Anatomy
Bones more elastic and malleable
- absorb much more energy
Very thick periosteum
- can be periosteal sleeve fracture
Ossification
Triradiate cartilage fuses 13-16
Iliac / Ilium / ASIS apophysis
- appear as teenager
- fuse a couple of years later
- can confuse with fracture
Classification Key & Conwell 1951
1. No break in continuity of pelvic ring
A. Avulsion fractures
1. ASIS
2. AIIS
3. Ischial Tuberosity
B. Fracture of pubis or ileum
C. Fractured wing of ileum
D. Fracture sacrum or coccyx
2. Single break in ring
A. Fracture of 2 ipsilateral pubic rami
B. Fracture near or subluxation of symphysis pubis
C. Fracture near or subluxation of SIJ
3. Double break in ring
A. Double vertical fractures or dislocation of pubis (straddle fracture)
B. Double vertical fractures or dislocation (Malgaigne fracture)
C. Severe multiple fractures
4. Fracture of acetabulum
A. Small fragment associated with dislocation of hip
B. Linear fracture associated with non-displaced pelvic fracture
C. Linear fracture associated with hip joint instability
D. Fracture secondary to central dislocation
Torode Classification
1. Avulsion fracture
2. Pelvic wing
3. Stable pelvic fracture
4. Unstable pelvic fracture
Associated Injuries Rang 1983
Local
Haematuria 30%
Urological / bladder 10%
Abdominal injury 11%
Perineal or gluteal lacerations 7%
Vascular injuries much more rare than in adults
Distant
Head 61%
Chest 9%
Upper extremity fracture 17%
Lower Extremity fracture 17%
Mortality rate 8%
Death usually not a direct result of pelvic fracture
- rather is due to associated injuries i.e. head injury
Examination
EMST / ATLS
Vaginal and rectal examination
Neurological and vascular examination
Management
Avulsion Fractures
Tensor fascia lata, sartorius, RF, Psoas, Hamstrings
- rarely require treatment
Pubic fractures
Exclude genito-urinary injury
Unilateral Fractures
- stable
- mobilise with crutches
- weight bear as tolerated
- usually 3-4 weeks
Bilateral Fractures
Child
- if associated with posterior ring or sacral fracture
- potentially unstable
- usually doesn't need ORIF
- heals quickly with bed rest
Teenager
- treat as Adult
- ORIF where appropriate
Pubic Symphysis Diastasis
Assess
- urological injury
- posterior ring injury
Treatment
- heals with periosteal sleeve
- if wide should close with external fixator
- if remains widened child walks with ER deformity
Acetabular Fractures
Triradiate fractures
- uncommon
- usually from extension of adjacent rami and iliac fracture
- usually stable
Complication
- child < 10
- early closure triradiate cartilage
- acetabular dysplasia
Management
Tri-radiate fracture
- skeletal traction
- CT
- if severely displaced fragment ORIF with smooth pins
Physeal bar across triradiate cartilage
- follow up all displaced & non displaced
- consider bony bidge excision and fat graft
Vertical Shear Fractures
Unstable
- associated visceral injuries
- blood loss is substantial and should be replaced
- is rare for child to die of blood loss from pelvis compared with adults
Management
- 6 weeks of skeletal traction
- rarely need external fixator
Complication
- LLD usually < 2 cm
- contralateral hemi-epiphysiodesis