A 70 year old male presents after a fall with left hip pain. The radiologist interprets the CT scan as revealing no fracture. The patient is able to bear weight and is discharged home. 10 days later the patient presents with persisting pain and difficulty ambulating. A fracture is now clearly seen in the inferior public ramus. Looking back at the prior scan, a subtle fracture was actually visible 10 days prior. You want to make sure this doesn’t happen to you again. Can physical diagnosis help?
The pelvis is a complex three dimensional structure, but most parts are palpable from the outside. In fact, physical examination for fractures performs much better than x-rays, with one study showing x-rays as 79% sensitive but physical examination rising to 96% (Duane 2008).
Press over the symphysis pubis as well as compressing the bilaterally iliac crests. Check the acetabular integrity by compressing over the greater trochanter. Palpate the sacrum. Grab the ischial tuberosity and try to shake it, checking for fractures of the pubic rami. By the end of this examination, you will know exactly where the patient might have a fracture. Such vigilence is rewarded with a 98% sensitivity and 94% specificity for fractures (McCormick 2003).
Some recommend digital rectal examination for coccygeal fractures, and this certainly is reasonable if there is coccygeal pain. The hip is brought through a full range of motion including flexion, abduction, and internal and external rotation.
Not every trauma patient needs such a detailed pelvic bone examination, but if the patient is complaining of hip or pelvic pain then dive in, knowing that a good physical examination is MUCH better than a set of x-rays.
A few weeks later you see a patient with pelvic pain after a fall, and the tenderness is maximal when you manipulate the ischial tuberosity and symphysis pubis. You look at the CT scan focusing in on the pubic rami and indeed see what you are looking for- both rami are fractured.
Take home points:
-The pelvis is an external bone and all areas of the pelvis are accessible to palpation and compression.
-A thorough physical examination is highly sensitive for fractures (Sauerland 2004).