Pelvic fractures and associated injuries in children

Injury Patterns and Associated Demographic Characteristics in Children with a Fracture from Equines: A US National Based Study

BACKGROUND

Fractures often occur due to equestrian activities with injury patterns varying by age. The purpose of this study was to investigate in detail fracture patterns and associated demographics in children due to equine activities.

MATERIALS

The US National Electronic Injury Surveillance System was queried for all injuries with the consumer product code 1239 (horseback riding) from 2000 to 2023. Those <16 years old with fractures were extracted. Statistical analyses were performed with SUDAAN 11.0.01™ software to obtain national estimates.

RESULTS

There were an estimated 101,677 patients with a fracture. Girls comprised 72.5% and the patient was discharged from the hospital in 81.5% of cases. Fractures involved the upper extremity in 80,973 (80.0%), the pelvis/lower extremity in 11,794 (11.7%), the spine in 3060 (3.0%), the skull/face in 4321 (4.4%), and the rib/sternum in 940 (0.9%). The humerus, elbow, radius/ulna, and wrist accounted for 62.4% of all the fractures. The youngest age group (0- to 5-year-olds) had more boys and was more likely to be admitted to the hospital. The child was injured due to a fall from the horse in 75.7%, bucked/thrown off/kicked off in 17.0%, with the remaining 7.3% from other mechanisms.

CONCLUSIONS

This extensive description of fractures in children due to equestrian injuries can be used to determine the effectiveness of future prevention strategies, such as protective equipment and educational programs. It also gives pediatric trauma and orthopedic surgeons an overall view of the types of fractures which occur in children due to equestrian activities.

Associated injuries and complications in pediatric pelvic fractures requiring hospitalization: A series of 315 cases

Purpose

Pediatric pelvic fractures are uncommon. This study aimed to investigate the clinical characteristics of pediatric pelvic fractures requiring hospitalization and analyze their correlation with associated injuries and complications.

Methods

Data from 315 pediatric pelvic fracture patients admitted to our hospital from January 2006 to December 2021 were retrospectively analyzed. Sex, age, modified Torode-Zieg classification, abbreviated injury scale score, injury severity score, mortality, and concomitant injuries were analyzed.

Results

Of the 285 (90.5%) cases of combined injuries, most injuries occurred in the abdomen (64.8%) and lower extremities (47.6%), followed by the chest (45.4%) and head (34.6%). A total of 78 patients (24.8%) were transferred to the intensive care unit. In total, 94 patients (29.8%) had complications during hospitalization. There were differences based on injury mechanism (p = 0.001), with the highest complication rate in the fall injury group (32 cases (46.4%)). Approximately 51.4% of patients received surgical treatment for problems that were not related to pelvic fractures. Among these, 30.2% necessitated surgical intervention on the lower limbs. Abdominal surgery was necessary in 19.0% of patients.

Conclusions

Children who have pelvic fractures frequently require hospitalization due to the presence of severe injuries in other areas of their bodies. IIIB pelvic fractures frequently occur in conjunction with more severe abdominal injuries; therefore, the prompt management of cavity and organ injuries is of particular importance. Blood transfusion and injury severity score were associated risk factors for intensive care unit admission.

The clinical characteristics and management of paediatric pelvic fractures: a changing landscape based on skeletal maturity

INTRODUCTION

Paediatric pelvic fractures (PPFs) are uncommon but signify serious trauma. A comprehensive multidisciplinary approach is needed due to a high number of associated injuries. This study aims to retrospectively analyse PPFs over a 5-year period and evaluate how advancing skeletal maturity changes fracture patterns and management plans.

METHODS

The trauma database was retrospectively reviewed for pelvic fractures in patients aged ≤ 18 years. Radiographs and CT scans were used to classify pelvic injuries according to the modified Torode classification and determine the status of the triradiate cartilage (open: skeletally immature; closed: skeletally mature). Data collected also included the mechanism of injury, clinical and functional outcomes, and associated injuries. Logistic regression analysis was performed to identify risk factors for associated abdominal injuries.

RESULTS

65 PPFs (2.8% of paediatric trauma admissions during the study period) were classified as type I (3.1%), type II (7.7%), type IIIa (32.3%), type IIIb (38.5%), type IV (18.5%) according to the modified Torode classification. The mean age was 13.41 ± 3.82. Skeletally immature children were more likely to be hit by a motor vehicle as a pedestrian (p < 0.001), be intubated (p = 0.009), acquire Torode type II (p = 0.047) and rami fractures (p = 0.037), and receive chest (p = 0.005) and head injuries (p = 0.046). Skeletally immature children were also less likely to acquire Torode type IV fractures (p = 0.018), receive surgical treatment for their pelvic injuries (p = 0.036), and had a faster time to full weight bearing (p = 0.013). Pelvis AIS score ≥ 4 (OR 5.3; 95% CI 1.3-22.6; p = 0.023) and a pedestrian accident (OR 4.9; 95% CI 1.2-20.7; p = 0.030) were risk factors for associated abdominal injuries. There was a strong association between a higher pelvic fracture grade and the proportion of patients with closed triradiate cartilage (p = 0.036), hospital length of stay (p = 0.034), mean pelvic AIS score (p = 0.039), a pelvis AIS score of ≥ 4 (p = 0.022), mean ISS (p = 0.003), an ISS score between 25 and 75 (p = 0.004), average time to FWB (p = 0.001), requirement of blood products (p = 0.015), and a motor vehicle accident (p = 0.037).

CONCLUSION

PPFs occurring in skeletally mature and immature patients are significantly different in terms of mechanism of injury, fracture severity, fracture pattern, and management strategy. There is a high rate of associated injuries, necessitating an integrated multidisciplinary approach in paediatric trauma centres.

Paediatric pelvic fractures - an updated literature review

BACKGROUND

Pelvic fractures in children are indicative of significant trauma. Patients will often have associated injuries - some of which require urgent intervention to prevent death and disability. Paediatric and adult pelvises respond to traumatic forces differently and distinct approaches are required for each population. Historically, pelvic fractures have been treated conservatively, but this trend is changing with a better understanding of the pelvis' inability to remodel significant deformity, as well as new techniques for operative fixation.

METHODS

A comprehensive search of the literature was conducted for articles published between 2000 and 2020 on paediatric pelvic fractures using medical databases including PubMed, Embase and the Cochrane Library.

RESULTS

We included 143 studies in our literature review and summarized the incidence, pathophysiology, assessment, management and complications associated with paediatric pelvic fractures.

CONCLUSIONS

The rarity of paediatric pelvic fractures corresponds with a paucity of randomized clinical trials covering this topic. Trends such as the screening pelvic x-ray are derived from adult populations but are now questioned in children. Other aspects of assessment and management of these children warrant such levels of scrutiny.

Therapeutic effect of an external fixator in the treatment of unstable pelvic fractures in children

BACKGROUND

Unstable pelvic fractures in children are serious and complex injuries, and the optimal method to manage these injuries is controversial.

HYPOTHESIS

We hypothesized that an external fixator would be a satisfactory method of treating unstable pelvic fractures in children.

PATIENTS AND METHODS

We retrospectively reviewed 40 pediatric patients with unstable pelvic fractures who were treated with an external fixator in Beijing Children's Hospital from June 2006 to June 2016. Postoperative follow-up was 12 to 108 months, with an average of 26 months. One year after the operation, fracture healing, pelvic asymmetry, and deformity index were assessed by X-ray. Pelvic function was evaluated with the Cole evaluation standard, and daily cognitive and motor functions were evaluated by weeFIM. Patient complications were recorded.

RESULTS

The average age of the 40 patients was 5.9±3.1 years (2 to 14.5), including 25 boys and 15 girls. Among these cases, 37 (92.5%) had injuries caused by traffic accidents and 3 (7.5%) had injuries caused by falling from height. Based on the Tile classification, there were 18 cases of class B (14 class B2 and 4 class B3) and 22 cases of class C (15 class C1, 6 class C2, and 1 class C3). The X-rays showed good fracture healing at the 1-year postoperative follow-up. The pelvic asymmetry was reduced from 1.13cm before the operation to 0.88cm after (p<0.05), and the deformity index was decreased from 0.09 before to 0.05 after the operation (p<0.05). At the 1-year postoperative follow-up, 36 patients had excellent Cole scores, and 4 had good Cole scores, with a good or excellent rate of 100%. According to the weeFIM, 28 patients had complete independence, 11 had basic independence, and 1 had conditional independence. Three patients (7.5%) had complications, all of which were postoperative pin-site infections.

DISCUSSION

For children with horizontally unstable pelvic fractures, an external fixator can be used alone. For children with horizontally and vertically unstable pelvic fractures, after external fixator placement and reduction, lower extremity traction can be performed to achieve better reduction and maintain stability, and the therapeutic effect is satisfactory.

LEVEL OF EVIDENCE

IV, retrospective observational cohort study.

Surgical management of paediatric pelvic fractures: a prospective case series and early experience from a level one Egyptian trauma centre

PURPOSE

We aimed to report our early experience treating paediatric pelvic fractures (PPF) surgically, reporting on indications, outcomes, and complications.

METHODS

Patients aged 0-15 with PPF treated surgically at a level I trauma centre were included prospectively between 2016 and 2018. Fractures were classified according to AO/OTA classification system. Functional evaluation was performed using a modification of the Majeed functional scoring system. Radiological evaluation of vertical and posterior displacement was performed according to Matta and Tornetta criteria and the method described by Keshishyan et al. for assessing pelvic rotational asymmetry.

RESULTS

We included 45 patients (77.8% males and 22.2% females), with a mean age of 9.53 ± 3.63 and 19.87 ± 8.84 months of mean follow-up. The functional outcome was excellent in 42 (93.3%) patients, good in two (4.4%), and fair in one (2.2%). Radiologically, the vertical displacement improved from 5.91 ± 4.64 to 3.72 ± 2.87 mm (p-value 0.065), the posterior displacement improved from 7.87 ± 8.18 to 5.33 ± 13.4 mm (p-value 0.031), and the symphyseal diastasis improved from 9.88 ± 7.51 mm to 7.68 ± 3.18 mm (p-value 0.071). Residual pelvic asymmetry improved from 1.2 ± 0.61 to 0.8 ± 0.7 (p-value 0.001). Complications occurred in 21 (46.7%) patients, 11 (24.4%) pin tract infection, six (13.3%) limb length discrepancy, two (4.4%) prominent metals, one (2.2%) subcutaneous haematoma, one (2.2%) infected ISS.

CONCLUSIONS

We achieved acceptable functional and radiological outcomes after surgically treating a group of patients with PPF, which was relatively safe with minimal complications. The proper approach and fracture fixation tool should be tailored according to the fracture classification and the presence of associated injuries.

Critical review of the classification and treatment of pediatric pelvic fractures

BACKGROUND

Historically most pediatric pelvic fractures were treated non-operatively because of the presumed potential of the pediatric pelvis to remodel and the subsequent increased fracture stability. Currently a wide variety of classifications in pediatric pelvic fractures is used to assess fracture stability and guide treatment, yet none have proven to be ideal since the structural behavior of the pediatric pelvis differs greatly from the adult pelvis. The aim of this review is to critically appraise the use of these different classification systems, fracture (in)stability, the treatment of pediatric pelvic fractures and how it reflects on long-term complications such as pelvic asymmetry and functional outcome.

METHODS

A literature search was performed in Medline, Embase, Cochrane, PubMed, Google Scholar and references of the selected articles. Studies that reported on pain, leg length discrepancy (LLD), abnormal gait (GA), pelvic asymmetry, and functional outcomes of pediatric pelvic fractures were included.

RESULTS

A total of six different classification systems were used, the most common were Tile (n= 9, 45%) and Torode and Zieg (n= 8, 40%). There was great disparity in treatment choice for the same type of fracture pattern, resulting in several pelvic ring fractures that were defined as unstable being treated non-operatively. Pelvic asymmetry is seen in rates up to 48% in non-operatively treated patients. In contrast, pelvic asymmetry in surgically fixated unstable pelvic fractures was rare, and these patients often showed excellent functional outcomes during follow-up.

CONCLUSION

There is a substantial heterogeneity in which fracture patterns are considered to be unstable or in need of surgical fixation. Functional outcomes seem to be correlated with the frequency of pelvic asymmetry and are likely due to an underestimation of the stability of the pelvic fracture. Taking into consideration the force that is necessary to cause a facture in the pediatric pelvis, a fracture of the pelvic ring alone could be suggestive for instability. The results of this review imply that the field of pediatric pelvic surgery is currently not grasping the full scope of the complexity of these fractures, and that there is a need for a pediatric pelvic classification system and evidence-based treatment guideline.

Current Concepts in Pediatric Pelvic Ring Fractures: A Narrative Review

Trauma is still the leading cause of death in children. Post mortem studies have shown a high incidence and a high rate of deaths related to pelvic fractures and associated injuries. The pelvic ring in children has characteristics that differentiate it from the adult. The bone tissue is more elastic and is covered with a thick periosteum. Elasticity mainly translates into plastic deformity when it is impacted. Overall, lesions tend to be more stable as the relatively thick periosteum limits bone breakdown. As a result of this elasticity, the intrapelvic organs are more vulnerable and injuries can occur in the absence of fractures. High energy is required to produce a fracture and this energy can be transferred to the pelvic organs. Minimally displaced fractures may be the result of high energy trauma with a significant risk of further intrapelvic and intra-abdominal injury. This leads to a relatively high incidence of pelvic and abdominal organ injuries associated with stable fractures. A complete lesion of the pelvic ring anteriorly or posteriorly or a complex pelvic lesion is a high risk factor for morbidity and mortality. Treatment in the pediatric patient with a pelvic fracture has historically been guided by concepts that have become established in adults. The main parameters in the decision making process are hemodynamic stability and the degree of mechanical instability of the pelvis. The purpose of this review is to report current knowledge on pelvic ring fractures with a particular focus on their management and treatment.

Operative intervention of unstable paediatric pelvic fracture: radiological and functional assessment

PURPOSE

The aim of the study was to add to the literature new data regarding the evaluation of surgical fixation of challenging unstable paediatric pelvic fractures, radiologically and clinically besides recording any complications through the follow-up period.

METHODS

Prospective study was conducted at our hospital between 2012 and 2017 where 21 patients less than 16 years with unstable fracture pelvis were surgically fixed. The method of fixation varied between the external percutaneous fixation and internal fixation. The Infix system was used in for anterior ring fixation in some cases. Patients were evaluated radiologically and functionally using the functional independence measure questionnaire (FIM) and the modified Merle d'Aubigne and Postel (MDP) score.

RESULTS

Twelve males and 9 females were fixed with mean age of 12.5 years. Motorcar accident was the main mode of trauma. Nine patients had fracture pelvis Tile's type B and 12 had Tile's type C injuries. All fractures united by 8 weeks. No patients suffered from pelvic asymmetry or leg length discrepancy at a mean follow-up of 2 years. The mean of FIM was 122.5 and the mean of MDP score was 16.2.

CONCLUSION

Displaced unstable pelvic fractures in children need a systematic evaluation of the injury pattern. These serious fractures should be referred for anterior ± posterior ring stabilization. Promising clinical outcomes with surgical fixation can be reached with a low rate of complications. Further large-scale studies should be conducted for the calling literature.

Clinical characteristics, injury pattern and management of pediatric pelvic fracture: An observational retrospective study from a level I trauma center

Background

Pediatric pelvic fractures (PPF) are uncommon among children requiring hospitalization after blunt trauma. The present study explored our experience for the prevalence, patients demographics, clinical characteristics, injury pattern and management of pediatric pelvic fractures in a level I trauma center.

Methods

This is a retrospective review of prospectively collected data obtained from trauma registry database for all pediatrics trauma patients of age ≤18 years. Data were analyzed according to different aspects relevant to the clinical applications such as Torode classification for pelvic ring fracture (Type I–IV), open versus closed triradiate cartilage, and surgical versus non-surgical management.

Results

During the study period (3 and half years), a total of 119 PPF cases were admitted at the trauma center (11% of total pediatric admissions); the majority had pelvic ring fractures (91.6%) and 8.4% had an acetabular fracture. The mean age of patients was 11.5 ± 5.7, and the majority were males (78.2%). One hundred and four fractures were classified as type I (5.8%), type II (13.5%), type III (68.3%) and type IV (12.5%). Patients in the surgical group were more likely to have higher pelvis AIS (p = 0.001), type IV fractures, acetabular fractures and closed triradiate cartilage as compared to the conservative group. Type III fractures and open triradiate cartilage were significantly higher in the conservative group (p < 0.05). Patients with closed triradiate cartilage frequently sustained spine, head injuries, acetabular fracture and had higher mean ISS and pelvis AIS (p < 0.01) than the open group. However, the rate of in-hospital complications and mortality were comparable among different groups. The overall mortality rate was 2.5%.

Conclusion

PPF are uncommon and mainly caused by high-impact trauma associated with multisystem injuries. The majority of PPF are stable, despite the underlying high-energy mechanism. Management of PPF depends on the severity of fracture as patients with higher grade fractures require surgical intervention. Furthermore, larger prospective study is needed to understand the age-related pattern and management of PPF.

Outcomes following pelvic ring fractures in the paediatric population: A systematic review

BACKGROUND

Pelvic fractures represent a small proportion of all paediatric fractures, but are likely to be associated with a high-energy mechanism, multiple injuries, and significant morbidity and mortality. Operative fixation of unstable pelvic fractures is accepted. However, there remains a paucity of data on functional outcomes and complications following pelvic fractures in the skeletally immature.

METHODS

A PRISMA-compliant systematic review was performed, searching Medline, Embase, and Cochrane central review. The primary outcome was functional outcome after pelvic fractures in the paediatric population following operative or non-operative treatment. Secondary outcomes included mechanism of injury, associated injuries, mortality rate, and method of surgical fixation if required. Where possible, weighted totals of the data set were performed.

RESULTS

In total, 23 studies were included in this review. Only eight studies reported functional outcomes, with limb length discrepancy and limp being the most common complication. Only 8.8% of all pelvic fractures underwent surgical fixation. Motor vehicle collision was the most common cause of injury, and extremity fracture was the most common associated injury.

CONCLUSION

Paediatric pelvic fractures are caused by high-energy mechanisms and have significant morbidity and mortality. There remains a paucity of information on functional outcomes after these injuries.

Management and outcome of pelvic fracture associated with vaginal injuries: a retrospective study of 25 cases

Background

Pelvic ring fractures associated with vaginal injuries were rarely reported due to low incidence. The displaced segments of pelvic ring may increase the risk of vaginal injury. The aim of this retrospective study was to evaluate the correlation between pelvic fracture and vaginal injury.

Methods

We conducted a retrospective review of 25 patients with pelvic fractures associated with vaginal injury treated at our institution. The medical records of these patients were collected and 24 patients were followed-up for 10–36 months.

Results

All patients suffered anterior pelvic ring fracture. Young-Burgess fracture classification and compromised pubic symphysis were related to severity of vaginal injury. Gauze packing was done in 6 patients and 18 patients received surgical repair. Infection occurred in 6 patients, among them 4 were due to delayed diagnosis. Factors associated with pelvic outcome were age, urethral injury, and infection. Four patients suffered pain in sexual intercourse but no influence factor found correlated to sexual function.

Conclusion

VS type pelvic fracture and compromised pubic symphysis were related to higher severity of vaginal injury. Disruption of anterior ring and an unstable pelvic ring caused by forces on coronary and axial plane may increase the risk of vaginal injury.

Trial registration

ChiCTR1900020540. Registered 28 January 2019. Retrospectively registered. Trial registry: Chinese Clinical Trial Registry.

Anatomic, diagnostic and management challenges in paediatric pelvic injuries: a review

Pelvic injuries have an incidence of 1: 100 000 children per year in the UK, of which 10% are unstable. A literature review was conducted. Clinical examination alone in a stable patient precludes the need for imaging. Imaging options in the acute pelvic injury are critically reviewed. Where appropriate Judet views or limited exposure computed tomography scan remain of diagnostic benefit. Displacement greater than 1 cm should be reduced and held with an appropriate method. Closed reduction and external fixation for rotationally unstable fractures, and closed or open reduction with internal fixation of two columns should be considered for rotationally and vertically unstable fractures.

Does skeletal maturity affect pediatric pelvic injury patterns, associated injuries and treatment intervention?

INTRODUCTION

Pediatric pelvic injuries are rare. Due to anatomic differences of the immature pelvis, different injury patterns may occur as compared to adults. The purpose was to analyze the effect of skeletal maturity on pediatric pelvic injury pattern, associated injuries, and treatment intervention.

PATIENTS AND METHODS

Ninety children with a pelvic injury receiving treatment at a private orthopaedic practice in association with a Level One Teaching Trauma Center, between March 2002 and June 2011, were retrospectively analyzed. Skeletal maturity was determined as closed triradiate cartilage. Forty-one (46%) were skeletally immature and 49 (54%) were skeletally mature. Mean age was 11.5 years (2-16). Fractures were 23 A2, 1 A3, 4 B1, 44 B2, 16 B3, and 2 C2 according to OTA/AO classification. OTA B and C fractures were 26 LC1 (lateral-compression), 20 LC2, 10 LC3, 4 APC1 (anterior-posterior-compression), 5 APC2, and 1 VS (vertical-shear) injury according to Young and Burgess. Treatment of the pelvic injury was operative in 28 (31%) and non-operative in 62 (69%) of children. Mechanism of injury, Injury Severity Score (ISS), deaths, and associated injuries were recorded.

RESULTS

More complex and unstable injuries occurred in skeletally mature vs. immature children (p = 0.014). Skeletally mature children had a significantly higher rate of operative intervention (p = 0.009). The ISS in skeletally mature children was higher 25 (1-66) than in skeletally immature children 17 (4-43) (p = 0.013). 84% (41) skeletally mature and 78% (32) skeletally immature children sustained associated injuries. Twenty-two% (11) of all skeletally mature children sustained urinary tract injuries, but only 7% (3) of all skeletally immature children (p = 0.049).

DISCUSSION

Skeletally mature children are more likely to sustain more complex injury patterns with a higher rate of operative treatment, to have a higher rate of associated injuries, and to have a higher ISS than immature patients.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Pelvic fractures in severely injured children: Results from the TraumaRegister DGU

Injuries in the pelvic region in children and adolescents are very rare and often associated with a high energy trauma. Aim of this prospective multicenter study was, by analyzing the data from the TraumaRegister Deutsche Gesellschaft für Unfallchirurgie (TR-DGU), to evaluate any correlation between the severity of pelvic fractures and resulting mortality in different age groups.These study findings are based on a large pool of data retrieved from the prospectively-setup pelvic trauma registry established by the German Trauma Society (DGU) and the German Section of the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) International in 1991. The registry provides data on all patients suffering pelvic fractures within a 14-year time frame at any 1 of the 23 level 1 trauma centers contributing to the registry. The analysis covers 4 age groups ranging from 0 to 17 years, covering different factors regarding pelvic fractures and their treatment.We identified a total of 9684 patients including 1433 pelvic fractures in children aged ≤17 years. Those patients were divided into 4 subgroups according to the patients' age (groups A-D) and according to the fracture severity (group 1 =  Abbreviated Injury Scale (AIS) score pelvis ≤2, and group 2 = AIS pelvis ≥3). The mortality in group 1 was 8.8% with a RISC (Revised Injury Severity Score) II of 8.6%, standard mortality rate (SMR) of 1.02 and 7.2% in group 2 with an RISC II of 9.9% (SMR 0.73). In pelvic factures of Type A (Tile classification of pelvic fractures), an SMR of 0.76 was recorded, in Type B fractures the SMR was 0.65, and in Type C fractures 0.79. Severe pelvic injuries (AIS pelvis ≥2) were associated with a higher rate of whole body computer tomograph (CT) scans (1-5 years: 80%, 6-10 years 81.8%, 11-14 years 84.7%, and 15-17 years 85.6%). The rate of pelvic surgery rose with the pelvic injury's severity (AIS 2: 7.6%, AIS 3: 35%, AIS 4: 65.6%, AIS 5 61.5%). We observed higher rates of preclinical and initial clinical hypotension defined as Riva-Rocci (RR) <90 mmHG) as well as of preclinical fluid application in all age groups. The presence of a pelvic injury was associated with a higher rate of severe abdominal injuries with an AIS of ≥3 (25.1% vs. 14.6%) and of severe thorax injuries with an AIS≥3 (43.6% vs. 28.6%).We have been able to analyze an enormous number of pelvic fractures in children and adolescents including different age groups by relying on data from the TR-DGU. Mortality seems to be associated with the severity of the pelvic injury, but is lower than the RISC II score's prognosis.

Open complete anterior dislocation of the sacro-iliac joint in a 4-year-old boy: a case report of a rare injury with 5-year follow-up

Pelvic fractures are uncommon in children and account for between 0.3 and 7.5% of all pediatric injuries. Open pelvic fractures only account for up to 12.9% of all pediatric pelvic fractures. An unusual case of open complete anterior sacro-iliac joint dislocation in a 4-year-old boy is presented with a long-term follow-up. The multidisciplinary approach is reported with review of the current literature. A 4-year-old male presented to our institution in January 2012 after having been run over by a tractor. He presented with gross hemodynamical instability, MISS of 25, and an unstable lateral compression type III pelvic fracture with complete anterior dislocation of the left hemipelvis and a groin wound extending into the left thigh. The patient was managed in accordance with the ATLS and open fracture guidelines. Reduction in the dislocated SI joint was achieved via a posterior approach to the SI joint, followed by fixation with 2K wires in S1 and S2 sacral segments, with an anterior external fixator. Pelvic asymmetry post-reduction was 0.9 cm, compared to 16 cm post-injury, and asymmetry persisted till final follow-up at 5 years. At 5 years, patient regained full function, including recreational sport activities. Patients scored a 96/96 on the Majeed score (after excluding 4 points for sexual function). We believe that posterior reduction in an anteriorly dislocated SI joint in the pediatric population is a viable option. A coordinated, multidisciplinary approach and restoration of pelvic ring stability can lead to optimal outcome.

Analysis of pelvic fracture pattern and overall orthopaedic injury burden in children sustaining pelvic fractures based on skeletal maturity

PURPOSE

The purpose of this study was to review pelvic fractures and concomitant orthopaedic injuries in children who have a patent triradiate cartilage (TRO) compared with children whose triradiate cartilage has closed (TRC). We hypothesise that these injuries will differ, leading to correlated alterations in management.

PATIENTS AND METHODS

Using a database, we retrospectively reviewed patients aged below 18 years with pelvic fractures presenting to our Level 1 trauma center. Radiographs and CT scans were reviewed to identify orthopaedic injuries and categorise pelvic injuries using the modified Torode classification between the two groups.

RESULTS

A total of 178 patients met inclusion criteria (60 TRO and 118 TRC). Mean age ± SD for TRO and TRC groups were 8 ± 4 years and 16 ± 2 years, respectively. TRO patients were more likely to present as a pedestrian struck by a vehicle (odds ratio (OR) 6.0; p < 0.001) and less likely to present after a motor vehicle collision (OR 0.2; p < 0.001). TRO patients were more likely to sustain rami fractures (OR 2.1; p = 0.020) and Torode IIIA injuries (OR 3.6; p < 0.001). They were less likely to sustain acetabular fractures (OR 0.5; p = 0.042), sacral fractures (OR 0.4; p = 0.009), hip dislocations (p = 0.002) and Torode IV injuries (OR 0.4; p = 0.004). TRO patients were less likely to be treated operatively for their pelvic (OR 0.3; p = 0.013) and orthopaedic injuries (OR 0.4; p = 0.006).

CONCLUSION

We suggest that patients with open triradiate cartilage are unique. Their pelvic injuries may be treated more conservatively as they have a greater potential for periosteal healing and bone remodelling. Patients with closed triradiate cartilage should be treated similarly to adults, as they share a similar mechanism of injury and need for operative fixation.

Traumatic pelvic fractures in children and adolescents

Although traumatic pelvic fractures in children are relatively rare, these injuries are identified in about 5% of children admitted to level 1 trauma centers after blunt trauma.^1-4 Such injuries differ from adult pelvic fractures in important ways and require distinct strategies for management. While the associated mortality rate for children with pelvic fractures is much lower than that for adults, the patient may require urgent surgical intervention for associated life-threatening injuries such as head trauma and abdominal injury. Unstable pelvic ring fractures should be acutely managed using an initial approach similar to that used in adult orthopedic traumatology. Although very few pediatric pelvic fractures will ultimately need surgical treatment, patients with these injuries must be followed over time to confirm proper healing, ensure normal pelvic growth, and address any potential complications. The trauma team suspecting a pelvic fracture in a child must understand the implication of such a finding, identify fracture patterns that increase suspicion of associated injuries, and involve pediatric or adult orthopedic specialists as appropriate during the management of the patient.

Paediatric pelvic fractures: how do they differ from adults?

BACKGROUND

The aim of this article was to review the incidence, presentation, treatment and complications of paediatric pelvic fractures of children who were admitted to our level 1 trauma centre and to compare them with our data from adult pelvic fracture patients.

METHODS

We conducted a retrospective chart review of all children with pelvic fractures who were managed at our institution between January 1993 and December 2013 and compared the data with our database on pelvic fractures in adults during the period 2007 to 2012.

RESULTS

We identified 51 children and 268 adults with pelvic fractures. The median age of the paediatric patients was 11 years. Children were significantly more involved in traffic accidents than adults (p < 0.001). Adults had a significantly higher Injury Severity Score (ISS) (31 vs 24.5; p < 0.03) and were significantly more often haemodynamically unstable (p < 0.01). Adults had a type C fracture more often, while children had a type B fracture (p < 0.001). Associated injuries were seen in both groups; however, thoracic injuries were significantly higher in adults (p < 0.01) and injuries to the extremities were higher in children (p < 0.01). Adults were significantly more often treated with open reduction and internal fixation (p < 0.001). Mortality in both groups, however, did not differ (6% vs 8%).

CONCLUSION

Paediatric pelvic fractures are rare. They differ from adult pelvic fractures in presentation, associated injuries and management. Mortality, however, is substantial and does not differ from the adult population. Mortality is often due to concomitant injuries and not to exsanguination from the pelvic fracture.

Age- and gender-related characteristics of the pubic symphysis and triradiate cartilage in pediatric computed tomography

BACKGROUND

There is little information on the pubic symphysis' normal CT appearance in children.

OBJECTIVE

We sought to generate age-, gender- and maturity-related symphyseal width appearances in CT scans.

MATERIALS AND METHODS

Pelvic CT scans performed for any reason during a 6-year period in patients younger than 18 years were retrospectively analyzed. The symphysis width was measured in the axial plane and the triradiate cartilage was classified as open or closed.

RESULTS

Four hundred twenty-seven CT scans were evaluated and 350 remained for analysis. Age- and gender-related measurements of the symphysis width are illustrated on various centile graphs. When grouping children by age in years 0-6, 7-11, 12-15 and 16-17, mean (standard deviation) symphysis width was 5.4 mm (0.9), 5.3 mm (1.1), 4.1 mm (1.1) and 3.5 mm (1.0), respectively, in girls and 5.9 mm (1.3), 5.4 mm (1.2), 5.2 mm (1.1) and 4.0 mm (1.0), respectively, in boys. Boys and girls were significantly different in the age groups 12-15 years (P<0.001) and 16-17 years (P=0.04). In the mature pelvis, the symphyseal gap is significantly (P<0.001) shorter in both genders, and in girls compared to boys (P=0.04).

CONCLUSION

The pubic symphysis width in children differs according to age, gender and maturity. The reference values published herein may help detect symphyseal injury.

Pediatric pelvic ring injuries: How benign are they?

INTRODUCTION

With an incidence of less than 0.2% of all pediatric fractures, pelvic ring injuries are rare. Historically they were conservatively treated, but because malunion and long-term morbidity are associated with unstable injuries, a trend towards operative treatment can be observed. The purpose was to determine clinical and radiographic outcomes following these complex pediatric pelvic ring injuries.

PATIENTS AND METHODS

This Level IV retrospective analysis was completed at a private orthopaedic practice in association with a Level One teaching trauma center. There were 33 children with pelvic ring injuries with a mean age of 12.6 years (4-16) and an average follow up of 28.6 months (range 6-101). Injuries were 2 A2, 3 B1, 16 B2, 10 B3, and 2 C2 according to OTA/AO classification. Group 1 had 16 unstable, operatively treated injuries and Group 2 had 17 stable, non-operatively treated injuries. Radiographic deformity, leg length discrepancy, low back, and SI joint pain were evaluated.

RESULTS

For Group 1, 10 of 15 patients (67%) had a permanent ischial height difference >5mm compared to Group 2, in which 5 of 12 (42%) had an ischial height difference of >5mm. Group 1 had more pelvic asymmetry (12.3mm vs. 6.6mm) and ring width difference (6.9mm vs. 3.9mm) on final X-rays as compared to Group 2. Children with 5-10mm posterior sacral displacement had significantly more pain than children with 0-4mm displacement (p=0.034). Thirteen children (39%) had residual low back/SI joint pain; the rate was significantly higher in the Group 1 (3/17 vs. 10/16, p=0.008). In three (9%) children with 2 B2 and 1 B3 injury, leg length discrepancy between 5mm to 15mm occurred.

DISCUSSION AND CONCLUSION

In pediatric patients with pelvic ring injuries, radiographic deformity persisted and did not remodel. Pelvic ring deformity occurred more commonly with complex unstable ring injuries. The complex displaced injuries have higher rates of operative intervention, residual deformity, and low back and SI joint pain.

Risk factors associated with bladder and urethral injuries in female children with pelvic fractures: An analysis of the National Trauma Data Bank

BACKGROUND

Bladder and/or urethral injuries (BUIs) secondary to pelvic fractures are rare in children and are associated with a high morbidity. These injuries are much less likely to occur in females and are often missed in the emergency department. To help clinicians detect these injuries in female children, larger studies are needed to identify risk factors specific to this patient population. This study aimed to identify risk factors associated with BUI in female children with a pelvic fracture.

METHODS

We reviewed the National Trauma Data Bank for females younger than 16 years who sustained a pelvic fracture from 2010 to 2012. Patients with penetrating injuries were excluded. Variables including patient characteristics, mechanism of injury, and type of pelvic fracture were selected for bivariate analysis. Variables with an association of p < 0.05 were then tested using binary logistic regression.

RESULTS

Of the 149,091 females younger than 16 years in the National Trauma Data Bank, 2,639 patients (2%) with pelvic fractures were identified. The median patient age was 12 years (interquartile range [IQR], 7-14 years). BUI was identified in 81 patients (3%). Patients with BUI had a significantly higher median Injury Severity Score (ISS) (25 [IQR, 17-34] vs. 13 [IQR, 6-22], p < 0.001). Four variables were found to be independently associated with BUI in the logistic regression model: vaginal laceration (adjusted odds ratio [OR], 9.1; 95% confidence interval [CI], 4.4-18.7), disruption of the pelvic circle (adjusted OR, 3.0; 95% CI, 1.6-5.6), multiple pelvic fractures (adjusted OR, 2.3; 95% CI, 1.3-3.9), and sacral spine injury (adjusted OR, 1.6; 95% CI, 1.0-2.6). In total, 62 patients (77%; 95% CI, 67-86%) with BUI had at least one of these findings.

CONCLUSION

Female children who sustained a pelvic fracture and have a vaginal laceration, disruption of the pelvic circle, multiple pelvic fractures, or a sacral spine injury seem to be at highest risk for BUI.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Associated Injuries in Skeletally Immature Children with Pelvic Fractures

BACKGROUND

Pediatric pelvic fractures are rare injuries resulting from high-energy mechanisms that warrant an extensive work-up for associated injuries.

OBJECTIVES

We performed a retrospective study to review concomitant injuries in children who suffered a pelvic fracture and have an open triradiate cartilage.

METHODS

Using a database, pediatric pelvic fractures presenting to the authors' institution were extracted. Radiographs and computed tomography scans were reviewed, ensuring that triradiate cartilages were not fused and the pelvic injuries were classified using the Modified Torode Classification. Epidemiologic data extracted included Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and Abbreviated Injury Score (AIS).

RESULTS

Sixty patients met the inclusion criteria, and their average age was 8.3 years (range 2-14 years). There were no mortalities. The most common mechanism of injury was a vehicle striking a pedestrian. There were no significant correlations between GCS, ISS, and AIS. All 60 children (100%) suffered extremity injuries. Nineteen patients required surgical orthopedic intervention, and 6 required operative stabilization of the pelvis. Patients who were struck by a motor vehicle were more likely to have multiple pelvic fractures (p < 0.05). Patients with multiple pelvic fractures were more likely to require orthopaedic surgical intervention and require a blood transfusion (p < 0.05). Patients who had type III-B or IV fractures were more likely to require a transfusion than patients with III-A fracture (p < 0.05).

CONCLUSIONS

Patients sustaining fractures to an immature pelvis are likely to have additional injuries, which may be fatal or disabling if not diagnosed in a timely manner.

Treatment of an open book pelvic fracture and bilateral femoral fractures with an external fixator in a 14-month-old: a case report

A 14-month-old girl was involved in a road traffic accident that resulted in an open book pelvic fracture and bilateral femoral fractures. Acute treatment involved a novel collar and the cuff pelvic closure technique to tamponade the pelvis and reduce bleeding. The patient was treated surgically with an external fixator, which provided good reduction of the pelvic and femoral fractures. A literature search found no previous information on open book pelvic fractures in infants younger than 2 years. The success of this surgery led us to suggest that the use of an external fixator is a potential treatment method for open book pelvic fractures and bilateral femoral fractures in extremely young infants.

PELVIC INJURY IN CHILDHOOD: WHAT IS ITS CURRENT IMPORTANCE?

OBJECTIVE

The purpose of this study was to assess the importance of pelvic fractures in childhood by analyzing epidemiological characteristics and associated injuries.

METHODS

This is a retrospective study performed between 2002 and 2012 at two trauma referral centers in São Paulo. We identified 25 patients aged 16 years old or younger with pelvic fracture.

RESULTS

The main mechanism of trauma was traffic accident (80%), followed by fall from height (16%). At hospital admission, 92% had traumatic brain injury and 40% had hemodynamic instability. Besides pelvic fractures, 56% of the children had other associated injuries (genitourinary, abdominal, vascular, chest and neurological), and 79% of them required operative treatment. According to the Torode and Zieg classification, the majority of cases were types III and IV. Seventy-two percent of all pelvic fractures were treated by surgery; 52% involved external fixation and 20% involved open reduction and internal fixation.

CONCLUSIONS

The pelvic fractures in childhood can be considered a marker for injury severity, because the associated injuries usually are severe, needing operative treatment and leading to a high mortality rate (12%). Level of Evidence IV, Case Series.

Radiological evaluation of the posterior pelvic ring in paediatric patients: Results of a retrospective study developing age- and gender-related non-osseous baseline characteristics in paediatric pelvic computed tomography - References for suspected sacroiliac joint injury

INTRODUCTION

The prevalence of paediatric pelvic injury is low, yet they are often indicative of accompanying injuries, and an instable pelvis at presentation is related to long-term poor outcome. Judging diastasis of the sacroiliac joint in paediatric pelvic computed tomography is challenging, as information on their normal appearance is scarce. We therefore sought to generate age- and gender-related standard width measurements of the sacroiliac joint in children for comparison.

PATIENTS AND METHODS

A total of 427 pelvic computed tomography scans in paediatric patients (<18 years old) were retrospectively evaluated. After applying exclusion criteria, 350 scans remained for measurements. Taking a standard approach we measured the sacroiliac joint width bilaterally in axial and coronal planes.

RESULTS

We illustrate age- and gender-related measurements of the sacroiliac joint width as a designated continuous 3rd, 15th, 50th, 85th and 97th centile graph, respectively. Means and standard deviations in the joint width are reported for four age groups. There are distinct changes in the sacroiliac joint's appearance during growth. In general, male children exhibit broader sacroiliac joints than females at the same age, although this difference is significant only in the 11 to 15-year-old age group.

CONCLUSION

The sacroiliac joint width in children as measured in coronal and axial CT scans differs in association with age and gender. When the sacroiliac joint width is broader than the 97th centile published in our study, we strongly encourage considering a sacroiliac joint injury.

Do Safe Radiographic Sacral Screw Pathways Exist in a Pediatric Patient Population and Do They Change With Age?

OBJECTIVES

Iliosacral screw pathways in the first (S1) and second (S2) sacral segments are commonly used for adult pelvic ring stabilization. We hypothesize that radiographically "safe" pathways exist in pediatric patients.

SETTING

Academic level I Trauma Center.

PATIENTS

All patients between ages 2 and 16 years with a computed tomography scan including the pelvis obtained over a 6-week period (174 children, mean age 10.8 ± 3.9 years; 90 boys, 84 girls).

INTERVENTION

The width and height at the "constriction point" in 3 safe screw pathways were measured bilaterally by 3 orthopaedists (resident, trauma fellow, trauma attending). Pathways corresponding to: (1) an "iliosacral" screw at S1, a "trans-sacral trans-iliac" (TSTI) screw at S1, and a TSTI screw at S2.

MAIN OUTCOME MEASUREMENTS

(1) Mean width and height of pathways, (2) interrater reliability coefficient, (3) availability of pathways greater than 7 mm, (4) growth of pathways with age, (5) sacral morphology.

RESULTS

The interrater reliability coefficient was above 0.917 for all measurements. Radiographically safe pathways were available for 99%, 51%, and 89% of children for iliosacral screws at S1 (width 16.4 ± 2.8 mm, height 15.1 ± 3.3 mm), TSTI screws at S1 (width 7.2 ± 4.9 mm, height 8.3 ± 5.6 mm), and TSTI at S2 (width 9.3 ± 2.2 mm, height 11.5 ± 2.7 mm), respectively.

CONCLUSIONS

Contrary to our hypothesis, almost all children aged 2-16 had a radiographically safe screw pathway for an iliosacral screw at S1, and most of the children had an available pathway for a TSTI screw at S2. However, only 51% had a pathway for a TSTI screw at S1.

Pelvic Fractures in Children Results from the German Pelvic Trauma Registry: A Cohort Study

As pelvic fractures in children and adolescents are very rare, the surgical management is not well delineated nor are the postoperative complications. The aim of this study using the prospective data from German Pelvic Trauma Registry study was to evaluate the various treatment approaches compared to adults and delineated the differences in postoperative complications after pelvic injuries.Using the prospective pelvic trauma registry established by the German Society of Traumatology and the German Section of the Arbeitsgemeinschaft für Osteosynthesefragen (AO), International in 1991, patients with pelvic fractures over a 12-year time frame submitted by any 1 of the 23 member level I trauma centers were reviewed.We identified a total of 13,525 patients including pelvic fractures in 13,317 adults and 208 children aged ≤14 years and compared these 2 groups. The 2 groups' Injury Severitiy Score (ISS) did not differ statistically. Lethality in the pediatric group was 6.3%, not statistically different from the adults' 4.6%. In all, 18.3% of the pediatric pelvic fractures were treated surgically as compared to 22.7% in the adult group. No child suffered any thrombosis/embolism, acute respiratory distress syndrome (ARDS), multiorgan failure (MOF), or neurologic deficit, nor was any septic MOF detected. The differences between adults and children were statistically significant in that the children suffered less frequently from thrombosis/embolism (P = 0.041) and ARDS and MOF (P = 0.006).This prospective multicenter study addressing patients with pelvic fractures reveals that the risk for a thrombosis/embolism, ARDS, and MOF is significant lower in pediatric patients than in adults. No statistical differences could be found in the ratios of operative therapy of the pelvic fractures in children compared to adults.

SURGICAL TREATMENT OF UNSTABLE PELVIC RING FRACTURE IN SKELETALLY IMMATURE PATIENTS

OBJECTIVES

To present the outcomes from definitive surgical treatment for unstable fractures of the pelvic ring in children undergoing surgical reduction and stabilization.

METHODS

We studied 10 patients with immature skeletons who suffered unstable fractures of the pelvic ring and were treated between March 2004 and January 2008. The study was retrospective, based on clinical and radiographic evaluations.

RESULTS

The mean age at the time of the trauma was 8.8 years (2 to 13 years). Seven patients were female and three was male. There were eight cases of trauma caused by being run over, and one case each of a motorcycle accident and falling from a height. Five patients had other associated injuries such as fractures of the clavicle, femoral diaphysis, proximal humerus, lower leg bones, olecranon and bladder injury. All the patients evaluated showed an excellent clinical outcome. The pelvic asymmetry before surgery ranged from 0.7 to 2.9 cm (mean 1.45 cm), and dropped to values between 0.2 and 0.9 cm (mean 0.39 cm) after reduction. In no case was any change observed in pelvic asymmetry measured in the immediate postoperative period and at the end of follow-up.

CONCLUSION

Pelvic ring fractures in skeletally immature patients are rare and surgical treatment is unusual. Several authors have questioned conservative treatment because of the complications encountered. Bone remodeling does not seem enough to cause an improvement in pelvic asymmetry, and this justifies the choice of surgical treatment for reduction and correction of pelvic ring deformities.

Pelvic Fractures in Paediatric Polytrauma Patients: Classification, Concomitant Injuries and Early Mortality

Purpose of this Study :

To review the characteristics, concomitant injuries and mortality in children with polytrauma and associated pelvic fractures treated in a Level-I Trauma Centre.

Materials and Methods :

Between December 2003 and November 2013, 49 children with an Injury Severity Score (ISS) of 16 or greater and a pelvic fracture met the inclusion criteria and were evaluated. The mortality, transfusion requirements and length of intensive care unit stay were correlated with the ISS, Abbreviated Injury Scale, concomitant limb and spine fractures, and type of pelvic ring injury (AO/OTA classification).

Results :

The mean ISS at presentation was 31.4 (range 16 to 57). 19 (38.7%) patients sustained a Type A, 27 (55.1%) a Type B and 3 (6.2%) a Type C injury. Head and face trauma was present in 33 (67.3%) cases. Blood transfusion during the resuscitation process was necessitated in six (12.2%) patients. Thirty-eight (77.5%) patients were managed non-operatively for their pelvic injuries. The mean duration of hospital stay was 23.9 days (range 1 to 146 days). In this cohort of polytrauma paediatric patients there were five (10.2%) mortalities (all suffered an associated head trauma ) within 30 days from the initial injury.

Conclusion:

Severe head injury and a high ISS are significantly associated with mortality in children with pelvic fractures. These patients have a high incidence of concomitant spine and chest injuries Hemorrhage due to pelvic injuries is rare. Severe head injuries predict a longer ICU stay in this population.

[Current treatment of pelvic ring fractures]

Pelvic injuries are often associated with multiple injuries of other body regions, neurovascular and visceral lesions, as well as hemodynamic instability. The use of a standardized classification characterizing the severity and stability of pelvic fractures and the early stabilization of pelvic ring injuries in appreciation of damage control principles has helped to improve the number of survivors. This is particularly necessary due to the higher number of older patients. Complex pelvic trauma still represents a life-threatening situation for the patient, particularly in multiple traumatized patients. Standardized clinical investigations and modern concepts even in the preclinical therapy of complex pelvic fractures make a contribution to enhancement of treatment options. Because of the still problematic long-term results after surgery of instable pelvic fractures, the need for modern treatment concepts has to be adapted to the requirements.

Short-term pelvic fracture outcomes in adolescents differ from children and adults in the National Trauma Data Bank

BACKGROUND

Pediatric pelvic fractures are associated with high-energy trauma and injury to other systems, leading to an increased incidence of complication and mortality. Previous studies analyzed the pediatric population as a whole, including both children and adolescents. The purpose of this study was to examine whether adolescents with pelvic fracture have different complication and mortality rates compared to younger children and adults.

METHODS

Using the National Trauma Data Bank, 37,784 patients below the age of 55 years with pelvic fractures were identified and divided into children (age <13 years), adolescents (age 13-17 years), and adults (age >17 years). Descriptive statistics and bivariate and multivariate analyses were performed.

RESULTS

Children had an increased odds of death [odds ratio (OR) 2.29, 95 % confidence interval (CI) 1.96-2.67] and complications (OR 1.36, 95 % CI 1.20-1.55), whereas adolescents had a decrease in odds of death (OR 0.89, 95 % CI 0.74-1.06) and complications (OR 0.70, 95 % CI 0.61-0.81) compared to the adult population.

CONCLUSIONS

Adolescents with pelvic fractures exhibit a different physiologic response to the children and adult populations. This emphasizes the need to distinguish these subpopulations in future epidemiological research and treatment planning.

Surgical treatment for unstable pelvic fractures in skeletally immature patients

OBJECTIVE

To present the results and conclusions of our study on surgical treatment for unstable pelvic fractures in children subjected to surgical reduction and stabilisation.

METHODS

We analysed the cases of fourteen skeletally immature patients with unstable pelvic fractures who underwent surgery for this condition between March 2004 and January 2011. The surgical technique used was based on the principle of surgical reduction and stabilisation of anterior and posterior lesions of the pelvic ring. This was a retrospective study, based on clinical assessment and X-ray analyses.

RESULTS

The mean age of patients at the time of the condition was 9.4 years (range 2-13 years). Eight patients were female and six were male. The cause of the trauma was being hit by a car in ten cases, falls in three cases and an accident involving a motorcycle in one case. Five patients presented with other associated injuries, including fracture of the clavicle, femur shaft, proximal humerus, tibial shaft or olecranon, and bladder damage. All the patients assessed showed excellent clinical progress. Pelvic asymmetry prior to surgery varied from 1.1 to 2.9 cm (mean 1.5 cm) and dropped to a range of 0.2 to 0.9 cm (mean 0.4 cm) after reduction. In none of the cases was there a change between the pelvic asymmetry measured immediately after surgery and at the end of the follow-up period.

CONCLUSION

Pelvic fracture in skeletally immature patients is rare and surgery is not normally indicated. Various authors have questioned this conservative type of treatment due to complications encountered. Bone remodelling does not seem to be sufficient to ensure an improvement in pelvic asymmetry, which justifies opting for surgery to reduce and correct deformities in the pelvic ring.

[Current treatment of pelvic ring fractures]

Pelvic injuries are often associated with multiple injuries of other body regions, neurovascular and visceral lesions, as well as hemodynamic instability. The use of a standardized classification characterizing the severity and stability of pelvic fractures and the early stabilization of pelvic ring injuries in appreciation of damage control principles has helped to improve the number of survivors. This is particularly necessary due to the higher number of older patients.Complex pelvic trauma still represents a life-threatening situation for the patient, particularly in multiple traumatized patients. Standardized clinical investigations and modern concepts even in the preclinical therapy of complex pelvic fractures make a contribution to enhancement of treatment options. Because of the still problematic long-term results after surgery of instable pelvic fractures, the need for modern treatment concepts has to be adapted to the requirements.

Childhood obesity as a risk factor for bone fracture: a mechanistic study

OBJECTIVE

To investigate the risk of bone fracture sustained by obese children exposed to falls. The bone fracture risk of obese children would be greater than that of their nonobese counterparts was hypothesized.

DESIGN AND METHODS

Finite element-based computational models for children that reflected various levels of obesity by varying body mass and the thickness of the subcutaneous adipose tissue layer was developed. The models took account of both the momentum effect of variation of body mass and the cushion effect of variation of soft tissue thickness and examined these two contradictory effects on pelvic bone fracture risk through a set of sideways fall simulations with a range of impact speeds.

RESULTS

The critical impact speed that yielded pelvic bone fracture decreased as the levels of obesity increased, which meant that the momentum effect of a greater body mass took precedence over the cushion effect of the soft tissue layer.

CONCLUSIONS

The result suggests that obese children have a greater risk of pelvic bone fracture than do their nonobese counterparts in sideways falls. A further implication is that current child safety devices, systems, and regulations will need to be revisited as the prevalence of child obesity increases.

Retroperitoneal pelvic packing for haemodynamically unstable pelvic fractures in children and adolescents: a level-one trauma-centre experience

PURPOSE

This study aims to review the outcomes of haemodynamically unstable paediatric patients with pelvic fractures undergoing protocol intervention of retroperitoneal pelvic packing (RPP) with external fixation and angiography.

METHODS

From 2004 to 2011, consecutive patients younger than 19 years treated in our centre for haemodynamically unstable pelvic fractures were retrospectively reviewed. From 2008, protocol intervention triad of external fixation, RPP, and angiography with embolization was implemented.

RESULTS

Before 2008, only 2 boys with fall injuries received intervention. One received initial angiography showing extravasation near iliac bifurcation. Laparotomy proceeded without embolization for multiple visceral injuries, but he succumbed postoperatively. The other had persistent bleeding after external fixation but became stabilized after embolization. After 2008 protocol implementation, 5 youngsters received the triad of interventions for unstable pelvic fractures. Mean age was 15.4 yrs. The mean injury severity score was 42 (18-66) with 62.5% mean probability of survival (6.8-98.8%). The mean operating time for RPP was 23 mins (20-35 mins). One boy died of rapid exanguination intraoperatively. The other 4 youngsters recovered for rehabilitation.

CONCLUSION

Fall from heights is a major cause for severe pelvic injuries in our locality. RPP is a simple effective procedure to include in protocol intervention for pelvic fractures. This case series suggests it helps improve haemostasis and survival in unstable young patients, although larger cohorts will be necessary to validate this.

Fractures of the pelvis in children: a review of the literature

Trauma is the leading cause of death in children. Pelvic ring injuries account for 0.3-4% of all paediatric injuries. The pattern of fractures differs to that seen in adults as it is more ductile. Pelvic ring injuries tend to be more stable as the relatively thick periosteum restricts bony displacement. Intrapelvic viscera are not well protected and can sustain injury in the absence of pelvic fractures. These injuries have traditionally been treated non-operatively. In this paper, we comprehensively review the literature and propose a protocol for treatment taking into consideration associated organ injuries, hemodynamic status of the patient, patient's age, type of fracture and the stability of the pelvic ring.

Bilateral acetabular fractures in an adolescent after low-energy trauma

BACKGROUND

Pediatric pelvic fractures are rare, accounting for approximately 2.4% to 5.5% of annual admissions at large level I trauma centers. An acetabular fracture is involved in only about 1% to 15% of these cases and is almost exclusively caused by a high-energy trauma.

METHODS

This is a report of an otherwise healthy 15-year-old male adolescent who sustained a nondisplaced bilateral anterior column and wall acetabular fracture after a low-energy mechanism during a hockey game. The patient was managed nonoperatively with non-weight-bearing restrictions and had complete resolution of his symptoms by 10 weeks.

RESULTS

This case shows that a low-energy mechanism can create significant bilateral acetabular fractures in the immature skeleton.

CONCLUSIONS

The presented case may represent an underdiagnosed cause of hip and groin pain in the adolescent patient/athlete when initial radiographs appear normal.

[Pelvic injuries in childhood and adolescence: Retrospective analysis of 5-year data from a national trauma centre]

BACKGROUND

Pelvic fractures are uncommon injuries in paediatric trauma patients because of specific anatomical features. Due to the low incidence there is no standardized therapeutic algorithm.

MATERIAL AND METHODS

This retrospective review evaluates paediatric pelvic fractures of a Level I Trauma Centre over 5 years. In addition, we compared the data with adult pelvic fractures and reviewed the literature. A total of 37 pelvic fractures (≤16 years) were documented, with an incidence of 9.9% in the child with multiple injuries. The most common injury mechanisms were traffic accidents, followed by falls from heights.

RESULTS

Type A injuries occurred in 50% (type B: 16%, type C: 27%, acetabular injuries: 11%). Osteosynthesis was performed in nine cases. Therapeutic intervention was necessary in three cases of haemodynamically relevant bleeding; 97% of all children had associated injuries (mean ISS: 38).

CONCLUSION

Our data showed some differences to the literature. Pelvic fractures are predictors for high injury severity. Despite similar fracture pattern, in contrast to adults most injuries could be treated non-operatively. In unstable or dislocated fractures open reduction and stabilization must be performed.

Surgical treatment of unstable pelvic fracture in children: long term results

Paediatric pelvic fractures are rare lesions. In the literature still controversy exists regarding the management of these injuries. The sequelae of these types of lesions has been described. We report the management and long term outcome of 8 patients with paediatric pelvic fractures treated in our institution. Associated injuries to the Risser's growth nuclei are described that has not been previously reported. Anatomical reduction of the displaced fracture should be considered to minimise the risk of long term functional impairment.

Impact of timing of pelvic fixation on functional outcome

Pelvic fractures are the third most common cause of death in motor vehicle accidents. Recent improvements in mortality can be attributed to the progress made in modern critical care medicine, multidetector CT, ATLS principles, multidisciplinary protocols and early fracture stabilisation. Currently, the timing of pelvic fixation is often based on the haemodynamic status and response of the patient to resuscitation, the fracture pattern, the presence of associated injuries and the immuno-inflammatory status of the patient. The purpose of this review is to focus on the impact of timing of reconstruction of pelvic fractures on the functional outcome of the patients. Thirty seven scientific studies on the outcome of pelvic and acetabular injuries were reviewed. Four on pelvic ring fractures, and one study on pelvic and acetabular fractures met our second inclusion criterion of prospective or retrospective studies investigating the outcome after early or late pelvic and acetabular fixation. These five studies suggested early pelvic and acetabular fixation for optimal outcome but their main difference was the definition of the length in time of that early period. In polytrauma patients, the "damage control orthopaedics" principle should be applied for haemodynamic and skeletal stabilisation (and faecal diversion, if indicated in cases of open fractures of the pelvis). The definitive fixation should be performed after the fourth post-injury day, when the physiological state of the patient is conducive to surgery.

Pelvic Fractures in Children

Although rare, pelvic fractures in children have significant morbidity and mortality. No specific guidelines have been developed for the management of these injuries. We reviewed all trauma patients of age 16 years or younger with pelvic fractures treated at our Level I trauma center over the past 12 years. Of 1008 patients with pelvic fractures, 74 were children. Early hemodynamic instability was seen in 14 per cent of cases. Blood transfusions were required in 26 per cent of cases, angiography in 3 per cent of cases, operations for associated injuries in 46 per cent of cases, operative pelvic fracture fixation in 18 per cent of cases, and intensive care unit care in 58 per cent of cases. Mortality was 5 per cent, mostly from hemorrhage and multiple complex injuries. We conclude that pelvic fractures in children are associated with a high frequency of pelvic bleeding and associated injuries that often require operative interventions and intensive care unit care.

A trauma series in the injured child: do we really need it?

BACKGROUND

To study the use of trauma series radiographs in children that required activation of a trauma call.

METHODS

A retrospective review of patients younger than 16 years who presented to The Children's Hospital at Westmead between January and December 2004 with an injury that required activation of the trauma team. Patients transferred from other institutions were excluded.

RESULTS

Two hundred seventy-four children were included in the study, with 166 boys. The mean age was 8 years, and average Injury Severity Score was 4. Sixteen children had an Injury Severity Score of above 15. One hundred thirty-one children had a complete trauma series performed; 104 had one or more of the series performed, whereas 39 had no radiographs. Data analysis revealed that patients with findings in a chest radiograph (13) had either chest wall contusion(s) or reduced air entry on the involved side. Logistic regression analyses identified features that were significantly associated with a positive finding on the radiographs of the anteroposterior chest including a distracting injury in the chest area (odds ratio [OR], 10.49; 95% confidence interval [CI], 2.98-36.97), abnormal air entry on auscultation (OR, 31.86; 95% CI, 2.80-365.12), and need for intubation (OR, 6.23; 95% CI, 1.56-24.91). However, no clinical variable(s) showed a statistically significant correlation with abnormal radiographic findings on the lateral cervical spine (2) or anteroposterior pelvis (4).

CONCLUSIONS

This study suggests that selective use of individual components of the full trauma series in the conscious pediatric patient, when an adequate clinical examination can be performed, would be safe. This approach should reduce the exposure to ionizing radiation of pediatric trauma patients and hospital staff.

Pediatric Pelvic Fractures: A Marker for Injury Severity

Pelvic fractures comprise a small number of annual Level I pediatric trauma center admissions. This is a review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures. This is a retrospective review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures during the 12-year period from 1992 to 2004. From 1992 to 2004, there were 2850 pediatric trauma admissions. Thirteen patients were identified with pelvic fractures; seven were boys and six were girls. The average age was 8 years old. The mechanism of injury in all cases was motor vehicle related; 11 patients (87%) sustained pedestrian-motor vehicle crashes. According to the Torode and Zeig classification system, type III fractures occurred in eight patients (62%) and type IV fractures occurred in six patients (31%). Associated injuries occurred in eight patients (62%). Seven of these patients (88%) had associated injuries involving two or more organ systems. Of the associated injuries, additional orthopedic injuries were the most common, occurring in 62 per cent of our patients. Neurological injuries occurred in 54 per cent of patients, vascular injuries in 39 per cent, pulmonary injuries in 31 per cent, and genitourinary injuries in 15 per cent. Five patients (38%) were treated operatively; only two patients underwent operative management directly related to their pelvic fracture. The remaining three patients underwent operative management of associated injuries. The mortality rate was 0 per cent. Although pelvic fractures are an uncommon injury in pediatric trauma patients, the morbidity associated with these injuries can be profound. The majority of pelvic fractures in children are treated nonoperatively, however, more than one-half of these patients have concomitant injuries requiring operative management. When evaluating and treating pediatric pelvic fractures, a systematic multidisciplinary approach must be taken to evaluate and prioritize the pelvic fracture and the associated injuries.

Paediatric trauma at an adult trauma centre

BACKGROUND

Trauma in children remains the commonest cause of mortality. The majority of injured children who reach hospital survive, indicating that additional more sensitive outcome measures should be utilized to evaluate paediatric trauma care, including morbidity and missed injury rates. Limited contemporary data have been presented reviewing the care of injured children at an adult trauma centre (ATC).

METHODS

A review was undertaken of injured children who warranted activation of the trauma team, treated within the emergency department of an ATC (Royal North Shore Hospital) situated in the Lower North Shore area of Sydney. Data were collected prospectively and patients followed through to death or discharge from the ATC or another institution to which they had been transferred.

RESULTS

A total of 93 children were admitted to the ATC between January 1999 and April 2002. Mean age was 9 years 3 months (range 5 weeks-15 years 9 months) and 70% were male. The median injury severity score was 15 (range 1-75) and there were three deaths. Forty-two children were transferred to a paediatric trauma centre (PTC), including three children who had been transferred to the ATC from another hospital. There was one missed injury and one iatrogenic urethral injury.

CONCLUSIONS

The majority of children with trauma were treated safely and appropriately at the ATC. The missed injury rate was < 1% and there were no adverse long-term sequelae of initial treatment. Three secondary transfers could have been avoided by more appropriate coordination of the initial referral to a PTC.

Pediatric pelvic injury: functional outcome at 6-month follow-up

BACKGROUND/PURPOSE

Data on functional outcomes after pediatric pelvic fractures are limited to those obtained at hospital discharge. This study assesses functional status at both hospital discharge and at 6 months after injury.

METHODS

A national multicenter prospective study began in February 2002 and is ongoing. Patients completed WeeFIM functional assessments at hospital discharge and at 6-month follow-up as part of this study. This report summarizes preliminary functional assessment results from 20 patients.

RESULTS

Patient data were accrued into 3 domains (self-care, mobility, and cognition), which constitute a total raw rating. Significant improvement at 6 months after injury was evident in self-care, mobility, and total raw ratings. This significance remained when total raw ratings were converted to age-adjusted functional quotients.

CONCLUSIONS

This preliminary assessment shows that after pelvic fractures, children improve their functional status at 6 months, returning to near-normal status.