Session VIII - Pediatrics/Spine

Pelvic Fractures in a Pediatric Level I Trauma Center

Nicolas Grisoni, BS; Susan Connor, PhD; Eric Marsh, RN, MSN; George H. Thompson, MD; Daniel R. Cooperman, MD, Rainbow Babies and Children's Hospital, Cleveland, OH

Purpose: Pediatric pelvic fractures are uncommon, yet they have a high rate of associated injuries and complications. We retrospectively reviewed 57 consecutive pelvic fractures treated over a 7-year period in a pediatric Level I trauma center.

Materials and Methods: From 1993 through 1999, we treated 3,468 patients, 57 of whom (2%) had pelvic fractures. There were 32 males (56%) and 25 females, with mean age at injury of 9 (range, 1.2-15). All fractures were classified according to the Orthopaedic Trauma Association's Fracture and Dislocation Compendium. We analyzed the types of pelvic fractures, their causes, associated injuries, and type of management. Patient demographics were compared on a year-to-year basis by analysis of variance and chi square. Fisher's exact test and chi square were used to compare characteristics and variables associated with the two primary pelvic injury types, acetabular and pelvic ring fractures, to identify trends or isolate key differences in injury mechanism, treatment, mortality or associated injuries.

Results: Patient and pelvic fracture demographics were similar for all 7 years. The overall mortality rate during the study period was 2%, while the mortality rate of pediatric pelvic fracture patients was slightly higher at 5% (3 patients). Thirty-seven pelvic fractures (66%) were motor vehicle related (21 pedestrian, 13 passenger, 4 bicycle), while 9 patients (16%) were injured in falls and 4 (7%) were involved in recreational vehicle accidents; the remaining 6 patients (11%) were injured in accidents that were not readily categorizable. Thirty patients (53%) sustained multiple pelvic fractures; there was no significant correlation between the incidence of multiple fractures and mechanism of injury (P = .1). Fifty-two patients (91%) were treated nonoperatively; only 5 (9%) required open reduction and internal fixation. There were no significant differences between injury mechanisms in the proportion of patients requiring operative treatment (P = .5). The mean hospital stay was 5.8 days (range, 1-27 days); there were no significant differences in length of stay for operative/nonoperative patients (P = .74). While 12 patients required transfusions (21%), only 1 received a transfusion directly related to pelvic injuries. Thirty-four patients (60%) had associated injuries. Extremity fractures were the most common (47%), followed by head injuries (29%), abdominal injuries (14%), hemorrhage (10%), and thoracic injuries (7%). Associated neurological (2%), genitourinary (3%) and gynecological (2%) injuries were rare. Forty-six patients (81%) sustained pelvic ring fractures, while 11 (19%) had acetabular fractures. Patients with acetabular fractures were significantly more likely to require surgical intervention than those with pelvic ring fractures (P < .005). No injury mechanism was significantly more likely than any other to result in acetabular fracture (P = .29).

Discussion: Pelvic fractures were relatively uncommon in our Level I trauma center, and most (66%) were the result of motor vehicle related accidents. The mortality rate was lower than that reported in reviews of adult trauma populations and selected pediatric trauma populations. All 3 mortalities were due to central nervous system injuries sustained in automobile-pedestrian accidents. The majority of patients did not require surgical intervention. Of the 5 patients who did, 4 had sustained acetabular fractures and 1 had a complete displacement of the sacroiliac joint. No individual injury mechanism could be identified as being more likely to result in multiple pelvic fractures, associated injuries, or complications. The need for transfusion was low and related primarily to associated injuries.

Conclusion: Our data support aggressive evaluation of pediatric pelvic fracture patients because of the increased incidence of associated head and abdominal injuries and their relationship to mortality.