Authors: Alexander T. M. Nguyen, David P. Drynan, Andrew J. A. Holland
Categories: Review Articles, child, lower extremity, orthopaedics, pelvis, wounds and injuries, Review Article
Source: Anz Journal of Surgery
Doi: 10.1111/ans.17890
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.
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.
We included 143 studies in our literature review and summarized the incidence, pathophysiology, assessment, management and complications associated with paediatric pelvic fractures.
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.
Keywords: child, lower extremity, orthopaedics, pelvis, wounds and injuries
Pelvic fractures in children secondary to trauma are rare and usually occur after sustaining a high‐energy impact – in most instances motor vehicles are involved but other mechanisms include falls from a height. The level of force required to fracture the pelvis is high and will likely be transmitted to other parts of the body. ^1^ Therefore, surgeons should be alert to associated injuries including the abdomen, urogenital system, spine or head. While pelvic fractures in adults are better understood with more evidence regarding classification, assessment and management (both operative and non‐operative), this is not the case for children. ^2^ Children cannot be treated with the same principles as adults because the developing pelvis differs in anatomy and physiology. They therefore respond differently to trauma and clinicians need to be aware of these differences to determine the best workup and management of these children. Historically, non‐operative management has been the key modality in facilitating the healing of pelvic fractures. While this is still the case for a majority of patients, contemporary views are that pelvic remodelling potential is more limited than previously thought. Thus, there is an increasing interest in understanding the indications and methods for operative fixation of pelvic fractures to prevent a lifetime of ongoing morbidity and complications. In our literature review, we reviewed the current evidence on the incidence, pathophysiology, assessment, management and complications of paediatric pelvic fractures.
In our literature review, we used the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) Guidelines to ensure that our search strategy and study selection process was thorough and up to date. ^3^ A search of PubMed (which now incorporates MEDLINE), Embase and the Cochrane Library (for articles published between January 2000 and September 2021) was conducted by the first author. The keywords ‘paediatric’, ‘pediatric’, ‘child’, ‘children’, ‘pelvis’, ‘pelvic’ and ‘fracture’ were manipulated with appropriate Boolean operators (Data S1). The reference lists of selected articles were also hand searched for further relevant papers. The Covidence software (Victoria, Australia) was utilized to manage articles and remove duplicates. Only articles in English were included.
As outlined in Figure 1, we identified 1951 articles to be screened. After removal of duplicates and further screening of the titles, abstracts and full texts we included 143 studies in our review. We used the following criteria (Table 1) to guide the selection process.
Fig. 1 Preferred reporting items for systematic reviews and meta‐analyses (PRISMA) flow diagram.
Pelvis fractures are rare; while 180 in 1000 children in the USA will fracture a bone in their childhood (between 0 and 19 years old), only 1 in 1000 children will sustain a pelvic fracture in the same time period. ^4^ Estimates vary between cohort studies, with some demonstrating that the incidence of pelvic fractures is between 0.04–4.6% of paediatric trauma patients. ^5^ , ^6^ , ^7^ , ^8^ , ^9^ Recently, Salášek et al. found an incidence of 4.2 pelvic ring injuries per 100 000 children per year. ^10^ Although rarer than other fractures, pelvic fractures are disproportionately more severe injuries with the longest length of stay in hospital (6 days; SD 11 days) and a hospital charge (US40048 per patient) second only to vertebral fractures (US53992). ^8^ , ^11^ The mean age of traumatic paediatric pelvic fractures ranges between 6.8 and 15 years old, ^1^ , ^7^ , ^8^ , ^9^ , ^10^ , ^11^ , ^12^ , ^13^ , ^14^ , ^15^ , ^16^ , ^17^ , ^18^ , ^19^ , ^20^ , ^21^ , ^22^ , ^23^ , ^24^ , ^25^ , ^26^ , ^27^ , ^28^ with a median age of between 8 and 10 years old. ^29^ , ^30^ , ^31^ , ^32^
To better understand and treat paediatric pelvic fractures, it is important to realize that the child's pelvis is not a smaller version of the adults – even among children of differing ages and sex, there is variation in the maturity and structure of the pelvis. These differences are summarized in Table 2.
Mechanisms of injury usually involve a high force or impact such as being hit by a motor vehicle (range 24–71% (outliers excluded)) or being an occupant in a motor vehicle collision (range 13–53% (outliers excluded)) (Data S2). Children struck by a vehicles tended to be younger than 12 years old (43% versus 27%, P = 0.004). ^5^ This is supported by several studies, which found that children with an open triradiate cartilage (i.e. more immature) were also likelier to be hit by automobiles. ^38^ , ^40^ Children are also more likely to sustain a lateral compression pelvic injury in contrast to adults, who usually sustain an antero‐posterior compression injury. ^37^ Crashes involving vehicle intrusion or older children (age > 12 years old) increased the likelihood of pelvic fractures. ^41^ , ^42^ While cars are the major vehicle involved, there is also increasing concern for all‐terrain vehicles, motorcycles and dirt bikes, especially those that are used off‐road. ^43^ , ^44^ , ^45^ , ^46^ , ^47^
Other common mechanisms include falls – Demetriades et al. reported that the incidence of pelvic fractures increases with increasing age in a comparative study of patients falling from a height of >4.5 m (P < 0.0001). ^48^ In rare cases, pelvic fractures are resultant from non‐accidental injury. ^49^ In a case series by Starling et al. the authors describe 2 children with pubic rami fractures who also sustained fractures to their upper and lower limbs, skull and rib cage. ^50^ Paediatric pelvic fractures with a questionable mechanism of injury may be resultant from physical child abuse and clinicians should be aware of other red flags including multiple fractures at different stages of healing and skin or soft tissue injuries. ^50^
The injuries sustained relate to the directions of the forces applied to the pelvis. Struck pedestrians typically sustain lateral compression (LC) forces which translate into transverse pubic rami, sacral and iliac wing fractures. ^36^ , ^51^ An antero‐posterior compression (APC) force can be sustained after being a passenger in a motor vehicle accident; this can lead to the classic open‐book fracture although these injuries are much rarer in children (12% in study by Mulder et al.). ^5^ , ^51^ Life‐threatening haemorrhage is a concern in adults who sustain APC fractures, but this is also extremely rare in children (0 out of 166 children in a series by Silber et al.). ^17^ Other injuries associated with an AP force include vertical pubic rami fractures and disruption to the sacroiliac ligamentous complex (anterior or posterior aspects). ^51^
In the literature, several studies looking at potential risk factors for paediatric pelvic fractures have been published. In Maryland (USA), Nabaweesi et al. looked at 13 360 children and showed that children between 5 and 14 years old or having a mechanism of trauma involving motor vehicles were associated with paediatric pelvic fractures. ^52^ Shore et al. agree that children with a mature pelvis (i.e. older) were more likely to sustain a higher grade of fracture compared to those with an immature pelvis (P = 0.013). ^9^ A retrospective review investigating the association between obesity and pelvic fractures failed to show an important statistical correlation. ^53^
The high energy required to fracture the pelvis should alert clinicians to the presence of other fractures and soft tissue injuries (range 58–100% (outliers excluded)) (Data S3). On average, patients can present with 5.2 other injuries, higher than any other fracture on admission to hospital. ^8^
The number of classification systems developed highlights the complexity of the pelvis and the many variations of fractures that can be sustained. In children with a skeletally immature pelvis, common classification systems include the modified Torode and Zieg system ^9^ (the most popular system in paediatrics, Fig. 2), the Tile/AO system ^54^ (appraising fractures in increasing levels of instability) and the Young and Burgess system for those with a mature pelvis ^55^ (linking direction of impact with fractures sustained) (Table 3 with examples in Fig. 3). For acetabular fractures, the Judet and Letournel system is utilized in adults, but the involvement of the acetabular triradiate cartilage in children means that the Salter and Harris system can be used.
Fig. 2 Modified Torode and Zieg Classification System. ^9^
Fig. 3 Examples of pelvic fractures. (a) 14‐year‐old boy with left iliac wing and left superior pubic ramus fractures (Tile/AO A2 and YBC LC 2 injuries). MTZ II If his triradiate cartilages were still unfused. (b) A 12 year old girl bilateral superior pubic rami (blue arrows), right midshaft femur fractures and a left anterior sacroiliac ligament injury (red arrow). (Tile/AO A2 and YBC LC 1 injury). MTZ III‐B if her triradiate cartilages were unfused.
However, classification systems are not universal and some fractures in the literature are unable to be classified, making it difficult to compare data and published literature. Examples of rare pelvic fracture types are elaborated on in Table 4. ^63^ Additionally, none of the popular systems take into account the different stages of pelvic maturation. ^51^
At the end of a thorough assessment, several key facts should be elicited to direct further investigations and management. These
Children should be assessed following Paediatric Advanced Life Support (PALS) and Advanced Trauma Life Support (ATLS) principles with resuscitation measures initiated as necessary. ^33^ , ^37^ , ^64^ They will often have associated injuries that should be identified as promptly as possible. Unstable patients after blunt abdominal trauma should also receive a Focused Assessment with Sonography in Trauma (FAST). ^65^
A secondary survey is subsequently performed on the stable, alert patient. This includes asking for symptoms including pain or discomfort in the pelvic region, incontinence or sensory/motor changes in the lower limbs. Clinical examination was associated with high sensitivity (92%, 95% CI 0.89–0.95), positive predictive value (0.84) and negative predictive value (0.89) in a retrospective study. ^66^ When the same authors conducted a prospective study (n = 140), they found a decrease sensitivity (0.69), but high specificity (0.95) and high negative predictive value (0.91). ^67^ Despite the confusion surrounding these statistics (which are affected by low patient numbers in these studies), clinicians should examine the lower abdomen, external genitalia, perineum and rectum, with key findings including open wounds, blood at the urethral meatus or vaginal introitus and scrotal bruising. Open fractures occur very rarely (1.7%). ^10^ The presence of blood from a vaginal laceration in a child who has multiple pelvic fractures, disruption of the pelvic ring or a sacral injury increases the likelihood of a bladder or urethral injury in girls. ^68^ This is crucial as these injuries are easily missed (more so in girls) and potentially worsened with urinary catheter insertion. ^69^ A retrograde urethrogram is warranted when a urethral or bladder injury is suspected. ^36^ , ^70^ Meltzer et al. suggest urethroscopy as an investigation for girls with suspected urethral injury where possible, keeping in mind the urgency with unstable patients. ^69^
An orthopaedic examination of the pelvis involves looking at the pelvis for asymmetry, soft tissue injury and leg length discrepancy or rotation. On palpation of the pelvis, clinicians should assess for crepitus, stability or pain in the sacroiliac and pubic symphyseal joints. Morel‐Lavallée lesions (shearing of the subcutaneous tissues from the underlying fascia) are occult pathologies that can be missed if not suspected. ^36^ , ^71^ Assessment of pelvic stability involves applying pressure to compress the pelvis medially and the iliac wings posteriorly. Finally, movement can be assessed with the FABER (flexion, abduction, external rotation) test. ^33^
Associated sacral fractures are very rare (Table 4). ^72^ Clinicians should complete a full neurovascular examination of the lower limbs (including assessment of anal sensation and tone) to identify neurological deficits including motor and sensory loss as well as incontinence. ^36^ , ^73^
Figure 4 summarizes the initial approach to pelvic fractures by our team at a tertiary paediatric trauma centre (with specialist paediatric pelvic orthopaedic surgeons, trauma surgeons, paediatric urologists, intensive care and interventional radiology). Key aspects are expanded in the subsequent sections.
Fig. 4 Initial decision‐making tree for paediatric pelvic fractures presenting to the emergency department (ED).
Trauma imaging after blunt abdominal trauma historically included radiographs of the cervical spine, chest and pelvis. ^34^ However, the role of this routine pelvic radiograph is contested because of its unclear benefit at the cost of radiation exposure to the gonads. ^74^ Several studies show that most pelvic radiographs in blunt abdominal trauma were negative for pelvic fractures. ^74^ , ^75^ , ^76^ Therefore, pelvic radiographs should not be routinely ordered in alert, haemodynamically stable children without suspicious examination findings. They are warranted in haemodynamically unstable patients or those with suspicious examination findings. ^74^ Clinical factors which are suggestive of the need for a pelvic radiograph include hip/pelvic pain, pelvic instability, pelvic contusion/abrasion, a hip held in rotation, abdomen, pain, abdominal contusion, femur deformity/thigh pain or back pain. ^52^ , ^77^
While CT can provide superior visualization and more detailed information of pelvic fractures than a standard pelvic radiograph, its routine use is contentious given high radiation exposures, cost and time compared with bedside pelvic radiographs. ^34^ , ^78^ , ^79^ , ^80^ , ^81^ They should only be considered if the added information will affect a patient's management as most paediatric pelvic fractures are managed conservatively. ^78^
Of further note (and not included in Fig. 4), patients who have acute indications for an abdominopelvic CT scan, such as those with a suspected intraabdominal injury should not have a pelvic x‐ray. ^79^ , ^82^ CT scans allow surgeons to diagnose injuries not visible on radiographs. For instance, children with an SIJ disruption and an intact L5 transverse process can also have avulsion of the iliac crest – a finding that requires 3D imaging to detect. This is especially important, as injuries involving the iliac apophysis can be unstable. ^83^ CT scans are also a better modality than radiographs for identification of sacral fractures and should be done in patients complaining of pain over the SIJ. ^36^ , ^72^ Similarly, CT scans are able to detect acetabular fractures better than x‐rays (up 70% of acetabular fractures are missed on pelvic radiographs alone) and should therefore be ordered if there is clinical suspicion. ^84^ Measurements of pubic symphysis and SIJ width should be done in the axial and coronal planes with comparison to the standardized values recorded by Bayer et al. ^85^ , ^86^ Joints found to be wider than the 97th percentile should make clinicians suspicious of a pubic symphysis or SIJ injury. ^85^ , ^86^ As pelvic and abdominal CT scans typically use higher doses than other scans, surgeons should be mindful of the risks of developing cancers especially as tissues such as the paediatric gonads are more sensitive to its effects. ^87^ , ^88^ , ^89^ Techniques to minimize radiation exposure in children include shielding, following the ‘as low as reasonably achievable’ (ALARA) principle and adjustment of settings including exposure area and dosage for the size of the child and area of interest. ^89^
MRI is not routinely recommended in the acute setting but can help identify and determine the extent of ligamentous or soft tissue damage, as in patients with SIJ injuries. ^36^ , ^90^ Cross‐sectional imaging studies are also very useful in acetabular fractures as they can show instability of the joint as well as trapped bone fragments. ^91^ Bone scans can help identify occult fractures or avulsion injuries. ^36^
Pelvis fractures rarely cause significant bleeding in children, but clinicians must be on guard for the possibility. ^92^ Most children with a suspected pelvic fracture will arrive in the emergency department with a binder in situ – if a patient does not meet the indications (e.g. haemodynamically unstable with a high‐risk mechanism of injury) then it should be removed promptly to prevent skin integrity compromise. Bleeding can originate from disrupted cancellous bone, an arterial source or from the retroperitoneal venous plexus. ^93^ The treatment therefore is focused on controlling the source of bleeding. In a haemodynamically unstable patient with a pelvic fracture, the bleeding from fractured cancellous bone can be limited by stabilizing the pelvis with a pelvic binder, bedsheets or external fixation. ^34^ , ^64^ Patients can also require emergent surgical pelvic stabilization (damage control Orthopaedics) to facilitate transfer or to improve access by other surgical teams. ^65^ Ongoing haemodynamic instability can warrant the need for angiography and angioembolization for arterial bleeds (1.9% of patients). ^94^ While pre‐peritoneal packing has been described as a relatively fast means to tamponade a venous plexus bleed, the evidence base for it is poor (most articles published are case studies and series). ^33^ , ^93^ , ^95^ , ^96^ , ^97^
The need for blood transfusion is varied but is estimated between 11% and 39.5% of all paediatric pelvic fracture patients. ^9^ , ^13^ , ^19^ , ^23^ , ^24^ , ^31^ , ^66^ , ^98^ , ^99^ On average, patients who did need transfusion received 3.7 units of packed red blood cells. ^100^ Those with MTZ type III‐B (16 out of 39 children) were more likely to need a blood transfusion compared those with a type III‐A (7 out of 43) (OR 3.58; 95% CI 1.28–10.03). ^9^
Multidisciplinary care is crucial for ensuring the best outcomes in paediatric pelvic fractures. For instance, urological and orthopaedics surgeons should agree together on the insertion location of a suprapubic catheter for operative planning of anterior pelvic fixation if needed. ^34^
Most stable fractures can be managed non‐operatively. ^33^ Stable fractures include avulsion, iliac wing, pubic rami, ischial and undisplaced sacral alar fractures. In classification terms, these fractures are MTZ I, II or III‐A; Tile A; APC I; LC I or LC II fractures. ^34^ , ^36^ Conservative management historically involved traction, bed rest, pelvic sling and spica cast immobilization. ^101^ However, it is currently thought that the disadvantages of prolonged immobilization are outweighed by early mobilization. As such, patients can be kept non‐weight bearing on the affected side with repeat x‐rays at weekly intervals to monitor fracture healing and stability. ^34^ Progression to partial and then full weight bearing accompanies callus formation and radiographic signs of healing and stability. Usually, fracture healing will occur by 4 to 6 weeks and patients should be fully weight‐bearing by this time. Follow‐up with repeat x‐rays every 2 to 3 months for a year can be done to monitor for growth abnormalities and remodelling. ^34^
Although less than 10% of patients require operative fixation, ^100^ there is an increasing trend for operative management of unstable pelvic fractures (involving two or more breaks in the pelvic ring with displacement and/or pubic symphysis diastasis). This reflects concerns that any asymmetries or displacement will not correct spontaneously, therefore requiring surgical intervention to prevent long‐term issues including chronic pain, gait disturbance and leg‐length discrepancy. ^102^ , ^103^ However, there are no level I or II studies to support surgical intervention and the remaining evidence varies widely in strength. ^104^
MTZ type III‐B fractures with >2 cm displacement or fracture lines close to the pubic symphysis and MTZ IV fractures (which are unstable by definition) warrant operative fixation; in retrospective cohort studies the rate of operative fixation for these fractures is more than 90%. ^36^ , ^100^ , ^105^ With other classification systems, unstable Tile B (stability can be assessed with manipulation under anaesthesia) or Tile C; APC 2, APC 3, LC 3 or VS fractures warrant consideration of surgical fixation. Additional criteria for operative management include open fractures, to facilitate patient care in special circumstances (i.e. improving access in a polytrauma patient), for severely displaced fractures and to improve patient mobility. ^104^ The overall aim is to obtain anatomic reduction and stabilization to keep pelvic symmetry, with fixation methods divided into anterior ring and posterior ring constructs.
Anterior ring injuries can be fixed with a variety of fixation options including external fixation with a frame; osteosutures (non‐absorbable sutures that hold bone to bone), or plates and screws. ^106^ , ^107^ Surgical approaches include a horizontal incision (Pfannenstiel) which can be laterally extended (modified Stoppa) or a vertical incision (performed on patients with previous midline laparotomy scars).
For children who are haemodynamically unstable, have other injuries requiring emergent treatment or present with open pelvic fractures – external fixation is an appropriate initial stabilization method for the anterior arch. ^105^ Fixation can then be deferred for several days to allow for surgery under more favourable conditions. Alternatively, osteosutures may have an advantage in open pelvic fractures as they can reduce the need for further dissection and the risk of infection as there is no metalware inserted. ^108^ New techniques include the use of an INFIX (Internal External Fixator) device for in children; this has been described for use in adults. ^109^ In an 8‐year‐old female with an MTZ IV injury, the INFIX was inserted without difficulty, held the reduction for 8 weeks before successfully removal and provided a less bulky and invasive alternative to external fixation. ^109^ Surgeons should be mindful of injury to the lateral cutaneous nerve of the thigh by INFIX devices. ^110^ Otherwise, pubic symphysis displacement of more than 2 cm can be fixed with plates and screws. ^105^
Posterior ring fixation usually involves reduction of the SIJ. A wide variety of techniques exists in the literature including the use of iliosacral screws or non‐metallic implants such as osteosuturing with PDS (polydioxanone). ^106^ , ^111^ , ^112^ , ^113^ In rare instances, spinal implants have been modified to treat younger patients with smaller anatomy. ^114^ Surgical approaches include the ilioinguinal approach (starting with a lateral window and adding incisions as needed) or posteriorly by a paramedian incision. ^106^ , ^115^ Alternatively, percutaneous screws may also be inserted in a standard operating theatre with fluoroscopic guidance, as in adult pelvic surgery. There are also case reports of percutaneous screws being inserted within an interventional radiology setting using CT to assist in positioning and planning of the screw pathway. ^116^ , ^117^ The availability of safe screw pathways in paediatric patients increases with age; placement of iliosacral screws at S1 are almost always possible (99%). ^118^
Acetabular fractures are also rare injuries in children; like other pelvic fractures they often result from high‐energy trauma, but low energy trauma has also been described. ^119^ , ^120^ Surgeons need to be wary of femoral head dislocation as this is an orthopaedic emergency. ^36^ Surgical intervention in paediatric patients with a closed triradiate cartilage is similar to adult patients, with most undisplaced fractures being stable and therefore treated conservatively. ^36^ , ^70^ , ^120^ For patients with an open triradiate cartilage the aim to preserve and maintain acetabular growth as much as possible. The indications for operative fixation include ^70^ :
Surgical approaches for acetabular fractures include Kocher‐Langenbeck (posterior), ilioinguinal (anterior) and extended iliofemoral (allowing visualization of the entire acetabulum) approaches.
Patients are initially non‐weight bearing, but progress through partial weight‐bearing once callus is seen on pelvic x‐rays. They may be able to fully weight‐bear as early as 6 weeks after the injury. ^70^
Fixation has been described using plates, screws and biodegradable suture anchors. ^121^ Novel techniques include the use of the Titanium Elastic Nail System (TENS) as a minimally invasive option for reduction of acetabular fractures; Abdul Razak et al. described a case of using three TENS to reduce a right anterior column posterior hemitransverse acetabular fracture. ^122^ Although the authors describe the fixation as stable intraoperatively, no comment was made on the patient's recovery or long‐term follow‐up results. ^122^
Conservative management have been reported in the literature for a majority of paediatric pelvic fractures, but case reports have been published on closed reduction and open reduction with Kirschner wires. ^123^ The indications for surgical intervention are unclear and the existing evidence is weak.
From the time of fracture to discharge, children with pelvic fractures are subject to increased risk of complications during their admission including infection, neurologic injury and acute respiratory failure. ^5^ , ^21^ , ^103^ The incidence of venous thromboembolism (VTE) in paediatric pelvic fractures has been reported as 1.47% by Guzman et al., with Askegard et al. showing that pelvic fractures are associated with an increased risk of VTE (OR 1.583, 95% CI 1.085–2.310, P = 0.017). ^124^ , ^125^ Thankfully VTE does not appear to cause significant morbidity or mortality in the paediatric population and the regular use of thromboprophylaxis may not be needed (especially in younger children). ^126^ Children had less post‐operative complications of acute respiratory distress syndrome, venous thromboembolism and multi‐organ failure compared to adults (no statistically significant difference in injury severity scores). ^21^
In a systematic review conducted by Sridharan et al., the functional complications of 454 patients were investigated with a mean follow‐up of 29 months. The most common complications recorded (weighted %) after pelvic fractures included pelvic asymmetry (9.2%), limp (6.0%) and leg‐length discrepancy (5.0%). ^100^ Other functional complications include chronic pain, scoliosis and the development of Trendeleberg gait. ^127^ , ^128^ , ^129^ Kruppa et al. suggest that patients with low back pain had worse asymmetry than those without, but their sample size (n = 33) was too small to draw valid conclusions. ^27^ Smith et al. presented a positive correlation between pelvic asymmetry at the time of injury and reported functional morbidity at a mean of 6.5 years follow‐up (correlation r = 0.6, P = 0.04), although this study was also limited by a small population (n = 20). ^103^ Despite these complications, Signorino et al. showed that children's average functional outcomes were close to normal or had resolved by 6 months after injury. ^130^
Traumatic injury to the ossification centres is particularly concerning as injuries can lead to epiphysiodesis or physeal bar formation with subsequent growth deformities. ^34^ , ^131^ In a case series of traumatic acetabular fractures, Badina et al. demonstrate safe resection of physeal bars in the acetabulum which can minimize acetabular and hip dysplasia. ^131^ Damage to Risser's nuclei (iliac wings) can similarly lead to iliac undergrowth. ^128^ Subsequently patients may then suffer from hip mobility restriction, heterotopic ossification and leg‐length discrepancy. ^132^
Bone union and remodelling, as well as resolution of other medical complications, are not the only endpoints for management of paediatric pelvic fractures. Up to 56% of children will be diagnosed with a psychiatric disorder (including dysthymic disorder, social phobia, post‐traumatic stress, separation anxiety, depression and specific phobia) after sustaining a traumatic pelvic fracture and therefore these issues need to be addressed for holistic care of these patients and their carers. ^37^ , ^129^ Children with a prolonged stay in hospital should continue their education with in‐hospital teachers where possible; this also has the added effect of allowing children to socialize. ^129^ Patients and parents will often have questions about treatment plans and the effect of pelvic fractures on future growth and function (i.e. ability to have children, inability to cope with incontinence or gait abnormalities) and it is imperative that surgeons communicate empathetically and clearly during admission and at follow‐up. ^129^
While rare, the urogenital system can be injured anywhere from the kidneys to the urethral opening following blunt abdominal trauma. ^133^ , ^134^ Surgeons should be mindful of patients with MTZ III and above pelvic fractures who also present with haematuria, dysuria, urinary retention or incontinence. ^134^ , ^135^ Organs such as the kidney are relatively larger in the child, and the perirenal fat is not as well developed to cushion against injury. ^136^ The incidence of urinary bladder injuries is thought to be between 1.5 and 3.7% of patients with pelvic fractures. ^137^ Urethral injuries vary from contusion, partial rupture and complete rupture. They may subsequently develop into strictures or fistulas that require specialist paediatric urology input. ^138^ The technicalities of repair are beyond the scope of this paper. In males with a pelvic fracture related urethral injury, up to half will develop erectile dysfunction in puberty. ^139^ In females, urethral injuries are much rarer the literature just as sparse. ^140^ , ^141^ Vaginal injuries that may not have been identified or were found to be minor at the time of the fracture can manifest with dyspareunia and vaginal stricture many years later, as demonstrated by a 26‐year‐old woman who presented with sexual dysfunction. ^142^ Paediatric patients should be followed‐up in the long term to ensure that potential delayed complications can be addressed. ^142^
The mortality of pelvic fractures is reported in the literature as between 0.55% and 16%, ^1^ , ^5^ , ^7^ , ^8^ , ^9^ , ^12^ , ^13^ , ^14^ , ^15^ , ^17^ , ^19^ , ^21^ , ^22^ , ^23^ , ^24^ , ^29^ , ^30^ , ^31^ , ^41^ , ^48^ , ^98^ , ^143^ , ^144^ , ^145^ , ^146^ with a mean calculated to be 8.6% by Sridharan et al. ^100^ Mortality has been found to be associated with more severe pelvic fractures (Abbreviated Injury Score (AIS) 4–5 mortality 26.3% versus AIS 3 mortality 9.7% versus AIS 2 mortality 3.3%, P < 0.0001). ^147^ Isolated pelvic fractures are rarely the cause of death; children who died had an associated catastrophic injury – usually a head injury. ^1^ , ^2^ , ^5^ , ^14^ , ^15^ , ^17^ , ^29^ , ^30^ , ^31^ , ^37^ , ^148^ Furthermore, the mortality rates differ between adolescents and younger children. In a study of 24 684 patients with pelvic fractures (including those with other associated injuries), children (aged less than 13 years old) with any closed pelvic fracture had increased odds of death (OR 2.29, 95% CI 1.96–2.67) compared with adults, while adolescents (aged 13–17 years old) did not (OR 0.89, 95% CI 0.74–1.06) (P < 0.05). ^6^ Other factors associated with mortality include a pelvic ring soft tissue injury (P = 0.004), positive FAST examination (P = 0.004) and admission to an intensive care unit (P < 0.001). ^144^
While traumatic pelvic fractures are rarer in children than adults, they can still result in severe concurrent injuries that require multidisciplinary input. The trend of operative fixation is increasing in children with unstable or significantly displaced fractures due to our better understanding of the limited remodelling capabilities of the paediatric pelvis and the morbidity associated with conservative treatment. Therefore, there is potential to significantly reduce the morbidity of these children as they grow and live with the long‐term sequelae of these injuries.
None declared.
Alexander T. M. Nguyen: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; writing – original draft; writing – review and editing. David P. Drynan: Conceptualization; supervision; validation; writing – review and editing. Andrew J. A. Holland: Conceptualization; supervision; validation; writing – review and editing.
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