Long-term results of unstable pelvic ring fractures in children

Pediatric-Specific Lesions in Unstable Pelvic Ring Fractures of Skeletally Immature Children: Impact on Diagnosis and Management Decisions

Surgical fixation of pediatric pelvic ring injuries is gaining popularity to avoid the poor long-term outcomes of pelvic asymmetry. The surgical techniques and fixation choices depend on the individual injuries affecting the anterior and posterior pelvic ring areas. The immature bony pelvis of young children has anatomic differences including soft bones, elastic ligaments, and the presence of growth centers. Understanding the unique pediatric lesions with unstable pelvic fractures is essential for treatment decisions. Anterior lesions include pubic symphysis disruption through the pubic apophysis, single ramus fractures, pubic rami fractures through the triradiate cartilage, and/or the ischiopubic synchondrosis; ischiopubic ramus infolding injury; or the unstable superior and inferior quadrant lesions. Posterior pelvic lesions include iliac wing infolding and sacroiliac joint dislocation or transiliac (crescent) fracture/dislocations through the iliac apophysis growth plate. Pubic symphysis and sacroiliac disruptions are physeal injuries in children, and they have excellent healing potential. External fixation is an ideal choice for anterior ring fixation including bony and pubic symphysis injuries. Posterior lesions are mostly sacroiliac joint disruptions with iliac apophysis separation that can serve as a landmark for vertical displacement correction. Posterior lesions can be treated by percutaneous iliosacral screw fixation or open reduction techniques.

Magnetic Resonance Imaging in Pediatric Acetabulum Fractures with Open Triradiate Cartilage-A Report of 3 Cases

We present three cases of posterior wall acetabulum fractures occurring in pediatric patients with open triradiate cartilage for whom preoperative magnetic resonance imaging was obtained and open reduction and internal fixation was done. All patients had excellent outcomes at an average of 68-week follow-up. Failure to adequately recognize the severity of pediatric acetabulum fractures can lead to detrimental long-term sequelae in acetabular development when treated nonsurgically. Management of this rare injury is not well reported in the literature. We highlight the utility of MRI in evaluating potential nonosseous injury and examining the articular surface to guide surgical management.

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.

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.

Case Report: Pediatric Posterior Wall Acetabulum with Piriformis Entrapment

Pediatric acetabular fractures are rare, accounting for only a small percent of pelvic injuries in children. This is a case of a 12-year-old healthy male who sustained a displaced, right posterior acetabular wall fracture following a ground-level fall. It was ultimately determined to be treated through operative management. Intraoperatively, it was noted that the displaced fragment had become trapped posterior to the piriformis muscle. This prompted the surgical release of the piriformis to mobilize the fragment. Afterward, a quarter tubular plate serving as a buttress and multiple cortical screws were placed to secure the fracture. An additional cortical screw and washer were placed for further compression and rotational stabilization. The piriformis was then repaired. The patient was made nonweight bearing for 6 weeks and seen at routine postoperative visits. At 10 weeks postoperatively, the patient had no complaints of pain or difficulty with ambulation and tolerated full range of motion within his right hip. The patient did not return for follow-up, but the mother was contacted at 1 year postoperatively, and she denied any gait or hip range of motion abnormalities within the patient. Unfortunately, no further follow-up was successfully obtained. While most pediatric pelvic injuries can be treated nonoperatively, it has been shown that nonoperative treatment has increased risk of long-term complications. Therefore, surgical consideration remains important as it presents an opportunity for fewer long-term sequelae.

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.

Posterior wall acetabular fracture in a 13-year-old boy treated by open reduction and mini-plate internal fixation: long-term follow-up of 17 years

BACKGROUND

Acetabular fractures are uncommon in children and adolescents, mainly because of predominant cartilaginous component and strong surrounding ligaments. Although acetabular fractures at this age can lead to significant disability, there is no consensus regarding management, which continues to be controversial. Particularly, long-term outcome after operative management has not been evaluated.

CASE PRESENTATION

We report a case of a 13-year-old boy skeletally immature who presented with an isolated acetabular fracture involving the posterior wall secondary to a traumatic hip dislocation. A Kocher-Langenbeck approach with a surgical luxation of the hip was used for reduction and mini-plate internal fixation of the fracture. Long-term (17-year) follow-up showed a good clinical outcome and a good congruence of the. The patient has bilateral beginning osteoarthritis due to a cam configuration of both hips CONCLUSION: We describe a case of successful operative management of an acetabulum fracture in a skelettaly immature child with a long-term follow-up. Aggressive management of this rare type of fractures may lead to durable positive outcome.

[Pediatric pelvic trauma]

The main injury mechanism of rare pelvic girdle injuries in children is high-energy trauma with a high rate of accompanying injuries and a mortality up to 6%. Anatomical features often result in complex pelvic trauma. Emergency treatment is based on established standards in adults. Definitive treatment is mostly conservative and implants adapted for children are increasingly used. Long-term consequences have to be considered, especially after unstable pelvic ring injuries. A correlation exists between clinical and radiological results. Due to the difficult radiological assessment, acetabular injuries are easily overlooked. The Salter-Harris classification appears to be prognostically useful. Most acetabular injuries can be treated conservatively. Considerable displacement or additional intra-articular injuries necessitate open reduction and internal fixation. Frequent follow-up examinations up to the end of the growth phase avoid posttraumatic acetabular dysplasia being overlooked.

High-Energy Fractures of the Pelvis and Acetabulum in Pediatric Patients

Fractures of the pelvis and acetabulum, although uncommon in the pediatric cohort, represent a range of injuries with similarities to those seen in the adult cohort but with key differences that are important for the treating physician to be aware of to allow for systematic evaluation and management of these potentially life-threatening injuries. As the pediatric skeleton matures, changes in anatomy and physiology influence injury pattern, diagnosis, treatment, and complications. High-energy fractures of the pediatric pelvis are particularly concerning given the reported mortality rates ranging from 3.2% to 18%, with severe fracture patterns being associated with visceral injury in up to 60% of patients. The unique complexity of pediatric patients requires a multidisciplinary team to fully address their care. A systematic approach to the initial evaluation and diagnosis of pediatric patients with fractures of the acetabulum or pelvic ring aids in choosing between surgical and nonsurgical management of these fractures and avoiding complications unique to the maturing skeleton. We present such an approach to assist the practitioner who infrequently treats these uncommon injuries.

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 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.

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.

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.

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.

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.

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.

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.

[Injuries of the pelvis and apophysis in childhood and adolescence]

BACKGROUND

Pediatric pelvic fractures are rare injuries. Typically they are associated with high-energy trauma, which often leads to life-threatening injuries of other organs. Anatomical differences (e.g., greater elasticity, different stages of maturation, remodeling) account for the different fracture mechanisms, fracture management, and outcome in children. The AO Classification (International Association for Osteosynthesis) is useful and can be used as a basis for the treatment algorithm in pediatric pelvic fractures.

AIM

This article provides a review on pediatric pelvic fractures and shows--based on the AO classification--principles of conservative und operative treatment.

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.

High-energy pediatric pelvic and acetabular fractures

Pediatric pelvic and acetabular fractures are rare injuries. They are almost always the result of a high-energy injury mechanism. A full trauma protocol should be instituted, having a high index of suspicion for associated life-threatening injuries. In the past, it was recommended that almost all of these injuries be treated nonoperatively. However, pelvic and acetabular fractures do not all remodel well. Prospective studies are needed to establish optimal treatment guidelines. Until then, in the presence of instability or significant displacement, operative fixation by a pelvic and acetabular fracture specialist should be considered to allow the best possible outcome.

[Acetabulum injuries in infancy and childhood]

In this article, the anatomical and morphological features of the acetabulum in infancy and childhood are presented. The pathology and treatment of older children and adolescents is deliberately not covered, because the fracture morphology and treatment of patients aged 13 to 15 years is based on the criteria of adult medicine. Especially in the younger child, the anatomical differences are of particular importance. The younger the child is, the more difficult the diagnosis. Therefore today, MRI examinations should be generous used, even if anesthesia is necessary. If the injured child is hemodynamic stable, anesthesia can be electively used for a more complex diagnosis. Acetabular fractures are particularly problematic in infancy because even with optimal treatment and perfect reduction growth disturbances can occur. These manifest as so-called secondary dysplasia. During treatment, care should be taken to ensure that a surgical team having experience with the infant and juvenile skeleton is available and that appropriate implants are available.

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.

A modified stoppa (technique) approach for treatment of pediatric acetabular fractures

Pediatric acetabular fractures are rare, and anterior column fractures are even rarer. Generally, conservative treatment is applied. If there is displacement of more than 2 mm or findings of instability or fragments within the joint, then surgical treatment is applied. Anterior and posterior approaches may be used in surgical treatment. With pediatric patients, even greater care should be taken in the choice of surgery to be performed according to the fracture pattern to avoid postoperative triradiate cartilage damage. Therefore, minimally invasive surgery is more appropriate. We herein present a case of an acetabulum anterior column posterior hemitransverse fracture following a traffic accident, which was treated surgically using a modified Stoppa (technique) approach.

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 sacroiliac joint dislocation (anterior and posterior) with triradiate cartilage injury: a case report

Pediatric sacroiliac joint injuries are uncommon. Significant pelvis ring disruptions in children are rare, and their management is complicated by patient size, differences in bony architecture, and future growth and remodeling potential. We present a rare case of anterior sacroiliac joint dislocation associated with triradiate cartilage injury with a posterior sacroiliac dislocation on the contralateral side. This appears to be the first such case reported in the literature.

Standard radiographs and computed tomographic scan underestimating pediatric acetabular fracture after traumatic hip dislocation: report of 2 cases

Posterior wall acetabular fractures are rare in the pediatric patient but require proper management to prevent significant complications. Plain radiographs and computed tomography scans are standard diagnostic imaging used with clinical examination of hip stability to determine if the injury requires open reduction and internal fixation. Two cases are presented of adolescent traumatic hip dislocations and posterior wall fractures in which radiography underestimated the extent of the posterior wall fracture. In one case, a magnetic resonance imaging study more clearly characterized the injury. Because the ossification of the posterior wall occurs throughout adolescence, magnetic resonance imaging may be a useful tool in characterizing these fractures and assisting with surgical planning.

[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.

Pelvic fractures in children: an exploration of practice patterns and patient outcomes

Pelvic fractures in children represent a unique set of patients for several reasons. Pediatric pelvic fractures are relatively uncommon and the long-term consequences of these fractures and their associated injuries often have a substantial impact on these patients for the rest of their lives. There is significant controversy regarding the appropriate approach toward the management of these injuries. Nevertheless, there is substantial variability in the orthopaedic management of pediatric pelvic fractures, which warrants a closer investigation. A good starting point for addressing some of these issues is to explore the relationship between practice patterns and patient outcomes. More specifically, a study exploring the relationship between the type of centers that treat these unique fractures and patient outcomes can yield some insightful information. In an effort to address these issues, the authors used the National Pediatric Trauma Registry to conduct a retrospective analysis of this unique pediatric population. The main outcome of interest focused on mortality. With respect to patient information, the independent variables involved demographics (gender, age, race), type of injury (penetrating, blunt, crush), presence of head injury, injury severity indices (Injury Severity Score [ISS], Glasgow Coma Scale), and the Functional Independence Measure. After adjusting for confounding and interaction effects between these variables, only ISS and the type of hospital were determined to be significant in predicting survival.

Operative treatment of unstable pediatric pelvis and acetabular fractures

The management of unstable pediatric pelvic and acetabular fractures continues to be controversial. Recent reports have suggested that closed management of unstable pelvic and acetabular fractures can result in significant long-term morbidity. The purpose of this study was to evaluate the results of operative stabilization of unstable pelvic and acetabular fractures in children and adolescents. Eighteen patients less than 16 years of age with unstable pelvic and acetabular fractures were treated operatively over a 7-year period. Fracture healing, time to union, complications, and functional outcome were assessed. All fractures healed by 10 weeks. No patients suffered wound complications, infection, or growth arrest at an average follow-up of 30 months. These results support operative fixation of unstable pediatric pelvic and acetabular fractures to restore pelvic symmetry and periarticular anatomy. Favorable clinical results can be achieved with a low incidence of complications.

Pelvic fractures in a pediatric level I trauma center

OBJECTIVES

Assess the characteristics associated with the risk of complications and mortality in children sustaining pelvic fractures.

SETTING

Urban university pediatric Level I trauma center in a large metropolitan community.

PATIENTS/PARTICIPANTS

Retrospective analysis of 57 consecutive children with 66 pelvic fractures seen between 1993 and 1999.

INTERVENTION

Fifty-two patients were treated nonoperatively, and five patients required operative stabilization (four acetabular fractures and one partial sacroiliac joint disruption).

MAIN OUTCOME MEASURE

Type and cause of pelvic fracture, type of management used, incidence of associated injuries, hemorrhage requiring transfusion, and mortality.

RESULTS

Hemorrhage directly related to the pelvic fracture occurred in only one patient (2%), whereas 11 other patients required transfusions associated with other body-area injuries. Three patients with pelvic fractures died (5%), but deaths were due to other body-area injuries.

CONCLUSIONS

Children with pediatric pelvic fractures require careful evaluation for other body-area injuries, as these are most likely to be related to hemorrhage or mortality.

Disruption of the pelvic ring in pediatric patients

Pelvic ring disruptions are rare in children. Generally, nonoperative treatment has been recommended for children with these injuries. The authors retrospectively reviewed the medical records and radiographs of 189 patients with pelvic ring disruptions who were evaluated at a tertiary care children's hospital during a 10-year period. Of the 189 patients, 57 were identified with unstable pelvic fractures. These fractures were classified according to Tile, and Torode and Zieg. Forty-three of these patients were available to complete a subjective evaluation of their treatment at midterm followup. Thirteen patients were treated operatively and 30 were treated nonoperatively. There was no significant difference in subjective scoring between the two groups for pain at rest, pain with activity, limp, leg length discrepancy, and overall satisfaction with treatment. Overall, there were 92% good or excellent results in the patients who were treated operatively and 80% good or excellent results in the patients who were treated nonoperatively. Patients in both groups reported a high level of satisfaction with their outcome regardless of their fracture classification and treatment method.