The clinical characteristics and management of paediatric pelvic fractures: a changing landscape based on skeletal maturity

Abstract

Introduction Paediatric pelvic fractures (PPFs) are uncommon but signify serious trauma. A comprehensive multidisciplinary approach is needed due to a high number of associated injuries. This study aims to retrospectively analyse PPFs over a 5-year period and evaluate how advancing skeletal maturity changes fracture patterns and management plans. Methods The trauma database was retrospectively reviewed for pelvic fractures in patients aged ≤ 18 years. Radiographs and CT scans were used to classify pelvic injuries according to the modified Torode classification and determine the status of the triradiate cartilage (open: skeletally immature; closed: skeletally mature). Data collected also included the mechanism of injury, clinical and functional outcomes, and associated injuries. Logistic regression analysis was performed to identify risk factors for associated abdominal injuries. Results 65 PPFs (2.8% of paediatric trauma admissions during the study period) were classified as type I (3.1%), type II (7.7%), type IIIa (32.3%), type IIIb (38.5%), type IV (18.5%) according to the modified Torode classification. The mean age was 13.41 ± 3.82. Skeletally immature children were more likely to be hit by a motor vehicle as a pedestrian (p < 0.001), be intubated (p = 0.009), acquire Torode type II (p = 0.047) and rami fractures (p = 0.037), and receive chest (p = 0.005) and head injuries (p = 0.046). Skeletally immature children were also less likely to acquire Torode type IV fractures (p = 0.018), receive surgical treatment for their pelvic injuries (p = 0.036), and had a faster time to full weight bearing (p = 0.013). Pelvis AIS score ≥ 4 (OR 5.3; 95% CI 1.3–22.6; p = 0.023) and a pedestrian accident (OR 4.9; 95% CI 1.2–20.7; p = 0.030) were risk factors for associated abdominal injuries. There was a strong association between a higher pelvic fracture grade and the proportion of patients with closed triradiate cartilage (p = 0.036), hospital length of stay (p = 0.034), mean pelvic AIS score (p = 0.039), a pelvis AIS score of ≥ 4 (p = 0.022), mean ISS (p = 0.003), an ISS score between 25 and 75 (p = 0.004), average time to FWB (p = 0.001), requirement of blood products (p = 0.015), and a motor vehicle accident (p = 0.037). Conclusion PPFs occurring in skeletally mature and immature patients are significantly different in terms of mechanism of injury, fracture severity, fracture pattern, and management strategy. There is a high rate of associated injuries, necessitating an integrated multidisciplinary approach in paediatric trauma centres.

Associated injuries and complications in pediatric pelvic fractures requiring hospitalization: A series of 315 cases

“…It could also be that acetabular fractures in children tend to occur after triradiate cartilage closure. Lu et al 19 reported that children with skeletal immaturity were less likely to have acetabular fractures compared with skeletally mature patients (12% versus 37.5%), and no acetabular fractures were found in our skeletally mature patients, which may be related to both the age of the child and the type of injury. For stable and unstable fractures, we found higher ISSs for stable fractures, meaning that stable fractures may be more likely to be combined with other injuries; for unstable fractures, owing to partial energy absorption, the associated injuries are less severe.…”

Pediatric-Specific Lesions in Unstable Pelvic Ring Fractures of Skeletally Immature Children: Impact on Diagnosis and Management Decisions

“…10,15 Furthermore, displaced sacroiliac joint (SIJ) disruptions are associated with markedly higher risk of more serious chest, intra-abdominal, and pelvic organ and vascular injuries with considerable morbidity and mortality. 10,16-18…”

“…10,15 Furthermore, displaced sacroiliac joint (SIJ) disruptions are associated with markedly higher risk of more serious chest, intraabdominal, and pelvic organ and vascular injuries with considerable morbidity and mortality. 10,[16][17][18] In a study of 9,684 patients younger than 17 years with pelvic fractures from the German pelvic trauma register, children with severe pelvic injuries (abbreviated injury scale (AIS) pelvis $ 2) had higher incidence of severe chest and abdominal injuries (AIS $ 2) with an overall mortality rate of 10.1% compared with 7.9% with AIS pelvis , 2. 10 In a pelvic trauma study from the US national trauma data bank of 5,325 children (younger than 13 years), 4,052 adolescents (13 to 17 years), and 28,407 adults (18 to 54 years), children had the highest odds of death after sustaining pelvic injuries compared with that in adolescents and adults with an overall mortality rate of 10% compared with 6.8% in adolescents and 8.5% in adults.…”