Orthopedics

Feature Article 

Pediatric Pelvic Ring Injuries

Laura W. Lewallen, MD; Amy L. McIntosh, MD; S. Andrew Sems, MD

Abstract

The purpose of this study was to determine whether pelvic fracture pattern is associated with transfusion requirements or concomitant injuries in pediatric patients. This was a single-institution, retrospective review from 1970 to 2000. Pelvic ring injuries were classified using the Orthopaedic Trauma Association system. Injury Severity Scores were assigned. Ninety patients were included in this study. There were 27 A-type (30.0%), 51 B-type (56.7%), and 12 C-type (13.3%) injuries. Mean Injury Severity Scores were 8.1 for 61 A-type, 12.7 for 61 B-type, and 23.6 for 61 C-type fractures (P<.0001). Transfusion was required for 14.8% of A-type, 18.4% of B-type, and 66.7% of C-type injuries (P=.0009). There was no significant association with the number of units transfused (P=.9614). Decreased pelvic ring fracture stability was associated with an increased need for blood transfusion, although not with the number of units. Pelvic ring fracture stability may be a marker of associated injuries. [Orthopedics. 201x; xx(x):xx–xx.]

Abstract

The purpose of this study was to determine whether pelvic fracture pattern is associated with transfusion requirements or concomitant injuries in pediatric patients. This was a single-institution, retrospective review from 1970 to 2000. Pelvic ring injuries were classified using the Orthopaedic Trauma Association system. Injury Severity Scores were assigned. Ninety patients were included in this study. There were 27 A-type (30.0%), 51 B-type (56.7%), and 12 C-type (13.3%) injuries. Mean Injury Severity Scores were 8.1 for 61 A-type, 12.7 for 61 B-type, and 23.6 for 61 C-type fractures (P<.0001). Transfusion was required for 14.8% of A-type, 18.4% of B-type, and 66.7% of C-type injuries (P=.0009). There was no significant association with the number of units transfused (P=.9614). Decreased pelvic ring fracture stability was associated with an increased need for blood transfusion, although not with the number of units. Pelvic ring fracture stability may be a marker of associated injuries. [Orthopedics. 201x; xx(x):xx–xx.]

Pelvic fractures are uncommon but potentially devastating in the pediatric population. Pelvic fractures are reported to account for between 2% and 8% of all skeletal fractures in adults and children1–5 and 1% to 3% of skeletal fractures in children.6 Pelvic fractures account for 2.4% to 7.5% of hospital admissions among children following blunt trauma.6–8 Demetriades et al,9 in a study of 16,630 blunt trauma patients, found that “adults were twice as likely to suffer pelvic fractures as pediatric patients.”

A study performed previously at the Mayo Clinic found the incidence of pelvic fractures for all age groups in the surrounding region to be “37.0 per 100,000 person-years for all pelvic fractures, including recurrences, and 35.2 per 100,000 for first pelvic fractures alone.”10

Several qualities of the pediatric skeleton may affect the injury pattern and management of pelvic fractures in these young patients, as compared with adults with similar injuries.11 The increased plasticity of bone, joint laxity, and greater remodeling potential seen in children can be advantageous, but open physes may present additional challenges.

Pelvic fractures usually result from high-energy trauma, although the specific mechanism of injury often varies by age group. Although motor vehicle accidents with the patient as the driver or passenger account for most pelvic fractures in adults, pedestrian vs automobile accidents cause most of those seen in children.6,12,13 In addition, low-energy (typically sporting) injuries, resulting in avulsion fractures, are not uncommon in children.13,14

Despite the rarity of pelvic fractures in children, they are associated with a disproportionate number of deaths.14 Recently reported death rates range from 2% to 12%.11 Most of these deaths can be attributed to associated injuries, particularly of the central nervous system, rather than the pelvic injury itself. This is in contrast to adults with severe pelvic fractures, for whom a common cause of death is exsanguination.6,15,16

Among patients who survive these injuries, long-term outcomes are yet to be well established. A study by Heeg and Klasen17 examined 18 children with sacroiliac disruptions with average follow-up of 14 years. Three patients reported daily back pain, and 6 patients had disabling symptoms and gait abnormalities secondary to incomplete neurologic recovery. These authors did not identify an association between radiographic changes and symptoms. A study by Subasi et al16 examined long-term outcomes of pediatric pelvic fractures treated conservatively. Although orthopedic outcomes were encouraging, associated urologic injuries and subsequent social/psychological issues were significant.

The purpose of this study was to determine whether pelvic fracture pattern, as defined by the Orthopaedic Trauma Association (OTA) classification system, is associated with transfusion requirements or concomitant injuries in pediatric and adolescent patients. Manson et al18 performed a similar study among a general population—adults and children of all ages—using the Young-Burgess system. However, to the best of the authors' knowledge, this has not been studied in the pediatric population or using the OTA system.

Materials and Methods

This single-institution, retrospective review of pelvic fractures in pediatric and adolescent patients between January 1970 and December 2000 received institutional review board approval. A search of the medical/surgical index database was performed using the keywords pelvic, acetabular, sacral, pubic ramus, or iliac fracture. A total of 292 pediatric patients with pelvic fractures in this time frame were identified. Existing records including clinical and operative notes, as well as imaging studies (radiography, computed tomography, and magnetic resonance imaging), were reviewed. Patients were selected for inclusion based on the following criteria: (1) age of 16 years or younger at the time of the injury, (2) pelvic ring fracture (OTA classification: location 61), and (3) pelvic radiographs available from the time of injury.

Of the initial 292 patients, 104 were excluded due to lack of imaging. Thirty-eight patients were excluded because there was no clear diagnosis of pelvic fracture or because the only available imaging was many years after the injury and original injuries could not be classified. Avulsion fractures (47 patients) and gunshot wounds (1 patient) were also excluded. Acetabular fractures (12 patients) were not included in this portion of this study. A total of 90 patients were included.

Data extracted from the charts included sex, age, mechanism of injury, details of the pelvic fracture, associated injuries (head, chest, abdominal/pelvic, extremity, or spine), pelvic orthopedic surgery, other surgical procedures, length of hospitalization, blood transfusion requirements during the hospitalization, medical/surgical complications, and late elective procedures related to the pelvis or spine.

Radiographic Analysis

Radiographs were reviewed by an orthopedic trauma fellowship-trained surgeon (S.A.S.) and a pediatric orthopedic fellowship-trained surgeon (A.L.M.). Injury pattern was assessed based on the OTA fracture classification system, including location, type, group, and subgroup. Associated injuries were recorded, and Injury Severity Score was assigned retrospectively using the 2005 Abbreviated Injury Scale. Radiographic measurements were made for vertical displacement, internal rotation, sacral displacement, sacroiliac widening, and symphyseal widening.

Statistical Analysis

Statistical analysis was performed using JMP version 9.0.1 software (SAS Institute Inc, Cary, North Carolina). Univariate analysis was performed for groups/subgroups based on the OTA classification system. Further analysis was performed using the chi-square test, with P=.05 being statistically significant.

Results

During the 30-year study period from 1970 to 2000, there were 292 pediatric patients with a diagnosis of pelvic or acetabular fracture at the authors' institution. Of these, 90 patients met inclusion criteria for this study. There was a nearly equal sex distribution, with 46 males (51.1%) and 44 females (48.9%). The average age at the time of injury was 10.9 years (range, 2–16 years).

The most common mechanism of injury was motor vehicle accident (41.1%) (ie, patient as driver or passenger), followed by pedestrian/bicycle vs automobile accidents (25.6%). Other mechanisms of injury included snowmobile or all-terrain vehicle accident, fall from height, crush injury, and sports injury (Table 1).

Mechanisms of Injury

Table 1:

Mechanisms of Injury

Pelvic ring injuries only (OTA 61) were included in this portion of the study and were further classified by type, group, and subgroup (Figures 12). There were 27 A-type (30.0%), 51 B-type (56.7%), and 12 C-type (13.3%) injuries. The most common fracture type subgroup was 61 B 2.1, with 29 patients (32.2%).

Anteroposterior radiograph of a 4-year-old girl with crush injury to the pelvis (type 61 B 2.3) at 5-year follow-up.

Figure 1:

Anteroposterior radiograph of a 4-year-old girl with crush injury to the pelvis (type 61 B 2.3) at 5-year follow-up.

Anteroposterior radiograph of a 5-year-old boy involved in pedestrian vs automobile accident (type 61 B 3.1) at 18-year follow-up.

Figure 2:

Anteroposterior radiograph of a 5-year-old boy involved in pedestrian vs automobile accident (type 61 B 3.1) at 18-year follow-up.

Blood transfusions were administered in 21 patients (23.3%), with an average of 6.9 units. Decreasing stability of pelvic ring fractures was associated with increasing transfusion requirements. A total of 14.8% of the A-type, 18.4% of the B-type, and 66.7% of the C-type injuries required transfusion (P=.0009) (Figure 3). However, there was no significant association with the number of units transfused (P=.9614).

Fracture type and blood transfusion.

Figure 3:

Fracture type and blood transfusion.

The average Injury Severity Score was 12.77 overall. The mean Injury Severity Scores by fracture type were 8.1 for 61 A, 12.7 for 61 B, and 23.6 for 61 C (P<.0001) (Figure 4). When comparing across groups, the authors also found significant differences: A–C (P<.0001), B–C (P<.0001), and A–B (P=.0165). Because of the limited numbers, no comparisons could be made among the subgroups.

Fracture type and mean Injury Severity Score (ISS).

Figure 4:

Fracture type and mean Injury Severity Score (ISS).

Age was not statistically associated with fracture type (P=.61 for 61 A/B/C), Injury Severity Score (P=.12), or the need for blood transfusion (P=.26).

Associated injuries were classified by region (Table 2). The most commonly associated injuries were head/face and extremity. There were 53 patients (58.9%) with head/face trauma and 42 patients (46.7%) with extremity trauma. The average Glasgow Coma Scale on admission, for those with documented Glasgow Coma Scale, was 12.6.

Associated Injuries

Table 2:

Associated Injuries

Seventeen patients (18.9%) underwent initial operative management of the pelvic fracture. This included closed reduction, external fixation, traction pinning/placement, or open reduction and internal fixation. Thirty-six patients (40%) underwent surgery for management of associated injuries. The average length of hospitalization was 12 days. One patient (1.1%) died as a result of injuries sustained (ie, intracerebral hemorrhage, uncal herniation, and splenic rupture).

Discussion

Pediatric patients with unstable pelvic ring injuries were more likely to require blood transfusion during hospitalization. Nearly one-fourth of the patients received a blood transfusion, which was approximately 7 units on average. This is a significant amount, particularly for the pediatric population. These patients also had more serious concomitant injuries, as determined by higher Injury Severity Score. This information is useful in highlighting the significance of these injuries.

Although fractures were classified by location, type, group, and subgroup, the final analysis was limited by the size of the sample. Given the small number of patients in each fracture subgroup, it was not possible to make comparisons beyond the level of fracture type. Another limitation was the retrospective nature of the study design.

In this series, motor vehicle accidents were more common than pedestrian/bicycle vs automobile accidents. This differs from Silber et al6 and Torode and Zieg13 reporting that pedestrian/bicycle vs automobile accidents accounted for most injuries.

Pelvic fractures in children are typically managed nonoperatively, with immobilization and pain control followed by protected weight bearing.11,14 In a study of 166 pediatric patients with pelvic fractures by Silber et al,6 97% (161 of 166) were treated nonoperatively. Children who did require surgery were, on average, considerably older than those treated without surgery (14.3 years vs 8.7 years).6 Nineteen percent of the patients in the current study underwent operative management. Given the small number of patients in this group, there was no statistical correlation between the need for operative management, OTA classification, or mechanism of injury.

High-energy injuries with pelvic fracture displacement may require surgery. However, controversy exists regarding which fractures require definitive operative management. Blasier et al19 examined midterm functional results, at average followup of 4 years, of 43 patients with pelvic fractures in childhood. These authors found similar outcomes among patients treated operatively vs nonoperatively. Subasi et al16 followed 58 children with unstable pelvic fractures treated nonoperatively. They reported positive outcomes from an orthopedic standpoint, but less success regarding urologic and psychiatric outcomes.

Conclusion

Pelvic ring fracture pattern and severity correlate with increased transfusion requirements in the pediatric population. In addition, unstable pelvic fracture patterns are a marker of associated injuries, as evidenced by dramatic increases in Injury Severity Score. In this series, only 1 patient (1.1%) died of associated injuries.

References

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Mechanisms of Injury

MechanismNo. of Patients
Motor vehicle accident37 (41.1%)
Pedestrian/bicycle vs automobile accident23 (25.6%)
Crush injury13 (14.4%)
Snowmobile or all-terrain vehicle accident8 (8.9%)
Fall from height8 (8.9%)
Sports injury1 (1.1%)

Associated Injuries

Injury LocationNo. of Patients
Head/face53 (58.9%)
Extremity42 (46.7%)
Abdomen/genitourinary28 (31.1%)
Chest18 (20%)
Spine8 (8.9%)
Authors

The authors are from the Department of Orthopedic Surgery (LWL, SAS), Mayo Clinic, Rochester, Minnesota; and the Texas Scottish Rite Hospital (ALM), Dallas, Texas.

Dr Lewallen has no relevant financial relationships to disclose. Dr McIntosh is a paid consultant for Globus. Dr Sems receives royalties from Zimmer Biomet.

Correspondence should be addressed to: S. Andrew Sems, MD, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ( sems.andrew@mayo.edu).

Received: January 25, 2018
Accepted: April 23, 2018

10.3928/01477447-20180806-03

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