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Endgames Picture quiz

Imaging after trauma to the pelvis and hip

BMJ 2009; 338 doi: (Published 12 March 2009) Cite this as: BMJ 2009;338:b289
  1. B A Petrisor, consultant orthopaedic trauma surgeon and assistant professor, McMaster University1,
  2. M Bhandari, consultant orthopaedic trauma surgeon and Canada research chair in musculoskeletal trauma1
  1. 1Orthopaedic Trauma Service, Hamilton Health Sciences: General Hospital, Hamilton, ON, Canada L8L 2X2
  1. Correspondence to: B A Petrisorpetrisor{at}

    The driver of a vehicle in a head-on collision was brought by ambulance to the emergency room on a spine board with the cervical spine immobilised. The trauma team carried out a full primary and secondary survey according to ATLS (advanced trauma life support) protocol. Vital signs were stabilised after initial resuscitation, and the Glasgow coma scale score was 15. An isolated injury to the left hip was identified and the hip was flexed and adducted, and his leg was internally rotated. There were no open injuries to the left leg, and the distal neurological and vascular examination revealed no deficits.

    An anteroposterior pelvic radiograph was done as part of the secondary survey trauma series of radiographs (fig 1).

    Fig 1 Initial presenting anteroposterior pelvic radiograph


    • 1 How would you interpret a pelvic radiograph?

    • 2 What are the abnormalities on this x ray?

    • 3 What are the next steps in managing this injury?

    • 4 What further imaging would help evaluate this injury?

    • 5 What is the clinical importance of this injury?


    Short answers

    • 1 Interpreting the pelvic radiograph consists of the sacroiliac joints for symmetry and widening, the symphysis pubis for widening, the L5 transverse processes for avulsion fractures, the iliac wings for fracture lines, checking the symmetry of the ischial tuberosities, and assessing the acetabulum for fractures by checking Letournel’s lines (ilioinguinal, ilioischial, acetabular dome, posterior wall, anterior wall, and teardrop). The proximal femur visible on this x ray should be assessed for any fractures of the femoral head and neck.

    • 2 Abnormalities are a triangular double shadow superior to the femoral head, adduction and internal rotation of the hip, the left femoral head image smaller …

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