Advertisement

Non-osseous considerations in diagnostic imaging for pelvic and acetabular trauma

Published:January 05, 2023DOI:https://doi.org/10.1016/j.injury.2023.01.010

      Highlights

      • Non-osseous injuries may be present in patients with pelvic ring and acetabulum injuries and should be evaluated for on diagnostic CT imaging.
      • Evaluation of the subcutaneous tissues should be performed routinely as severe injury may influence approach and perioperative management.
      • Consideration should be given to associated abdominal, genitourinary, and vascular injuries, particularly in pelvic ring injuries.
      • Anatomical variations, including sacral dysmorphism, a pelvic kidney, or spina bifida occulta, may affect fixation and surgical approach.
      • Multidisciplinary involvement in the management of patients with pelvic and acetabular trauma is critical to optimize care and outcomes.

      Abstract

      High-quality imaging is crucial for orthopedic traumatologists in the evaluation and management of pelvic and acetabular fractures. Computed tomography (CT) plays an essential role in the diagnosis and treatment of patients with these complex injuries. A thoughtful evaluation of associated soft tissues can reveal additional details about the patient and their injury that may impact treatment. This review aims to highlight soft tissue findings that should be identified when evaluating the initial diagnostic imaging after pelvic and acetabular trauma.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Guillamondegui O.D.
        • Pryor J.P.
        • Gracias V.H.
        • Gupta R.
        • Reilly P.M.
        • Schwab C.W
        Pelvic radiography in blunt trauma resuscitation: a diminishing role.
        J Trauma Acute Care Surg. 2002; 53: 1043-1047
        • Hilty M.P.
        • Behrendt I.
        • Benneker L.M.
        • Martinolli L.
        • Stoupis C.
        • Buggy D.J.
        • et al.
        Pelvic radiography in ATLS algorithms: a diminishing role?.
        World J Emerg Surg. 2008; 3: 11
        • Obaid A.K.
        • Barleben A.
        • Porral D.
        • Lush S.
        • Cinat M
        Utility of plain film pelvic radiographs in blunt trauma patients in the emergency department.
        Am Surg. 2006; 72: 951-954
        • Falchi M.
        • Rollandi G.A
        CT of pelvic fractures.
        Eur J Radiol. 2004; 50: 96-105
      1. Haase D., Villa S Emrad: Radiologic Approach to the Traumatic Hip/Pelvis[Internet]. Academic Life in Emergency Medicine; 2021 [cited 2022 Dec 20]. Available from:https://www.aliem.com/emrad-hip/

        • Ambos M.A.
        • Bosniak M.A.
        • Lefleur R.S.
        • Madayag M.A
        The pear-shaped bladder.
        Radiology. 1977; 122: 85-88
        • Mosley N.
        • Hale N.
        • Chueh S.C.J
        Pelvic hematoma with suprapubic distention.
        J Osteopat Med. 2013; 113 (931): 931
        • Kluger Y.
        • Altman G.T.
        • Deshmukh R.
        • Townsend R.N.
        • Diamond D.L
        Acute obstructive uropathy secondary to pelvic hematoma compressing the bladder: report of two cases.
        J Trauma Acute Care Surg. 1993; 35: 477-478
        • Fisher R.G
        Sacral fracture with compression of cauda equina: surgical treatment.
        J Trauma. 1988; 28: 1678-1680
        • Katz D.S.
        • Lane M.J.
        • Mindelzun R.E
        Unenhanced CT of abdominal and pelvic hemorrhage.
        Semin Ultrasound CT MRI. 1999; 20: 94-107
        • Dagur G.
        • Lee M.Y.
        • Warren K.
        • Imhof R.
        • Khan S.A
        Critical manifestations of pneumoscrotum.
        Curr Urol. 2016; 9: 62-66
        • Hudson D.
        • Knottenbelt J.
        • Krige J
        Closed degloving injuries: results following conservative surgery.
        Plast Reconstr Surg. 1992; 89: 853-855
        • Hak D.J.
        • Olson S.A.
        • Matta J.M
        Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallée lesion.
        J Trauma Acute Care Surg. 1997; 42: 1046-1051
        • Nickerson T.P.
        • Zielinski M.D.
        • Jenkins D.H.
        • Schiller H.J
        The mayo clinic experience with Morel-Lavallée lesions: establishment of a practice management guideline.
        J Trauma Acute Care Surg. 2014; 76: 493-497
        • McKenzie G.A.
        • Niederhauser B.D.
        • Collins M.S.
        • Howe B.M
        CT characteristics of Morel-Lavallée lesions: an under-recognized but significant finding in acute trauma imaging.
        Skeletal Radiol. 2016; 45: 1053-1060
        • Singh R.
        • Rymer B.
        • Youssef B.
        • Lim J
        The Morel-Lavallée lesion and its management: a review of the literature.
        J Orthop. 2018; 15: 917-921
        • Burgess A.R.
        • Eastridge B.J.
        • Young J.W.
        • Ellison T.S.
        • Ellis Jr, P.S.
        • Poka A.
        • et al.
        Pelvic ring disruptions: effective classification system and treatment protocols.
        J Trauma. 1990; 30: 848-856
        • Dalal S.A.
        • Burgess A.R.
        • Siegel J.H.
        • Young J.W.
        • Brumback R.J.
        • Poka A.
        • et al.
        Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome.
        J Trauma. 1989; 29 (discussion 1000-1002): 981-1000
        • Damschen D.D.
        • Landercasper J.
        • Cogbill T.H.
        • Stolee R.T
        Acute traumatic abdominal hernia.
        J Trauma. 1994; 36: 273-276
        • Gill I.S.
        • Toursarkissian B.
        • Johnson S.B.
        • Kearney P.A
        Traumatic ventral abdominal hernia associated with small bowel gangrene: case report.
        J Trauma Acute Care Surg. 1993; 35: 145-147
        • Cantu R.V.
        • Poka A
        Traumatic abdominal hernia and lateral compression type 1 pelvic fracture: a case report.
        J Orthop Trauma. 2006; 20: 289-291
        • Jones T.W.
        • Merendino K.A
        The deep epigastric artery: rectus muscle syndrome.
        Am J Surg. 1962; 103: 159-169
        • Bhattachan S
        Open pelvic fracture with rectal laceration: a case report.
        JNMA J Nepal Med Assoc. 2021; 59: 802-804
        • Brody J.M.
        • Leighton D.B.
        • Murphy B.L.
        • Abbott G.F.
        • Vaccaro J.P.
        • Jagminas L.
        • et al.
        CT of blunt trauma bowel and mesenteric injury: typical findings and pitfalls in diagnosis.
        Radiographics. 2000; 20 (discussion 1536-1527): 1525-1536
        • Bushnell B.D.
        • Dirschl D.R
        Small bowel obstruction from entrapment in a sacral fracture stabilized with iliosacral screws: case report and review of the literature.
        J Trauma Acute Care Surg. 2008; 65: 933-937
        • Hall E.G.
        • Fleming C.M.E.
        • Griffis E.C.E.
        • Strauss C.J.
        • Andersen C.R
        Recognition of small bowel entrapment in the pubic symphysis following combat-related traumatic pelvic fracture: a case report and literature review.
        JBJS Case Connect. 2012; 2: e13
        • Brandes S.
        • Borrelli J
        Pelvic fracture and associated urologic injuries.
        World J Surg. 2001; 25: 1578-1587
        • Vaccaro J.P.
        • Brody J.M
        CT cystography in the evaluation of major bladder trauma.
        Radiographics. 2000; 20: 1373-1381
        • Sandler C.
        • Hall J.
        • Rodriguez M.
        • Corriere Jr., J.
        Bladder injury in blunt pelvic trauma.
        Radiology. 1986; 158: 633-638
        • Kong J.P.
        • Bultitude M.F.
        • Royce P.
        • Gruen R.L.
        • Cato A.
        • Corcoran N.M
        Lower urinary tract injuries following blunt trauma: a review of contemporary management.
        Rev Urol. 2011; 13: 119-130
        • Mahat Y.
        • Leong J.Y.
        • Chung P.H
        A contemporary review of adult bladder trauma.
        J Inj Violence Res. 2019; 11: 101-106
        • Johnsen N.V.
        • Dmochowski R.R.
        • Young J.B.
        • Guillamondegui O.D
        Epidemiology of blunt lower urinary tract trauma with and without pelvic fracture.
        Urology. 2017; 102: 234-239
        • Ali M.
        • Safriel Y.
        • Sclafani S.J.
        • Schulze R
        CT signs of urethral injury.
        Radiographics. 2003; 23 (discussion 963-956): 951-963
        • Elliott S.P.
        • McAninch J.W
        Ureteral injuries: external and iatrogenic.
        Urol Clin. 2006; 33: 55-66
        • Morey A.F.
        • Brandes S.
        • Dugi D.D.
        • Armstrong J.H.
        • Breyer B.N.
        • Broghammer J.A.
        • et al.
        Urotrauma: AUA guideline.
        J Urol. 2014; 192: 327-335
        • Gayer G.
        • Zissin R.
        • Apter S.
        • Garniek A.
        • Ramon J.
        • Kots E.
        • et al.
        Urinomas caused by ureteral injuries: CT appearance.
        Abdom Imaging. 2002; 27: 88-92
        • Ortega S.J.
        • Netto F.S.
        • Hamilton P.
        • Chu P.
        • Tien H.C
        CT scanning for diagnosing blunt ureteral and ureteropelvic junction injuries.
        BMC Urol. 2008; 8: 1-5
        • Boudissa M.
        • Ruatti S.
        • Maisse N.
        • Arvin-Berod A.
        • Trilling B.
        • Long J.A.
        • et al.
        Bilateral testicular dislocation with pelvic ring fracture: a case report and literature review.
        Orthop Traumatol Surg Res. 2013; 99: 485-487
        • Bromberg W.
        • Wong C.
        • Kurek S.
        • Salim A
        Traumatic bilateral testicular dislocation.
        J Trauma Acute Care Surg. 2003; 54: 1009-1011
        • Smith C.S.
        • Rosenbaum C.S.
        • Harris A.M
        Traumatic bilateral testicular dislocation associated with an anterior posterior compression fracture of the pelvis: a case report.
        J Surg Orthop Adv. 2012; 21: 162-164
        • Wiznia D.H.
        • Wang M.
        • Yeon-Kim C.
        • Tomaszewski P.
        • Leslie M.P
        Traumatic testicular dislocation associated with lateral compression pelvic ring injury and T-shaped acetabulum fracture.
        Case Rep Orthop. 2016; 20169706392
        • Chouhan V.
        • Ladhania M.
        • Chouhan K
        Pelvic fracture associated with intrapelvic dislocation of testis.
        J Orthop Case Rep. 2021; 11: 90-94
        • Firoozabadi R.
        • Stafford P.
        • Routt M
        Risk of spermatic cord injury during anterior pelvic ring and acetabular surgery: an anatomical study.
        Arch Bone Jt Surg. 2015; 3: 269-273
        • Firoozabadi R.
        • Stafford P.
        • Routt M
        Inguinal abnormalities in male patients with acetabular fractures treated using an ilioinguinal exposure.
        Arch Bone Jt Surg. 2015; 3: 274-279
        • Gilliland M.D.
        • Ward R.E.
        • Barton R.M.
        • Miller P.W.
        • Duke J.H
        Factors affecting mortality in pelvic fractures.
        J Trauma. 1982; 22: 691-693
        • Moreno C.
        • Moore E.E.
        • Rosenberger A.
        • Cleveland H.C
        Hemorrhage associated with major pelvic fracture: a multispecialty challenge.
        J Trauma Acute Care Surg. 1986; 26: 987-994
        • Kertesz J.L.
        • Anderson S.W.
        • Murakami A.M.
        • Pieroni S.
        • Rhea J.T.
        • Soto J.A
        Detection of vascular injuries in patients with blunt pelvic trauma by using 64-channel multidetector CT.
        Radiographics. 2009; 29: 151-164
        • Uyeda J.
        • Anderson S.W.
        • Kertesz J.
        • Soto J.A
        Pelvic CT angiography: application to blunt trauma using 64MDCT.
        Emerg Radiol. 2010; 17: 131-137
        • Smith J.C.
        • Gregorius J.C.
        • Breazeale B.H.
        • Watkins G.E
        The corona mortis, a frequent vascular variant susceptible to blunt pelvic trauma: identification at routine multidetector CT.
        J Vasc Interv Radiol. 2009; 20: 455-460
        • Teague D.C.
        • Graney D.O.
        • Routt Jr, M.L.
        Retropubic vascular hazards of the ilioinguinal exposure: a cadaveric and clinical study.
        J Orthop Trauma. 1996; 10: 156-159
        • Darmanis S.
        • Lewis A.
        • Mansoor A.
        • Bircher M
        Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum.
        Clin Anat. 2007; 20: 433-439
        • Steinberg E.L.
        • Ben-Tov T.
        • Aviram G.
        • Steinberg Y.
        • Rath E.
        • Rosen G
        Corona mortis anastomosis: a three-dimensional computerized tomographic angiographic study.
        Emerg Radiol. 2017; 24: 519-523
        • Stubbart J.R.
        • Merkley M
        Bowel entrapment within pelvic fractures: a case report and review of the literature.
        J Orthop Trauma. 1999; 13
        • Westberg S.
        • Kupfer N.
        • Fung C.
        • Widder S.
        • Glasgow D
        Small bowel obstruction secondary to entrapment in a minimally displaced acetabular fracture: a case report.
        JBJS Case Connect. 2019; 9: e0222
        • Stenquist D.S.
        • Chavez T.J.
        • Weaver M.J
        Entrapment of the urinary bladder: a rare mechanism of bladder injury in pelvic trauma.
        Trauma Case Rep. 2019; 21100199
        • Wuellner J.C.
        • Shieh A.K.
        • Eastman J.G
        Sciatic nerve entrapment and transection in a combined pelvic ring-acetabular fracture: a case report.
        JBJS Case Connect. 2021; 11 (.00969): e20
        • Huijbregts J.E.
        • Luitse J.S.
        • Goslings J.C.
        • Eijer H
        Entrapment of the external iliac vein in a both-column acetabular fracture.
        J Orthop Trauma. 2004; 18: 630-633
        • Barrick E.F
        Entrapment of the obturator nerve in association with a fracture of the pelvic ring. A case report*.
        JBJS. 1998; 80: 258-261
        • Konety B.R.
        • Xerogeanes J.
        • Corral D.A.
        • Gruen G.
        • Hrebinko R
        Ureteral entrapment in the sacroiliac joint in pelvic trauma.
        J Trauma. 1996; 40: 150-151
        • Beyer S.
        • Klassen M.
        • Perry S.
        Endres T Case report: pediatric posterior wall acetabulum with piriformis entrapment.
        Case Rep Orthop Res. 2022; 5: 38-44
        • Tolkach Y.
        • Gadjiev N.
        • Korol V.
        • Gonchar I
        Vesico-acetabular fistula and urolithiasis in the hip joint cavity due to persistent bladder entrapment after acetabular fracture.
        Korean J Urol. 2011; 52: 221-224
        • Min W.
        • Gaines R.J.
        • Sagi H.C
        Delayed presentation of bladder entrapment secondary to nonoperative treatment of a lateral compression pelvic fracture.
        J Orthop Trauma. 2010; 24: e44-e48
        • Kingsnorth A.
        • LeBlanc K
        Hernias: inguinal and incisional.
        Lancet. 2003; 362: 1561-1571
        • Suzuki S.
        • Furui S.
        • Okinaga K.
        • Sakamoto T.
        • Murata J.
        • Furukawa A.
        • et al.
        Differentiation of femoral versus inguinal hernia: CT findings.
        Am J Roentgenol. 2007; 189: W78-W83
        • Abdeen N.
        • Shabana W
        Review of inguinal region hernias on MDCT: a vascular roadmap.
        Appl Radiol. 2011; 40: 16-21
        • Alderuccio M.
        • Vanguardia M.K.
        • Packiyanathan J.A.
        • Fitzgerald M
        Traumatic obturator foramen hernia. A rare aetiology of a rare condition: a case report.
        Trauma Case Rep. 2022; 39100635
        • Lu M.S.
        • Peng K.T.
        • Chin C.C.
        • Huang Y.K.
        • Huang W.S.
        • Kao C.L.
        • et al.
        Associated injury in pelvic fracture: colon herniation.
        J Trauma Acute Care Surg. 2008; 64: 1144
        • Gavlin A.
        • Kierans A.S.
        • Chen J.
        • Song C.
        • Guniganti P.
        • Mazzariol F.S
        Imaging and treatment of complications of abdominal and pelvic mesh repair.
        RadioGraphics. 2020; 40: 432-453
        • Gupta A.A.
        • Kim D.C.
        • Krinsky G.A.
        • Lee V.S
        CT and MRI of cirrhosis and its mimics.
        AJR Am J Roentgenol. 2004; 183: 1595-1601
        • Sangster G.P.
        • Previgliano C.H.
        • Nader M.
        • Chwoschtschinsky E.
        • Heldmann M.G
        MDCT imaging findings of liver cirrhosis: spectrum of hepatic and extrahepatic abdominal complications.
        HPB Surg. 2013; 2013129396
        • Bhangui P.
        • Laurent A.
        • Amathieu R.
        • Azoulay D
        Assessment of risk for non-hepatic surgery in cirrhotic patients.
        J Hepatol. 2012; 57: 874-884
        • Soni N.
        • Israrahmed A.
        • Singh P.
        • Lal H
        Caput medusa: a sign of portal hypertension in case of chronic Budd-Chiari syndrome.
        BMJ Case Rep. 2021; 14e242076
        • Sharma B.
        • Raina .S
        Caput medusae.
        Indian J Med Res. 2015; 141: 494
        • Downs R.A.
        • Lane J.W.
        • Burns E
        Solitary pelvic kidney. Its clinical implications.
        Urology. 1973; 1: 51-56
        • Reilly M.C.
        • Zinar D.M.
        • Matta J.M
        Neurologic injuries in pelvic ring fractures.
        Clin Orthop Relat Res. 1996; : 28-36
        • Miller A.N.
        • Routt Jr, M.L.
        Variations in sacral morphology and implications for iliosacral screw fixation.
        J Am Acad Orthop Surg. 2012; 20: 8-16
        • Conflitti J.M.
        • Graves M.L.
        • Jr Chip Routt ML
        Radiographic quantification and analysis of dysmorphic upper sacral osseous anatomy and associated iliosacral screw insertions.
        J Orthop Trauma. 2010; 24: 630-636
        • Kaiser S.P.
        • Gardner M.J.
        • Liu J.
        • Routt Jr, M.L.
        • Morshed S
        Anatomic determinants of sacral dysmorphism and implications for safe iliosacral screw placement.
        J Bone Joint Surg Am. 2014; 96: e120
        • Trimba R.
        • Spivak J.M.
        • Bendo J.A
        Conjoined nerve roots of the lumbar spine.
        Spine J. 2012; 12: 515-524
        • Böttcher J.
        • Petrovitch A.
        • Sörös P.
        • Malich A.
        • Hussein S.
        • Kaiser W.A
        Conjoined lumbosacral nerve roots: current aspects of diagnosis.
        Eur Spine J. 2004; 13: 147-151
        • Kanawati A.J
        Variations of the sciatic nerve anatomy and blood supply in the gluteal region: a review of the literature.
        ANZ J Surg. 2014; 84: 816-819
        • Beaton L.E.
        • BJ Anson
        The relation of the sciatic nerve and of its subdivisions to the piriformis muscle.
        Anat Rec. 1937; 70: 1-5
        • Smoll N.R
        Variations of the piriformis and sciatic nerve with clinical consequence: a review.
        Clin Anat Off J Am Assoc Clin Anat British Assoc Clin Anat. 2010; 23: 8-17
        • Huang B.
        • Decater T.
        • Iwanaga J.
        • Dumont A.S.
        • Tubbs R.S
        Reunification of a split sciatic nerve.
        Anat Cell Biol. 2020; 53: 369-371
        • Varenika V.
        • Lutz A.M.
        • Beaulieu C.F.
        • Bucknor M.D
        Detection and prevalence of variant sciatic nerve anatomy in relation to the piriformis muscle on MRI.
        Skeletal Radiol. 2017; 46: 751-757
        • Divizyon S.S
        Variations in the high division of the sciatic nerve and relationship between the sciatic nerve and the piriformis.
        Turk Neurosurg. 2009; 19: 139-144