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Pelvis Fractures - Pediatric

Topic updated on 08/24/16 9:36am
Introduction
  • Epidemiology
    • incidence
      • uncommon, only 1-2% of all pediatric fractures
    • demographics
      • avulsion injuries almost exclusively in adolescent patients
  • Pathophysiology
    • apophyseal avulsion
      • result of low energy trauma
      • avulsion injury occur from the disruption of tendon origin on the pelvis during "explosive" type activities (ie. jumping, sprinting)
        • ischial avulsion = hamstrings and adductors
        • ASIS avulsion = sartorius 
        • AIIS avulsion = rectus femoris 
        • iliac crest avulsion = abdominal muscles
    • pelvic ring/acetabular fractures
      • result of high energy trauma
        • often result from pedestrian vs MVA or rear seat passenger MVA
        • although rare, can be open
      • differences from adult pelvic ring injuries
        • higher incidence of lateral compression injuries than adults, who are more commonly AP compression injuries
        • higher rate of single bone pelvic fractures than adults due to increased bony plasticity and flexibility within SI joint/symphysis pubis
        • lower rate of hemmorhage secondary to
          • smaller vessels, which are more capable of vasoconstriction
          • injuries less commonly increase pelvic volume than in adult
  • Associated conditions
    • CNS and abdominal visceral injury
      • high rate (> 50%) in traumatic pelvic injuries, presumed secondary to higher energy required to create fracture
    • femoral head fractures/dislocations
      • associated with acetabular fractures 
    • GU injury
      • increased rate with Torode Type IV fractures
    • life threatening hemmorhage
  • Prognosis
    • complications are rare 
    • need for operative intervention increases after closure of triradiate carilage
Classification
 
 Tile Classification 
Type A  • Stable injuries (rotationally & vertically)
 
Type B  • Rotationally unstable
 • Vertically stable

Type C  • Unstable rotationally & vertically
 
Torode/Zieg Classification
Type 1  • Avulsion injuries
 
Type II  • Fractures of the iliac wing

Type III  • Fractures of the ring with no segmental instability
Type IV  • Fracture of the ring with segmental instability
 
Presentation
  • History 
    • pediatric pelvic ring fractures often occur secondary to motor vehicle accidents or when a pedestrian is struck by a motor vehicle
    • pelvic avulsion injuries often occur during sporting activities such as sprinting, jumping or kicking
  • Physical exam
    • as in all trauma patients, initial evaluation should include ABC's followed by primary and secondary surveys
    • important to thoroughly complete a rectal/genitourinary evaluation in polytrauma patient
Imaging
  • Radiographs 
    • recommended views
      • AP
      • judet (to evaluate the acetabulum), 
      • inlets/outlet (to evaluate the pelvic ring)
    • sensitivity
      • plain radiographs will miss ~50% of all pediatric pelvic fractures
  • CT 
    • indications
      • negative plain films with increased suspicion
      • preoperative evaluation
  • MRI
    • indications
      • occasionally required to detect apophyseal avulsion injuries
        • apophyseal avulsion injuries are usually easily detected and adequately imaged with plain radiographs
Treatment
  • Nonoperative
    • protected weight bearing followed by therapy
      • indications
        • Type 1 Avulsion Injuries with < 2 cm displacement
        • Type II Iliac Wing Fractures with < 2 cm displacement
        • Type III pelvic ring without segmental instability and non-displaced acetabulum
      • technique
        • for Type I and II
          • protected weight bearing for 2-4 weeks
          • stretching and strengthening 4-8 weeks
          • return to sport and activity after 8 weeks and asymptomatic
        • Type III
          • weight bearing as tolerated for 6 weeks
    • bedrest
      • indications
        • Type IV pelvic ring with instability AND < 2 cm pelvic ring displacement 
  • Operative
    • ORIF
      • indications
        • Type 1 Avulsion Injuries with > 2-3 cm displacement
        • Type II Iliac Wing Fractures with > 2-3 cm displacement
        • Type III pelvic ring with displaced acetabular fractures > 2mm
        • Type IV pelvic ring with instability and > 2 cm pelvic ring displacement
    • temporizing external fixation followed by ORIF
      • indications
        • vertical shear with hemodynamic instability
Complications
  • Death
    • rare
    • most often occur in association with head or visceral injury
  • Pelvic fracture asociated hemmorhage
    • rare
    • see above under death
  • Premature closure of triradiate cartilge
    • treatment
      • excision of physeal bar 
  • Malunion/nonunion
    • rare
    • pelvic asymmetry of >1- 2 cm can lead risk of scoliosis, lower back pain, Trendelenberg gait, sacroiliac joint tenderness
  • Leg length discrepancy
  • Neurovascular injury
  • Heterotopic ossification 

 

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