Obviously, as the leading cause of mortality in children, traumatic injuries warrant significant attention.  As such, the PedEM Morsels have covered various traumatic topics (ex, Abdominal Trauma, Aortic Injury, Traumatic Ptx, Pulmonary Contusion, and C-Spine Clearance), but one issue deserves specific attention: the Pelvic Fracture.

Pediatric Pelvic Fracture: Basics

• Pediatric pelvic fractures are relatively rare.
  • Reported incidences range from 2% to 7.5% of all blunt trauma.
• Pediatric trauma patients are less likely to suffer a pelvic fracture.
  • Adults are twice as likely to have a pelvic fracture. [Demetriades, 2003]
  • This is is true across all common mechanisms (ex, Fall from height, MVC, pedestrian strike).
• Mortality is, fortunately, low in children. [Demetriades, 2003]
• Pediatric pelvic fractures, like in adults, indicate high-energy mechanism.
  • Pelvic fractures are associated with other life-threatening injuries.
    • 11-20% have concomitant solid organ injuries.
    • ~5% have small bowel injuries. [Demetriades, 2003]
    • Aortic injuries were only found in adult patients. [Demetriades, 2003]
  • The severity of pelvic fracture is correlated with mortality. [Swaid, 2015]

Pediatric Pelvic Fracture: Different than Adults

• Mechanism is often different between adults and children.
  • Children are more likely to be pedestrians who are struck or by passengers in the rear seat of car and sustain lateral impact.
  • Adults more likely to be in driver’s seat and have direct AP compression, leading to greater chance of “open-book” pelvis.

• The pediatric pelvis is structurally different from the adult pelvis.
  • The immature pediatric pelvis is plastic and requires greater force to fracture.
    • Much of the pelvis is composed of cartilage in the young.
    • Sacroiliac joints and pubic symphysis are more elastic.
    • The pediatric bone has thicker periosteum than adult bones.
    • The elasticity of the pediatric pelvis allows it to absorb energy and dissipate it before it breaks.
    • The pediatric pelvis is able to a suffer single, displaced ring fracture while adults more often have two fracture sites within the ring.
  • The immature pediatric pelvis bleeds less.
    • The thicker periosteum is helpful in containing hemorrhage.
    • Vasculature is more able to constrict, further reducing bleeding.
    • The pelvic volume is also lesser in children, which can help tamponade bleeding.
    • WARNING: this may actually lead to misperception of stability. [Amorosa, 2014]
  • The pediatric patient is able to heal better than adults.
    • Great capacity to remodel bone.
    • Osteoblast to osteoclast ratio in children favor bone growth and remodeling.

Pediatric Pelvic Fracture: Classification

• There are several classifications, but the most commonly used one is developed by Torode and Zeig. [Torode, 1985]
• Based on CT imaging a Modified Torode and Zeig classification has recently been created. [Shore, 2012]
  • Torode I – Avulsion Fractures
    • Avulsion of bony element, often associated with adjacent growth plate.
    • Associated with sporting injuries (ex, gymnastics). [Ortega, 2014]
    • Not due to high-energy mechanisms.
  • Torode II – Iliac Wing Fracture
    • Disruption of the iliac apophysis.
    • Due to direct lateral force.
  • Torode III A – Simple Anterior Ring Fracture
    • Pubic rami or pubic symphysis fractures.
    • Stable on clinical exam.
    • Have similar resuscitation requirements to lower classifications. [Shore, 2012]
  • Torode III B – Stable Anterior and Posterior Ring Fractures
    • Both anterior and posterior ring segments involved.
    • Stable on clinical exam.
    • Have similar resuscitation requirements (increased blood transfusion requirements, ICU days, and length of stay) to Torode IV.
  • Torode IV – Unstable Ring Disruption
    • Ring disruptions, hip dislocations and combined pelvic and acetabular fractures.
    • Unstable

• Stability is determined clinically and radiographically. [Shore, 2012]
  • Clinical stability to AP compression and
  • < 2 mm of fracture displacement on CT

Pediatric Pelvic Fracture: Management

• For us in the ED, manage as you would any trauma patient:
  • Airway, Breathing, Circulation
  • Thorough secondary survey
  • Children will less likely require pelvic binding, but if there is ring disruption or clinical instability, do not hesitate to place pelvic binder.

• There is variability amongst orthopods in the management of pediatric pelvic fracture. [Vitale, 2005]
• In general, the pediatric pelvic fracture is managed non-operatively.
  • Operative repair has been favored for those with unstable pelvic fractures. [Amorosa, 2014]
• The status of the triradiate cartilage ossification is critical in the determination of management.
  • The triraditate cartilage closes on average around 12 years in girls and 14 years in boys.
  • If the triradiate cartilage has not fused, the pelvis is considered immature.
  • After closure of the triradiate cartilage, the pelvis is structurally more like an adult pelvis and can be classified and treated similar to adults. [Amorosa, 2014]

References