The Journal of Emergency Medicine, Vol. 40, No. 5, pp.

528 –533, 2011

Copyright © 2011 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$–see front matter

doi:10.1016/j.jemermed.2009.08.041

Ultrasound in
Emergency Medicine

ULTRASONOGRAPHIC DETERMINATION OF PUBIC SYMPHYSEAL WIDENING IN

TRAUMA: THE FAST-PS STUDY
Michael Bauman, MD,* Jonathan Marinaro, MD,*† Isaac Tawil, MD,*† Cameron Crandall, MD,*
Lizabeth Rosenbaum, MD,‡ and Ian Paul, MD‡
*Department of Emergency Medicine, †Department of Surgery, and ‡Department of Pathology, University of New Mexico Hospital,
Albuquerque, New Mexico
Reprint Address: Jonathan Marinaro, MD, Department of Surgery, MSC10-5610, 1 University of New Mexico, Albuquerque,
NM 87131-0001

e Abstract—Background: The focused abdominal sonog-
raphy in trauma (FAST) examination is a routine compo-
nent of the initial work-up of trauma patients. However, it
does not identify patients with retroperitoneal hemorrhage
associated with significant pelvic trauma. A wide pubic
symphysis (PS) is indicative of an open book pelvic fracture
and a high risk of retroperitoneal bleeding. Study Objec-
tives: We hypothesized that an ultrasound image of the PS
as part of the FAST examination (FAST-PS) would be an
accurate method to determine if pubic symphysis diastasis
was present. Methods: This is a comparative study of a
diagnostic test on a convenience sample of 23 trauma pa-
tients at a Level 1 Trauma Center. The PS was measured
sonographically in the Emergency Department (ED) and
post-mortem (PM) at the State Medical Examiner. The
ultrasound (US) measurements were then compared with
PS width on anterior-posterior pelvis radiograph. Re-
sults: Twenty-three trauma patients were evaluated with
both plain radiographs and US (11 PM, 12 ED). Four
patients had radiographic PS widening (3 PM, 1 ED) and
19 patients had radiographically normal PS width; all
were correctly identified with US. US measurements
were compared with plain X-ray study by Bland-Altman
plot. With one exception, US measurements were within
2 standard deviations of the radiographic measurements
and, therefore, have excellent agreement. The only ex-
ception was a patient with pubic symphysis wider than
the US probe. Conclusion: Bedside ultrasound examina-
tion may be able to identify pubic symphysis widening in
trauma patients. This potentially could lead to faster
application of a pelvic binder and tamponade of
bleeding. © 2011 Elsevier Inc.
e Keywords—FAST examination; pelvic fracture; pre-
hospital; trauma; ultrasound
INTRODUCTION
The focused abdominal sonography in trauma (FAST)
examination is a standard component of the primary
survey of trauma patients in the Emergency Department
(ED) (1–3). Hemodynamically unstable trauma patients
with a positive FAST examination frequently bypass
computed tomography scanning for emergent operative
control of hemorrhage. Hemodynamically unstable
trauma patients without evidence of free fluid on FAST
examination mandate a search for the source of pre-
sumed hemorrhage. The FAST examination evaluates
only the thoracic and abdominal cavities for etiologies of
obstructive or hemorrhagic shock. The retroperitoneum
is another possible source of life-threatening hemor-
rhage, particularly in the presence of significant pelvic
trauma, including anterior-posterior compression pelvic
fractures (APC).
APC-type fractures I–II–III are associated with a 30 –
67% incidence of presenting with shock and a 15–37%
incidence of mortality, depending upon the APC type

RECEIVED: 30 March 2009; FINAL SUBMISSION RECEIVED: 1 July 2009;

ACCEPTED: 2 August 2009
528
Ultrasonographic Determination of Pubic Symphyseal Widening in Trauma 529

(4). These fractures are traditionally identified by porta- surements were then recorded for comparison. All US
ble anterior-posterior (AP) pelvis X-ray studies taken measurements were made via computer-aided metrics on
during the secondary survey in the trauma suite. The the digital US images at the deepest visible segment of
hemodynamically unstable patient often has the FAST the PS (Figure 1). All radiographic PS width measure-
examination performed by an additional provider con- ments were made at the pubic tubercle. Per the orthope-
currently during the primary survey to expedite definitive dic literature, 25 mm was considered the maximal nor-
hemorrhage control. The FAST examination yields results mal width of a PS (6 – 8). ED patients’ radiographs were
in real time, often before interpretation of the chest and measured on digital radiographs using digital metrics.
pelvis radiography. Thus, ultrasound (US) imaging of the Those of PM patients were measured on analog radio-
pubic symphysis (PS) as part of the FAST examination may graphs using calipers.
speed diagnosis and potential application of a pelvic binder One pubic symphysis ⬎ 38 mm wide was wider than
to trauma patients with APC fractures. We hypothesized
the linear probe and, thus, was not able to be measured
that an US image of the PS as part of the FAST examination
sonographically. This subject’s PS measurements were
(FAST-PS) would be an accurate and rapid method to
recorded as ⬎ 38 mm. Bilateral hemi-symphysis images
determine the presence of pubic symphysis widening, sug-
were obtained using a pivoting probe technique to con-
gesting an open book pelvic fracture.
firm PS width greater than the probe. This technique
involves maintaining the view of the hemi-symphysis on
METHODS one-half of the screen and pivoting the probe on this axis
searching for the other hemi-symphysis (Figure 2).
Our facility is a 400-bed urban university teaching hos-
pital and regional trauma center with an annual census of
over 80,000 emergency patient visits and is the site of an
Accreditation Council for Graduate Medical Education-
accredited Emergency Medicine residency -program. We
identified a convenience sample of trauma patients in the
ED and post-mortem (PM) at the State Medical Exam-
iner (SME) from September 2006 to January 2007, for an
observational, non-blinded study evaluating US mea-
surement of the pubic symphysis vs. the AP pelvis ra-
diograph measurement. Images were obtained as part of
a resident quality assurance project performed for US
training during residency. Our institutional Human Re-
search Review Committee approved the study.
The ED imaging data were collected on a convenience
sample of trauma patients who required the trauma suite
for initial evaluation when the author (MB) was on duty.
To increase the likelihood of true positives, we also
enrolled recently deceased trauma patients who pre-
sented to the SME while the two study pathologists were
on duty. Exclusion criteria were: age ⬍ 18 years; preg-
nant subjects, as they may have atraumatic symphyseal
widening; and those who did not receive an AP pelvis
radiograph for comparison (5).
The pubic symphysis was measured sonographically
with a 5–10-MHz linear transducer from either a Sono-
site (Seattle, WA) Micromax or Titan model grey-scale
ultrasonographic machine in the ED or at the SME. The
sonographic data were archived electronically. All sono-
graphic PS measurements were made after a physical
examination and before the results of roentgenographic
data, by a single unblinded third-year Emergency Med-
icine resident (MB) who received basic Emergency Med- Figure 1. Sonogram of the public symphysis with measure-
icine ultrasound training. Radiographic pelvic PS mea- ment and probe position on the patient.
530
Figure 2. Linear probe pivot technique.
ED patients’ US images were obtained by placing a
linear transducer in transverse orientation on the pubic
symphysis (identified by palpation) with an approxi-
mately 30° caudad scanning plane (Figure 1). The PM
patients’ US images were obtained by one of two par-
ticipating pathologists at the SME. The two pathologists
had no US training before the study. Their training
consisted of one 30-min hands-on session with the author
and proctoring of the first three scans, collectively. These
proctored images were included in the study analysis.
The authors recorded data on pre-printed data collec-
tion forms. The raw data were then entered into Mi-
crosoft Excel (Microsoft Corporation, Redmond, WA)
with double entry verification and imported into S-Plus
Version 6.2 (Insightful Corporation, Seattle, WA) for
analysis. The sonographic PS measurements were com-
pared with AP pelvis radiograph symphyseal width using
a Bland-Altman plot (9). The Bland-Altman plot mea-
sures agreement for continuous data and uses a two-
standard deviations (SD) measurement as one of the
criteria for agreement. Therefore, sonographic measure-
ments within two SDs of the radiographic measurements
were considered to be in agreement. Further, we calcu-
lated a kappa statistic to measure agreement between the
sonographic and roentgenographic measurements. We
used a cutoff of ⬍ 25 mm as normal.
RESULTS
There were 23 patients enrolled in the study; 12 in the
ED and 11 at the SME, 13 men and 10 women, with an
M. Bauman et al.
average age of 37 years (⫾ 13) and 35.6 years (⫾ 20),
respectively (Table 1). With one exception, US mea-
surements were within 2 SDs of the radiographic
measurements on a Bland-Altman plot and therefore
had good agreement (Figure 3). The one exception was
on a live patient with a superior ramus fracture, that
displaced the pubic tubercle. There was one SME
patient who had a PS width wider than the probe. This
patient’s data were excluded from the Bland-Altman
graph as the 16.7-mm difference between radiograph
and US were due to extreme width outside testing
abilities of the probe. Excluding that data point pro-
vided more accurate confidence intervals.
A pubic symphysis width of ⬎ 25 mm was consid-
ered positive; this width is considered diagnostic for
APC fracture of the pelvis in the non-pregnant patient
(6,7). Four subjects had PS widening on radiography
(3 PM, 1 ED) and 19 patients had radiographically
normal PS width. If the measurements are dichoto-
mized to wide and normal, with wide as ⬎25 mm, then
the FAST-PS examination achieved a sensitivity of
100% (95% confidence interval [CI] 51–100%) and
specificity of 100% (95% CI 83–100%) in detecting
pubic symphyseal widening compared to plain radiog-
raphy. When comparing the measuring methods and
categorizing the measurement as normal or abnormal,
there was complete agreement (kappa, ␬ ⫽1.0).
The patients with a positive FAST-PS had average
PS measurements of 32.4 mm (⫾ 5.7) sonographically
and 36.5 mm (⫾ 13.0) radiographically, whereas av-
erage normal PS measurements were 4.4 mm (⫾ 1.3)
Ultrasonographic Determination of Pubic Symphyseal Widening in Trauma 531

Table 1. Study Patients’ Demographics and Measurements

Patient # US PS (mm) XR PS (mm) Difference Age (Years) Sex 1 ⫽ M, 0 ⫽ F

L1 27.5 26.7 0.8 48 1

L2 3.8 3.4 0.4 34 1
L3 7.3 4.6 2.7 18 0
L4 3.8 4.2 ⫺0.4 54 0
L5 3.6 3.4 0.2 18 0
L6 6.8 5.4 1.4 32 1
L7 2.5 2.8 ⫺0.3 81 0
L8 5.3 4.6 0.7 45 1
L9 3.8 3.8 0 39 0
L10 4.9 5 ⫺0.1 43 1
L11 4.2 4.4 ⫺0.2 49 1
L12 5.1 4.2 0.9 52 1
D1 35.8 34.3 1.5 55 1
D2 3.3 7.3 ⫺4 26 0
D3 2.5 4.5 ⫺2 34 0
D4 5 5.5 ⫺0.5 20 0
D5 27.6 29.5 ⫺1.9 40 0
D6 38.6 WTP 55.3 ⫺16.7 40 1
D7 4 4.5 ⫺0.5 21 1
D8 2.8 4.5 ⫺1.7 19 1
D9 4.2 2.8 1.4 21 1
D10 5.4 5.5 ⫺0.1 26 0
D11 4.4 6.3 ⫺1.9 22 1

US PS ⫽ ultrasound of the pubic symphysis; XR PS ⫽ X-ray study of the pubic symphysis; D ⫽ dead; L ⫽ live; WTP ⫽ wider than probe.
WTP was excluded from Bland-Altman graph.

and 4.6 mm (⫾ 1.3), for the respective imaging mo-
dalities.
DISCUSSION
The FAST examination has several limitations, one of
which is its inability to visualize the retroperitoneum. A
sonographic measurement of the PS width may serve as
a surrogate marker for retroperitoneal hemorrhage in the
setting of APC fracture of the pelvis. Furthermore, a PS
width of ⬎ 25 mm (a “grade II APC pelvic fracture”)
indicates disruption of the sacrospinous and anterior sac-
roiliac ligaments, which is associated with a higher risk
for disruption of the pelvic vessels (8). Including this
measurement as part of the traditional FAST examina-

Figure 3. Bland-Altman plot.

532
tion has the potential to speed the diagnosis of APC
pelvic fractures and decrease the time to application of a
pelvic binder, potentially limiting the associated life-
threatening hemorrhage.
The authors are not suggesting this study as a surro-
gate for plain pelvic radiographs or physical examina-
tion, but as a means to diagnose APC fractures of the
pelvis in the primary survey and expedite their stabiliza-
tion. This examination would be indicated for hypoten-
sive blunt trauma patients without evidence of intraperi-
toneal or intrathoracic blood. It could be integrated into
the standard Extended-FAST (E-FAST) examination af-
ter the pneumothorax assessment with a linear probe.
Future studies with a greater cohort size are needed to
confirm the validity and ease of implementation of this
diagnostic test. Future studies may also evaluate whether
using this test decreases the time to application of a
pelvic binder and whether expediting pelvic binder ap-
plication improves outcomes in hemodynamically unsta-
ble trauma patients with APC fractures of the pelvis.
Also, the FAST-PS examination, if used in the pre-
hospital setting, may potentially provide the greatest
benefit of early pelvic binder application.
Limitations
We identified a limited number of living patients with
positive findings via a convenience sampling technique.
Additionally, on living patients, the sonographic tech-
nique was evaluated in only a single sonographer’s hands
and, thus, calculations of inter-rater reliability were not
possible, and this may have introduced operator bias.
Although the US images were obtained before the
radiographs, the investigators were not blinded to the US
anatomic measurements or the physical examination.
This could bias the correlation between US and radio-
graphic measurements. A further limitation was that au-
thor MB proctored three of the PM scans. This has the
potential for single operator bias. Additionally, three out
of four positive subjects were post-mortem. This may
account for the vast difference between normal and ab-
normal PS measurements in our study, as the PM sub-
jects had more severe injuries. This dichotomous rela-
tionship may not hold true for all APC fractures.
Specifically, non-fatal PS widening may be more subtle
to detect. Also, APC fractures of the pelvis are not the
M. Bauman et al.
only pelvic fracture pattern associated with life-threaten-
ing retroperitoneal hemorrhage, and this study did not
identify other fracture patterns.
The linear transducer used in the study is 38 mm
wide, thus, it is theoretically possible for the sonographer
to have one-half of the PS out of the scanning plane and
misinterpret the result as a PS wider than the probe. The
sonographic measurement outside 2 SDs of the Bland-
Altman plot was in a patient with a superior rami frac-
ture. This raises the possibility of other pelvic fractures
causing symphyseal widening.
CONCLUSION
In this small comparative study, we demonstrated that
the FAST-PS examination can have excellent agreement
with AP pelvis radiographs for the identification of PS
widening. This simple-to-perform bedside imaging test
could lead to rapid identification of a potentially treatable
cause of hypotension in the unstable trauma patient.
Further study with a larger cohort is needed to confirm
this technique’s validity for diagnosing PS widening in
APC pelvic fractures.
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Ultrasonographic Determination of Pubic Symphyseal Widening in Trauma 533

ARTICLE SUMMARY
1. Why is this topic important?
Processes that expedite the bedside work-up of trauma
patients— utilizing readily available technology—that
are easily reproducible and easily teachable, offer the
clinician significant advantages.
2. What does this study attempt to show?
This study hopes to show that physicians competent in
the focused abdominal sonography in trauma (FAST)
examination can easily add a fifth view that will rapidly
and reliably identify patients with pubic symphysis wid-
ening.
3. What are the key findings?
Ultrasound can reliably identify pubic symphysis wid-
ening. Ultrasound can be used to identify clinical evi-
dence of open book pelvic fractures.
4. How is patient care impacted?
Rapid identification of pubic symphysis widening in-
dicative of open book pelvic fractures can occur quickly
and reliably with the addition of the pubic symphysis
view to the standard FAST examination.