Paediatric pelvic fractures - an updated literature review

Irreducible Locked Symphysis Pubis Disruption Caused by Incarcerated Urinary Bladder in a 14-year-Old Boy, a Case Report and Review of the Literature

Urinary bladder entrapment or incarceration within pelvic fracture have been described in many reports in the literature, most of which were reported in adult patients. We describe a case of a 14-year-old boy presented with isolated locked symphysis pubis disruption after falling from a height. His initial evaluation was negative for any other associated injuries. The decision was made to treat him surgically by open reduction and internal fixation using a symphyseal plate; however, upon completing the Pfannenstiel incision, the surgeon faced a soft tissue mass hindering bony fragment dissection; upon careful examination, the soft tissue mass turned out to be entrapped urinary bladder within the symphyseal disruption. After careful soft tissue dissection, and with the help of Jungbluth distractor, the disruption was over-distracted, the bladder was freed entirely (which was intact) and reduced to its position, followed by the application of a symphyseal plate in a reduced symphysis pubis position. The patient did well postoperatively, and at three months follow up, the disruption and fracture united, and there were no urinary-related symptoms. Although rare, urinary bladder entrapment within an element of anterior pelvic fracture could be a reason for the difficult reduction; careful evaluation and steady soft tissue dissection are paramount for avoiding undue iatrogenic urinary bladder injury.

Number, treatment, and mortality of paediatric pelvic ring fractures in two level 1 trauma centres in the Netherlands : a multicentre retrospective cohort study

Aims

Paediatric pelvic ring fractures are rare but severe injuries, presenting significant treatment challenges. This study aimed to analyze patient characteristics and explore trends in incidence, treatment methods, and mortality associated with these injuries.

Methods

This multicentre, retrospective cohort study analyzed paediatric patients (aged ≤ 18 years) with pelvic ring fractures treated between 2001 and 2021 at two level 1 trauma centres. Data on patient demographics, injury characteristics, treatment approaches, and outcomes were collected, and visual trend analysis was conducted to identify patterns.

Results

A total of 157 patients with pelvic ring fractures were included. The median age was 15 years (IQR 12 to 17), with 52% (n = 81) being female. Traffic accidents were the leading cause of injury, accounting for 68% of cases (n = 106). Concomitant injuries were observed in 83% of patients (n = 131). The one-year mortality rate was 11.5%, with 76% of deaths occurring within 48 hours of admission, primarily due to traumatic brain injury (53%). Most patients (60%) were treated nonoperatively, while 48% of surgically treated patients underwent internal fixation without prior external fixation. Visual trend analysis revealed an increase in the absolute number of paediatric pelvic ring fractures over time, though no significant shift towards surgical treatment was observed. Among surgically treated patients, there was a trend towards open reduction and internal fixation rather than external fixation as definitive treatment. Nonoperative treatment was more common in children (69%) than in adolescents (55%). For surgical cases, external fixation was preferred in children (44%), while ORIF was more common in adolescents (53%).

Conclusion

The incidence of paediatric pelvic ring fractures has increased over time, with a high mortality rate largely attributable to severe neurotrauma. There has been a shift towards surgical treatment without prior external fixation, with differences noted in the treatment approaches between children and adolescents, particularly in surgical fixation methods.

Comparison of pediatric pelvic fractures and associated injuries caused by different types of road traffic accidents

PURPOSE

To explore the clinical characteristics of pediatric pelvic fracturs caused by traffic accidents and to analyze the accompanying injuries and complications.

METHODS

A total of 222 cases involved traffic accidents was enrolled in this case-control study. The data of children with pelvic fractures caused by traffic accidents who were admitted to our hospital from January 2006 to December 2021 were analyzed retrospectively. Sex, age, Tile classification, abbreviated injury scale score, injury severity score, mortality, and accompanying injuries were studied. The ANOVA was used for measurement data, and the non-parametric rank sum test was used for non-normally distributed data. The Fisher's exact probability method was used for the count data.

RESULTS

Of all enrolled cases, 140 are boys and 82 are girls, including 144 cases aged < 6 years, 65 aged between 6 and 12 years, and 13 aged > 12 years. Depending on the injury mechanism, there are 15 cases involving pedestrians vs. motorcycles (PVM), 91 cases involving pedestrians vs. passenger cars (PVC), 78 cases involving pedestrians vs. commercial vehicles (PVV), and 38 cases involving motor vehicles vs. motor vehicles (MVM). Associated injuries are reported in 198 cases (89.2%), primarily involving the abdomen injury in 144 cases (64.9%), and lower limb injury in 99 cases (44.6%). PVV injury involves longer hospital stay (p = 0.004). Intensive care unit admission rate is significantly higher in the MVM group than in other groups (p = 0.004). Head injury (p = 0.001) and face injury (p = 0.037) are more common in the MVM group, whereas abdominal injury (p = 0.048) and lower limb injury (p = 0.037) are more common in the PVV group. In the MVM group, the brain injury (p = 0.004) and femoral neck injury (p = 0.044) are more common. In the PVM group, the mediastinum (p = 0.004), ear (p = 0.009), lumbar vertebrae (p = 0.008), and spinal cord (p = 0.011) are the most vulnerable regions, while in the PVV group, the perineum (p < 0.001), urethra (p = 0.001), rectum (p = 0.006), anus (p = 0.004), and lower limb soft tissues (p = 0.024) are the most vulnerable regions. Children aged > 12 years have higher pelvic abbreviated injury scale scores (p = 0.019). There are significant differences in the classification of pelvic fractures among children < 6, 6 - 12, and > 12 years of age, with Tile C being more likely to occur in children > 12 years of age (p = 0.033). Children aged > 12 years are more likely to sustain injuries to the spleen (p = 0.022), kidneys (p = 0.019), pancreas (p < 0.001), lumbar vertebrae (p = 0.013), and sacrum (p = 0.024). The MVM group has the highest complication rate (p = 0.003).

CONCLUSION

PVC is the leading cause of the abdomen and lower extremities injury and has the most concomitant injuries. Different traffic injuries often lead to different associated injuries. Older children are more likely to sustain more severe pelvic fractures and peripelvic organs injuries. The MVM group has the highest extent of injury and complication rates.

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.

Multicenter epidemiological analysis of related factors in 10,808 hospitalized children with lower limb and pelvic fractures in China

To analyze the causes, locations, associated injuries, and relevant factors of lower limb and pelvic fractures in hospitalized children in China to provide a theoretical basis for reducing the incidence of such fractures. A retrospective analysis of children with lower limb and pelvic fractures admitted to 27 tertiary children's hospitals affiliated with China's Futang Research Center of Pediatric Development between December 1, 2015, and December 31, 2019, was conducted. Inpatient cases were analyzed in the following age groups: Infants (< 2 years), Preschool children (2-5 years), School children (6-11 years), and Adolescents (12-18 years). This study included 10,808 pediatric patients (7152 males, 3656 females). The proportion of preschool children of lower limb and pelvic fractures was the highest. The 10,808 patients sustained a total of 14,398 fractures. The shafts of the femur, tibia, and fibula, the distal tibia, distal fibula, and the pelvis were the six most common locations. Of the 734 pelvic fractures in children and adolescents, the top three locations were the ilium, pubic bone, and the ischium. Of the total patients, 9599 underwent surgery, while 1209 received non-surgical treatment. The three most common causes of pediatric lower limb and pelvic fractures were falling over, traffic accidents, and falling from a height. Among the 1806 concomitant traumas, respiratory traumas was the most common, mainly pulmonary contusion. The most common concomitant traumas of nervous, digestive and urinary system were scalp hematoma, liver injury and kidney injury respectively. The analysis of the location, age, causes, and concomitant injuries of lower limb and pelvic fractures showed that the most common fracture requiring hospitalization was tibia fracture, which was most common in preschool children. The most common cause of injury in preschool children was traffic accident. In addition, children are susceptible to accidental injuries from multiple sources in life, which can cause serious consequences of multi-system injuries.

Long-term musculoskeletal function after Open Pelvic ring fractures in Children (OPEC); a multicentre, retrospective case series with follow-up measurement

Background

The proportion of Open Pelvic fractures in the paediatric population is relatively high. While operative fixation is the primary approach for managing Open Pelvic fractures in adults, there is limited literature on treatment outcomes in Children, particularly regarding long-term musculoskeletal, neurological, and urogenital function.

Methods

This multicentre case series included paediatric patients (<18 years old) with Open Pelvic ring fractures treated at one of two major trauma centres in the Netherlands between January 1, 2001 and December 31, 2021. Data collection involved clinical records and long-term assessments, including musculoskeletal function, growth disorders, urogenital function, sexual dysfunction, and sensory motor function.

Results

A total of 11 patients were included, primarily females (73 %), with a median age at trauma of 12 years (P25-P75 7-14). Most patients had unstable Pelvic ring fractures resulting from high-energy trauma. Surgical interventions were common, with external fixation as the main initial surgical approach (n = 7, 70 %). Complications were observed in eight (73 %) patients. Musculoskeletal function revealed a range of issues in the lower extremity, daily activities, and mental and emotional domain. Long-term radiologic follow-up showed high rates of Pelvic malunion (n = 7, 64 %). Neurological function assessment showed motor and sensory function impairment in a subset of patients. Urogenital function was moderately affected, and sexual dysfunction was limited with most respondents reporting no issues.

Conclusion

Paediatric Open Pelvic fractures are challenging injuries associated with significant short-term complications and long-term musculoskeletal and urogenital issues. Further research is needed to develop tailored treatment strategies and improve outcomes of these patients.