Does skeletal maturity affect pediatric pelvic injury patterns, associated injuries and treatment intervention?

INTRODUCTION: Pediatric pelvic injuries are rare. Due to anatomic differences of the immature pelvis, different injury patterns may occur as compared to adults. The purpose was to analyze the effect of skeletal maturity on pediatric pelvic injury pattern, associated injuries, and treatment intervention. PATIENTS AND METHODS: Ninety children with a pelvic injury receiving treatment at a private orthopaedic practice in association with a Level One Teaching Trauma Center, between March 2002 and June 2011, were retrospectively analyzed. Skeletal maturity was determined as closed triradiate cartilage. Forty-one (46%) were skeletally immature and 49 (54%) were skeletally mature. Mean age was 11.5 years (2-16). Fractures were 23 A2, 1 A3, 4 B1, 44 B2, 16 B3, and 2 C2 according to OTA/AO classification. OTA B and C fractures were 26 LC1 (lateral-compression), 20 LC2, 10 LC3, 4 APC1 (anterior-posterior-compression), 5 APC2, and 1 VS (vertical-shear) injury according to Young and Burgess. Treatment of the pelvic injury was operative in 28 (31%) and non-operative in 62 (69%) of children. Mechanism of injury, Injury Severity Score (ISS), deaths, and associated injuries were recorded. RESULTS: More complex and unstable injuries occurred in skeletally mature vs. immature children (p = 0.014). Skeletally mature children had a significantly higher rate of operative intervention (p = 0.009). The ISS in skeletally mature children was higher 25 (1-66) than in skeletally immature children 17 (4-43) (p = 0.013). 84% (41) skeletally mature and 78% (32) skeletally immature children sustained associated injuries. Twenty-two% (11) of all skeletally mature children sustained urinary tract injuries, but only 7% (3) of all skeletally immature children (p = 0.049). DISCUSSION: Skeletally mature children are more likely to sustain more complex injury patterns with a higher rate of operative treatment, to have a higher rate of associated injuries, and to have a higher ISS than immature patients. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Acetabular Fractures in Children and Adolescents: Comparison of Isolated Acetabular Fractures and Acetabular Fractures Associated With Pelvic Ring Injuries.

OBJECTIVES: To compare mechanism of injury, fracture pattern, displacement, clinical, and radiographic outcome of isolated acetabular fractures (group 1) versus acetabular fractures associated with a pelvic ring injury (group 2). DESIGN: Retrospective cohort comparative analysis. SETTING: Private orthopaedic practice associated with a level one teaching trauma center. MAIN OUTCOME MEASUREMENTS: Mechanism of injury, fracture pattern, displacement and treatment, Glasgow Coma Scale, Injury Severity Score, leg length discrepancy (LLD), and hip dysplasia. PATIENTS: Thirty-two children (group 1: 12 fractures; group 2: 25) were classified as 9 A1, 21 A3, 3 B1, 3 B2, and 1 B3 OTA/AO types. Eighteen children (22 fractures) were included with average follow-up of 33.3 months (6-84). The average age was 12.8 years (4-16). RESULTS: Main fracture pattern (75%) in group 1 was a posterior wall fracture (A1) caused by falls and sports in 50%. Six socket injuries had a hip dislocation, present only in group 1 (P < 0.001). The majority (84%) in group 2 had anterior wall/column (A3) fractures, caused by traffic accidents (88%). Fracture displacement in group 1 was higher than in group 2 (3.8 vs. 0.8 mm; P = 0.009). Group 2 had a lower Glasgow Coma Scale (P = 0.031) and a higher Injury Severity Score (P < 0.001). Nine (24%) fractures were treated operatively, significantly more were in group 1 (P < 0.001). Three (14%) children had complications including (LLD) (2) or hip dysplasia (2). CONCLUSION: Compared with isolated pediatric acetabular fractures, fractures associated with pelvic ring injuries have less displacement and are less likely to require operative treatment, but they show more associated injuries. Because of potential hip joint growth disturbance, LLD and hip dysplasia can occur. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pediatric pelvic ring injuries: How benign are they?

INTRODUCTION: With an incidence of less than 0.2% of all pediatric fractures, pelvic ring injuries are rare. Historically they were conservatively treated, but because malunion and long-term morbidity are associated with unstable injuries, a trend towards operative treatment can be observed. The purpose was to determine clinical and radiographic outcomes following these complex pediatric pelvic ring injuries. PATIENTS AND METHODS: This Level IV retrospective analysis was completed at a private orthopaedic practice in association with a Level One teaching trauma center. There were 33 children with pelvic ring injuries with a mean age of 12.6 years (4-16) and an average follow up of 28.6 months (range 6-101). Injuries were 2 A2, 3 B1, 16 B2, 10 B3, and 2 C2 according to OTA/AO classification. Group 1 had 16 unstable, operatively treated injuries and Group 2 had 17 stable, non-operatively treated injuries. Radiographic deformity, leg length discrepancy, low back, and SI joint pain were evaluated. RESULTS: For Group 1, 10 of 15 patients (67%) had a permanent ischial height difference >5mm compared to Group 2, in which 5 of 12 (42%) had an ischial height difference of >5mm. Group 1 had more pelvic asymmetry (12.3mm vs. 6.6mm) and ring width difference (6.9mm vs. 3.9mm) on final X-rays as compared to Group 2. Children with 5-10mm posterior sacral displacement had significantly more pain than children with 0-4mm displacement (p=0.034). Thirteen children (39%) had residual low back/SI joint pain; the rate was significantly higher in the Group 1 (3/17 vs. 10/16, p=0.008). In three (9%) children with 2 B2 and 1 B3 injury, leg length discrepancy between 5mm to 15mm occurred. DISCUSSION AND CONCLUSION: In pediatric patients with pelvic ring injuries, radiographic deformity persisted and did not remodel. Pelvic ring deformity occurred more commonly with complex unstable ring injuries. The complex displaced injuries have higher rates of operative intervention, residual deformity, and low back and SI joint pain.

Outcomes After Intramedullary Nailing of Distal Tibial Fractures.

OBJECTIVES: To determine outcomes in the treatment of distal tibial fractures treated with intramedullary nails. DESIGN: Retrospective analysis. SETTING: Level I trauma center with follow-up in a private orthopaedic practice. MAIN OUTCOME MEASUREMENTS: Radiographic determination of alignment, nonunion, and malunion, clinical outcome (range of motion, and implant-associated complaints), wound complications, and fibular fixation. PATIENTS: A total of 105 patients with OTA/AO type A and C tibial fractures (<11 cm from the joint line) treated with intramedullary nailing. RESULTS: Distance of the fracture from the joint line averaged 6.1 cm (range, 0-11). Mean follow-up was 25.6 months (range, 12-74). Nonunion occurred in 20 (19%) fractures and were significantly associated with open fractures (P = 0.012), wound complications (P < 0.001), and the need for fibular fixation (P = 0.007). Sagittal plane alignment averaged 2.5 degrees (±4.4) valgus. Malunion occurred in 25 (23.8%) fractures and again were significantly associated with open fractures (P = 0.045). Fifty (47.6%) patients had implant-related pain, which resolved in 27 (54.0%) after removal. CONCLUSIONS: Intramedullary nailing of distal tibial fractures is a suitable treatment option. Acceptable alignment and range of motion can be achieved. Both nonunions and malunions were significantly associated with open fractures, wound complications, and fibular fixation. Implant removal was needed in 25% of cases. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.