Pelvic Fractures in Children Results from the German Pelvic Trauma Registry

As pelvic fractures in children and adolescents are very rare, the surgical management is not well delineated nor are the postoperative complications. The aim of this study using the prospective data from German Pelvic Trauma Registry study was to evaluate the various treatment approaches compared to adults and delineated the differences in postoperative complications after pelvic injuries. Using the prospective pelvic trauma registry established by the German Society of Traumatology and the German Section of the Arbeitsgemeinschaft für Osteosynthesefragen (AO), International in 1991, patients with pelvic fractures over a 12-year time frame submitted by any 1 of the 23 member level I trauma centers were reviewed. We identified a total of 13,525 patients including pelvic fractures in 13,317 adults and 208 children aged 14 years and compared these 2 groups. The 2 groups’ Injury Severitiy Score (ISS) did not differ statistically. Lethality in the pediatric group was 6.3%, not statistically different from the adults’ 4.6%. In all, 18.3% of the pediatric pelvic fractures were treated surgically as compared to 22.7% in the adult group. No child suffered any thrombosis/embolism, acute respiratory distress syndrome (ARDS), multiorgan failure (MOF), or neurologic deficit, nor was any septic MOF detected. The differences between adults and children were statistically significant in that the children suffered less frequently from thrombosis/embolism (P1⁄4 0.041) and ARDS and MOF (P1⁄4 0.006). This prospective multicenter study addressing patients with pelvic fractures reveals that the risk for a thrombosis/embolism, ARDS, and MOF is significant lower in pediatric patients than in adults. No rt P. Südkamp, Pr umann, MD, PD, and Hagen Schmal, Prof Abbreviations: AO = Arbeitsgemeinschaft für Osteosynthesefragen, ARDS = acute respiratory distress syndrome, EQ-5D = EuroQoL5D, ISS = Injury Severitiy Score, MOF = multiorgan failure, PTS = Hannover Polytrauma Score, VTE = venous thromboembolism. INTRODUCTION T rauma remains the leading cause of death in children. 1 Injuries in the pelvic region in children and adolescents are rare: the incidence is between 2.4% and 7.5%. The main causes of injury are high-energy trauma associated with concomitant injuries to other regions (neurovascular and musculoskeletal structures, abdominal trauma, injuries to the central nerve system, etc.). A postmortem study of trauma patients showed a high rate of pelvic fracture-related deaths and a high incidence of pelvic fractures. An analysis from the American National Inpatient Pediatric Database revealed that children with pelvic injuries presented 5.2 concomitant injuries on average. A summary of the present literature shows that 83.3% of all pediatric pelvic injuries were due to high-energy trauma. The United States analysis also reveals that a pedestrian being struck by a car was the mechanism in 57.8%, a motor vehicle passenger was injured in 17.8%, a bicyclist in 4.9%, and a motorcyclist in 0.6%. A fall from a height was responsible for causing a pediatric pelvic fracture in 9.2%. Crush injuries (2.2%), injuries sustained during sport activities (2.1%), and farm accidents (0.5%) were uncommon. A key prognostic injury mechanism is the history of roll-over or crush (Injury Severitiy Score [ISS] up to 40 points, 86.6% associated injuries, 20% mortality rate >70% local complication rate). The ligaments of the children’s pelvic are relatively stronger, and growth centers are present which together with the sacroiliac joints and pubic symphysis enable significant absorption capacity. Their pelvis is thus more elastic and more cartilaginous than that of adults. This elasticity results primarily in plastic deformation when the pelvic bone absorbs an impact which enables the pelvic anatomy’s potential to be entirely restored, but not normally to the preinjury point. Due to this elasticity, the intrapelvic viscera are insufficiently protected, and intrapelvic organ injuries can occur in the absence of pelvic fractures or dislocations. Therefore, even simple or minimally displaced fractures are usually the result of a highenergy trauma, accompanied by the significant risk of additional intrapelvic and intraabdominal injuries. This leads to a relatively high incidence of isolated pubic rami fractures or iliac wing fractures. plete disruption of the anterior and mplex pelvic injury can present a high ty and mortality. www.md-journal.com | 1 Polytraumatized children should undergo computer tomography scans to rule out both pelvic fractures and associated nonmusculoskeletal injuries. The majority of pediatric pelvic fractures heal with no sequelae. Delayed union, pseudarthrosis, and persisting ligamentous instability are very rare. Complex pelvic traumas are associated in 31% of cases in conjunction with a higher rate of complications such as chronic back pain, persisting length discrepancy of the legs, difficulty urinating, and malfunction of the anal sphincter. Pelvic asymmetry can occur in children because of injury to the triradiate epiphysis; their mortality rate after pelvic fractures is around 5% (compared to 11%–18% in adults). The aim of this study based on a review of prospectively collected registry data was to evaluate the epidemiological data on children over a lengthy interval and to analyze how often and which emergency procedures were done to treat their pelvic fracture, as well as the postoperative complications these children suffered. Moreover, we were able to examine the clinical follow-up in a small subgroup of children to compare with a group of adults’ follow-up. Our a priori hypothesis was that there are relevant differences between the pelvic fractures in children compared to adults in terms of their epidemiological data, treatment methods, clinical outcomes, and types and rates of complications.