taking care of injured patients.
authors.affiliation: Department of Orthopedics and Trauma Surgery, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany. joerg.bayer@uniklinik-freiburg.de.|University Emergency Center, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany. joerg.bayer@uniklinik-freiburg.de.
authors.forename: Jörg
authors.identifier: http://orcid.org/0000-0001-5446-6840
authors.initials: J
authors.lastname: Bayer
authors.affiliation: Department of Orthopedics and Trauma Surgery, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.|University Emergency Center, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
authors.forename: Thorsten
authors.initials: T
authors.lastname: Hammer
authors.affiliation: Department of Orthopedics and Trauma Surgery, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
authors.forename: Dirk
authors.initials: D
authors.lastname: Maier
authors.affiliation: Department of Orthopedics and Trauma Surgery, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
authors.forename: Norbert Paul
authors.initials: NP
authors.lastname: Südkamp
authors.affiliation: Department of Orthopedics and Trauma Surgery, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
authors.forename: Oliver
authors.initials: O
authors.lastname: Hauschild
mesh_terms: D000328:Adult; D004636:Emergency Service, Hospital; D005593:Fracture Fixation, Internal; D050723:Fractures, Bone / Q000000981:diagnostic imaging* / Q000209:etiology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D010384:Pelvic Bones / Q000000981:diagnostic imaging / Q000293:injuries*; D011631:Pubic Symphysis / Q000000981:diagnostic imaging / Q000293:injuries*; D014057:Tomography, X-Ray Computed
keywords: Computed tomography; Missed injury; Patient safety; Pelvic binder; Pelvic fracture; Pelvic injury; Pelvic stabilization; Symphyseal disruption