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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

The reliability of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta-analysis

S Sauerland, B Bouillon, D Rixen, MR Raum, T Koy, and EA Neugebauer.

Review published: 2004.

CRD summary

This review found that clinical examination is able to detect relevant fractures of the pelvis, and that fractures that are missed tend not to require immediate treatment. Although these findings appear reliable, they should be interpreted with some degree of caution given the possibility of publication bias, differences between the studies and the failure to adequately assess study quality.

Authors' objectives

To determine the accuracy of clinical examination in detecting fractures of the pelvis.


MEDLINE, EMBASE and the Cochrane Library were searched to May 2003; the search terms were reported. Some journals not indexed in any databases were handsearched. The references of retrieved articles were screened to identify additional studies. No language restrictions were applied. Studies published only as abstracts were excluded.

Study selection

Study designs of evaluations included in the review

Clinical cohort studies were eligible for inclusion. Both prospective and retrospective studies were included.

Specific interventions included in the review

Studies that assessed clinical symptoms and/or physical examination of the pelvis for detecting pelvic fractures (including acetabular fractures) were eligible for inclusion. Specific components of the clinical assessment investigated by the included studies were: history, swelling, compression, instability, neuropathy, inspection, hip range of movement, rectal examination, deformity and urethral bleeding.

Reference standard test against which the new test was compared

No inclusion criteria relating to the reference standard were specified. The reference standards in the included studies were anteroposterior pelvic radiographs, computed tomography or clinical follow-up.

Participants included in the review

Studies of adults or children who had experienced blunt trauma were eligible for inclusion. Some of the included studies only included patients scoring over specified values on the Glasgow Coma Scale (from 10 or more to 15); other studies included patients with any grade on this scale.

Outcomes assessed in the review

Studies had to report data on sensitivity or specificity to be included in the review. The majority of the studies reported data on both the sensitivity and specificity, whereas one only reported sensitivity and two only reported specificity.

How were decisions on the relevance of primary studies made?

The authors did not state how the papers were selected for the review, or how many reviewers performed the selection. [A: A single reviewer assessed studies for inclusion.]

Assessment of study quality

The authors did not state that they assessed validity, although some methodological features were discussed in the results. [A: A single reviewer assessed studies for mode of data collection and blinding.]

Data extraction

The data were extracted as 2x2 tables of test performance. If data were reported separately for different tests or subgroups of patients, only the relevant data were extracted. The sensitivity and specificity, together with binomial 95% confidence intervals (CIs), were calculated for each study.

Methods of synthesis

How were the studies combined?

For studies reporting sufficient data, the sensitivity and specificity were plotted in receiver operating characteristic (ROC) space. The Moses-Littenberg method was used to construct a summary ROC curve weighted by the inverse of the variance. Pooled estimates of sensitivity and specificity were obtained using random-effects models.

How were differences between studies investigated?

Heterogeneity was not formally assessed. Sensitivity analysis was conducted to investigate the effect of study design (prospective or retrospective), age (adults or children) and presence of neurologic impairment of patients.

Results of the review

Sixteen studies (n=6,281) were included in the review. The sample size ranged from 36 to 2,176. Twelve studies (n=5,454) presented sufficient data and were included in the meta-analyses.

In terms of study quality, only 1 study specifically reported that the readings of X-rays and clinical examination were blinded to the results of the other.

The sensitivity ranged from 59 to 100% and the specificity from 71 to 100%. Twelve studies were able to contribute to the meta-analysis; of these, two did not include patients without pelvic fractures and one did not include any patients with pelvic fractures. The pooled sensitivity and specificity were 90% (95% CI: 85, 93) and 90% (95% CI: 84, 94), respectively. Although there were 49 pelvic fractures not identified by clinical examination in the 12 studies that were included in the meta-analysis, only three of these were considered to be clinically relevant.

Estimates of pooled sensitivity did not differ between prospective and retrospective studies or between studies in unselected patients and those with alert patients only, although specificity was slightly higher in the prospective studies and in studies restricted to alert patients. Estimates of sensitivity and specificity were similar for adults and children.

Authors' conclusions

A thorough clinical examination is able to detect a relevant fracture of the pelvis. Fractures that are missed tend to be those that do not require immediate treatment.

CRD commentary

This review addressed a focused question. Some inclusion criteria were reported but the review lacked clarity relating to the types of patient and outcome data required for inclusion. The literature search was limited to three databases and attempts to locate unpublished studies were not made. Relevant studies may therefore have been missed and the review may be subject to publication bias. A detailed quality assessment was not undertaken, thus it is not possible to determine the validity of the included studies. [A: Only one reviewer assessed studies for inclusion and for methodological quality; bias and errors may therefore have occurred during the review process.]

Details of the included studies were clearly summarised in a table and the inclusion of an ROC plot helped illustrate the results of the individual studies. The methods used to pool the studies were acceptable, although it is questionable whether it was appropriate to pool the studies given the differences in clinical signs and symptoms investigated and the differences in results.

The authors' general conclusions are supported by the results, but should be interpreted with some degree of caution given the possibility of publication bias, differences between the studies and the failure to adequately assess study quality. However, seven criteria were listed that, according to the authors, can be used to accurately rule out pelvic fracture. It is unclear from the data presented exactly where these criteria came from, thus their validity is uncertain and they should be interpreted with caution.

Implications of the review for practice and research

Practice: The authors stated that clinical examination can be used to safely rule out pelvic fracture. Most fractures that are missed by clinical examination are those that are unlikely to require immediate treatment.

Research: The authors did not state any implications for further research.


Deutsche Forschungsgemeinschaft, grant number SA 862/1-1.

Bibliographic details

Sauerland S, Bouillon B, Rixen D, Raum M R, Koy T, Neugebauer E A. The reliability of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta-analysis. Archives of Orthopaedic and Trauma Surgery 2004; 124(2): 123-128. [PubMed: 14745568]

Indexing Status

Subject indexing assigned by NLM


False Negative Reactions; False Positive Reactions; Fractures, Bone /diagnosis; Humans; Pelvic Bones /injuries; Physical Examination; ROC Curve; Reproducibility of Results; Sensitivity and Specificity; Wounds, Nonpenetrating /complications



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 14745568

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