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

[Clinical and functional evaluation of pediatric patients with pelvic fracture treated in a third level Hospital]

INTRODUCTION

pelvic fracture in children is considered one of the most important injuries due to its high mortality. They are rare, but have a major impact on patients' functional outcomes.

OBJECTIVE

to evaluate the clinical evolution and functional grade in pediatric patients with pelvic fractures who have already been treated, either conservatively or surgically.

MATERIAL AND METHODS

descriptive-cross-sectional-retrospective study. Sample of 24 patients, aged five to 16 years with pelvic fracture, treated from 2016 to 2021. Clinical and functional outcome was assessed using the Barthel index and hip range of motion, as well as surgical or conservative treatment, accompanying lesions and injury mechanism.

RESULTS

to find out if there is an association between the Torode and Zieg classifications with the Barthel index and hip range of motion, an association analysis was performed with the 2 statistic, obtaining a 2 value = 19.213. with p = 0.004 for the Barthel index and a 2= 14.253 with p = 0.0026 for hip ranges of motion; these results indicate that there is statistically significant association.

CONCLUSION

the most frequent type of pelvic fracture in pediatric patients treated is type III on the Torode and Zieg scale, which according to the Barthel index is associated with a degree of independence and complete hip mobility arches, so the clinical and functional outcome in these patients is high in severe injuries.

Traumatic injuries of the immature hip and pelvis

PURPOSE OF REVIEW

The pelvis and hip account for 0.3--4% of fractures of the immature skeleton, and generally result from high energy trauma. These fractures range in severity from apophyseal avulsions to complete disruptions of the pelvic ring. The purpose of this article is to review the presentation, diagnosis, treatment and complications of these injuries in order to inform clinicians involved in their management. There is a lack of evidence-based management protocols for fractures of the immature pelvis largely due to their rarity and lack of robust scientific literature on the topic.

RECENT FINDINGS

Computed tomography/MRI is essential as up to 30% of pelvis and 70% of acetabular fractures are not identified on initial radiographs. A sub-optimal outcome is common in unstable fractures treated conservatively and adequate reduction and surgical stabilization is often required to avoid long-term morbidity.

SUMMARY

A coordinated approach involves resuscitation and temporary stabilization with planned definitive fixation. It is generally accepted that these injures should be managed in paediatric trauma centres. Whilst injuries vary in pattern and severity, we present an overview that considers the evaluation and treatment of the paediatric patient with pelvic and hip fractures to ensure that these injuries are identified promptly and treated by surgeons familiar with contemporary management algorithms.

Secure paediatric pelvic fracture external fixation using an intraoperative support device

Secure fixation by inserting a half-pin into the iliac crest as a pelvic external fixator is important. However, the thickness of the iliac bone depends on its location and this makes it difficult to insert a half-pin accurately. The iliac crest is especially narrow in the paediatric pelvis, making it difficult to insert the half-pin accurately compared with an adult pelvis. A case of pelvic external fixation is described for a paediatric pelvic fracture in this report, in which preoperative planning for half-pin insertion was performed accurately using a preoperative three-dimensional CT based on an intraoperative support device that uses the functional pelvic plane as a reference.

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.

Current Concepts in Pediatric Pelvic Ring Fractures: A Narrative Review

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.