Orthopedics

FEATURE ARTICLE

Pediatric Pelvic Ring Injuries

Laura W. Lewallen, MD; Amy L. McIntosh, MD; S. Andrew Sems, MD
Orthopedics. https://sci-hub.se/https://doi.org/10.3928/01477447-20180806-03
Posted August 10, 2018

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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).
 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 1–2). 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%).

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.

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).
 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.
 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.
 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.

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Figures/Tables $

References $

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).

Copyright 2018, SLACK Incorporated

Received: January 25, 2018

Accepted: April 23, 2018
10.3928/01477447-20180806-03

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