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PAEDIATRIC PELVIC FRACTURES

Dr Richard Donovan

MSc Orthopaedic Trauma Sciences,

QMUL 2017-18

INTRODUCTION

INTRODUCTION

Why is this topic important?

What's the rationale for reviewing the literature?

Is it worth researching?

CLINICAL RELEVANCE

RELEVANCE

  • Trauma remains a leading cause of death in children in UK [1]
  • Globally, M&M from trauma is predicted to increase by 2030 [2]
  • Very high-energy mechanisms
  • Due to skeletal immaturity, management and outcomes differ compared with adults
  • Mis-diagnosis or mis-management can result in significant sequelae

HOW MUCH EVIDENCE EXISTS?

RATIONALE

  • Uncommon injury
  • Trauma scenario (polytrauma)
  • Difficult to produce high-level prospective evidence

  • However, there are:
  • Guidelines
  • Case series
  • Multi-centre retrospective data sets

EPIDEMIOLOGY

EPIDEMIOLOGY

  • Uncommon (0.3 - 4% of paediatric injuries) [3-6]
  • More common in males 1.4 : 1 [3-4]
  • 20% of paediatric polytrauma patients have pelvic ring injuries [7]
  • 58 - 87% of children with pelvic fractures have associated injuries [7]
  • 10% of immature pelvic fractures are unstable [8]
  • 80% of immature pelvic fractures are complex [8]
  • Mortality is commonly due to head injury, rarely due to exsanguination

LITERATURE

REVIEW

LITERATURE

REVIEW

Which authors have made significant contributions to this field?

What does their literature tell us?

SILBER

(2001)

SILBER (2001) [6]

  • Largest consecutive series of paediatric pelvic fractures from one institution (at the time); level-1 trauma centre (Philadelphia, US); retrospective study; n=166
  • Analysed: mechanisms of injury, fracture patterns, associated injuries, overall injury severity, and death rates
  • Outcomes:
  • 3.6% mortality (head +/- visceral in all cases)
  • Life-threatening hemorrhage did not occur
  • Urethral injury was not seen as often as in adults
  • Anterior ring fractures were the most common type (RTAs)
  • Anatomical differences and mechanism of injury may play a role in these contrasting findings

  • Critique:
  • Largest study to date to dispel the idea that mortality was due to exsanguination
  • Authors had to modify the Torode classification system to account for isolated acetabular fractures
  • Can the findings be extrapolated? Numbers are still small

SMITH

(2005)

SMITH (2005) [8]

  • Retrospective, multi-centre study (two level-1 trauma centres in Denver, US); n=23
  • Assessed long-term clinical and functional outcomes in unstable paediatric fractures (citing only 2 previous papers)
  • Findings and recommendations:
  • Estimate 10% of immature pelvic fractures are unstable and 18% are complex
  • Fractures with >11mm pelvic asymmetry post-closed reduction should be treated with ORIF or ex-fix to improve alignment and long-term functional outcome
  • Pelvic asymmetry did not remodelin any patient, even in younger patients
  • All patients with >11mm pelvic asymmetry had 3 or more of: non-structural scoliosis, lumbar pain, a Trendelenburg sign, or SIJ tenderness and pain
  • Patients with fewer associated injuries and pelvic asymmetry of <10mm had better clinical results

  • Critique:
  • Use of the Tile classification
  • Cite consistency in management within the two sites, but retrospective
  • Treatment was based on the attending surgeon's preference
  • Small study size
  • Evaluated functional outcomes with a validated measure

HOLDEN

(2007)

HOLDEN (2007) [3]

  • Cornerstone paper in the management of paediatric pelvic fractures
  • Outlined: differences between paediatric vs. adult injuries; key aspects of history and examination; diagnostics; classifications; treatments; and complications
  • Significant points:
  • Recognition that paediatric mortality from pelvic injury is lower than adults (paediatric mortality due to TBI/concomitant injuries)
  • Recommended CT imaging for diagnosis (including concomitant injuries) and operative planning
  • MRI deemed of limited role; except soft tissue assessment
  • Advocated use of Torode classfication over Tile, but admitted no classification is ideal due to none accounting for skeletal immaturity
  • Correlated Type 4 pelvic fractures with iliac/retroperitoneal haemorrhage
  • Advocated ORIF / ex-fix if > 20mm displacement of pelvic ring +/- unstable fracture
  • Deemed paediatric long-term prognosis better than adults (greater capacity to heal/remodel/adapt)

  • Critique:
  • Comprehensive yet concise evidence-based guidelines
  • Sets standards for diagnosis and treatment
  • Scanty evidence regarding MRI and bone scans

BANERJEE

(2009)

BANERJEE (2009) [5]

  • Retrospective analysis of 10 years of data; level-1 trauma centre (London, UK); n=44
  • Findings:
  • Good long-term outcomes with conservative management
  • Commonest associated injuries:
  • Long bone fractures
  • Head injuries
  • Injury Severity Score (ISS), Revised Trauma Score (RTS) and Glasgow Coma Scale (GCS) were all statistically significantly (p<0.05) worse in non-survivors compared with survivors
  • Pelvic fractures deemed to be an indicator for other serious injuries (which carry high mortality)

  • Critique:
  • Small data set
  • Correlation between injury severity and survival

GANSSLEN

(2013)

GANSSLEN (2013) [4]

  • Extensive review of literature: including multiple reports and multi-centre studies
  • In-depth analysis of mortality, morbidity and long-term outcomes
  • Key points:
  • Reported mortality rates vary between 0 - 25% (mean: 6.4%); no significant change in last 30 years
  • Mortality linked to severe head injuries and overall ISS
  • Other significant factors include complex pelvic trauma (19% mortality), open crush injuries (20% mortality)
  • Long-term results:
  • Majority of reported complications are due to problems of bone healing including: leg length discrepancies, delayed union, malunion, and low back pain
  • Poor outcomes and complications are linked to pelvic instability at presentation

  • Critique:
  • Extensive paper with great depth of analysis, with systematic analysis
  • The most inclusive data set for analysis so to date
  • Aggregates many small data sets - are there inconsistencies?

AMOROSA

(2014)

AMOROSA (2014) [9]

  • Key points/recommendations:
  • In the past, almost all paediatric pelvic/acetabular fractures were treated non-operatively; however, they do not all remodel well
  • Prospective studies are needed to establish optimal treatment guidelines
  • If unstable or significant displacement --> operative fixation by a pelvic/acetabular specialist (to prevent deformity and long-term disability and pain)
  • Most paediatric acetabular fractures involving the posterior wall require MRI to better judge the size of the fracture fragments
  • Little evidence for the optimal treatment of triradiate acetabular fractures, and outcomes are poor for the most severe crush injuries

  • Critique:
  • Development of indications for MRI usage
  • Acknowledges the lack of prospective data guiding treatment

RECOMMENDATIONS

RECOMMENDATIONS

How can the current literature base be improved?

FURTHER

RESEARCH

IDEAS

AREAS FOR FURTHER RESEARCH & DEVELOPMENT

1. Larger, prospective studies are required:

- will likely need to be multi-centre

- to clarify the impact of initial displacement and residual asymmetry on:

- clinical outcomes

- functional outcomes

2. A updated classification system is required:

- to enable equal comparisons between data sets

- to include all variants and avoid inconsistencies

- to allow fracture patterns to be matched to treatments

3. Is there a growing role for the use of MRI and/or bone scans?

4. Does the use of angioembolisation vs. pelvic packing in those with Type 4 +/- unstable fractures influence mortality?

CONCLUSIONS

CONCLUSIONS

4 take-home messages

Future research should focus on multi-centre prospective data and universal classifications

Beware the anatomical between children and adults

1

3

2

4

A lack of high level evidence is available on this topic

Paediatric pelvic fractures, when associated with polytrauma, carry significant M&M

REFERENCES

REFERENCES

1. The Trauma Audit and Research Network (TARN). Severe injury in children [Internet] 2018 [13 May]. Available at: https://www.tarn.ac.uk/Content/ChildrensReport/files/assets/common/downloads/TARN%20document.pdf

2. World Health Organisation (WHO). Injury deaths rise in ranks [Internet]. 2018 [13 May]. Available at: http://www.who.int/violence_injury_prevention/key_facts/VIP_key_fact_3.pdf?ua=1

3. Holden CP, Holman J, Herman MJ. Pediatric pelvic fractures. J Am Acad Orthop Surg. 2007;15:172-177

4. Gansslen A, Heidari N, Weinberg, AM. Fractures of the pelvis in children: a review of the literature. Eur J Orthop Surg Traumatol. 2013;23:847-861

5. Banerjee S, Barry MJ, Paterson JM. Paediatric pelvic fractures: 10 years experience in a trauma centre. Injury. 2009;40:410-413

6. Silber JS, Flynn JM, Koffler KM, et al. Analysis of the cause, classification, and associated injuries of 166 consecutive pediatric pelvic fractures. J Pediatr Orthop. 2001;21:446-450

7. Sink EL, Flynn JM. Thoracolumbar spine and lower extremity fractures. In: Weinstein, SL, Flynn JM, Lovell and Winter’s Pediatric Orthopaedics. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2014:1776-1778

8. Smith W, Shurnas P, Morgan S, et al. Clinical outcomes of unstable pelvic fractures in skeletally immature patients. J Bone Joint Surg Am. 2005; 87:2423-2431

9. Amorosa LF, Kloen P, Helfet DL. High-energy pediatric pelvic and acetabular fractures. Orthop Clin N Am. 2014;45:483-500

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