Ilio-Sacral (IS) Screw Fixation for Sacral and Sacroiliac Joint (SIJ) Injuries in Children

Post-traumatic sacroiliac joint remodeling in a pediatric patient: a case report

BACKGROUND

Sacroiliac joint (SIJ) remodeling in pediatric patients following trauma is a rare phenomenon with limited documentation in medical literature. This case report presents a unique instance of post-traumatic SIJ remodeling in an 11-year-old girl following a motorbike accident, highlighting novel imaging findings and successful outcomes achieved through a multidisciplinary approach.

CASE PRESENTATION

The patient presented ten days post-injury with severe right hemi-pelvic pain and limited leg mobility. Initial imaging revealed dislocation of the right SIJ, along with superior and posterior hemi-pelvic displacement and pubic symphysis separation. Initial attempts at closed reduction were unsuccessful, necessitating surgical intervention with percutaneous SIJ screw placement and external fixation. Despite incomplete reduction, multidisciplinary rehabilitation was initiated. At the three-month follow-up, the patient was walking pain-free, with CT scans showing significant SIJ remodeling as the joint adapted to the sacral surface. The SIJ screw was removed at six months, with the patient returning to full function, equal limb lengths, and no residual deficits.

CONCLUSIONS

This case underscores the distinct anatomical and physiological responses of the pediatric SIJ to trauma. Early diagnosis, multidisciplinary management, and careful consideration of growth factors are crucial for favorable outcomes in pediatric post-traumatic SIJ injuries. This report highlights the potential for significant joint remodeling and emphasizes the importance of tailored rehabilitation in pediatric cases.

Operative management of sacroiliac joint dislocation in children with unstable pelvic fractures - A STROBE-compliant investigation

Objective

Injuries involving severe spinal axial loading may be accompanied by sacroiliac joint dislocations. In children, these injuries are relatively rare, and there is little information on their optimal management in young patients. We conducted a multicentre study to investigate the outcome of surgical treatment of unstable pelvic fracture with sacroiliac joint dislocation in children.

Patients & methods

We assessed the quality of surgical reduction and functional outcome at follow-up in 7 patients (5 girls, 2 boys) with a median age of 6.4 years (range: 4.2-14.8 years). Patients with pelvic fractures and sacroiliac joint dislocations were treated at four international paediatric level 1 trauma centres between January 2008 and August 2023. We applied the Matta criteria to assess the quality of fracture reduction and graded the functional follow-up results using adjusted Majeed score.

Results

At follow-up, 3 patients showed excellent fracture reduction, with 2 patients showing good reduction and 2 patients exhibiting fair fracture reduction according to the Matta criteria. At follow-up visits at a median of 12 months (range: 3-84 months) after the injury, patients achieved a median adjusted Majeed score of 76 (range: 63 to 76).

Conclusions

Unstable pelvic injuries with sacroiliac joint dislocation without comminution can be stabilised with a single iliosacral screw in children. Comminuted pelvic fractures with unstable sacroiliac dislocation require stabilisation with lateral compression screws or plates. In case of residual pelvic instability after internal fixation, an additional external fixator or pelvic hammock should be applied to optimize the stability of fixation.

Treatment of unstable pelvic fractures in children with an external fixator: Retrospective study of 56 patients

Purpose

We retrospectively analyzed the data of patients who underwent external fixation treatment for unstable pelvic fractures and evaluated the clinical effects of this treatment and factors influencing pelvic function recovery.

Methods

The data of patients with unstable pelvic fractures treated with an external fixator between January 2006 and December 2018 were retrospectively analyzed. The analyzed parameters included demographic data, fracture healing, pelvic asymmetry, deformity index, and complications. Fractures were categorized using the Tiles classification. Pelvic function was evaluated using the Cole score. Pelvic risk factors were identified using univariate and multivariate logistic regression analyses.

Results

Fifty-six patients (29 and 27 with type B and C fractures, respectively) were included. All fractures were healed at the time of the final follow-up. Nine and three patients had pin tract infections and loosened external fixators postoperatively, respectively. Pelvic asymmetry was reduced from 1.34 ± 0.15 cm to 0.70 ± 0.19 cm (p < 0.01), and the deformity index decreased from 0.13 ± 0.03 to 0.07 ± 0.02 (p < 0.01). The Cole score was excellent and good in 41 and 15 patients, respectively. Risk factors for pelvic function recovery included injury severity score > 25.5, age > 11.3 years, and lower-extremity fractures.

Conclusions

External fixation is an effective method for treating unstable pelvic fractures in children, with the advantages of a simple operation, short surgical time, no interference with treatments for associated injuries, and avoidance of re-trauma caused by open reduction. An ISS > 25.5, patient age > 11.3 years, and associated lower-extremity fractures are predictors of pelvic function recovery.

Level of evidence

Level IV.

Percutaneous sacroiliac screw fixation in a pediatric with unstable bilateral superior rami and sacral fracture-dislocation; a case report and review of the literature

Complex pelvic ring injuries in childhood can be difficult to treat, and literature mentions several techniques for fixing SIJ fracture-dislocations. In accordance with the CAse REport (CARE) guidelines, this study describes a five-year-old boy with a complex pelvic ring fracture caused by a car accident: vertically unstable pelvic fracture consists of bilateral superior rami fractures and type I of Denis sacral fracture. Fixation was achieved by inserting a 6.5 mm major diameter cannulated screw with a 60 mm length and 16 thread into the SIJ at the level of S1. The pelvic inlet view corrected the anterior-posterior position, and the pelvic outlet view adjusted the superior-inferior position to determine a suitable sacral level. After three months, the SI joint has shown an anatomically fracture consolidation, and he could ambulate with full weight-bearing and full ROM with no pain. A 3-year follow-up showed promising results in radiological and functional terms. We conclude that percutaneous SI screw fixation using a cannulated screw is a suitable technique for pediatrics because it provides anatomic reductions and is minimally invasive. Children as young as five can be treated safely with SI screws for sacral fractures and SIJ injuries.

Is the Iliac Cortical Density Similarly Positioned in the Developing Pediatric Pelvis?

OBJECTIVES

The iliac cortical density (ICD) is a critical fluoroscopic landmark for pelvic percutaneous screw placement. Our purpose was to evaluate the ICD as a landmark in pediatrics and quantify the diameter of osseous pathways for 3 screw trajectories: iliosacral (IS) at S1 and transiliac-transsacral (TSTI) at S1 and S2.

METHODS

Two hundred sixty-seven consecutive pelvic CT scans in children 0-16 years of age were analyzed. ICD and S1 vertebral heights were measured at multiple regions along S1. Their height and corresponding ratios, as well as osseous screw corridor dimensions were compared between age groups and by the dysmorphic status.

RESULTS

In the nondysmorphic pelvises, S1 height, ICD height, and the ICD to S1 height ratio increased across age groups for all locations (P < 0.001). All 3 screw pathway diameters increased with age (P < 0.001). In the dysmorphic group, there was no increase in ICD to S1 height ratio with age. Except for the age 0-2 group, the ICD to S1 height ratios were significantly larger in the nondysmorphic group. In the dysmorphic group, S1 TSTI pathway remained narrow with age, whereas IS at S1 and TSTI at S2 had a significant increased diameter with age (P < 0.001).

CONCLUSION

The ICD is a useful fluoroscopic landmark for percutaneous screw placement in the pediatric pelvis. For nondysmorphic pelvises, the ICD to S1 height ratio, as well as osseous corridors for IS, TSTI at S1, and TSTI at S2 screw trajectories increase significantly with age. The margin for safe screw placement in S1 is smaller for younger and dysmorphic pelvises.

Suture Fixation of a Pediatric Pelvic Ring Injury: A Case Report

CASE

A 2-year-old male child presented as a polytrauma after having been run over by a motor vehicle. His orthopaedic injuries included a pelvic ring injury, a displaced subtrochanteric femur fracture, and a clavicle fracture. His pelvic ring injury ultimately required open reduction with suture fixation after failure of closed management.

CONCLUSION

Pelvic ring injuries are relatively uncommon in young children, and even more rarely do they require surgical intervention. We detail the case of one such patient who required open management of his anteroposterior compression II pelvic ring injury, and we describe an alternative fixation technique using suture wire.

Optimal ilio-sacral screw trajectory in paediatric patients : a computed tomography study

Pelvic fixation during procedures performed to treat spinal deformities in paediatric patients remains challenging. No computed tomography studies in paediatric have assessed the optimal trajectory of ilio- sacral screws to prevent screw malposition. We used pelvic computed tomography from 80 children divided into four groups : females <10 and ≥10 years and males <10 and ≥10 years. A secure triangular corridor parallel to the upper S1 endplate was delineated based on three fixed landmarks. The optimal screw insertion angle was subtended by the horizontal and the line bisecting the secure corridor. Student’s t test was applied to determine whether the optimal screw insertion angle and/or anatomical parameters were associated with age and/or sex. Mean optimal angle was 32.3°±3.6°, 33.8°±4.7°, 30.2°±5.0°, and 30.4°±4.7° in the younger females, younger males, older females, and older males, respectively. The mean optimal angle differed between the two age groups (p=0.004) but not between females and males (p=0.55). Optimal mean screw length was 73.4±9.9 mm. Anatomical spinal canal parameters in the transverse plane varied with age (p=0.02) and with sex in the older children (p=0.008), and those in the sagittal plane varied with sex (p=0.04). Age affected ilio-sacral screw positioning, whereas sex did not. Several anatomical spinal canal parameters varied with age and sex. These results should help to ensure safe and easy ilio-sacral screw placement within a secure corridor.

Developmental sacral morphology: MR study from infancy to skeletal maturity

PURPOSE

The primary aim of this study was to document the growth and spatial relationship of the sacrum in relationship to the lumbar spine and the ilium during childhood and adolescence.

METHODS

MRIs of 420 asymptomatic subjects (50% female) with age range 0-19 years at the time of their MRI (mean ± SD 8.5 ± 5.5 years) were used to characterize the reference distributions of MRI anatomic measurements as a function of age and gender. Eight dimensional measurements and eight angles were measured using PACS tools. Reliability of the measurements was studied on a subset of N = 49 images (N = 24 males; mean ± SD age 6.8 ± 5.2 years).

RESULTS

The dimensional measurements increase with age, often with a rapid "growth spurt" in the first few years of life, with a decreased but steady rate of growth continuing until the late teenage. An exception is the S1 canal width, which reaches near-adult size by age 5. Angle measures are less dependent on age or gender, and the associations with age are not necessarily uniformly increasing or decreasing.

CONCLUSION

These data on the sacral morphology are a valuable information source for surgeons treating young patients for deformity of the spine and pelvis. Knowledge of normative data of children through growth may allow for adaptation of adult surgical techniques to this pediatric age-group of patients. These slides can be retrieved under Electronic Supplementary Material.

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.

A New Modified Method for Inserting Iliosacral Screw versus the Conventional Method

Study Design

Methodological study.

Purpose

To our knowledge, this is the first study to introduce a new modified method for inserting iliosacral screws and to compare its results with those of a conventional method.

Overview of Literature

Previous techniques, such as open reduction and internal fixation, are associated with perioperative hemorrhage, postoperative infection, and neurological deficits. Although percutaneous iliosacral screw insertion confers the advantage of being minimally invasive, leading to less blood loss and a low postoperative infection rate, it harbors the risk of screw malpositioning due to narrow sacral proportions and a high interindividual variability.

Methods

Nine cadaveric pelvises were included in this study, with one hemipelvis of each being assigned to the new modified method and the other to the conventional iliosacral screw insertion method. In the new modified method, the guidewire entry point was determined using a lateral sacral X-ray. To do so, we first identified the anterosuperior quadrant of the S1 body on one hemipelvis. The anterosuperior quadrant was further divided into four imaginary quadrants, and the guidewire was inserted into the posteroinferior quadrant. The guidewire trajectory was perpendicular to the sagittal plane so that the guidewire resembled a single point in the lateral sacral view. Guidewires were inserted into corresponding hemipelves using the conventional method as described in the literature. Subsequently, an axial computed tomography scan with 1-mm fine cuts was obtained, and sagittal and coronal views were reconstructed. The distance of the guidewire from the sacral canal, anterior sacral cortex, and first sacral foramen was measured in axial, sagittal, and coronal views. The minimum measurement among different views was defined as the safety index of the insertion methods. The conventional and new modified methods were then compared in terms of safety and duration of the procedure.

Results

The minimum distance of the guidewire from the S1 foramen and anterior sacral cortex was not significantly different between the two methods. However, the minimum distance between the guidewire and sacral canal was significantly greater in the new modified method than in the conventional method. The duration of guidewire insertion was significantly shorter in the new modified method than in the conventional method.

Conclusions

This new modified method of iliosacral screw insertion could be safely and simply implemented while taking less surgical time than the conventional methods.

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.