Changing patterns of pediatric pelvic fractures with skeletal maturation: implications for classification and management.

Orthopaedic traumatologists have recognized the unique fracture patterns and injury constellations of pediatric pelvic fractures. However, an understanding of the effect of advancing skeletal maturation is needed to avoid applying adult classifications and management. The authors determined how pelvic fracture patterns and management change with advancing skeletal maturity. At their pediatric trauma center, they identified 166 consecutive pelvic fractures. Eighty percent of patients had plain radiographs adequate to evaluate the triradiate cartilage. Physes were scored as open, narrowed, or closed. The Risser sign, fracture pattern, survival after injury, and need for open reduction and internal fixation were recorded. Ninety-seven patients (mean age 5.7 years) had an open triradiate or an "immature pelvis." Thirty-two patients (mean age 14 years) had a closed triradiate cartilage or a "mature pelvis." The immature group had a higher propensity for isolated pubic rami and iliac wing fractures. The mature group had a higher predilection for acetabular fractures and pubic or sacroiliac diastasis. All patients requiring open reduction and internal fixation had a mature pelvis. The incidences of specific pelvic fracture patterns between the two groups were statistically different. Management of fractures to the immature pelvis should focus on associated injuries. Once the triradiate cartilage has closed, adult pelvic fracture classifications and management principles should be used.     

Open complete anterior dislocation of the sacro-iliac joint in a 4-year-old boy: a case report of a rare injury with 5-year follow-up

Pelvic fractures are uncommon in children and account for between 0.3 and 7.5% of all pediatric injuries. Open pelvic fractures only account for up to 12.9% of all pediatric pelvic fractures. An unusual case of open complete anterior sacro-iliac joint dislocation in a 4-year-old boy is presented with a long-term follow-up. The multidisciplinary approach is reported with review of the current literature. A 4-year-old male presented to our institution in January 2012 after having been run over by a tractor. He presented with gross hemodynamical instability, MISS of 25, and an unstable lateral compression type III pelvic fracture with complete anterior dislocation of the left hemipelvis and a groin wound extending into the left thigh. The patient was managed in accordance with the ATLS and open fracture guidelines. Reduction in the dislocated SI joint was achieved via a posterior approach to the SI joint, followed by fixation with 2K wires in S1 and S2 sacral segments, with an anterior external fixator. Pelvic asymmetry post-reduction was 0.9 cm, compared to 16 cm post-injury, and asymmetry persisted till final follow-up at 5 years. At 5 years, patient regained full function, including recreational sport activities. Patients scored a 96/96 on the Majeed score (after excluding 4 points for sexual function). We believe that posterior reduction in an anteriorly dislocated SI joint in the pediatric population is a viable option. A coordinated, multidisciplinary approach and restoration of pelvic ring stability can lead to optimal outcome.     

Critical review of the classification and treatment of pediatric pelvic fractures

BackgroundHistorically most pediatric pelvic fractures were treated non-operatively because of the presumed potential of the pediatric pelvis to remodel and the subsequent increased fracture stability. Currently a wide variety of classifications in pediatric pelvic fractures is used to assess fracture stability and guide treatment, yet none have proven to be ideal since the structural behavior of the pediatric pelvis differs greatly from the adult pelvis. The aim of this review is to critically appraise the use of these different classification systems, fracture (in)stability, the treatment of pediatric pelvic fractures and how it reflects on long-term complications such as pelvic asymmetry and functional outcome.MethodsA literature search was performed in Medline, Embase, Cochrane, PubMed, Google Scholar and references of the selected articles. Studies that reported on pain, leg length discrepancy (LLD), abnormal gait (GA), pelvic asymmetry, and functional outcomes of pediatric pelvic fractures were included.ResultsA total of six different classification systems were used, the most common were Tile (n= 9, 45%) and Torode and Zieg (n= 8, 40%). There was great disparity in treatment choice for the same type of fracture pattern, resulting in several pelvic ring fractures that were defined as unstable being treated non-operatively. Pelvic asymmetry is seen in rates up to 48% in non-operatively treated patients. In contrast, pelvic asymmetry in surgically fixated unstable pelvic fractures was rare, and these patients often showed excellent functional outcomes during follow-up.ConclusionThere is a substantial heterogeneity in which fracture patterns are considered to be unstable or in need of surgical fixation. Functional outcomes seem to be correlated with the frequency of pelvic asymmetry and are likely due to an underestimation of the stability of the pelvic fracture. Taking into consideration the force that is necessary to cause a facture in the pediatric pelvis, a fracture of the pelvic ring alone could be suggestive for instability. The results of this review imply that the field of pediatric pelvic surgery is currently not grasping the full scope of the complexity of these fractures, and that there is a need for a pediatric pelvic classification system and evidence-based treatment guideline.     

Treatment of unstable fractures of the pelvic ring in pregnancy

Unstable fractures of the posterior pelvic ring during pregnancy are rare. Pregnancy increases the high demands on the therapy of these types of fractures. The aim of the therapeutic strategy in such a situation is a good functional outcome of the mother without influencing the fetal health. Some osteosynthetic techniques result in good functional outcomes, but they are associated with high amounts of ionizing radiation. We report the case of a pregnant woman who sustained a vertical unstable fracture of the posterior pelvic ring as a result of a traffic accident. The fracture was treated surgically by open reduction and internal fixation with two transiliac reconstruction plates with minimal radiographic exposure to the fetus. One year later, a good functional result concerning the mother was shown. The child was healthy without any signs of prenatal impairment. Surgical treatment of an unstable fracture of the pelvic ring during pregnancy is possible with a justifiable risk to the mother and the child. Consideration of the expected fetal radiation exposure in the course of the therapy is particularly recommended. Using minimal doses of ionizing radiation, the described method results in a good clinical outcome of the mother while simultaneously reducing the radiation exposure of the fetus to an acceptable level.     

Early functional outcome in children with pelvic fractures

BACKGROUND/PURPOSE: Although the mortality, morbidity, and spectrum of associated injuries in children with pelvic fractures have been extensively studied, little is known about the functional outcomes in these patients. The authors examined retrospectively functional independence measurement (FIM) at discharge in children with pelvic fractures to determine how it should influence their management protocol. METHODS: The authors reviewed the records of all patients who sustained pelvic fractures between 1993 and 1998 in the trauma registry of a level I pediatric trauma center. Patients were stratified according to demographics, type of pelvic fracture, functional independence measurement, and discharge disposition. Fractures graded 1, 2, or 3 were defined as stable, whereas grade 4 fractures were deemed unstable. RESULTS: A total of 88 children sustained pelvic fractures. Seventy-four percent had stable fractures, whereas 26% sustained unstable fractures. There was no difference in age or sex between the groups; boys were more commonly injured than girls. Motor vehicle-related crashes accounted for most injuries. The mean injury severity score (ISS) for patients with a stable fracture was 17 +/- 14 and 20 +/- 13 for unstable fractures. There was no difference in overall hospitalization nor intensive care unit stay between the unstable and stable fracture patients. Eighty percent of the patients with unstable and 52% of the patients with stable pelvic fractures were dependent based on locomotion, and similar proportions were seen for the transfer category. CONCLUSIONS: Short-term function appears to be significantly impaired in a high percentage of children with stable and unstable pelvic fractures. Therefore, aggressive rehabilitation should be instituted early in all children with pelvic fractures to achieve optimal functional outcome.     

内外固定治疗不稳定性骨盆骨折18例报告

18例不稳定性骨盆骨折采用切开复位内固定或骨盆外固定器治疗,其中旋转不稳型10例,垂直不稳型8例.平均随访17个月,疗效满意.认为旋转不稳型骨盆骨折宜首选外固定器治疗,垂直不稳型骨盆骨折应争取解剖复位,为此必须采用切开复位内固定治疗.     

Associated aortic rupture-pelvic fracture: an alert for orthopedic and general surgeons.

Blunt trauma patients with pelvic fractures have been shown to have a two-fold to five-fold increased risk of aortic rupture compared with the overall blunt trauma population. A retrospective review was performed to determine whether the relationship between aortic rupture and pelvic fracture could be further delineated using a pelvic fracture classification based on mechanism of injury. Of 4,157 consecutive blunt trauma patients, 371 (8.9%) had pelvic fractures, 34 (0.8%) had ruptured thoracic aortas and 12 had both injuries. When pelvic fractures were classified according to vector of force, 10 of 12 (83%) aortic ruptures occurred in patients with an anterior-posterior compression fracture pattern, an incidence of aortic rupture eight times greater than that of the overall blunt trauma population. There was no increased incidence of aortic rupture among patients with any other pelvic fracture pattern. We conclude that the previously reported association between aortic rupture and pelvic fracture can be further specified to include, predominantly, those patients with an anterior-posterior compression fracture pattern.     

骶髂螺钉固定治疗垂直不稳定骨盆后环骨折的疗效分析

目的评价骶髂螺钉治疗不稳定型骨盆骨折的临床疗效。方法采用骶髂螺钉治疗42例不稳定型骨盆骨折。应用Tornetta复位情况评价表评估复位情况,应用Majeed骨盆骨折评分系统评价疗效。结果 42例均获随访,随访时间为4~34个月,平均15个月。闭合复位骶骨钉内固定骨盆骨折后环不稳术后分疗效满意。结论掌握骶骨置钉技巧,应用骶骨钉固定骨盆骨折后环不稳,手术操作简单、疗效好、适于基层医院广泛开展。     

不稳定骨盆骨折的手术治疗

作者5年来手术治疗不稳定骨盆骨折13例,平均随访1.5年,结果满意者11例,占85％。本文讨论了不稳定骨盆骨折手术治疗的必要性,认为手术可有效复位固定骨折,恢复骨盆的稳定性,促进康复,减少并发症和后遗症的发生。     

儿童不稳定骨盆骨折治疗的回顾分析

 目的 总结儿童不稳定骨盆骨折的治疗方法与教训。方法 1998年 10月至 2011年 3 月, 治疗不稳定骨盆骨折患儿 30例, 男 19例, 女 11例;年龄 2~16岁, 平均 7.9岁;均为 Torode-Zieg郁 型, 其中骶髂关节前脱位 4例。合并其他部位骨折 11例, 合并泌尿生殖系统损伤 14例, 合并骶丛损伤3例, 合并髂血管损伤 2例, 合并膈肌破裂、膈疝 1例;发生失血性休克 14例。 15例行保守治疗, 9例行外 固定治疗, 4例行内固定治疗, 1例行内、外联合固定治疗, 1例行半骨盆离断术。结果 1例患儿因大量失血而在急诊手术中死亡;13例失访, 16例获得随访, 随访时间 3个月~11年。根据 Cole等评分标准, 优 12例, 良 1例, 可2例, 差 1例;优良率为 81.25%。 1例患儿骨牵引后残留骶髂关节垂直移位, 遗留骨 盆倾斜, 双下肢不等长。 1例患儿因坐骨神经损伤而发生髋关节半脱位, 致严重跛行。 1例合并骶丛损伤 的患儿术后发生轻度跛行。结论 儿童不稳定骨盆骨折的治疗不同于成人, 损伤控制对其更为重要, 下肢骨牵引仍是主要治疗手段之一, 常可获得良好预后。若牵引治疗对垂直移位复位不理想, 则可考虑手术治疗。此外, 合并神经损伤是影响患儿预后的重要因素, 应注意检查和随访。     

Intelligent robot-assisted minimally invasive reduction system for reduction of unstable pelvic fractures

ObjectiveCurrently, minimally invasive internal fixation is recommended for the surgical treatment of unstable pelvic fractures. The premise and difficulty of minimally invasive internal fixation are minimally invasive reduction of fractures. This review aimed to investigate the indications, surgical strategy and techniques, safety, and efficacy of intelligent robot-assisted fracture reduction (RAFR) system of pelvic ring injuries.MethodsThis retrospective study reviewed a case series from March 2021 to November 2021. A total of 22 patients with unstable pelvic fracture injuries underwent minimally invasive internal fixations. All pelvic ring fractures were reduced with our intelligent RAFR system. The robot system intelligently designs the optimal position and reduction path based on the patient's preoperative 3D CT. During the operation, the three-dimensional visualization of the fracture is realized through image registration, and the Robot completes the automatic reduction of the fracture. The global 3D point cloud error between the preoperative planning results and the actual postoperative reduction results was calculated. The postoperative reduction results of residual displacement were graded by the Matta Criteria.ResultsMinimally invasive closed reduction procedures were completed in all 22 cases with our RAFR system. The average global 3D point cloud reduction error between the preoperative planning results and the actual postoperative reduction results was 3.41mm±1.83mm. The mean residual displacement was 4.61mm±3.29mm. Given the Matta criteria, 16 cases were excellent, five were good, and one was fair, with an excellent and good rate of 95.5%.ConclusionOur new pelvic fracture reduction robot system can complete intelligent and minimally invasive fracture reduction for most patients with unstable pelvic fractures. The system has intelligent reduction position and path planning and realizes stable pelvis control through a unique holding arm and a robotic arm. The operation process will not cause additional damage to the patient, which fully meets the clinical requirements. Our study demonstrated the safety and effectiveness of our robotic reduction system and its applicability and usability in clinical practice, thus paving the way towards Robot minimally invasive pelvic fracture surgeries.     

Is computed tomography cystography indicated in children with pelvic fractures?

Purpose: Pelvic fracture evaluation with abdominopelvic computed tomography (CT) and formal CT cystography for rule out of urine bladder injury have been commonly employed in pediatric trauma patients. The additional delayed imaging required to obtain optimal CT cystography is, however, associated with increased doses of ionizing radiation to pelvic organs and represent a significant risk in the pediatric population for future carcinogenic risk. We hypothesized that avoidance of routine CT cystography among pediatric pelvic fracture victims would not result in an appreciable rate of missed bladder injuries and would aid in mitigating the radiation exposure risk associated with these additional images. Methods: A retrospective cohort study involving blunt trauma pelvic fractures among pediatric trauma patients (age<14) between the years 1997 and 2016 was conducted utilizing the Israeli National Trauma Registry. Statistical analysis was performed using SAS statistical software version 9.4 via the tests of Chisquare test and two-sided Fisher''s exact test. A p value of less than 0.05 was considered statistically significant. Results: A total of 1072 children were identified from the registry for inclusion. Mean age of patients was 7.7 years (range 0-14) and 713 (66.5%) were male. Overall mortality in this population was 4.1% (44/1072). Only 2.1% (23) of pediatric patients with pelvic fractures had bladder injury identified, with just 9 children having intraperitoneal bladder rupture (0.8% of all the patients). Conclusion: The vast majority of blunt pediatric trauma victims with pelvic fractures do not have urine bladder injuries. Based on our study results we do not recommend the routine utilization of CT cystography in this unique population.     

切开复位内固定治疗垂直不稳定骨盆骨折

目的探讨切开复位内固定治疗垂直不稳定骨盆骨折的临床疗效。方法28例垂直不稳定骨盆骨折患者在大重量牵引纠正垂直移位后,全部行切开复位内固定,骨盆前环骨折均用重建钢板内固定。结果随访12~48个月,平均23.2个月,均骨性愈合,无下肢不等长,骨盆畸形基本纠正,按刘利民等功能评定标准,优10例,良13例,可5例。结论切开复位内固定治疗垂直不稳定骨盆骨折可取得满意疗效,对前后环骨盆骨折尽可能手术固定。     

Pediatric fractures and dislocations of the hip and pelvis

Recognition of an unstable pelvic fracture or a significant hip injury in children is important. Clinical assessment plays a valuable role as does the judicious use of imaging modalities in determining the most effective form of treatment, but the routine use of the standard AP pelvic radiograph is questioned. The concept of age and skeletal maturity has been re-evaluated, allowing the appropriate identification of cases that would benefit from an aggressive operative approach. A dual-tier approach to the treatment of pediatric pelvic trauma is suggested with an appreciation that there is no substantial evidence base for the surgical treatment of most injuries. Displaced femoral neck fractures and injuries to the hip joint that damage the articular or physeal cartilages require careful assessment and prompt and careful reduction and stabilization.     

Clinical outcomes of unstable pelvic fractures in skeletally immature patients

BACKGROUND: The orthopaedic literature contains few studies evaluating the long-term outcomes of unstable pelvic fractures in skeletally immature patients. The purpose of this study was to determine the factors that may influence the clinical and functional outcomes of such fractures. METHODS: A retrospective review of all patients with open triradiate cartilages and an unstable pelvic (Tile type-B or C) fracture treated, from 1986 to 2000, at one of two level-I trauma centers was performed. Patients were evaluated with a review of their medical records, the Modified Injury Severity Score (MISS), standardized physical examination, standardized radiographic evaluation, and the Short Musculoskeletal Function Assessment Questionnaire (SMFA). The outcomes were then used to assess the difference between patients who had been treated operatively and those who had been treated nonoperatively. RESULTS: Of 230 pelvic fractures treated during the study period, twenty-three in twenty-three patients were unstable. Of the twenty-three patients, twenty, with a mean age of 9.5 years at the time of injury, were evaluated. The mean duration of follow-up was 6.5 years. There were four type-B and sixteen type-C fractures according to the Tile classification system. The four patients with a type-B fracture had a mean of 1.4 cm of pelvic asymmetry at the time of union and the last follow-up, whereas the sixteen patients with a type-C fracture had a mean of 1.5 cm of pelvic asymmetry at those times. Pelvic asymmetry did not remodel even in younger patients. Eighteen patients were treated operatively with external fixation, internal fixation, or a combination of both, and pelvic asymmetry of < or =1 cm was achieved in ten of them. Patients who had < or =1 cm of pelvic asymmetry had no lumbar or sacroiliac pain, no or mild sacroiliac tenderness, no Trendelenburg sign, no lumbar scoliosis, and lower (better) bother and dysfunction scores on the SMFA compared with patients with more pelvic asymmetry. All patients with > or =1.1 cm of pelvic asymmetry had three or more of the following: nonstructural scoliosis, lumbar pain, a Trendelenburg sign, or sacroiliac joint tenderness and pain. Patients with fewer associated injuries and pelvic asymmetry of < or =1 cm had better clinical results. CONCLUSIONS: Unstable pelvic fractures in children can result in long-term morbidity and functional problems. Fractures associated with > or =1.1 cm of pelvic asymmetry following closed reduction should be treated with open reduction and internal or external fixation in order to improve alignment and the long-term functional outcome.     

有限切开复位钢板内固定治疗Tile C型骨盆骨折

目的探讨有限切开复位钢板内固定治疗Tile C型骨盆骨折的方法和疗效。方法 2010年6月至2012年5月,采用有限切开复位钢板内固定治疗Tile C型骨盆骨折15例。其中:C1型10例,C2型4例,C3型1例。评估术中出血量、手术时间及术后患者功能恢复情况。结果 15例患者术后获12~24个月(平均15个月)随访。骨盆前环手术的手术时间和出血量平均分别为61 min、92 mL;后环手术平均分别为71 min、165 mL。术中均无重要血管、神经损伤等并发症发生。1例耻骨处伤口发生浅表感染,经换药治愈。骨折复位按Matta影像学评分标准评定:解剖复位10例,满意复位4例,可1例。骨折愈合时间为2~6个月,平均2.9个月。末次随访时采用Majeed骨盆骨折评分标准评定疗效:优12例,良2例,可1例。结论通过有限切开复位和钢板内固定可以对Tile C型骨盆骨折进行良好的显露和牢靠的固定,并且不需要暴露神经、血管等结构,具有微创特点,疗效显著。     

旋转和垂直不稳定型骨盆骨折患者的诊断和治疗

目的探讨旋转和垂直不稳定型骨盆骨折的临床特点及其急诊处理、诊断和治疗方法选择。方法回顾性分析18例存在旋转和垂直不稳定的骨盆骨折患者，10例保守治疗，8例手术治疗。8例手术患者骨盆前环骨折均行切开复位内固定，2例耻骨上支骨折采用重建钢板固定，2例采用拉力螺钉固定，4例耻骨联合分离患者均采用双钢板固定；6例骨盆后环骨折患者采用切开复位双钢板固定，2例在CT引导下经皮置入骶髂关节松质骨拉力螺钉固定。结果18例患者全部恢复行走功能，所有保守治疗患者骨盆骨折均畸形愈合，遗留骶髂关节部位酸痛6例，遗留双小腿、双足麻木3例，行走跛行2例。8例手术治疗患者骨盆外形均恢复好，仅1例患者诉沿髂嵴切口有不适，2例CT引导下经皮置入骶髂关节螺钉患者骨盆外形接近完全恢复，功能恢复快而满意。结论旋转和垂直不稳定型骨盆骨折患者保守治疗效果差，宜首选内固定手术治疗，宜同时固定骨盆前、后环或先行前环切开复位内固定，2～3d后再次在CT引导下经皮置入骶髂关节螺钉内固定。CT引导下经皮置入骶髂关节螺钉手术操作简单、时间短、出血少、固定牢靠，是固定骶髂关节骨折脱位的首选方法。     

Beckenfrakturen in der unfallchirurgischen Klinik Kiel

48 injuries to the pelvis were treated from January 1991 through December 1991. We found 45 fractures of the pelvic ring with associated acetabular fractures in 15 cases and three isolated acetabular lesions. 19 injuries were caused by car accidents, 18 fractures resulted from a fall, especially in older patients. Isolated fractures of the pelvis occurred in 18 cases. The average total severity of the injuries was 19.7 points according to the Hannover Polytrauma Score (PTS). Every fracture was classified using the Tile-classification. There were 15 (33%) Tile A lesions, 18 (40%) Tile B fractures and twelve (27%) type C pelvic ring injuries. In 18 cases surgery was the method of treatment. Seven out of 18 injuries to the acetabulum were treated with open reduction and internal fixation. In ten patients the unstable pelvic ring was fixed by means of an external fixator. To do so, a pair of 6 mm diameter pins were placed on both sides in the supraacetabular region of the iliac bone directed towards the sacroiliac joints. We used a triangular form of external fixation. An open reduction and internal fixation (ORIF) was necessary in five cases, one injury required a combination of external and internal procedures. There were 14 cases in which we found sacral fractures as an additional dorsal lesions. Nine of 14 sacral fractures were recognized only by CT examination. In elevent cases the conventional radiographs showed simple anterior pelvic ring fractures while the CT examination revealed an additional lesion of the sacroiliac joint in nine of these cases. A CT examination of every pelvic fracture is therefore indispensable. Complications occurred in eight of 18 patients treated surgically, a further operation was necessary in three of these cases.     

骨盆骨折合并尿道断裂的早期手术治疗

目的探讨骨盆骨折合并尿道断裂的早期手术方法及其治疗效果。方法自1995年1月至2005年1月,共收治骨盆骨折合并尿道断裂患者25例。根据Tile的分型方法,骨盆稳定型损伤1例,旋转不稳定型损伤17例,旋转及垂直均不稳定型损伤7例。尿道完全断裂23例、部分断裂2例。手术方法包括：（1）急诊尿道吻合、尿道会师部分吻合、尿道会师、尿道阴道贯通伤修补,同期行骨盆骨折开放复位内固定术9例。（2）急诊尿道会师,延期（7—21d）行骨盆骨折切开复位内固定术10例。（3）急诊膀胱造瘘,限期（3～21d）行尿道会师及骨盆骨折切开复位内固定术6例。结果术后随访6～120个月,平均34个月。骨盆损伤根据Majeed的疗效标准,优17例,良5例,可3例。尿管拔除后,19例（76％）患者排尿通畅,最大尿流率平均为18．6mL／s,排泄性尿路造影示尿道断端对位良好,瘢痕平均长度为0．51cm;5例（20％）出现不同程度的排尿困难,须定期扩张尿道或改行其他手术;1例（4％）女性患者不能控制排尿,须进一步治疗。术后耻骨上原发软组织撕脱伤感染伴耻骨后脓肿形成1例,后尿道狭窄5例,阳痿3例,尿失禁1例。结论骨盆骨折的早期复位和有效固定是实现“无张力尿道修复”的解剖基础。     

Open reduction and internal fixation of the distal radius

Fractures of the distal radius are one of the most common problems treated by orthopaedic surgeons. The managementof unstable fractures is now almost routinely surgical, and multiple techniques have been developed to accomplish this including pins and plaster, external fixation, and internal fixation. Recent studies and classification systems have stressed the importance of identification of specific fracture fragments. Given that the goal of operative management of the fracture is an anatomic reduction and stable fixation, open reduction and internal fixation has been utilized recently to a greater degree. This allows direct reduction of the fracture with a stable construct. Advantages over external fixation or pins and plaster include a more anatomic reduction, establishment of early range of motion, and avoidance of complications associated with external pins. A dorsal or volar approach can be employed depending on fracture pattern and associated bony or soft tissue injuries. A variety of plating systems are now available, many of which are contoured specifically for the distal radius. Results of open reduction and internal fixation for distal radius fractures have generally shown greater than 80% good results. Complications can also occur including tenosynovitis, tendon rupture, and carpal tunnel syndrome.