REVIEW JURNAL

CT SCAN (PELVIC)

Dosen Pengampu
I MADE PURWA DHARMITA, S.ST., M.Kes.

Disusun oleh :
HENDRI DUNANTIKO
NIM. 022306112

PROGRAM STUDI SARJANA TERAPAN

TEKNOLOGI RADIOLOGI PENCITRAAN
AKADEMI TEKNIK RADIODIAGNOSTIK DAN RADIOTERAPI BALI
(ATRO BALI)
2023
 REVIEW JURNAL CT SCAN (PELVIC)

Judul Use of The Initial Trauma CT Scan to Aid in Diagnosis of Open Pelvic
Fractures
Published Injury-Internasional Journal of the Care of the Injured • Vol. 46, Issue 10,
2015 • www.elsevier.com/locate/injury
Tahun 2015
Penulis John A. Scolaro, David J. Wilson, Milton Lee ‘‘Chip’’ Routt, Reza
Firoozabadi
Reviewer Hendri Dunantiko

Abstrak Luka terbuka akibat patah tulang panggul/pelvis merupakan cedera

dengan risiko tinggi yang dapat mengancam jiwa jika tidak ditangani
dengan tepat. Deteksi dan penanganan cepat terhadap cedera ini
dapat mengurangi morbiditas dan mortalitas yang terkait.
Pemeriksaan CT scan sering dilakukan untuk evaluasi awal pasien
dengan cedera tulang panggul. Tujuan dari penelitian ini adalah
untuk mengidentifikasi penyebab dan sumber keberadaan udara
yang terlihat pada CT scan daerah abdomen dan panggul pada
pasien dengan fraktur panggul, serta mengevaluasi penggunaan CT
scan sebagai salah satu alat diagnostik untuk mengidentifikasi
cedera terbuka. Penelitian ini dilakukan melalui tinjauan retrospektif
terhadap database yang dikumpulkan secara prospektif di sebuah
institusi. Dari 722 pasien dengan gangguan panggul selama periode
dua tahun, 98 pasien diidentifikasi memiliki kepadatan udara ekstra-
luminal pada hasil CT scan. Delapan puluh satu pasien dimasukkan
dalam analisis akhir setelah penerapan kriteria inklusi dan eksklusi.
 Udara terdeteksi oleh radiolog dalam 45 (55,6%) kasus. Enam
pasien (7,4%) didiagnosis secara klinis mengalami gangguan cincin
panggul terbuka; pada dua pasien (2,4%) di diagnosis terlambat
pada kasus ini. Dalam beberapa kasus, temuan udara pada CT
mungkin merepresentasikan luka terbuka pada cincin panggul. Pada
semua pasien, CT scan mampu melacak udara dari sumbernya.
Pada pasien dengan gangguan panggul, CT scan juga harus
dievaluasi untuk keberadaan dan sumber udara ekstra-luminal.
Evaluasi fisik lengkap dan evaluasi CT scan harus digunakan
bersama untuk mengurangi diagnosis yang terlewat atau tertunda
dari cedera terbuka pada cincin panggul.
Metode Dalam jurnal ini, peneliti menggunakan metode retrospektif untuk
Penelitian mengevaluasi database yang dikumpulkan secara prospektif di
sebuah institusi tunggal. Mereka melakukan tinjauan terhadap 722
pasien dengan gangguan panggul selama periode dua tahun.
Semua pasien yang mengalami cedera pada cincin panggul
(AO/OTA 61-A, 61-B, 61-C) dan memiliki foto rontgen polos
anteroposterior (AP) panggul serta CT scan abdomen dan panggul
sebelum dilakukan intervensi bedah dimasukkan dalam penelitian
ini. Kriteria pengecualian termasuk pasien dengan fraktur patologis,
evaluasi radiografi yang tidak lengkap, atau CT scan yang dilakukan
setelah prosedur bedah panggul atau abdomen terbuka. Setelah
penerapan kriteria inklusi dan eksklusi, 81 pasien dimasukkan dalam
analisis akhir. Peneliti kemudian mengevaluasi hasil CT scan
menggunakan protokol bone/tulang dan protokol lung/paru-paru
untuk mengidentifikasi keberadaan udara ekstra-luminal. Mereka
juga memeriksa laporan radiologi resmi untuk mencatat apakah
kepadatan udara dalam jaringan lunak dicatat oleh radiolog.
Penelitian ini bertujuan untuk mengidentifikasi keberadaan, lokasi,
dan sumber udara yang terdeteksi pada CT scan pra-operasi, serta
 untuk mengkorelasikan keberadaan udara dengan diagnosis klinis
fraktur panggul terbuka

Latar Belakang Cedera cincin panggul (pelvis) yang tidak stabil dapat
mengancam nyawa jika tidak ditangani dengan tepat. Cedera cincin
panggul terbuka jarang terjadi, tetapi biasanya merupakan cedera
yang beresiko tinggi. Luka terbuka umumnya terjadi di dekat krista
iliaka atau daerah perineum/anorektal. Luka terbuka mempersulit
penatalaksanaan awal pasien selama resusitasi karena pendarahan
yang berhubungan dengan pelvis keluar tanpa terkendali melalui
lesi. Setelah dilakukan stabilisasi, cedera panggul terbuka membuat
pasien beresiko terkena infeksi panggul dalam ketika daerah
anorektal terlihat. Diagnosis cedera cincin panggul terbuka mudah
dilakukan jika lukanya luas atau terlihat jelas. Cedera panggul
terbuka lainnya sulit di diagnosis dan memerlukan pemeriksaan
manual atau visual.
Pemeriksaan CT abdomen dan pinggul sering dilakukan dalam
evaluasi awal pasien dengan cedera cincin pinggul. Informasi
diagnostik berharga dapat didapat dari hasil CT tersebut. Di
abdomen dan pinggul, keberadaan udara pada CT dapat berasal
dari berbagai sumber dan seharusnya memperhatikan kemungkinan
terjadinya luka terbuka pada cincin pinggul.
Tujuan penelitian ini adalah mengidentifikasi dan
mendeskripsikan keberadaan udara di luar lumen yang terlihat pada
pemeriksaan CT pasien dengan disrupsi cincin pinggul traumatik.
Peneliti ingin mengetahui apakah evaluasi CT abdomen dan pinggul
dapat meningkatkan identifikasi luka terbuka pada cincin pinggul.
Hipotesis peneliti adalah pemeriksaan CT standar dengan protokol
tulang (bone window) dan paru-paru (lung) dapat melacak udara di
 luar lumen dan meningkatkan deteksi luka terbuka pada cincin
pinggul yang semula salah diagnosa sebagai cedera tertutup.
Rumusan Beberapa permasalahan yang menjadi dasar dilakukannya
Masalah penelitian dalam jurnal tersebut adalah:
1. Luka terbuka pada cincin pinggul jarang terjadi namun biasanya
merupakan cedera berenergi tinggi dengan risiko morbiditas dan
mortalitas yang tinggi jika tidak ditangani dengan tepat.
2. Diagnosis luka terbuka pada cincin pinggul tidak selalu mudah,
terutama jika luka tidak terlihat jelas di permukaan kulit.
Umumnya memerlukan pemeriksaan fisik yang menyeluruh.
3. CT abdomen dan pinggul rutin dilakukan dalam evaluasi awal
pasien cedera cincin pinggul, namun potensi keberadaan udara
ekstra-lumenal pada CT belum dimanfaatkan secara optimal
untuk mendiagnosis luka terbuka.
4. Keberadaan udara ekstra-lumenal pada CT dianggap abnormal
dan dapat berasal dari berbagai sumber, termasuk kemungkinan
luka terbuka cincin pinggul.
5. Riwayat menunjukkan beberapa kasus luka terbuka cincin
pinggul melewatkan diagnosis awal atau terlambat didiagnosis.
Oleh karena itu, penelitian ini dilakukan untuk mengevaluasi
kemampuan CT abdomen dan pinggul dalam mengidentifikasi udara
ekstra-lumenal yang dapat digunakan untuk mendiagnosis luka
terbuka cincin pinggul sejak tahap awal, sehingga dapat mengurangi
angka diagnosis yang terlewat atau terlambat.
Alur Penelitian Berikut adalah alur penelitian yang digunakan dalam jurnal
tersebut:
1. Dilakukan reviu retrospektif terhadap basis data ortopedi yang
dikumpulkan secara prospektif di rumah sakit akademis level 1
trauma selama 2 tahun (2009-2011).
 2. Dipilih secara berurutan 722 pasien yang mengalami cedera
pada cincin pinggul berdasarkan kriteria inklusi dan eksklusi.
3. Data pasien seperti umur, jenis kelamin, klasifikasi cedera
AO/OTA dan tanggal cedera dikumpulkan.
4. Dua peneliti secara independen melakukan reviu terhadap hasil
pemeriksaan radiologi awal:
- Gambar rontgen pelvis AP untuk mendeteksi keberadaan
udara
- CT abdomen dan pinggul dengan protokol tulang dan paru-
paru untuk mendeteksi udara ekstra-lumenal
5. Adanya udara ekstra-lumenal dicatat berdasarkan lokasi, pola
dan sumbernya.
6. Dijumpai 98 pasien dengan udara ekstra-lumenal pada CT awal.
Setelah diterapkan kriteria, 81 pasien dimasukkan ke analisis.
7. Dianalisis korelasi antara keberadaan udara pada CT dengan
diagnosa luka terbuka secara klinis.
8. Dianalisis laporan hasil radiologi apakah mendeteksi udara atau
tidak.
Tujuan utama penelitian ini adalah mengidentifikasi udara ekstra-
lumenal pada CT dan menggunakannya untuk mendiagnosis lebih
dini luka terbuka cincin pinggul.
Hasil dan Dari penelitian yang telah dilakukan, didapatkan hasil berupa :
Pembahasan 1. Dari 722 pasien dengan cedera cincin pinggul yang direviu, 81
pasien (11,2%) memenuhi kriteria untuk dimasukkan ke analisis.
2. 54 pasien (66,7%) menunjukkan keberadaan udara ekstra-
lumenal di jaringan subkutan pada CT awal.
3. 21 pasien (25,9%) mengalami udara intra-abdominal pada CT.
4. Udara ditemukan berkorelasi dengan lokasi disrupsi cincin
pinggul pada 30 pasien.
5. Sumber udara subkutan utama adalah pneumothoraks (21
pasien), luka kulit terbuka (20 pasien), dan cedera kandung
kemih (16 pasien).
6. Hanya 6 pasien (7,4%) yang secara klinis didiagnosis luka
terbuka pinggul.
7. Diagnosis terlewat terjadi pada 2 pasien yang baru didiagnosis
telat dengan luka rektum dan perineum.
8. CT mampu melacak asal usul udara di seluruh kasus.
9. Laporan radiologi melewatkan deteksi udara pada 36 dari 81
CT scan (44,4%).

Dari hasil yang didapatkan, peneliti kemudian memberikan

jawaban serta solusi atas permasalahan yang ada, yaitu :
1. Pemeriksaan CT abdomen dan pinggul awal harus dievaluasi
untuk mendeteksi keberadaan udara ekstra-lumenal, terutama di
jaringan subkutan.
2. Udara ekstra-lumenal yang ditemukan pada CT perlu dilacak asal
usulnya, apakah berasal dari luka terbuka atau sumber lain
seperti pneumothoraks.
3. Informasi keberadaan udara yang terdeteksi pada CT perlu
dikorelasikan dengan hasil pemeriksaan fisik pasien secara
keseluruhan untuk mendiagnosis luka terbuka cincin pinggul.
4. Evaluasi mandiri dokter terhadap hasil CT, dan tidak hanya
berdasarkan laporan radiolog, penting untuk mengidentifikasi
udara ekstra-lumenal yang signifikan.
5. Penggunaan CT sebagai alat diagnostik tambahan dapat
meningkatkan deteksi kasus luka terbuka cincin pinggul yang
sebelumnya terlewatkan diagnosisnya.
6. Evaluasi gabungan antara pemeriksaan fisik yang menyeluruh
dan pemeriksaan CT awal perlu dilakukan untuk mengurangi
 diagnosis terlewat atau terlambatnya luka terbuka pada cincin
pinggul.
Oleh karena itu, solusi utama yang dihasilkan adalah
memaksimalkan informasi yang terkandung pada CT awal untuk
mendiagnosis lebih dini luka terbuka cincin pinggul.
Kesimpulan Berdasarkan hasil dan pembahasan yang telah dijelaskan
sebelumnya, kesimpulan utama dari penelitian pada jurnal tersebut
adalah:

1. Pemeriksaan CT abdomen dan pinggul awal pasien dengan

cedera cincin pinggul dapat mendeteksi keberadaan udara
ekstra-lumenal, khususnya di jaringan subkutan.
2. Udara ekstra-lumenal yang terdeteksi pada CT perlu dilacak asal
usul dan sumbernya, termasuk kemungkinan berasal dari luka
terbuka cincin pinggul.
3. Informasi keberadaan udara pada CT perlu dikorelasikan dengan
hasil pemeriksaan fisik secara keseluruhan untuk mendiagnosis
luka terbuka cincin pinggul.
4. Penilaian mandiri dokter terhadap hasil CT, dan tidak hanya
berdasarkan laporan radiolog, penting untuk mengidentifikasi
udara ekstra-lumenal yang signifikan.
5. Evaluasi gabungan antara pemeriksaan fisik dan CT awal dapat
meningkatkan deteksi dini luka terbuka cincin pinggul yang
sebelumnya terlewatkan diagnosisnya.
6. Secara keseluruhan, pemeriksaan CT abdomen dan pinggul
dapat dimanfaatkan sebagai alat diagnostik tambahan untuk
mendiagnosis lebih dini luka terbuka cincin pinggul dan
mengurangi diagnosis yang terlambat.
Saran Beberapa saran yang bisa diberikan kepada peneliti terhadap
jurnal tersebut antara lain:
1. Dilakukan studi komparasi antara hasil pemeriksaan fisik saja
versus gabungan pemeriksaan fisik dan CT dalam diagnosis luka
terbuka cincin pinggul. Ini untuk menguji efektivitas penggunaan
CT secara kuantitatif.
2. Ditambahkan analisis mengenai outcome klinis pasien dengan
luka terbuka yang terdiagnosis dini berkat CT dibandingkan yang
didiagnosis terlambat. Misalnya lama rawat, komplikasi,
mortalitas.
3. Dilakukan studi prediktor mana saja pada CT scan yang paling
berhubungan dengan adanya luka terbuka, seperti lokasi, jenis
dan volume udara.
4. Ditambahkan contoh kasus dengan gambar CT scan yang jelas
menunjukkan udara ekstra-lumenal dan asal-usulnya.
5. Dilakukan studi independen oleh radiolog untuk menilai
keakuratan deteksi udara CT antara hasil peneliti versus laporan
radiolog.
6. Ditambahkan jumlah sample yang lebih besar untuk
meningkatkan kekuatan statistik hasil penelitian.
7. Dilakukan studi serupa pada pasien anak-anak dengan cedera
cincin pinggul.
Dengan saran-saran tersebut, hasil dan kredibilitas penelitian
diharapkan dapat semakin baik untuk mendukung
kesimpulan yang ditarik.
Citra CT Scan
Pelvis pada
kasus Trauma

Gambar 1 : Potongan aksial (protokol lung) pasien dengan gangguan pada

cincin panggul. Udara divisualisasikan dalam jaringan subkutan
disepanjang sisi kanan dan kiri dari pneumotoraks. Udara ekstraluminal
juga terlihat di perut akibat cedera visceral.

Gambar 2 : Potongan aksial (protokol bone) pasien dengan gangguan

pada cincin panggul dan patahan sayap iliaka. Udara terlihat di jaringan
subkutan di sepanjang sisi kiri pasien mulai dari cedera kulit terbuka hingga
patah tulang panggul.
Gambar 3 : Potongan aksial (protokol bone) dari pasien dengan cedera
cincin panggul terbuka. Udara terlihat di jaringan subkutan di sisi kanan
dari pneumothoraks. Selain itu, udara juga divisualisasikan secara
posterior dekat sisi kanan sakrum. Udasra ini dilacak langsung dari luka
terbuka ke cedera sakral dan mewakili cedera cincin panggul terbuka.
G Model
JINJ-6284; No. of Pages 4

Injury, Int. J. Care Injured xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Use of the initial trauma CT scan to aid in diagnosis of open

pelvic fractures
John A. Scolaro a,*, David J. Wilson b, Milton Lee ‘‘Chip’’ Routt c, Reza Firoozabadi d
a
University of California, Irvine, Orange, CA, USA
b
Madigan Army Medical Center, Tacoma, WA, USA
c
The University of Texas, Health Sciences Center at Houston, Houston, TX, USA
d
Harborview Medical Center, University of Washington, Seattle, WA, USA

A R T I C L E I N F O A B S T R A C T

Article history: Open pelvic disruptions represent high-energy injuries. The prompt identification and management of
Accepted 29 June 2015 these injuries decreases their associated morbidity and mortality. Computed tomography (CT) scans are
routinely obtained in the initial evaluation of patients with pelvic injuries. The purpose of this study is to
Keywords: identify the incidence and source of air densities noted on computed tomography (CT) scans of the
Pelvic ring abdominal and pelvic region in patients with pelvic fractures and evaluate the use of initial CT imaging as
Open fracture an adjunctive diagnostic tool to identify open injuries. A retrospective review of a prospectively collected
Computed tomography
database was performed at a single institution. Seven hundred and twenty-two consecutive patients
Air
with a pelvic disruption over a two-year period were included. Review of initial injury CT scans was
performed using bone and lung viewing algorithms to identify the presence of extra-luminal air. The
primary outcome was the presence, location and source of air identified on pre-operative CT scans.
Secondary measurements were identification of air by plain radiograph and correlation between
identified air densities on CT and clinically diagnosed open pelvic fractures. Ninety-eight patients were
identified as having extra-luminal air densities on CT scans. Eighty-one patients were included in the
final analysis following application of inclusion and exclusion criteria. Air was noted by the radiologist in
forty-five (55.6%) instances. Six patients (7.4%) were clinically diagnosed with an open pelvic ring
disruption; in two patients (2.4%) this diagnosis was delayed. In all patients, the CT was able to track air
from its origin. In patients with pelvic disruptions, the injury CT should also be evaluated for the presence
and source of extra-luminal air. In some patients, this finding may represent an open pelvic ring
disruption. A complete physical exam and CT evaluation should be used to decrease the missed or
delayed diagnosis of an open pelvic ring injury.
ß 2015 Elsevier Ltd. All rights reserved.

Introduction
Unstable pelvic ring injuries can be life threatening if not cared
for appropriately. Open pelvic ring injuries occur rarely but usually
represent high-energy injuries [1–3]. Open wounds commonly
occur adjacent to the iliac crest or perineal/anorectal area. Open
wound(s) complicate the patient’s initial management during
resuscitation as pelvic related bleeding escapes unchecked
through the lesion. Following stabilization, the open pelvic injury
exposes the patient to the risk of deep pelvic infection, especially
* Corresponding author at: University of California, Irvine, Department of
Orthopaedic Surgery, 101 The City Drive South, Pavilion III, Building 29A, 2nd Floor,
Orange, CA 92868, USA. Tel.: +1 714 456 1699; fax: +1 714 456 7547.
E-mail addresses: jscolaro56@yahoo.com (J.A. Scolaro), dav.j.wilson@gmail.com
(D.J. Wilson), chiproutt@gmail.com (M.L.&. Routt), rezaf2@uw.edu (R. Firoozabadi).
when the anorectal region is involved. Diagnosis of open pelvic ring
injuries is straightforward when the wound is extensive or
obvious. Other open pelvic injuries are more difficult to diagnose
and require manual or visual examination of the vagina, anorectal
area, and intertriginous areas [4,5].
Computed tomography (CT) scans are routinely obtained in
the evaluation of a patient with a pelvic ring injury. Valuable
diagnostic information can be obtained from the CT scan of the
abdomen and pelvis. In the abdomen and pelvis, CT air densities
can originate from multiple sources and should alert the treating
physician to this possibility of an open pelvic ring injury, whenever
identified. Identification of CT air densities about the knee has been
described in the identification of open fractures and traumatic
arthrotomies about the knee [6,7]. The use of abdominal and pelvic
CT to evaluate the source of air densities, in an effort to increase
identification of open pelvic ring injuries, has not been described.

http://dx.doi.org/10.1016/j.injury.2015.06.045
0020–1383/ß 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Scolaro JA, et al. Use of the initial trauma CT scan to aid in diagnosis of open pelvic fractures. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.06.045
G Model
JINJ-6284; No. of Pages 4

2 J.A. Scolaro et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx

The purpose of this study was to identify and characterize

extra-luminal air densities seen in CT studies of patients with
traumatic pelvic ring disruptions. We sought to determine if
evaluation of the abdominal and pelvic CT scan could improve the
identification of open pelvic fractures. Our hypothesis was that
the review of standard abdominal and pelvic CT scans, using both
the bone and lung algorithms, would allow us to identify extra-
luminal air and improve detection of open pelvic ring injuries
initially misdiagnosed as closed injuries.

Patients and methods

Institutional review board approval was obtained for this study.

A retrospective review of a prospectively collected orthopaedic
database at a single academic level-one trauma centre was
performed between January 1, 2009 and January 1, 2011. All
patients who had sustained an injury to the pelvic ring (AO/OTA
61-A, 61-B, 61-C) were identified. Inclusion criteria included
patients who had sustained a traumatic injury, had an available
plain anteroposterior (AP) radiograph of the pelvis, as well as a CT
scan of the abdomen and pelvis before any surgical intervention
had been performed. Exclusion criteria included patients with
pathologic fractures, an incomplete radiographic evaluation (plain
AP pelvis radiograph, CT scan of abdomen and pelvis, or both), or a
CT study performed after open pelvic or abdominal procedure.
Final study analysis included only patients with air density seen on
the CT scan of the abdomen and pelvis.
Seven hundred twenty-two consecutive patients with an injury
to the pelvic ring were identified over the defined study period
Fig. 1. Inclusion/exclusion diagram.
following application of initial inclusion and exclusion criteria.
Subject age, sex, AO/OTA injury classification and date of injury
were collected. Two authors (DJW and JAS) independently skin wounds in 20 patients (37%) (Fig. 3), and bladder injury in
reviewed all selected imaging studies. Plain AP pelvis radiographs 16 patients (29.6%). Three patients had identified air densities in
were first evaluated for the presence of observable air. Axial CT more than one location.
scans were then reviewed using both lung and bone viewing Initial radiology reports failed to report the presence of air on
algorithms to determine if air was present within the soft tissues, 36 of 81 scans (44.4%). Six (7.4%) patients were classified as having
outside of identifiable lumen. Each scan was reviewed from the an open pelvic ring injury. Two patients had open injuries that
first lumbar vertebrae to 5 cm below the lesser trochanter of were identified on a delayed basis (1 rectal injury, 1 perineal
the femur. The location, pattern and identifiable cause of air within wound). Both patients had air densities on admission CT scans that
the soft tissues were documented. If the CT scan alone could not were not identified during the initial assessment and evaluation of
determine the cause of air, chart review was performed. Finally, the the patient (Fig. 4).
official radiology reports of both the plain AP pelvic radiograph and
the axial CT scan was reviewed to note whether air densities within Discussion
the soft tissues were noted by staff radiologists.
Ninety-eight patients were initially identified as having extra- Open pelvic fractures are uncommon injuries and represent less
luminal air present on initial injury CT scans. Fourteen patients than 5% of all pelvic ring injuries [9]. Unfortunately, mortality rates
were excluded from this group as the initial CT scan was performed
following emergent abdominal surgery, resulting in iatrogenic air
densities. Three patients were further excluded as air densities
were identified and isolated to the sacroiliac joint(s) without
evidence of air within the surrounding soft tissues [8] (Fig. 1).

Results

Eighty-one patients (11.2%) were included in the final analysis.

The mean age of subjects in our study was 42 years (range 4–85);
there were 53 males and 28 females. The most common mechanisms
of injury were motorcycle collisions (n = 27), motor vehicle
collisions (n = 23) and pedestrians struck by motor vehicles (n = 12).
Fifty-four (66.7%) patients were identified as having air
densities within subcutaneous tissues. Twenty-one (25.9%)
patients had extra-luminal air densities within the intra-abdomi-
nal space (Fig. 2). In 30 patients, abnormal subcutaneous or extra-
Fig. 2. Axial CT image (lung algorithm) of a patient with disruption to the pelvic ring.
luminal air densities were identified adjacent to the disrupted Air is visualized in the subcutaneous tissues along the right and left side from a
pelvic ring. The source of subcutaneous extra-luminal air densities pneumothorax. Extra-luminal air is also visualized in the abdomen from a visceral
was determined to be a pneumothorax in 21 patients (39%), open injury.

Please cite this article in press as: Scolaro JA, et al. Use of the initial trauma CT scan to aid in diagnosis of open pelvic fractures. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.06.045
G Model
JINJ-6284; No. of Pages 4
J.A. Scolaro et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Fig. 3. Axial CT image (bone algorithm) of a patient with a disruption to the pelvic
ring and facture of the iliac wing. Air is seen in the subcutaneous tissues along the
left side of the patient which tracked from the open skin injury to the pelvic fracture.
Fig. 4. Axial CT image (bone algorithm) of a patient with an open pelvic ring injury.
Air is seen in the subcutaneous tissues on the right side from a pneumothorax. In
addition, air is also visualized posteriorly near the right side of the sacrum. This air
tracked directly from an open wound to the sacral injury and represented an open
pelvic ring injury.
as high as 50% have been reported for open pelvic ring trauma [10–
14]. Improved initial management and resuscitation has led to a
decrease in their mortality [1,2,15–17]. Early recognition of open
wounds, definitive or provisional stabilization of the pelvic ring,
and restoration of haemodynamic stability are essential elements
in the initial care of these patients.
Traumatic wounds that communicate with the pelvis can occur
anywhere, from the thorax to the proximal aspect of the lower
extremities, including the buttocks, groin and perineum. Lacera-
tions within intertriginous areas or skin folds can be missed if a
thorough physical exam is not performed. For this reason, a careful
digital rectal, speculum facilitated vaginal, and direct visual exam
of the perineum is necessary. Bacterial infections contribute to an
increase in mortality in patients with open pelvic ring fractures;
timely open wound identification, surgical debridement, along
with tetanus toxoid and IV antibiotics are therefore mandatory to
avoid complications [15].
The use of two-dimensional abdominal and pelvic CT scans in
the evaluation of the trauma patient with a pelvic ring disruption
is common. These studies are often promptly obtained
following initial resuscitation and management, and provide the
practitioner with useful clinical information. Extra-luminal air-
densities identified on CT scans is abnormal [18–20]. Injuries to the
Please cite this article in press as: Scolaro JA, et al. Use of the initial trauma CT scan to aid in diagnosis of open pelvic fractures. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.06.045
3
integumentary, pulmonary, gastrointestinal, genitourinary and
musculoskeletal systems must be evaluated to identify the source
of air. In the setting of an injury to the pelvic ring, the presence of
extra-luminal air may represent an open skeletal injury, especially
when present in the subcutaneous soft tissues. The CT scan should
therefore be utilized, in conjunction with a complete physical
exam, to improve identification of open pelvic ring injuries.
Our study identified abnormal extra-luminal subcutaneous air
in the CT scans of over 10% of patients with a pelvic ring injury. In
39 cases, the air had tracked from a concurrent pneumothorax.
In one fifth of patients with subcutaneous air seen on CT, a
corresponding open soft tissue wound was identified. In two
patients, information from the CT helped to identify tracking
abnormal extra-luminal air from the perineum and vagina to the
osseous pelvic disruption. Our study found that in less than half of
all cases, the official radiology report failed to note the presence,
location or potential significance of air seen on the abdominal
and pelvic CT scan. This finding emphasizes the responsibility of
the surgeon to review the CT scan images and not just review the
radiology report.
Computed tomography scans of the abdomen and pelvis are
routinely obtained in the initial evaluation of trauma patients with
a disruption to the pelvic ring. This study is the first to recognize
the source and significance of abnormal extra-luminal air found in
these scans, specifically as a means to diagnose and manage open
pelvic ring injuries. Despite an established institutional physical
exam protocol for all trauma patients with a pelvic ring injury, CT
information was used to diagnose two open injuries that were
initially overlooked. Computed tomography scans in all patients
with pelvic ring trauma should be reviewed to identify subcuta-
neous air and correlate this information with the clinical exam to
ensure an open pelvic ring injury does not go unrecognized.
Conflict of interest
Each author certifies that he has no commercial association
(e.g., consultancies, stock ownership, equity interest, patent,
licensing arrangements, etc.) that might pose a conflict of interest
in connection with the submitted article.
John A. Scolaro, M.A., M.D.: This author, their immediate family,
and any research foundation with which they are affiliated did not
receive any financial payments or other benefits from any
commercial entity related to the subject of this article.
David J. Wilson, M.D.: This author, their immediate family, and
any research foundation with which they are affiliated did not
receive any financial payments or other benefits from any
commercial entity related to the subject of this article.
Milton Lee ‘‘Chip’’ Routt, M.D.: This author, their immediate
family, and any research foundation with which they are affiliated
did not receive any financial payments or other benefits from any
commercial entity related to the subject of this article.
Reza Firoozabadi, M.A., M.D.: This author, their immediate
family, and any research foundation with which they are affiliated
did not receive any financial payments or other benefits from any
commercial entity related to the subject of this article.
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