CT Scan Indications in Pelvic Fracture

Hemodynamically Stable Patients

The American College of Radiology recommends performing thoraco-abdomino-pelvic CT scan with IV contrast immediately when the patient can tolerate transport to the scanner, with 100% sensitivity and specificity for bone fractures 1, 3
CT with IV contrast is the gold standard imaging study for hemodynamically stable patients with pelvic fractures, providing optimal characterization of solid organ injury and active bleeding 2, 3

Use multi-phasic CT protocol including arterial, portal venous, and delayed phases to optimally evaluate for hemorrhage or hematoma, with portal venous phase providing optimal characterization of solid organ injury and active bleeding 1, 2, 3
Obtain 3D bone reconstructions to reduce tissue damage during subsequent procedures, decrease operative time, and improve surgical planning 2, 4

Contrast extravasation (arterial blush) has 98% accuracy for identifying arterial bleeding, though absence doesn't exclude active bleeding 2
Pelvic hematoma ≥500 cm³ strongly suggests arterial injury even without visible contrast blush 2, 3
The predictive positive and negative values of CT with contrast compared to angiography are 93.9%, 77.8%, 88.6%, and 87.5% respectively 1

Perform chest X-ray and E-FAST first, then stabilize, and proceed to CT with contrast and angiography/embolization as needed once minimally stabilized 1, 3, 4
Pelvic X-ray helps identify life-threatening pelvic ring injuries that require immediate external fixation 3, 4

Obtain CT cystography if clinical symptoms suggest bladder or urethral injury, which occurs in 3.5-19% of pelvic fractures 1
Perform retrograde urethrogram (RUG) prior to urethral catheterization when signs of urethral injury are present, such as perineal/scrotal hematoma, blood from urethral meatus, high-riding or non-palpable prostate on rectal exam, or unstable pelvic fracture pattern 2, 3
Elderly patients warrant special consideration and may require angiography regardless of hemodynamic status, even with mechanically stable low-risk fractures, due to age-related factors like osteoporosis and anticoagulation use 2

Never delay initial CT imaging to arbitrary time points in stable patients—perform it immediately 1
Never perform noncontrast CT as it significantly reduces sensitivity for vascular and visceral injuries 1
Do not rely on hemoglobin/hematocrit as early indicators of blood loss—they lag behind actual hemorrhage 2
Never insert a transurethral catheter without prior investigation when urethral injury is suspected 3
Do not assume absence of contrast blush excludes active bleeding—consider hematoma size and clinical trajectory 2, 3