Diagnostic accuracy of physical examination for detecting pelvic fractures among blunt trauma patients: a systematic review and meta-analysis

Abstract

Background Pelvic fractures are common among blunt trauma patients, and timely and accurate diagnosis can improve patient outcomes. However, it remains unclear whether physical examinations are sufficient in this context. This study aims to perform a systematic review and meta-analysis of studies on the diagnostic accuracy and clinical utility of physical examination for pelvic fracture among blunt trauma patients. Methods Studies were identified using the MEDLINE, EMBASE, and CENTRAL databases starting from the creation of the database to January 2020. A total of 20 studies (49,043 patients with 8300 cases [16.9%] of pelvic fracture) were included in the quality assessment and meta-analysis. Two investigators extracted the data and evaluated the risk of bias in each study. The meta-analysis involved a hierarchical summary receiver operating curve (ROC) model to calculate the diagnostic accuracy of the physical exam. Subgroup analysis assessed the extent of between-study heterogeneity. Clinical utility was assessed using decision curve analysis. Results The median prevalence of pelvic fracture was 10.5% (interquartile range, 5.1–16.5). The pooled sensitivity (and corresponding 95% confidence interval) of the hierarchical summary ROC parameters was 0.859 (0.761–0.952) at a given specificity of 0.920, which was the median value among the included studies. Subgroup analysis revealed that the pooled sensitivity among patients with a Glasgow Coma Scale score ≥ 13 was 0.933 (0.847–0.998) at a given specificity of 0.920. The corresponding value for patients with scores ≤ 13 was 0.761 (0.560–0.932). For threshold probability < 0.01 with 10–15% prevalence, the net benefit of imaging tests was higher than that of physical examination. Conclusion Imaging tests should be performed in all trauma patients regardless of findings from physical examination or patients’ levels of consciousness. However, the clinical role of physical examination should be considered given the prevalence and threshold probability in each setting.

Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients

“…Accurate initial clinical assessment of trauma patients for LLTIs is a known challenge, especially for internal injuries of torso and major vascular injuries [ 11 , 19 , 40 – 48 ]. Studies have reported a wide range of sensitivity of clinical examination per body region: head (58–93%) [ 40 , 42 ], thoracic (45–60%) [ 40 , 42 ], abdominal (39–59%) [ 40 , 42 , 43 ], pelvic (45–86%) [ 19 , 42 , 44 , 45 ], spinal (60–92%) [ 42 , 46 – 48 ], and extremity injuries (33–91%) [ 42 ]. Similarly, the PPV of clinical examination varied according to body region: head (91%) [ 41 ], thorax (70–90%) [ 11 , 41 ], abdomen (43–70%) [ 41 , 43 ] pelvis (69%) [ 41 ], spine (62%) [ 41 ], and extremity injuries (91%) [ 41 ].…”

“…Accurate initial clinical assessment of trauma patients for LLTIs is a known challenge, especially for internal injuries of torso and major vascular injuries [11,19,[40][41][42][43][44][45][46][47][48]. Studies have reported a wide range of sensitivity of clinical examination per body region: head (58-93%) [40,42], thoracic (45-60%) [40,42], abdominal (39-59%) [40,42,43], pelvic (45-86%) [19,42,44,45], spinal (60-92%) [42,[46][47][48], and extremity injuries (33-91%) [42]. Similarly, the PPV of clinical examination varied according to body region: head (91%) [41], thorax (70-90%) [11,41], abdomen (43-70%) [41,43] pelvis (69%) [41], spine (62%) [41], and extremity injuries (91%) [41].…”

“…Furthermore, it is often unclear how experienced the clinicians are who perform the examination. Known factors that influence the accuracy of clinical assessment in trauma include the mechanism of injury, polytrauma, and reduced level of consciousness [16][17][18][19]. Uncertainty is ubiquitous in emergency medical practice [20], yet its impact on the accuracy of clinical examination to identify LLTIs remains poorly understood.…”

Osteoporotic Pelvic Ring Fractures

“…Rotational instability suggests bilateral pelvic ring fractures. Sensitivity may be also found on the palpation of sacrum 20 . Multiple tests can also be used during the examination, such as the FABER test or the Gaenslen's test, but do not show high specificity especially in patients experiencing intense pain.…”