Fractures and dislocations of the pelvis and proximal end of the femur in children are the result of high-energy trauma and are therefore rare. Because of diagnostic, treatment, and outcome implications, these injuries are best grouped as pelvic fractures and dislocations (including acetabular fractures), proximal femoral fractures, and hip dislocations.
Section I: Pelvic Fractures and Dislocations
Introduction/Pathology
Relevant Anatomy
Apart from size, pelvic anatomy in children differs little from that in adults. The pelvis consists of the ilium, ischium, and pubis, together with their apophyseal growth centers, and the sacrum ( Fig. 13-1 , A ). The acetabular cartilage complex is a unit: flat and triradiate medially and cup-shaped laterally interposed between the ischium, ilium, and pubis ( Fig. 13-1 , B ). The critical differences between children and adults, then, are the epiphyseal growth centers and apophyseal growth regions. This cartilaginous volume, as well as the fact that the bones are more flexible, provides a greater capacity for energy absorption than that available to adults. When fractures do occur, they can arise within the cartilaginous regions and make diagnosis more difficult. Fractures in these regions can result in growth disturbances from direct trauma or can result in misdirected biomechanical forces from bony malunion. The resiliency afforded by the increase in cartilage volume allows for greater displacement on impact without apparent injury. In a dramatic representation of this fact, radiographically, 93% of 66 postmortem examinations of children injured by blunt trauma demonstrated bilateral posterior pelvic ring injury. Osseous vascular anatomy is also important, and it may be disturbed by direct or indirect trauma. The major area of vulnerability is that of the femoral head. Because of the changing biomechanics of the pelvis and acetabulum with maturity, the patterns of pelvic fracture change with increasing age of the patient.
Prevalence
The true prevalence of fracture of the pelvis or acetabulum in children is difficult to determine. There is a male predominance with a male:female ratio of 1.4:1 and an average age of 9 years. Watts stated that 10 injuries (pelvic fractures) per year could be expected in a large children’s hospital, that 97% of them would be of the stable type, and that acetabular fractures were rare. Quinby identified 255 children younger than 14 years admitted to the pediatric surgery service of the Boston City Hospital for blunt trauma to the trunk over an 11-year period. Twenty patients in this group (7.8%), 6 girls and 14 boys with an age range of 2.5 to 13 years and a mean age of 8 years, had identifiable pelvic fractures. Of 1438 musculoskeletal injuries treated at the level I trauma center in Washington state in a single year, five (0.35%) were pelvic or acetabular fractures in children younger than 18 years. In a major German trauma center, 54 pelvic fractures were treated over a 19-year period; these injuries are relatively rare, and associated head injuries with neurologic sequelae were found to be more common in children than in adults. In a 1991 study, 2.4% of 2248 children admitted to a regional trauma center were identified as having a fracture of the pelvic ring. In a 1999 review of the experience of a busy trauma center in Israel, 12.9% (15 of 116) of the pelvic fractures in children younger than 12 years were open injuries. Current literature estimates the prevalence of pelvic fractures to be between 0.3% and 4%. ∗
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Sacral fractures are present in 0.16% of pediatric trauma and 4.76% of pediatric pelvic fractures.Acetabular fractures constitute 0.8% to 15% of fractures of the pelvis in children. †
†
Mechanism of Injury/Biomechanics
Pelvic and acetabular fractures in children are generally the result of high-energy trauma for the reasons outlined earlier. In Quinby’s 20 cases, 19 patients were injured by impact with an automobile, truck, or train; one fell from a roof. In eight of the 19 cases of trauma produced by collisions with motor vehicles, it was suspected that the vehicle ran over or crushed the child. In an 8-year review of children younger than 16 years treated at the University of Manitoba, 84 children with pelvic fractures were identified. Of these fractures, 58% were the result of cars striking pedestrians, 17% of the patients were passengers in motor vehicles involved in accidents, 7% of the injuries were caused by impacts or falls from bicycles, and 8% were from crush injuries. A 1995 report of 43 patients indicates that the mechanism of injury is related to motor vehicles in 70% of cases and to falls from significant height in 30%. This is echoed by a 2001 study on 166 consecutive pediatric pelvic fractures showing pedestrians struck by motor vehicles to be the leading cause of injury (100/166; 60%), followed by passengers in motor vehicle accidents (37/166; 22%), falls (22/166; 13%), and other (7/166; 4%). A high-energy impact with ductile structures produces these injuries. Side impact motor vehicle crashes have been recently implicated. An article in Morbidity and Mortality Weekly Report has identified the fact that many pediatric injuries occurring around motor vehicles, including crush injuries, occur because the child is left unattended.
Consequences of Injury
Because of the significant energy involved in producing fractures of the pelvis, the major consequences are from associated visceral injuries. Nineteen percent of patients in Reed’s large series had associated visceral injuries, most commonly involving the viscera within or just superior to the pelvic brim. Seven of the 10 associated visceral injuries involved the lower urinary tract, and seven involved intraabdominal structures. Three cases each of significant intrathoracic, intracranial, and soft tissue injuries occurred, again pointing to the velocity of the impact and the amount of energy involved with this blunt trauma. Of Quinby’s 20 patients, nine required laparotomy for visceral injuries, and another five had severe hemorrhaging with visceral injuries requiring laparotomy in addition to the significant vascular injury; three of five in this group eventually died. Forty-two percent of a series of 66 pediatric fatalities in a recent postmortem study performed in Russia died as a result of pelvic fractures and severe hemorrhaging. A cohort of surviving patients was included in this report; 24 of 43 patients had at least three organ systems injured, and 62.8% of these patients were admitted with some degree of hypotension. However, a 1987 study showed that children who died had higher injury severity scores and lower Glasgow Coma Scale scores, and severe head trauma was found to be the cause of death in all eight mortality cases. Multisystem injuries occurred in 60% of patients, and 50% sustained additional injuries in a recent report of 166 consecutive pediatric pelvic fractures. In this report, head injuries, visceral injuries, or both were the causes of all death and carried a mortality rate of 3.6%.
The major consequences of a pelvic fracture then are hemorrhaging, shock, and death; bladder or urethral injury (particularly in males); neurologic injury (in particular, injury to the lumbosacral plexus with sacroiliac [SI] disruption or sacral fractures); and infection after open fractures that involve the perineum, rectum, or vagina. ∗
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A 2004 review identified associated injuries in 78% of pediatric patients with pelvic fracture. The severity of the pelvic fracture is correlated with the risk of visceral injury. In the 1991 Children’s National Medical Center series, 80% of children with multiple pelvic fractures had concomitant abdominal or genitourinary injuries compared with 33% of children with fractures of the ilium or pelvic rim and 6% of children with isolated pubic fractures. This pattern was not found in a 14-year retrospective review showing all pelvic fractures except the avulsion type to be associated with significant injuries to different organ systems and high Injury Severity Scores. Urethral injuries were found to be closely associated with displaced inferomedial pubic bone and pubic symphysis diastasis. In adults, the mortality rate from major pelvic fractures is 5% to 20%. In children, the rate has been reported to be 1.4% to 14%. ∗∗
Published mortality rates for a severely traumatized groups of adult patients with open pelvic fractures range from 8% to 50%; death results from hemorrhaging early and pulmonary failure and sepsis on a delayed basis. ††
The mortality rate of open pelvic fractures in children is up to 20%. One study that compared data from the National Pediatric Trauma Registry with data from a level I trauma center documented a much lower mortality rate from hemorrhaging: 5% for children and 17% for adults. The incidence of lower urinary tract injury in combined large series is 7.5% to 25% in adults and 7.4% to 13.5% in children. However, the incidence of severe lower urinary tract injuries is only between 0.6% to 0.9% in the two most recently reported large series.Without considering organ system injuries, the pelvic fracture itself results in serious sequelae. When the triradiate cartilage is involved, growth arrest can result in the “mini,” shallow acetabulum described by Rodrigues ( Fig. 13-2 ). Six of 15 patients reported by McDonald had injuries to the triradiate acetabular cartilage; fortunately, of the four patients monitored long term, the deformity described by Rodrigues that resulted in femoral head subluxation did not develop in any. McDonnell and associates observed that a low-energy sport-related triradiate cartilage fracture in a 13-year-old patient healed without complication. Acetabular fractures can also result in lateral subluxation of the hip, heterotopic ossification, and ankylosis. Other reported consequences of extraacetabular pelvic fractures include delayed union, SI fusion with pelvic distortion, leg-length discrepancy, and pelvic obliquity.
Commonly Associated Injuries
As noted earlier, the injuries commonly associated with pelvic fractures are both visceral and skeletal. The visceral injuries directly related to the pelvic injury are bladder and urethral injuries, traction injury to or avulsion of the lumbosacral plexus, and injury to the major and minor arterial and venous systems, with resultant hemorrhage. Injuries associated with high-energy blunt trauma may involve the pulmonary, cardiac, gastrointestinal, and central nervous systems (see Chapter 5 ). Associated injuries occur in as many as 67% of patients with pelvic fracture. Children with at least one other associated fracture had a significantly higher incidence of head and abdominal injuries and an associated need for blood transfusions in a 1993 review of a 5-year experience in 79 children. Chest injuries, the need for additional operative procedures, and mortality tended to be higher in the associated fracture group, but because of inadequate numbers, it did not reach statistical significance. The most commonly associated fractures are those of the femur, skull, ribs, tibia and fibula, clavicle, facial bones, and humerus, in that order. Identification of a pelvic injury in the primary phase of the resuscitation and injury survey should alert the physician to the possibility of these associated injuries. The associated injuries are more difficult to treat and generally affect the outcome to a greater extent than the pelvic fracture does.
Evaluation
History
Because of children’s skeletal flexibility, pelvic and acetabular fractures in the pediatric age group occur secondary to children being struck by automobiles or as a result of their being unrestrained passengers in motor vehicle accidents, not by minor trauma such as falls or sporting contact. A history of high-energy trauma directs the emergency medical service team to an appropriate response in the field and during transfer of the patient to a regional trauma center. If shock is part of the initial findings, transportation is frequently by air ambulance. The history of violent injury dictates full-scale primary and secondary surveys, institution of large-bore venous access, and other measures as outlined in Chapter 5 . Minor apophyseal avulsion injuries, usually occurring in patients 12 to 15 years of age, are generally caused by athletic injuries.
Physical Examination
The evaluation procedure for a trauma patient is outlined in Chapter 5 ; the following comments are directed toward patients with a potential for pelvic or acetabular fractures. Inspection of the body surface is the initial step; the anterior surface is examined, and then the patient is logrolled so that spinal examination can be conducted at the same time. Contusions, abrasions, and areas of degloving where the subcutaneous fat has been sheared off the fascia (a Morel–Lavaelée lesion) are identified and recorded. Patients with acetabular fractures frequently have large peritrochanteric ecchymoses as a result of the orientation of the force that produced the fracture. Lacerations, especially anterior ones, are not uncommon in pediatric patients and are frequently associated with vascular injury. In the perineum, lacerations are often the result of open fractures, in that ischial fragments have produced the wound. Vaginal lacerations are not unusual, and a digital pelvic examination should be performed in all female patients with a displaced anterior ring fracture; preferably, this examination is done with the patient under sedation or with the use of an anesthetic in prepubescent children. Similarly, a digital rectal examination is done to check for gross blood, indicative of a rectal perforation or sphincter injury. However, the routine use of digital rectal examination in the setting of 213 pediatric trauma patients failed to diagnose 12 of 12 (100%) pelvic fractures.
When the inspection is completed, pelvic stability is evaluated, preferably while the patient is still on the backboard. Anteroposterior (AP) stability is assessed by the clinician placing the palms of the hands on the anterior iliac crests and applying posteriorly directed pressure ( Fig. 13-3 , A ). By placing the palms on the lateral aspect of the anterior crests and applying pressure directed toward the midline, the examiner can check for rotational instability, such as that created by an open-book fracture ( Fig. 13-3 , B ). Pain on AP or medially directed pressure in a conscious patient is carefully documented. In addition, the examiner uses palpation along the posterior iliac spine, SI joint, and sacrum to look for pain consistent with a posterior pelvic ring injury. A final check on vertical or rotational instability can be made by assessment of the relative height of the anterior superior iliac spines and relative leg length.
After the inspection and palpation phases are completed, a thorough evaluation of the arterial circulation is made. The femoral, popliteal, dorsalis pedis, and posterior tibial pulses are palpated; if they cannot be palpated, a Doppler ultrasound examination is done for determination of biphasic pulsatile flow. Limb temperature is assessed by palpation. Finally, in an alert and cooperative patient, a gross motor examination of all major muscle groups in the lower extremity is completed bilaterally, as well as a sensory examination with light touch and pinprick. The latter should include the perirectal area because of the frequent involvement of the sacral plexus with sacral fractures. This is not possible in younger children who are unable to cooperate with the demands of this type of evaluation. Rectal tone should already have been assessed during the digital rectal examination.
Imaging
Radiographic Evaluation
An important part of the initial evaluation of a multiply injured child is an AP radiograph of the pelvis. Gonadal shielding should not be used because it may obscure the anterior pelvic ring ( Fig. 13-4 , A ). Two additional views are indicated if a fracture of the AP pelvic ring is identified on the initial radiograph: a 30° to 45° (aimed distally) inlet view or “down shot,” which will demonstrate a posterior pelvic ring injury more clearly, and a 40° to 45° (aimed toward the head of the patient) “tangential,” outlet, “brim shot,” or “up view,” which will delineate the anterior pelvic ring ( Fig. 13-4 , B and 13-4 , C ). Both are helpful for identifying internal or external rotation of one of the hemipelves relative to the other. These three radiographs can help determine the mechanism of injury and the form of treatment of most fractures. Sacral fractures and SI joint injuries are frequently missed with a standard radiographic technique. If suspicion is high because of findings on the clinical examination or because of hemorrhaging, shock, or radiologic abnormalities on the inlet or outlet view, computed tomography (CT) of the pelvis is indicated. CT is helpful in diagnosing pelvic hematoma, an important factor in the initial treatment of the patient. Cut intervals of 2.5 to 3 mm are generally sufficient for delineating the skeletal injury, although some have recommended 1.5 mm for intraarticular avulsion loose body diagnosis. Images are obtained from L5 to the lower pelvic region in the axial plane with the use of contiguous sections and soft tissue and bone window techniques. Because CT is becoming more widely used to screen for abdominal injuries, the images should be scrutinized by the treating orthopaedist. These images are not formatted for bone but are still useful for detecting fracture or SI joint disruption. CT has been shown to have greater sensitivity than the AP pelvic radiograph in children; however, the radiation dose exposure to children should prompt careful consideration of the value of treatment implications from the information gleaned.
Because of the complex anatomy of the innominate bone, fractures of the acetabulum require a different approach for radiographic evaluation. The 45° oblique views described by Letournel and associates are indicated when the scout AP pelvic film demonstrates involvement of the acetabulum ( Fig. 13-5 ). The iliac oblique view shows the posterior column in profile, as well as the iliac ring and anterior wall. The obturator oblique view places the anterior column in profile and shows the obturator foramen clearly, as well as the posterior wall. The two views combined with the AP pelvic view allow the physician to classify the fracture according to the scheme of Letournel and Judet ( Figs. 13-5 and 13-6 ). CT is an important adjunct to these conventional radiographic views but is not a substitute. It is especially helpful for detecting intraarticular loose fragments, which occur commonly in patients with associated hip dislocation. CT also helps define fragments impacted in the acetabular margin (posterior wall), as well as occult posterior pelvic ring fractures. Sacral fractures can easily be missed without CT imaging; these injuries may also be associated with lumbosacral disk herniation. Finally, with unduly displaced, associated acetabular fracture patterns, three-dimensional reconstructions of the CT data may prove to be useful. Fractures with less than 2 mm of displacement may not be demonstrated with sufficient resolution on three-dimensional CT, and the CT slices used to produce the “3D” view must be reviewed.
In the case of young children (younger than 8 years) in whom a fracture or dislocation of the proximal end of the femur is suspected, hip arthrography or magnetic resonance imaging (MRI) may be useful. A recent report of four cases of underestimation of posterior acetabular fractures in patients less than 12 years old that relied on standard radiographs and CT scans has led some to consider MRI as the choice for diagnosis of traumatic pediatric acetabular fracture–dislocations.
Special Studies
When injury to the lower urinary tract is suspected, either by blood at the penile meatus or by widely displaced anterior ring fractures, a retrograde urethrogram should be performed. Once a Foley catheter has been definitively placed with appropriate urologic consultation and the examination is continued with larger contrast volumes, a cystogram can be performed to exclude bladder rupture. If renal or urethral injury is suspected from the results of physical examination or other diagnostic tests (if shown on an abdominal CT scan), an intravenous pyelogram or CT scan with a cystogram may be indicated so that renal and urethral anatomy and function can be determined. The traditional threshold of greater than 20 red blood cells per high-power microscopic field for urine analysis cannot be used without clinical judgment as an indication for diagnostic evaluation; 28% of genitourinary tract injuries in one series would have been missed with this criterion. However, urologic consultation and lower genitourinary tract imaging are not recommended for those patients with isolated microhematuria.
In the case of posterior pelvic ring injury in which sacral fracture or SI joint disruption has produced a sacral plexus injury, an electromyogram 3 to 6 weeks after the injury may help define the extent and depth of the damage to neurologic function. MRI may be helpful in terms of documenting lumbosacral nerve root avulsion. Patients who are seen with shock, especially those with radiographically unimpressive pelvic fractures, may benefit from diagnostic angiography and therapeutic embolization with hemostatic gelatin (Gelfoam), blood clot, or coils. This procedure may not be appropriate when open wounds are associated with major proximal (common) femoral arterial or venous injury, in which case immediate exploration and repair are indicated.
Diagnosis/Classification
Because of the severe nature of the associated injuries, Quinby suggested dividing pelvic fractures into those that do not require laparotomy, those that do, and those associated with severe vascular injury. Although this system reflects an increasing severity of injury, complication rate, and mortality rate, it does not help the physician with decision making or prognostic judgment. Many classification systems exist for adult pelvic fractures. The one developed by Trunkey and associates was applied to a series of 84 pediatric pelvic fractures. This system divides pelvic fractures into stable and unstable categories. Stable injuries include pubic fractures, isolated fractures, and avulsion fractures. Unstable injuries include pubic diastasis, acetabular fractures, and diametric fractures (fractures on both sides of the pelvic ring). Watts believed that pediatric pelvic fractures are better classified according to the severity of the skeletal injury, as follows: (1) avulsion, such as epiphysiolysis (secondary to violent muscular activity); (2) fracture of the pelvic ring (secondary to crushing injury), stable and unstable; and (3) fracture of the acetabulum (associated with hip dislocation).
In their 1985 report on a series of 141 pelvic fractures, Torode and Zieg improved on the Watts classification and expanded it as follows:
Type I —avulsion fractures
Type II —iliac wing fractures
Type III —simple ring fractures, including pubic symphysis diastasis without disruption of the posterior SI joint
Type IV —any fracture pattern that creates a free bony fragment, including bilateral pubic ramus fractures, fractures of the anterior pelvic ring with an acetabular fracture, and pubic ramus fractures or pubic symphysis disruption with a fracture through the posterior bony elements or disruption of the SI joint
In a useful addition to the literature, these authors also proposed a classification of complications based on increasing severity: type I, none; type II, occasional altered growth with subsequent remodeling; type III, occasional delayed union; and type IV, nonunion, malunion, triradiate cartilage injury, closure of the SI joint, and leg-length discrepancy.
Tile modified Pennal’s original classification of pelvic fractures in adults. This system, based on the mechanism of injury, has the most widespread application and utility. The types are AP compression, lateral compression, and vertical shear. Burgess and colleagues recently expanded on the system in their study of 210 adults with pelvic fractures and added combined-mechanism injury as a combination of these patterns. In this review, AP compression and combined mechanical disruption had the highest associated blood replacement requirement and mortality rate. Similarly, two retrospective reviews by McIntyre and colleagues and Bond and colleagues revealed the bilateral posterior ring fracture pattern to be associated with the greatest degree of blood loss and abdominal visceral injury. Tile’s system has recently been placed into the A, B, C code system of increasing severity used by the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) and adopted by the Orthopaedic Trauma Association ( Fig. 13-7 , Table 13-1 ). This classification system is not useful for predicting which patients are at risk of urethral injury. Of course, injury patterns are continuous variables (infinite number of combinations); therefore no classification system will have high interrater reliability.
| TYPE | CHARACTERISTICS |
|---|---|
| A | Stable A1—Fracture of the pelvis not involving the ring A2—Stable, minimally displaced fracture of the ring |
| B | Rotationally unstable, vertically stable B1—Open-book injury B2—Lateral compression, ipsilateral B3—Lateral compression, contralateral (bucket-handle pattern) |
| C | Rotationally and vertically unstable C1—Unilateral C2—Bilateral C3—Associated with an acetabular fracture |
Because of anticipated continued use in the literature, both the Torode–Zieg and the Pennal–Tile systems are referred to here. For acetabular fractures, the classification of Letournel and Judet, the most universally used system is summarized in Fig. 13-6 .
Management
Evolution of Treatment/History
In the literature, treatment of pediatric pelvic fractures has been nearly universally conservative until the past decade. ∗
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High levels of satisfaction regarding their outcomes were seen in both operative and nonoperative unstable pelvic fractures. However, a recent retrospective study of 31 children treated with bed rest revealed that 36% had poor results, defined as continuous pain, marked disturbances in posture and gait, and loss of hip motion. Stable avulsion injuries of the anterior iliac spines, ischial hamstring origin, or iliac crests are best treated by conservative means. Significantly displaced avulsion fractures, painful nonunion, and inability to return to competitive sports have been proposed by some as indications for operative treatment of these injuries. Open-book AP compression injuries have historically been treated by pelvic slings or spica casts. When these injuries are widely displaced or associated with severe hemorrhaging or intraabdominal injuries, treatment is evolving toward external fixation or open reduction and internal fixation with small plates. Stable injury to the anterior ring (isolated fractures of the pubic or ischial rami) and more severe four-ramus (or straddle) fractures have been and continue to be best treated by bed rest or spica casts ( Fig. 13-8 ). It is for the most severe, unstable pelvic fractures that treatment recommendations have changed. The standard treatment regimen for a vertical shear pelvic fracture (ipsilateral or contralateral fracture of both pubic and ischial rami or symphysis disruption anteriorly associated with a displaced fracture of the posterior iliac crest, sacrum, or SI joint) recommended in the literature has been skeletal traction with a pin through the distal end of the femur. With more widespread use of external fixation, pediatric pelvic fractures of this nature have also been treated in such a fashion ( Fig. 13-9 ). Both treatments frequently result in SI joint fusion or malunion and leg-length inequality; however, these outcomes are less common than when a pelvic band or bed rest is the only treatment. Optimal treatment of displaced fractures of the SI joint, posterior iliac ring, and sacrum is now considered to be reduction (closed, if possible) and percutaneous internal fixation ( Figs. 13-10 and 13-11 ). ∗∗
Recent outcome assessments support this notion.
Acetabular fractures in children have historically also been treated conservatively. Specifically, such treatment consists of bed rest or non–weight-bearing treatment for minimally displaced fractures and 4 to 6 weeks of skeletal traction for displaced fractures. Poor results have been reported, particularly for comminuted fractures, those for which traction did not improve the position of the fragments, and those that result in triradiate cartilage injury in younger children. ∗
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In publications of clinical series when poor radiographic results have not been associated with poor clinical results, an inadequate length of follow-up is generally involved. Children with these injuries need to be monitored to early adulthood before one can be assured of the final functional results. The excellent results published for adults with displaced acetabular fractures have influenced the treatment of pediatric fractures; the current recommendation for fractures involving the major weight-bearing surface with greater than 2-mm displacement and for unstable posterior wall fracture–dislocations are open reduction and internal fixation ( Table 13-2 ).| FRACTURE | DESCRIPTION | TREATMENT |
|---|---|---|
| Pelvic Fractures | ||
| A1, A2 | Fractures not involving the pelvic ring Isolated avulsions (ASIS, AIIS, ischium, ilium) Isolated pubic rami fractures | Conservative management |
| B1 | Open-book, isolated | Conservative management Exception : When associated with major hemorrhage or laparotomy or with displacement of more than 3 mm External fixation vs. open reduction and internal fixation |
| B2, B3 | Lateral compression Isolated Displaced <5 mm | Conservative management Exception : When associated with laparotomy, open reduction and internal fixation (if the anterior ring is amenable) Exception : When widely (>1 cm) displaced, attempt closed reduction; open reduction and internal fixation if not reducible |
| C1 | Vertical shear, displaced | Open reduction and internal fixation of posterior complex with or without internal or external fixation anteriorly (see Fig. 13-13 ) |
| Acetabular Fractures | ||
| Displaced <2 mm | Conservative management | |
| Displaced ≥2 mm | Open reduction and internal fixation | |
Pelvic Fractures
Emergent Treatment
Emergency treatment follows the same protocols established in adult patients and focuses on restoration of hemodynamic stability and damage-control orthopaedic surgery. In a recent German pelvic registry study, 17.9% of children required emergency measures as compared with 11.1% of adults. Emergent pelvic bleeding control, provisional pelvic ring fixation, and prompt treatment of life-threatening additional pelvic injuries are the measures necessary for achieving hemodynamic stability. Pelvic fractures associated with significant hemorrhage or concomitant intraabdominal injury requiring laparotomy may benefit from more aggressive emergency treatment. This situation is indeed rare in children. Direct retroperitoneal or preperitoneal packing has been shown to be effective in stabilizing hemodynamically unstable pediatric pelvic fractures. Embolization should still be considered in the setting of patients not responding to direct packing, although the survival rate is not significantly improved in those cases. Pelvic hemorrhaging frequently responds to closing down the pelvic volume. Pneumatic antishock garments are generally effective for control of hemorrhaging during patient transport. The sizes appropriate for smaller children are not widely available, which limits the application of this technology to larger adolescents. When these garments are used, they must be removed early in the resuscitation process so that compartment syndrome in the lower extremity is avoided and so that no fractures or open wounds are missed. Recently, pelvic straps have been developed that are placed at the level of the trochanters and can be tightened and held with Velcro, closing down the pelvic volume. If appropriate sizes are not available, this procedure can also be accomplished with a sheet and towel clamps. Closing pelvic volume down is also easily accomplished with simple external fixation frames with one or two pins in each iliac wing and a connecting bar ( Fig. 13-9 ). Anterior external fixation does not optimally control displacement in the posterior pelvic ring. Posterior antishock clamps have recently been developed and have proved to be effective for SI disruption and displaced sacral fractures associated with severe hemorrhaging in children. These clamps can be difficult to apply, and their utility is limited (because of clamp size) to larger children and adolescents. They should be applied under fluoroscopic control; optimally, application of the clamps can be done in the angiography suite while the angiography team is being assembled.
In cases of open-book pelvic fractures with diastasis of 3 cm or more in which a laparotomy is being done, simple open reduction and internal fixation can be performed with a four- or five-hole 3.5-mm dynamic compression (DC) plate and two to three cortical screws in each pubis ( Fig. 13-12 ). In situations in which the patient is hemodynamically unstable and no laparotomy has been performed, a pelvic fracture of any pattern can be stabilized by a bilateral long leg spica cast with distal femoral pins incorporated. In all other settings of multiple injury (not involving associated blood loss from the pelvic fracture), pelvic fracture management is best delayed 3 to 5 days and initiated after the full diagnostic evaluation is complete.
Indications for Definitive Treatment
Open pelvic fractures with significant soft tissue injuries and uncontrolled hemorrhaging, despite aggressive resuscitation ; optimization of patient mobility ; prevention of deformity in severely displaced unstable fractures ∗ ;
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and special circumstances in polytrauma patients have all been suggested as acceptable indications for operative fixation. Currently, only case series are reported in the literature, and no universal agreement exists on the indication for definitive fixation.Nonoperative Treatment
Bed Rest and Non–Weight-Bearing
Indications/Contraindications
Bed rest treatment is indicated for all avulsion fractures of the pelvic ring and for stable pelvic fractures. These injuries include avulsion fractures of the anterior superior (sartorius origin) and anterior inferior (rectus femoris) iliac spines, the iliac apophysis (external oblique origin), the ischial rami (hamstring origin; a common athletic injury), and isolated or bilateral pubic ramus fractures. Probably the most severe injury that can be treated in this fashion is a straddle fracture (four rami); however, posterior ring injury must be definitively ruled out by CT and inlet–outlet radiographs. Other AP compression variants, including the minimally displaced open-book injury (<3 cm), can also be treated in this manner. Unstable pelvic injuries of the B1, B2, C1, or C2 type should not be treated in this fashion.
Timing
Treatment should begin as soon as all other injuries have been diagnosed and stabilized.
Technique
The muscle associated with an avulsion injury should be relaxed. Therefore, patients with anterior superior or anterior inferior iliac spine avulsions or iliac apophysis avulsions and those in whom the rectus abdominis muscles are attached to pubic segments adjacent to fractures are placed in the semi-Fowler position with the hips flexed 30° to 45°. Lower extremity exercises (ankle and foot) are encouraged. Patients with hamstring avulsion injuries are treated by bed rest with the hip extended and the knee flexed as much as possible. If the patient cannot be positioned in this way and made comfortable, a spica cast should be considered. The child is treated in this position for 2 to 4 weeks and then advanced to crutch ambulation ( Fig. 13-13 ).
Skeletal Traction
Indications/Contraindications
The remaining indication for distal femoral pin traction is a vertical shear injury through the iliac wing, SI joint, or sacrum that is shown to be reduced (and remains reduced with follow-up radiographs) in traction. This injury generally occurs in children younger than 8 to 10 years. Contraindications to skeletal traction treatment are lateral compression injuries, open-book A2 injuries, and stable avulsion-type fractures. In addition, fractures that do not achieve reduction in traction should not be managed with this form of treatment because leg-length discrepancy will result.
Timing
After complete diagnosis of all injuries and institution of appropriate management, the child is sedated or given an anesthetic. The skeletal traction pin is inserted proximal to the distal femoral physis, and the child is placed in skeletal traction. Fluoroscopic control is recommended so that inadvertent physeal injury is avoided. The best chance for reduction is when the traction treatment is instituted as soon as possible after the injury, preferably within 24 hours.
Technique
A distal femoral Steinmann pin is inserted proximal to the physis by 2 to 3 cm under fluoroscopic control. A Bohler traction bow is used to help prevent pin loosening with the child’s increasing motion in bed. In contrast to the Kuntscher traction bow, the Bohler bow allows rotation at pin collars rather than being firmly fixed to the pin. The opposite leg is held in skin traction so that significant abduction does not occur; such traction is more often necessary in children younger than 8 years. Balanced skeletal traction with a Thomas splint and Pearson attachment is helpful for toileting in older children. As much as 10 to 20 lbs may be necessary for reduction of the fracture; depending on the child’s age, it is helpful to elevate the foot of the bed on blocks. If reduction to within 2 mm is not obtained within 5 days, despite increasing weight, traction should be discontinued and consideration given to reduction and fixation. The older the child, the more frequently this is the case. Traction should continue for 4 weeks in children younger than 10 years and for 6 weeks in those ages 10 to 14 years. Strong consideration should be given to open surgical treatment of displaced vertical shear fractures in adolescents 12 years and older. The progression is from traction for 4 to 6 weeks to several days of bed rest after traction, and, after radiographic confirmation of continued reduction, initiation of partial weight-bearing with a walker or crutches.
Pelvic Sling
Indications/Contraindications
This relatively dated form of treatment is appropriate only for B1-type open-book closed pelvic injuries that are not associated with shock or hemodynamic instability. Symphyseal displacement greater than 3 cm (2 cm in younger children) should be reduced, and a pelvic sling accomplishes the reduction in some instances. By definition, injuries with anterior displacement of this degree have anterior SI disruption on one or both sides and warrant reduction. This form of treatment is contraindicated for B2 and C injuries because compression directed toward the midline will not accomplish reduction.
Timing
Pelvic sling treatment should be instituted as soon as all other injuries have been diagnosed and stabilized. Early reduction is most likely to succeed because of less resistance to bringing the hemipelves together in the midline before the pelvic hematoma begins to organize.
Technique
A canvas sling 6 to 9 inches in width is placed underneath the supine patient. The ends are connected to traction rope and laterally directed pulleys with sufficient weight to suspend the patient’s pelvis, generally 5 to 10 inches for most children. Greater compressive forces can be obtained by crossing the traction ropes over the patient’s midline. Reduction should be confirmed by a radiograph obtained within 24 hours of initiating treatment. If the symphyseal gap is not closed down to within 1 cm or less, another form of treatment should be considered.
Spica Cast
Indications/Contraindications
The use of a spica cast is indicated in patients who are hemodynamically unstable and in whom internal or external fixation is not possible. Patients with severely displaced pelvic fractures and posterior ring involvement benefit from immobilization of the lower limbs in a double long leg spica cast. For definitive management of pelvic injuries, the spica cast is helpful in minimally displaced pelvic fractures or avulsion injuries because the patient can be treated at home. Other than in the case of a B1 open-book pelvic disruption, in which the spica cast is applied in the lateral position to allow reduction by gravity, these casts do not reduce displaced pelvic fractures. If the displacement is not acceptable, another form of definitive treatment should be selected.
Timing
Spica casts can be applied at any point during the treatment of pelvic fractures for mobilization of the patient. The cast should be applied emergently in the case of hemodynamic instability. If the purpose is to reduce and hold an open-book type of injury, the cast should be applied in the lateral position as soon as the patient’s general status permits.
Technique
For general treatment purposes, the cast is applied in the supine position on a spica board for children 10 years and younger and on a fracture table equipped for casting for older children. If vertical displacement or acute hemorrhaging is part of the clinical picture, it is helpful to incorporate distal femoral Steinmann pins into the cast. These pins are placed under fluoroscopic control so that physeal injury is avoided. When the cast is applied in the lateral position, a fracture table or spica box with a peroneal post that can be removed is most useful. In this instance, the reduction should be confirmed by fluoroscopy with the patient in the lateral position before the cast is completed. If reduction is not confirmed and the residual symphyseal gap is greater than 1 cm, another form of definitive treatment should be considered. These casts are left in position for a total of 4 to 6 weeks if the cast is applied after initial bed rest or traction treatment ( Fig. 13-14 ).
Surgical Treatment
Closed Reduction
Indications/Contraindications
The two primary indications for attempting closed reduction by manipulation without internal fixation are a lateral compression injury with a locked symphysis and the tilt fracture described by Tile. In the former, the goal is to unlock the displaced symphysis from the posterior position to the intact side. In the latter, the goal is to get the displaced free-floating pubic segment away from the vaginal wall in female patients. Because of the lack of stability after reduction of a vertical shear or AP compression injury, closed reduction in this setting is not indicated.
Timing
To optimize the chances of complete reduction, the surgeon should perform manipulation as soon as possible after the injury.
Anesthesia
For both fracture patterns, general anesthesia is preferable with the patient in the supine position.
Technique
For a lateral compression injury, the displaced iliac ring is grasped on its inner aspect, and lateral traction is applied while the intact ring is pushed away. If the patient’s body habitus does not allow a firm grasp in the iliac ring, two Schanz screws of appropriate size (2.5, 4, or 5 mm) can be inserted to use as manipulation handles. They are removed after the reduction maneuver or incorporated into an external fixator. The reduction after manipulation of this injury is nearly always stable. The patient is prescribed bed rest for 3 to 4 weeks and then mobilized with touch-down weight-bearing on the injured side.
For a tilt fracture in female patients, bimanual pelvic examination is performed. If the bony fragment is palpable along the vaginal wall, reduction is indicated. With the intravaginal digit, the pubic segment is lifted anteriorly and superiorly. The external hand grasps the pubis in an attempt to coax the segment anteriorly. If reduction is obtained, it should be radiographically confirmed, and stability should be tested by putting lateral compression on the pelvis. If the segment is not stable, consideration should be given to placing a Steinmann pin across the medial-most fracture line through a small incision to hold the reduction. This pin is removed as soon as callus is evident on follow-up radiographs.
External Fixation
Indications/Contraindications
The indications for this form of treatment are nearly identical to those for a spica cast. External fixation is also a useful management technique for open pelvic fractures. Patients who are hemodynamically unstable will benefit from closing the intrapelvic volume down (see under the section on Pelvic Sling). External fixation provides definitive treatment only for B1-type open-book injuries. This method of treatment cannot hold reductions of displaced posterior ring injuries. An external fixator with a modular frame can be used to treat an open-book pelvic ring fracture or can be used as a supplemental anterior fixation for Tile B2, B3, and C fractures after a posterior SI injury has been stabilized ( Figs. 13-10 and 13-11 ).
Timing
Placement of the frame in circumstances of hemodynamic instability or associated open wounds must be done emergently. If an external fixator is chosen as definitive treatment of an open-book injury, the earlier it is applied, the easier it will be to achieve reduction and allow the hemipelvis to be moved medially before the intrapelvic hematoma begins to organize.
Preoperative Planning
Depending on the size of the patient, the surgeon must check on the availability of an external fixation system with pins that are appropriate for the width of the iliac crest and with connecting bars long enough for the intrailiac dimensions. The pins most commonly used are 4- and 5-mm Schanz pins, but 2.5-mm pins are available for infants and toddlers. Connecting rods 4 and 10 mm in diameter are available; the larger size is generally used, and they can be used with either the 4- or 5-mm pins. Radiolucent connecting rods should be used to allow for radiographic imaging without obstruction.
Anesthesia and Positioning
General anesthesia is the technique of choice for either resuscitative application or definitive reduction. The patient is positioned supine for application of the frame.
Technique
In general, a modular system with a minimal number of components is prepared ( Fig. 13-9 ). Open wounds must be irrigated and débrided (left open) before placement of the frame. Schanz pins or pins specific for the external system and of the appropriate diameter are selected. For children older than 6 to 8 years, standard 4- to 5-mm pins are not too large. Keshishyan and colleagues determined that in children 7 years or younger, 4- to 4.5-mm pins can be used and inserted to a depth of 50 mm; in children 7 to 11 years old, 5-mm pins can be inserted to a depth of 70 mm; and in older children, it is possible to use 6-mm pins up to a depth of 110 mm. However, it is not necessary to use pins larger than 5 mm in any patient with a fractured pelvis. In younger children, pins 2.5 mm in diameter may be more suitable. If the clamps are flexible enough to firmly grip the pin, threaded Steinmann pins of smaller diameter can be used. One or two pins in each ilium are introduced through 1-cm stab wounds ( Fig. 13-9 ). The pins are introduced through predrilled holes of slightly smaller diameter. The holes should just penetrate the superior iliac ring cortex, and the pins are placed by a hand chuck so that the chance of perforation of the inner or outer table of the ilium is minimized. Fluoroscopic control is recommended for perfect placement of the pins between the tables of the ilium. Smooth K-wires can be placed on the inner and outer cortices of the iliac ring as directional guides. The bar or bars can be loosely applied, and then the assistant pushes the two sets of pins to the midline while the surgeon tightens the clamps. Reduction should be confirmed by radiograph. Adequate room should be left between the bars and the abdomen so that the patient can sit up and so that repeated abdominal examination can be performed.
Open Reduction and Internal Fixation
Indications
Indications for reduction and internal fixation of pelvic fractures are an open fracture with massive displacement of the fragments and widely displaced fractures of the A2, B1, B2, C1, and C2 types. Failed closed reduction and failure of an external fixator to hold reduction are relative indications for open reduction because no other means of manipulation will be successful, especially if the injury is more than 5 days old.
Timing
Closed or open reduction of displaced pelvic fractures is optimally done 48 to 72 hours after injury. Active hemorrhaging will have ceased by then, and preoperative studies such as CT scans can be obtained and carefully reviewed. Delaying operative reduction more than 5 to 7 days increases the difficulty of obtaining anatomic reduction.
Preoperative Planning
Selection of the surgical approach is based on the location of the posterior ring injury. The plain radiographs and CT scans are studied for determination of optimal positioning of the implants. In patients younger than 10 years, 3.5- or 4.5-mm cannulated or 3.5-mm cortical screws are the optimal implants. They must be available (special order) in lengths up to 100 mm for pediatric application. An experienced pelvic fracture surgeon should be consulted.
Anesthesia and Positioning
A general anesthetic is appropriate for all closed or open pelvic reductions. The patient is positioned supine for anterior ring approaches; SI joint or posterior iliac ring injuries can be addressed with the iliac fossae portion of the ilioinguinal approach. For posterior approaches to the SI joint and for displaced sacral fractures, the patient is positioned supine or prone. In both instances, the patient should be on a radiolucent table; the C-arm is used to confirm placement of the hardware intraoperatively.
Technique
For anterior ring injuries, a Pfannenstiel approach is made to the symphysis and medial pubis. This incision is extended laterally to a formal ilioinguinal approach if more lateral displacement must be addressed. It is extended proximally to the posterior aspect of the iliac fossa for posterior iliac fractures and simple SI joint disruptions. For symphysis disruptions, simple two-hole 3.5-mm DC plates or six-hole 2.7- or 3.5-mm reconstruction plates are used with 3.5-mm cortical screws ( Fig. 13-12 ). The longer reconstruction plates are preferred because they offer increased stability of the symphysis. The 2.7- or 3.5-mm reconstruction plates are also useful for posterior iliac fractures if long 2.7-mm or 3.5-mm cortical lag screws will not suffice. Disruptions of the SI joint may be stabilized in children with 3.5- or 4.5-mm cannulated screws placed percutaneously under fluoroscopic control and the patient in the supine position. The authors’ preferred technique is shown in the case presented in Fig. 13-11 . Experience with this technique is required because of the high frequency of sacral anatomic variations (which may preclude the use of this technique) and the technical difficulty of this procedure; expert fluoroscopic skills are also required and iatrogenic neurologic injuries of the lumbosacral nerve have been reported. A recent iatrogenic ureteral injury has also been reported. Alternatively, the joint can be stabilized in an open fashion with one (or two) two-hole 3.5-mm DC plate; one screw is placed in the sacrum, and the other one is in the iliac wing. When the open posterior approach is selected for SI joint disruption, the screws are placed across the iliac wing and into the SI body of the sacrum. One screw is relatively easy to place if the inlet and outlet views are observed under fluoroscopy during the procedure and if the lateral sacral view shows the screw to be inferior to the sacral slope. If adequate intraoperative visualization can be achieved, this approach is preferable to plate fixation. A technique has also been described in which CT is used as an aid in safe placement of the screw implants. A second screw can be placed posterior to the sacrum into the opposite intact iliac wing and capped with a washer and nut to prevent loss of compression, but a second screw is rarely necessary. This screw must not be overcompressed because opening of the anterior SI joint could occur, nor should it be overcompressed in the case of a transforaminal sacral fracture because the sacral nerve roots could be crushed. If a percutaneous technique is used for a comminuted sacral fracture, then a fully threaded screw is recommended because its use will avoid injury to the sacral nerve roots with compression of the sacral foramina. In the special case of a crescent fracture dislocation with enough posterior iliac bone still attached to the sacrum, 3.5-mm or 4.5-mm lag screw fixation with or without anterior external fixation is normally adequate ( Fig. 13-10 ).
Postoperative Care and Rehabilitation
Immobilization
The duration and type of immobilization depend on the fracture type and which treatment is selected, but the treating physician should bear in mind the following general rules: 6 to 8 weeks’ healing time for pelvic and acetabular fractures, about 2 weeks less for children younger than 7 years, and 2 to 4 weeks more for adolescents older than 14 years. If the initial treatment is bed rest, traction, or a pelvic sling, the younger child may be placed in a spica cast for the remaining healing time.
Beginning at about 4 to 5 weeks, cooperative children with adequate strength and coordination may be mobilized with a walker or crutches; such mobilization is possible only in those with an intact posterior pelvic ring complex on one side. The intact side is made fully weight-bearing, and the injured side is made partially weight-bearing for the 3 to 4 weeks necessary for complete healing. Care must be taken when patients who have had significant posterior iliac wing injuries treated by reduction in traction are mobilized. Because significant leg-length inequality can result from this form of treatment, the patient should be taken out of bed cautiously—and only when healing has been confirmed radiographically and no clinical tenderness is present. If in doubt, the physician should err on the side of conservatism and leave the child in traction longer than strictly necessary. Patients who have been treated surgically with anterior ring open reduction and internal fixation may be treated with bed rest, bed-to-wheelchair ambulation, or a spica cast for the necessary healing time and then mobilized to full weight-bearing. Children and adolescents who have received anterior or posterior iliac reconstruction plating, anterior SI joint plating, or iliosacral sacral screws with or without additional fixation to the intact posterior iliac crest can be treated with bed rest or a spica cast for the 6 to 8 weeks’ healing time and then mobilized with a walker or crutches gradually, with progressive weight-bearing.
Finally, patients who have been treated with external fixation may be converted to internal fixation if the procedure is done within the first 7 to 10 days. Fractures older than 7 to 10 days, especially in younger children, must be considered to be malunited, and operative reduction requires removal or osteotomy of the fracture callus. If the anterior ring disruption is to be managed definitively with external fixation, it must be left in place for the required 6 to 8 weeks’ healing time. The patient can generally be safely converted to a spica cast after 4 weeks of external fixation but should not continue with bed rest because external rotation forces in the pelvis may cause significant discomfort or late displacement.
Mobilization
At 4 to 5 weeks after the injury, children with radiographically documented healing pelvic fractures can be mobilized with a walker or crutches (full weight-bearing on the intact side of the pelvis, partial weight-bearing on the injured side). Caution must be exercised in patients who have significant posterior pelvic ring displacement; frequent radiographs are recommended.
Physical Therapy
Other than for crutch ambulation instruction, physical therapy is not generally required for children with pelvic or acetabular fractures. Swimming is excellent rehabilitative therapy for both pelvic and acetabular fractures and can be initiated 6 to 8 weeks after injury.
Disabilities
Barring complications, children and adolescents with pelvic fractures are fully functional by 4 to 6 months after injury. The same general time frame is valid for acetabular fractures that have been anatomically reconstructed. Patients with significant residual posterior pelvic ring displacement and those with remaining acetabular articular incongruities may have permanent disability.
Implant Removal
Removal of implants is necessary only in children with significant growth remaining ( Fig. 13-10 ). Children younger than 10 years should have implants transfixing the SI joint or symphysis pubis removed 6 to 12 months after injury. Implants placed in the ilium, ischium, or pubis to fix anterior ring or acetabular fractures may be removed in children younger than 8 to 10 years so that encasement in bone is prevented, along with the great difficulty of removing them if later reconstructive surgery is required.
Acetabular Fractures
Emergent Treatment
Acetabular fractures should be managed after the goal of achieving hemodynamic stability and damage control has been achieved; a short delay (1 or 2 days) for optimization of preoperative planning might occur.
Indications for Definitive Care
Most displaced acetabular fractures with more than 2 mm of displacement should be considered for definitive operative fixation.
Nonoperative Treatment
Bed Rest/Non–Weight-Bearing
Bed rest or non–weight-bearing ambulation with crutches is appropriate only for nondisplaced or extremely minimally displaced (1 mm or less) fractures. Nothing specific is different about the bed rest treatment other than avoidance of pushing off with the injured limb. The patient must be closely supervised so that ambulation is prevented. Similarly, patients allowed touch-down weight-bearing with crutches on the injured side must be carefully supervised to avoid weight-bearing forces being transmitted across the fracture surface and subsequent displacement; such treatment is appropriate only for older children who can be relied on to cooperate ( Fig. 13-15 ).
Skeletal Traction
Traction treatment is appropriate only for acetabular fractures that are reducible to less than 1 to 2 mm of displacement. Because of the elastic nature of skeletal tissue in children, however, such is rarely the case. A traction pin should be inserted in the distal end of the femur under fluoroscopic control and with the patient under anesthesia so that physeal injury is avoided. The fracture must be demonstrated to be reducible with follow-up AP and obturator and iliac oblique radiographs (with gonadal shielding) within the first 5 days. Fracture patterns that may be reducible with traction include two-column fractures and associated variants. Isolated columnar injuries or posterior wall fractures are not generally reducible with traction.
Surgical Treatment
Open Reduction and Internal Fixation
All displaced acetabular fractures (with ≥2 mm of displacement documented on CT) should undergo operative reduction and internal fixation. The surgical approach varies according to the pattern of the fracture and the nature and direction of the displacement, as determined on preoperative AP, iliac, and obturator views and CT scans. All posterior wall injuries are amenable to reduction with the Kocher–Langenbeck approach. When a posterior wall fracture is combined with posterior column injuries, this surgical approach is also generally effective. The authors prefer to use the Kocher–Langenbeck approach with the patient in the prone position when it is being used for an isolated posterior wall fracture. When the approach is being performed for a fracture involving the posterior column, it should also be done with the patient prone, as described by Letournel and colleagues. Anterior column injuries are optimally managed with the ilioinguinal approach of Letournel and colleagues. The associated injuries are best dealt with on an individual basis. When the posterior wall is not involved, the authors generally prefer the ilioinguinal approach because of the lower incidence of heterotopic ossification, better range of motion, and earlier return to function. Some transverse fractures and transverse fractures with associated posterior wall injuries may require the extended iliofemoral approach or the combined Kocher–Langenbeck incision along with the iliofemoral approach, although use of the simultaneous dual approach is rarely necessary and is associated with greater blood loss and a higher incidence of heterotopic ossification. Internal fixation devices for children’s fractures are generally of the 3.5-mm (small fragment) and 2.7-mm family. Extra-long screws must be specially ordered. The authors generally prefer 3.5- or 2.7-mm reconstruction plates for posterior wall fractures to allow early unrestricted motion of the hip (particularly unrestricted hip flexion) ( Fig. 13-16 ). As a general rule, most children’s associated (more complex) fractures that do not involve the posterior wall can be treated with lag screws alone. Multiple assistants, Schanz pins with universal chucks, femoral distractors, specialized pelvic clamps, among others, are all useful. Delayed presentation of a posterior acetabular fracture should still be reduced within 3 weeks of injury ( Fig.13-17 ). A surgeon experienced in acetabular fracture approaches and fixation in adults should be consulted for all operative children’s fractures.
Postoperative Care and Rehabilitation
Immobilization
Patients with acetabular fractures also require 6 to 8 weeks of healing time before weight-bearing can be allowed without fear of displacement of the fracture. Younger children may be mobilized at 5 to 6 weeks; adolescents older than 12 years should be treated with partial weight-bearing for 3 to 4 weeks longer (for a total of 10 to 12 weeks). Fractures that are minimally displaced and those treated with internal fixation can tolerate partial weight-bearing on the injured side with a walker or crutches beginning 2 to 3 weeks after the injury. Fractures reduced in traction should be held there for the full 5 to 6 weeks.
Mobilization
Minimally displaced or operatively fixed acetabular fractures can be mobilized (partial weight-bearing on the injured side) 4 to 5 weeks after injury.
Physical Therapy
Other than for crutch ambulation instruction, physical therapy is not generally required for children with pelvic or acetabular fractures. Swimming is excellent rehabilitative therapy for both pelvic and acetabular fractures and can be initiated 6 to 8 weeks after injury.
Disabilities
See the Disabilities section under Pelvic Fractures and Dislocations.
Implant Removal
See the Implant Removal section under Pelvic Fractures and Dislocations.
Complications
Complications in the early phase of management of a significant pelvic injury are bladder rupture, urethral injury, vaginal or rectal laceration, vascular injury, lumbosacral plexus injury, deep venous thrombosis, hemorrhage, and death. The more general complications and their prevention are covered in Chapter 7 . The other associated injuries are a result of the primary trauma, and little can be done to prevent them short of preventing the initial injury.
Long-term complications of pelvic fractures include delayed union, nonunion, malunion, fusion of the SI joint, and leg-length inequality ( Fig. 13-18 ). Delayed union and malunion can generally be prevented by an adequate period of immobilization. Nonunion as a complication is rare ; malunion is far more common. Fusion of the SI joint is probably a result of the severe trauma producing the fracture, but the rate of this complication may be favorably influenced by anatomic reduction. To this extent, no less than anatomic reduction of an SI joint should be accepted in a child. These standards and an adequate period of immobilization will prevent leg-length inequality. Adherence to these high standards requires a high percentage of accurate closed reductions with percutaneous fixation or open reductions for displacements in the posterior pelvic ring.
Avascular necrosis of the femoral head has been reported as a complication after isolated avulsion of the greater trochanter in children. Long-term complications of acetabular fractures are premature closure of the triradiate cartilage, ∗
∗
joint space narrowing and sclerosis, femoral head subluxation, and avascular necrosis. Acceptance of no more than 1 to 2 mm of displacement in the acetabulum and careful surgical exposure minimize their incidence. The acetabular dysplasia that results from premature closure of the triradiate cartilage is distinctly different from other forms of dysplasia. The marked retroversion that is produced is correctable by acetabular osteotomy, which is technically demanding.The treatable long-term complications of pelvic fractures include leg-length inequality, malunion, and nonunion. Leg-length inequality in a young child is best managed by properly timed contralateral epiphysiodesis. In an older child, closed femoral shortening as developed by Winquist and colleagues is appropriate after it has been determined that the inequality is functionally significant. Symptomatic nonunion is best managed by stabilization with internal fixation and bone grafting. Malunion of the anterior pelvic ring may require osteotomy and stabilization if it proves to be disabling in terms of sexual function, especially in females.
The most severe long-term complications of acetabular fractures (i.e., avascular necrosis, loss of joint space, and degenerative arthritis) are treatable only with drastic surgical measures. With these complications, temporizing with weight loss, canes, modification of activity, and antiinflammatory medications is the wisest course. Ultimately, the choice, in most cases, is between arthrodesis and arthroplasty. The latter is best delayed as long as possible. Premature closure of the triradiate cartilage may be optimally managed by bridge resection and fat interposition, but the difficulty of surgical access and visualization makes this procedure hard to recommend, except for the most experienced pelvic surgeons. The misshapen growth and lateral femoral head extrusion must be well defined and documented by CT, three-dimensional CT, or MRI before such a procedure is undertaken. The safer course may be a lateral coverage procedure, such as an acetabular osteotomy, in early adolescence.
Outcome
Functional and Anatomic Parameters
Anatomic parameters, important to consider for pelvic fractures, are based on radiographic evaluation alone. For a pelvic ring injury, reconstruction of normal anterior and posterior pelvic ring anatomy is the goal. The SI joint should not be fused, and the symphyseal cartilage space must be maintained. For acetabular fractures, a symmetric joint space must be maintained, with no femoral head avascular necrosis or evidence of acetabular or femoral head osteophytes or lateral extrusion of the femoral head, as with premature closure of the triradiate cartilage.
Anatomic assessment of the results of a pelvic fracture influences the functional outcome only minimally. The critical result is patient function. An appropriate functional assessment for both pelvic and acetabular fractures in children includes an evaluation of pain, limping, motion of the hip, leg-length inequality, activities of daily living, and sports performance, as well as an evaluation of altered activities (see Chapter 8 ). Both males and females can have residual genitourinary, reproductive, and sexual problems in rare instances. A recent midterm assessment of functional outcomes (mean, 6.5 years after injury) supports open reduction and internal fixation in cases in which closed reduction within 1.1 cm of pelvic asymmetry cannot be obtained.
Rating Scales
Heeg and colleagues suggested that the rating scale of Harris be used to assess the functional results of acetabular fractures. Until an alternative scale specific to these injuries is developed and validated, this scale may be the best available. No published rating scale has been used to assess a population of children with pelvic or acetabular fractures; however, validated functional outcome scores have been used to report the results of adults with pelvic fracture. Physical rating scales and functional outcomes scales for children have been reviewed by Young and Wright (see Chapter 8 ).
Expected Results
Mortality rates for children with pelvic fractures range from 2% to 12%, which is not significantly different from figures published for adults with pelvic fractures. Open pelvic fractures and those with significant major vascular injury carry the highest risk. Patients with avulsion injuries and minor anterior pelvic disruption can be expected to have no residual disability, although nonunion can rarely result. On follow-up at maturity, two thirds of patients with serious pelvic displacement have no significant functional disability, and half have normal radiographic results that accompany their functional outcomes. One third have residual limping and pain and have had to alter their activities. Growth arrest deformities may be related to triradiate cartilage injury, but these deformities are seen much more rarely than growth arrest resulting from proximal femoral physeal injury.
Of the 23 patients with acetabular fractures monitored by Heeg and colleagues, 18 were treated conservatively. Good to excellent functional results were achieved in 21, and radiographic results were good to excellent in 10. These investigators reported no improved results with operative management versus nonoperative treatment in patients with comminuted fractures or type V triradiate cartilage injuries. Excellent long-term results have been reported with widely displaced transverse fractures managed operatively. As more experience is gained with the operative management of acetabular fractures in general, good to excellent functional results can be expected in 80% to 90% of children and adolescents with such fractures.
Metaanalyses and Systematic Reviews
Gänsslen and colleagues have recently published two comprehensive reviews on pediatric pelvic fractures and acetabular fractures. Similar but less scaled reviews were done by Schlickewei and Keck and Quick and Eastwood. A proposed protocol for treatment taking into consideration associated organ injuries, hemodynamic status of the patient, the patient’s age, and type and stability of the fracture were all being considered when recommendations were made for treatment of this rare injury.
Guidelines (Discussion of Guidelines)
No clear guidance or didactic approach is present in the current literature. The rates of operative intervention by various authors range from 0.6% to 30%, and comparable rates of external and internal fixation are comparable. ∗
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Cost-Effectiveness
In the study by Hughes and colleagues, lack of mobility was identified as the major problem when children were treated with spica casts for femur fractures. An average of 3 weeks’ time off and 8 weeks of home tutoring were noted, and none of the children was allowed back in school with a spica cast. A similar conclusion could be made for spica cast management of pelvic ring fractures. Pelvic fractures in children were the second most expensive hospitalization with the total cost of $15,011.61 according to a 2005 study. These fractures were also associated with the second highest mortality rate of 0.55% (5 of 900 patients). The length of stay in the hospital was an average of 5.3 days. Other studies suggested much longer stays of 6 to 22 days (median, 8 to 9 days). A recent study of a national database of children seen with pelvic fractures suggested those treated at pediatric trauma centers had significantly better outcomes, potentially because of fellowship trained surgeons, volume of care, and specialization. No comparable literature exists for the cost effectiveness of different treatments for pediatric pelvic ring or acetabular fractures.
Conclusion
Pediatric pelvic fractures are the result of high-energy injuries and are rare. Significant hemorrhaging and associated visceral injuries should be prioritized and treated aggressively with the goal of achieving hemodynamic stability. Pelvic fractures can be provisionally stabilized and definitively treated 3 to 5 days later. Open pelvic fractures have a high mortality rate and should be considered an orthopaedic emergency. Thorough débridement and irrigation plus appropriate antibiotic coverage and tetanus shots can help to lower the rate of complications. The majority of pelvic fractures can be managed closed, and most complications and poor outcomes are related to unstable pelvic fractures. A trend toward definitive fixation with either a closed or open approach has been seen in multiple case series. No current consensus exists on the indications for definitive surgical management of pediatric pelvic fractures. External fixator, percutaneous SI screw fixation, anterior pelvic ring plating, posterior SI plating, or combined approaches have all been reported with good outcomes. Acetabular fractures are also the cause of high-energy trauma and are even rarer. Associated injuries must be scrutinized and treated. Displacement of more than 2 mm requires open reduction and internal fixation. There is good correlation between the clinical and radiologic result.
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