|SYMPOSIUM ON PELVIC TRAUMA
|Year : 2014 | Volume
| Issue : 1 | Page : 33-36
Pelvis fractures in children
Alok C. Agrawal, Roop Bhushan Kalia
Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
|Date of Web Publication||6-Jun-2014|
Alok C. Agrawal
Department of Orthopaedics, All India Institute of Medical Sciences, Raipur - 492 099, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Injuries of the pelvis causing fractures in paediatric patients are rare injuries due to the elasticity of the bones and joints and account for 1-2% of all fractures in children. Injuries involving the tri-radiate cartilage are difficult to diagnose and have sequelae of growth arrest which are difficult to treat. Bony avulsion fractures are common in young children while acetabular and pubic or sacroiliac diastases are more common in adolescents. These injuries need radiographs and CT scanning for accurate characterization. Most injuries can be treated conservatively; however treatment needs to be individualized depending on the personality of the injury.
Keywords: Children, fracture, pelvis
|How to cite this article:|
Agrawal AC, Kalia RB. Pelvis fractures in children. J Orthop Traumatol Rehabil 2014;7:33-6
Fractures of the pelvis in children are uncommon.  Pediatric pelvic fractures account for only 1% to 2% of fractures seen by orthopaedic surgeons who treat children. Pelvis in children differs from that in adults as it is more malleable. This is due to the nature of the bone itself, the increased elasticity of joints and the ability of the cartilaginous structures in a child to absorb energy. Elasticity of the joints around the pelvis is greater, which allows for significant displacement before a fracture. In children pelvic ring may break only from one site in contrast to a double ring fracture of adults. As the cartilage at the apophyses is inherently weak, bone avulsion fractures occur more frequently in children and adolescents compared with those in adults. Fractures into the tri-radiate cartilage cause growth arrest leading to leg-length inequality and faulty development of the acetabulum. In children and adolescents isolated pubic rami and iliac wing fractures occur more often in immature hips (open tri-radiate cartilage), whereas; ace tabular fractures and pubic or sacroiliac diastases occur more often in mature hips (closed tri-radiate cartilage). 
Pelvic fractures in children are typically associated with high-energy trauma, requiring a comprehensive workup for concomitant life-threatening injuries. Anteroposterior radiographs and rapid-sequence computed tomography are the standards of diagnostic testing required to identify the fracture and recognize associated injuries. Treatment is individualized based on patient age, fracture classification, stability of the pelvic ring, extent of concomitant injuries, and hemodynamic stability of the patient. ,
| Classification of pelvic fractures in children|| |
- Torode and Zieg four-part classification [Figure 1]:
|Figure 1: Torode and Zieg four-part classification of fracture pelvis in children|
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Type I: Avulsion of the bony elements of the pelvis
Type II: Iliac wing fractures
Type III: Simple ring fractures (involving the pubic rami or disruptions of the pubic symphysis)
Type IV: Ring disruption fractures, which create an unstable segment of the pelvic ring, including bilateral pubic rami (straddle) fractures, fractures involving the right or left pubic rami or the pubic symphysis and a fracture through the posterior elements or disruption of the sacroiliac joint, and fractures involving the anterior structures and acetabular portion of the pelvic ring. This classification does not include acetabular fractures.
- Quinby and Rang classification:
- Uncomplicated fractures
- Fractures with visceral injuries requiring surgical exploration
- Fractures associated with immediate massive hemorrhage
This classification is useful concerning the patient's ultimate outcome but emphasizes less on pelvic fracture itself.
- Key and Conwell's classification: Is a classification of pelvic fractures in adults and is based on the number of breaks in the pelvic ring. This system includes acetabular fractures and also is applicable in children
- The Orthopaedic Trauma Association classification:
- Lesion sparing (or with no displacement of) posterior arch
- Incomplete disruption of posterior arch, partially stable
- Complete disruption of posterior arch, unstable.
Other Classifications: Moreno et al., who described four types of "fracture geometry" based on radiographic appearance and used to identify patients at risk for severe hemorrhage. Classifications by Judet et al., Pennal et al., Ogden, and the AO/ASIF group emphasize fracture stability. Young et al. classified pelvic fractures according to the direction of force: Lateral compression, anteroposterior compression, vertical shear, and combined mechanisms.
Avulsion fractures occur most commonly in adolescent athletes; they occur in the anterior superior and anterior inferior iliac spines and in the ischial tuberosity) and are caused by over pull of the sartorius muscle, rectus femoris muscle and hamstring muscles [Figure 2].
Operative treatment of these injuries is rarely indicated, regardless of the amount of displacement. Rarely, excessive callus formation or myositis ossificans occurs after a displaced ischial tuberosity fracture. This may need excision but the current literature does not suggest a patient returning to pre injury sports level following internal fixation.
| Pelvic Fractures are associated with three physical signs|| |
- Destot sign: A large superficial hematoma formation beneath the inguinal ligament or in the scrotum.
- Roux sign: A decrease in the distance of the greater trochanter to the pubic spine on the affected side in lateral compression fractures.
- Earle sign: A bony prominence or large hematoma and tenderness on rectal examination, indicating a significant pelvic fracture.
Posterior pressure on the iliac crest causes pain at the fracture site as the pelvic ring is opened, and compression of the pelvic ring at the iliac crest from lateral to medial causes pain and possibly crepitation. Downward pressure on the symphysis pubis and posteriorly on the sacroiliac joints causes pain and motion if a break in the pelvic ring is present. Pain in the inguinal area can be elicited by flexion and extension of the hips. In patients with an immature pelvis, treatment of pelvic fractures should focus on associated injuries (e.g., head, abdominal) that often are the cause of mortality. ORIF (Open reduction and internal fixation)rarely is necessary for these fractures. Generally, the long-term results of conservative treatment are satisfactory because of the remodeling potential of the pelvis in children.
Soft tissue injuries occurring in conjunction with pelvic fractures may be severe and require emergency treatment. Many pelvic fractures occur in children struck by moving vehicles. Associated injuries include skull, cervical, facial, and long bone fractures; subdural hematomas, cerebral contusions, and concussions; lung contusions; hemothorax; hemo-pneumothorax; ruptured diaphragm; and lacerations of the spleen, liver, and kidney. Injuries that may be associated with and adjacent to pelvic fractures include damage to major blood vessels, retroperitoneal bleeding, rectal tears, and rupture or laceration of the urethra or bladder 2.
The location and number of pelvic fractures are strongly associated with the probability of abdominal injury: 1% for isolated pubic fractures, 15% for iliac or sacral fractures and 60% for multiple fractures of the pelvic ring. Because of these other injuries, mortality in children is high (9% to 18%). In a study of 54 patients with major pelvic fractures, 87% had associated pelvic or extra-pelvic (soft tissue) injuries; 14.8% died. Most patients (70.4%) were treated conservatively. This suggests that the principles of management in children should not differ greatly from those in adults. Serious associated pelvic or extra-pelvic injuries may pose more treatment problems than the actual pelvic fractures. The death rate from pelvic fractures alone is quite low (0% to 2.3%). Torode and Zieg reported 11 deaths in 141 patients with pelvic fractures and 40% of patients with type IV injuries required laparotomy because of other injuries. Frequently, a child who has what radiographically appears to be a minor pelvic fracture also has had significant and possibly life-threatening soft tissue injuries around the pelvis.
Most pelvic fractures in children can be treated closed, usually by a few days or weeks of bed rest.  Any residual deformity usually is unimportant or remodels with growth. Occasionally, significant diastasis of the symphysis requires bed rest in a pelvic sling, followed by a spica cast in the reduced position. We also have used a pelvic external fixator to close the diastasis of the symphysis. Symphysis pubis and sacroiliac subluxations should be treated as aggressively in children as in adults because little or no remodeling occurs to compensate for joint subluxations or dislocations. The Malgaigne fracture, a double vertical fracture in the pelvic ring or a fracture with a dislocation renders the hemipelvis unstable, but it is less common in children than in adults. A CT scan may be helpful in determining the amount of joint displacement. Various methods of treatment for Malgaigne or severely comminuted fractures have been described. Previously they were being treated by a combination of skeletal traction followed by a spica cast and on occasions by an external fixator or ORIF for anterior and posterior instability.
Acetabular fracture-dislocations in children differ from those in adults because they can be caused by trivial trauma in children. Damage to the tri-radiate cartilage in a child may cause growth arrest and a shallow, dysplastic acetabulum [Figure 3]. CT may help determine the extent of acetabular involvement and femoral head stability. The classification of acetabular fractures is based on the extent of acetabular involvement:
|Figure 3: Diagram showing injury to the acetabular rim and tri-radiate cartilage|
Click here to view
- Small fragments most often associated with dislocation of the hip,
- linear fractures associated with pelvic fractures without displacement,
- large linear fractures with hip joint instability and
- central fracture-dislocations.
Reduction of a hip dislocation may reveal a small chip fracture from the posterior margin of the acetabulum, but the hip usually is stable. Radiographs before reduction often reveal the occult fragment more readily than films taken after the reduction. Union almost always occurs. Occasionally, an osteo- chondral fragment may be caught within the hip joint after an apparently satisfactory reduction. Radiographs of the opposite hip should be taken for comparison to ensure that the reduction is congruous. Stable linear fractures require only conservative treatment; a period of non-weight bearing on crutches is all that is necessary. Linear fractures producing hip joint instability require skeletal traction and an accurate reduction. This injury usually occurs in older children and treatment should be the same as for adults. In these patients, skeletal traction has been recommended for 6 to 12 weeks in adults to prevent superior displacement of the acetabular roof. Depending on the skeletal age of the child, however, this lengthy period of traction may be unnecessary but it is better to continue traction longer than necessary rather than allow superior displacement of the fragment. We have used open reduction to obtain a congruous reduction and avoid prolonged traction and bed rest.
Central fracture-dislocations in children should be reduced promptly because the tri-radiate cartilage may be involved. Because injury to the tri-radiate cartilage is easily missed on initial radiographs, all patients with pelvic trauma should be followed clinically and radiographically for at least one year. Two main patterns of physeal disruption have been identified in patients with tri-radiate cartilage injuries: A Salter-Harris type I or II injury, which has a favorable prognosis for continued normal acetabular growth and a Salter-Harris type V crushing injury which has a poor prognosis because of premature closure of the tri-radiate physes secondary to formation of a medial osseous bridge. In both patterns, the prognosis depends on the age of the patient at the time of injury. In young children, especially those younger than 10 years, abnormal acetabular growth can result in a shallow acetabulum. By skeletal maturity, disparate growth may increase the incongruity of the hip joint and lead to progressive subluxation. Acetabular reconstruction may be indicated for correction of the gradual subluxation of the femoral head [Figure 4].
|Figure 4: Types of injuries to the pelvis and triradiate cartilage. a, Normal hemipelvis. b, Salter-Harris type I fracture. c, Salter-Harris type II fracture. d, Salter-Harris type V fracture|
Click here to view
Longitudinal skeletal traction is necessary. If this is inadequate, lateral traction should be added to ensure a satisfactory reduction. Occasionally, ORIF may be necessary as in adults,  although operative reduction is required for unstable posterior fracture-dislocations and irreducible central fracture-dislocations and did not improve results in their patients, especially patients with type V fractures. ,
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]