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

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.

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.

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.

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.

Pediatric Pelvic Fractures and Differences Compared With the Adult Population

INTRODUCTION

Although pelvic fractures in children are rare, because of anatomical differences between an adult's skeleton and a child's skeleton, these lesions in the pediatric population have specific characteristics that need to be borne in mind when dealing with them.

MATERIALS AND METHODS

A retrospective chart review was performed on the pelvic fractures in skeletally immature patients treated in our hospital in the last 20 years.

RESULTS

Eighty-one pelvic fractures in children were treated between 1993 and 2013. The mean age was 9.98 years, with 61.7%(50/81) boys and 38.2% (31/81) girls. A traffic accident was the main injury mechanism (74%, 60/81), and height fall was in second place (16%, 13/81). Following Tile pelvic fracture classification, type A2 was the most frequent (58.04%, 47/81); and following Torode and Zieg classification, type IIIA (45.68%, 37/81).Associated injuries were present in 77.8% (63/81) of the patients; fractures of other bones and head trauma were the most frequent. An acetabular fracture was present in 13.5% (11/81) of the patients.Nonsurgical treatment was chosen for all the pelvic fractures except in 4 patients, which required surgical management for their pelvic injuries. Blood transfusion was required in 32% (26/81) of the patients, and arterial embolization was not needed in any case. Furthermore, 11.1% (9/81) required a stay in the pediatric care unit, and the death rate was 8.64% (7/81).The mean length of hospital stay was 12.4 days.

CONCLUSIONS

Because of the specific characteristics of pelvic fractures in children, fracture patterns are less severe than those of adults, but the injury mechanisms are high-energy traumas. The rate of associated injuries is very high, and a multidisciplinary management in pediatric trauma centers is needed to treat these patients.

The application of lateral-rectus approach on toddlers' unstable pelvic fractures

BACKGROUND

Pelvic fractures are rare in toddlers but are often associated with other injuries that make treatment difficult. Conservative treatment has been used with moderate success, but it is unclear if surgical correction could confer additional benefits and improve patient outcomes. The purpose of this study was to report authors' experience using the lateral-rectus approach (LRA) for surgical correction of unstable pelvic fractures in two toddlers.

METHODS

We retrospectively analyzed the cases of two toddlers with unstable pelvic fractures who underwent surgery through the LRA between April 2016 and October 2018. Patients' characteristics, fracture type, mechanism of injury, Injury Severity Score (ISS), operative time, intra-operative blood loss, and post-operative complications were assessed. Pelvic asymmetry, degree of deformity, Cole scoring criteria and modified Barthel Index (MBI) were used to evaluate radiographic and functional outcomes.

RESULTS

Successful surgical treatment was performed using the LRA, external fixation, and sacroiliac screw fixation. Surgery duration was 180 min on average, with an average intra-operative bleeding of 250 ml. There were no iatrogenic nerve injuries or infections. Pelvic asymmetry a week after surgery was 0.5 cm on average and dropped to 0.3 cm on average at the end of the follow-up period. The deformity index of the pelvis dropped from an average of 0.035 a week after surgery to 0.02 at the end of the follow-up period. The mean MBI was 100 in the last follow-up, and Cole scoring criteria categorized both patients as being in excellent condition. All patients achieved radiological bone union without discrepancy in length of the lower limbs. Neither patient had loss of reduction nor evidence of low back pain during the mean follow-up period of 22 months.

CONCLUSIONS

Pelvic fracture in toddlers is rare, and surgical treatment requires careful consideration. The lateral-rectus approach was proven as a viable alternative for managing unstable pelvic fractures in toddlers, with minimal blood loss and risk of nerve injury. Furthermore, anterior external fixation and posterior sacroiliac screw fixation would be adequate for this population, with excellent final outcome.

Pelvic fractures in children (pelvic ring and acetabulum)

Pelvic fractures in children are rare and often the result of high-energy trauma. The possibility of associated lesions cannot be ignored. Treatment at a specialized children's hospital is a must. The multidisciplinary care team must include a paediatric orthopaedic surgeon. In the emergency room, the surgeon contributes to haemodynamic stabilization of the child by reducing and stabilizing posterior arch fractures and restoring the skeletal cohesion to make it easier to move the child and allow other examinations to be performed. Imaging modalities are used to determine the stability of the pelvic ring fracture, the risk of epiphysiodesis of an acetabulum fracture if the triradiate cartilage is open and the joint congruency if the triradiate cartilage is closed. Internal fixation can be used if surgery is being performed for associated non-orthopaedic injuries. Most vertically stable fractures are treated non-surgically. Fractures that are unstable vertically will require surgical treatment. Treatment of acetabulum fractures depends on the status of the triradiate cartilage. In older children, it is similar to the treatments used in adults. In children with open growth plates, the goal is to make sure the acetabulum continues growing. In all cases, the patients must be instructed to start physical therapy as soon as possible. Full recovery can be expected after stable pelvic fractures. Unstable pelvic fractures can lead to sequelae, the severity of which depend on the residual pelvic displacement and involvement of the growth plates that can cause epiphysiodesis. Surgery to correct these deformities is challenging. The most serious occur when the vertical displacement of the hemipelvis must be corrected. After an acetabulum fracture, removal of the growth blocker can be done in children under 10 years of age. In older children, acetabular dysplasia requires periacetabular osteotomy.

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.

Operative Treatment of Pediatric Pelvic and Acetabulum Fractures

Pediatric pelvic fractures are rare and differ from adults in etiology, fracture type, and associated injuries. They are observed in multitrauma patients, with severe associated injuries. Treatment of these children in specialized hospitals is likely to provide the best outcome because of the rarity of these fractures. Only a small percentage of the fractures, particularly the displaced ones, need operative treatment with the aim to restore the anatomy of the pelvic ring. In a significant proportion of the operated patients, morbidity and mortality were not linked to the pelvic fractures but to the other associated injuries. Long-term prognosis depends on restoring pelvic symmetry. Nondisplaced fractures of the acetabulum or fractures with minimal displacement with a relatively low roof-arc angle or crush injuries of the triradiate physis are managed nonoperatively. In young patients where continuation of growth is expected, fixation that does not cross the physis anatomically could be used. In some very young children, plate removal may be indicated to allow for continued growth of the acetabulum. One of the major complications in this patient cohort is acetabular dysplasia.

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.

Pelvic fracture of the sacroiliac joint region in a child - a case study and literature review

The aim of the paper is to present the case of a 3-year-old boy with an unaligned fracture of the sacroiliac joint region to propose a minimally invasive method of fracture fixation without using metal implants and to review the literature addressing this injury, which is uncommon in children. The patient was hit by a car; he suffered a fracture of the iliac ala with a complete traumatic damage to the L4-L5 nerve roots. The fracture was fixated by osteosuture and normal bone fusion was achieved. The follow-up period was 4 years. The boy manifested persistent flaccid paresis of the right foot and symptoms of a neurogenic bladder. Late radiological follow-up indicated disturbances of pelvic bone development and shortening of the lower extremity at the side of the injury.

Open and contaminated pediatric pelvic ring injury case report: Fixation without metal

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Open pelvic fractures can present unique and difficult clinical problems.

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The pelvic ring is a dynamic structure in normal physiologic conditions.

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Suture and anchor fixation can be used as definitive fixation of the pelvic ring.

Introduction

Pelvic fractures are relatively uncommon in children, accounting for 0.3–7.5% of all pediatric injuries (Gänsslen et al., 2013; Ismail et al., 1996; Peltier, 1965; Galano et al., 2005; Spiguel et al., 2006). This case report describes a pediatric open pelvic injury caused by a crush mechanism between a car and guardrail.

Case

A 13 year old male presented with an open APC 3 pelvic injury after being pinned between a car and guardrail. His definitive treatment included bilateral SI screw placement, as well as a less invasive method for anterior pelvic ring disruption (Internal Brace suture anchor dynamic fixation).

Discussion/conclusion

A less invasive method for the anterior pelvic ring was used to avoid additional dissection due to extensive soft tissue loss, and to decrease hardware burden, which lessens the chance of complications such as infection. Suture fixation of the pubic symphysis provided stable fixation to allow healing in the current case of open pelvic fracture.

Surgical considerations with the operative fixation of unstable paediatric pelvic ring injuries

INTRODUCTION

The operative treatment of unstable pelvic injuries in paediatrics is not frequently indicated. The detailed modes of pelvic ring failure, surgical techniques, fixation choices, and peri-operative difficulties are not well reported.

METHODS

From September 2010 to March 2016, 62 paediatric patients were admitted to an academic level I trauma center with the diagnosis of pelvic ring injury. Of them, 29 (17 males and 12 females) had operative fixation of unstable pelvic injuries. Their average age was 11.7 ± 4.4 years.

RESULTS

There were six Tile's B injuries and 23 type C injuries. The commonest modes of pelvic ring failure were pubic rami fractures anteriorly and ligamentous sacroiliac joint injuries posteriorly. The iliac apophysis was avulsed in nine patients. Supra-acetabular external fixators were frequently used for anterior fixation while iliosacral IS screws and lateral compression LC screws were commonly used posteriorly. Difficulties were encountered with open reduction and repair of avulsed iliac apophyses in two patients. The IS screws pierced the soft iliac wing in three patients. In two patients with open triradiate cartilage, the purchase of retrograde LC screws was weak due the small sized crescent fragment.

CONCLUSION

The iliac apophysis needs to be repaired following reduction of the displaced hemipelvis. Anterior supra-acetabular external fixation is a good choice in paediatrics even with pubic symphysis diatasis as the pathology is commonly a pubic apophysis avulsion. IS screws might be inserted through plates to prevent piercing the soft iliac wing. Retrograde LC screws should be avoided in young children.

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.

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.

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.

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

BACKGROUND

Treatment of sacral fractures and sacroiliac joint (SIJ) disruption with percutaneous ilio-sacral (IS) screw fixation had become a more popular treatment option. There has been no study that specifically assessed IS fixation in children. The purpose of this study is present our results with fixation of the sacral fractures and SIJ disruption using IS screw in children 18 years old and younger.

METHODS

This is a retrospective review chart for children with sacral fracture or SIJ disruption who were treated by IS fixation in the period from 2000 to 2012. The patients were assessed for the following (age, sex, type of injury, associated injuries, surgery, complications, postoperative return of function, healing of the injury, and return to function).

RESULTS

In the studied period (2000 to 2012), 11 patients who had either sacral fracture (4 patients) or SIJ (7 patients) disruption were treated by IS screws. The average age of these patients was 14 years (range, 6 to 17 y). Six patients had 1 screw and 5 patients had 2 screws. Eight patients had their entire fixation in S1, and 3 patients had 1 screw in S1 and 1 screw in S2. All screws were cannulated and were inserted over a guidewire with fluoroscopy and/or navigation guidance. Five patients had added anterior fixation of the pelvis. One patient was lost for follow-up. All patients (except 1) achieved healing of their injuries with no displacement or implant failure with return of function. One patient had failure of fixation and needed revision. One patient had neurological complication related to screw insertion.

CONCLUSIONS

IS screws can be safely used to treat sacral fractures and SIJ injuries in children. This was feasible in children as young as 6 years old. The complications of the procedure were minimal with good stability obtained by IS screws.

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.

Unstable paediatric pelvic injuries: the patho-anatomical patterns of pelvic ring failure and the role of avulsion of the iliac apophysis

Unstable pelvic injuries in young children with an immature pelvis have different modes of failure from those in adolescents and adults. We describe the pathoanatomy of unstable pelvic injuries in these children, and the incidence of associated avulsion of the iliac apophysis and fracture of the ipsilateral fifth lumbar transverse process (L5-TP). We retrospectively reviewed the medical records of 33 children with Tile types B and C pelvic injuries admitted between 2007 and 2014; their mean age was 12.6 years (2 to 18) and 12 had an immature pelvis. Those with an immature pelvis commonly sustained symphyseal injuries anteriorly with diastasis, rather than the fractures of the pubic rami seen in adolescents. Posteriorly, transsacral fractures were more commonly encountered in mature children, whereas sacroiliac dislocations and fracture-dislocations were seen in both age groups. Avulsion of the iliac apophysis was identified in eight children, all of whom had an immature pelvis with an intact ipsilateral L5-TP. Young children with an immature pelvis are more susceptible to pubic symphysis and sacroiliac diastasis, whereas bony failures are more common in adolescents. Unstable pelvic injuries in young children are commonly associated with avulsion of the iliac apophysis, particularly with displaced SI joint dislocation and an intact ipsilateral L5-TP.

[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.

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.

Surgical treatment for pelvic ring fractures in pediatric and adolescence age

BACKGROUND

Fractures of the pelvis in pediatric population are extremely rare. Children with complex pelvic fractures are most often pedestrians who have been struck by a motor vehicle. Head injuries are the main cause of death, unlike the adult, where severe hemorrhages are common and contribute to mortality. Long-term follow-up studies have reported significant residual morbidity in children's pelvic fractures treated non-operatively. The aim of this study is to analyze our cases in order to evaluate the final outcome and to suggest the surgical indications for the management of this kind of injuries.

MATERIALS AND METHODS

From January 2000 to July 2011, eight pediatric patients were surgically treated for pelvic ring fractures in our department. The functional result at follow-up was evaluated using the functional independence measure (FIM).

RESULTS

In most cases the clinical outcome was good with functional recovery of the hip and complete resumption of physical activity. The mean FIM score was 125.3. One patient underwent permanent colostomy for perineal lacerations, one case showed a slight scoliosis at follow-up, and one patient showed the early fusion of the triradiate cartilage. One patient presented a deep thrombosis of the common femoral vein.

CONCLUSIONS

Fractures of the pelvic ring should be carefully assessed by radiographs and CT scan. The centralization of these young patients is important to get the experience and ensure the proper treatment. A correct indication for surgery may prevent or limit the consequences of these complex fractures.

Biomechanical analysis of a new minimally invasive system for osteosynthesis of pubis symphysis disruption

INTRODUCTION

We analysed the effectiveness of a new percutaneous osteosynthesis system for the treatment of pelvis fractures with rotational instability.

METHODS

A pre-clinical cross-sectional experimental study wherein Tile type B1 injuries (open-book fractures) were produced in 10 specimens of fresh human cadavers, including the L4-5 vertebrae, pelvic ring, and proximal third of the femur, keeping intact the capsular and ligamentous structures, is presented in this paper. The physiological mobility of the intact pelvis in a standing position post-injury was compared to that following the performance of a minimally invasive osteosynthesis of the symphysis with two cannulated screws. A specially designed test rig capable of applying loads simulating different weights, coupled with a photogrammetry system, was employed to determine the 3D displacements and rotations in three test cases: intact, injured and fixed.

RESULTS

After applying an axial load of 300 N, no differences were observed in the average displacement (mm) of the facet joints of the intact pubic symphysis in comparison to those treated with screws (p >0.7). A statistical difference was observed between the average displacements of the sacroiliac facet joints and pelvises with symphyseal fractures treated with screws after the application of a load (p <0.05).

CONCLUSION

The symphyseal setting with two crossed screws appears to be an effective alternative to osteosynthesis in pelvic fractures with rotational instability.