The orthopaedic care given to fractures of the long bones in patients who have trauma to multiple organ systems often differs in some way from the care recommended for a solitary fracture of a long bone. Generally, solitary fractures of the long bones in children are treated with closed reduction and immobilization with a cast, but casts can cause problems for some patients with multiple injuries. The creation of windows in the cast, which are needed to change dressings on wounds in the extremities, can lead to displacement of previously reduced fractures. Involuntary movement due to spasticity from a head injury can lead to pressure sores within the cast. A hip spica cast makes it more difficult to examine the abdomen clinically and to perform imaging studies in the abdominal and pelvic areas.
As a result, well padded casts and splints are used for primary treatment of closed, nondisplaced fractures in children with multiple injuries. The preferred treatment for open, nondisplaced fractures, once irrigation and débridement in the operating room has been completed, often is fixation with pins and an external frame, particularly if the cutaneous wound is large. Consideration should be given to operative treatment of all displaced fractures in this setting, even though many can be adequately and safely treated closed. The decision to use nonoperative or operative treatment depends on many factors and needs to be made on the basis of the individual needs of each child with multiple injuries.
Treatment of Open Fractures
The ideal time for stabilization of closed fractures is a bit unclear, but there is no doubt that open fractures need to be treated on an emergency basis. Although only a relatively small number of fractures in children who have multiple injuries are open, it is these fractures that need immediate care33.
An open fracture is generally classified with use of the criteria of Gustilo and Anderson14 when the patient arrives in the emergency room. When used for adults, this classification is associated with the number and extent of sequelae from the open fracture, including risks of infection, delayed union, nonunion, amputation, and residual functional impairment. The three major classifications of open fractures are based on the size of the wound, extent of the injury of the soft tissues, contamination of the wound, and associated vascular injury.
A fracture is classified as type I when the wound is less than one centimeter in size and there is minimum contamination or injury of the soft tissues. Most of these wounds are inside-to-outside punctures, caused when the sharp end of the fractured bone punctures the skin. Even open fractures associated with a small puncture wound should be treated with irrigation and débridement in the operating room. The fracture is considered to be type II when the wound is larger than one centimeter with moderate soft-tissue injury, and it is classified as type III when there is extensive soft-tissue injury and crushing as well as a large, open, contaminated wound. Fractures are classified as subtypes IIIB and IIIC when there is exposed bone and as subtype IIIC when there is associated vascular injury. The Gustilo-Anderson system can be used as a guide to classify open fractures in children, but the treatment, particularly that of type-III fractures, in children may differ from that in adults, given that wounds and fractures heal more quickly in young children than they do in adults. Subtype-IIIC injuries that may be considered an indication for primary amputation in adults should be considered treatable with a limb-salvage operation in most children.
In the emergency room, a sterile gauze dressing containing povidone-iodine solution should be applied to the open wound, and the fracture should be immobilized for transport to the radiology unit. It is not necessary to take samples for culture in the emergency room, but it may be helpful to obtain them in the operating room at the time of débridement. A broad-spectrum antibiotic, usually cefazolin at a dose of twenty-five milligrams per kilogram of body weight, is administered intravenously in the emergency room to all patients who have an open fracture. An aminoglycoside antibiotic is added for primary coverage for all patients who have a type-III fracture. It is also added for some patients who have a type-II fracture, such as those who have had a delay in treatment of longer than twelve hours or those who have contamination from a farmyard accident.
The open fracture should be irrigated and debrided in the operating room as soon as possible after the injury. Although an attempt should be made to perform irrigation and débridement within six hours after the injury, as has been recommended by some authors to decrease the risk of later infection20, débridement in patients with multiple injuries may be delayed for a few more hours to allow time for stabilization of the patient and for the imaging of other organ systems. If there is a delay in operative irrigation and débridement, early intravenous administration of cefazolin (twenty-five milligrams per kilogram of body weight) in the emergency room may help to keep the risk of infection acceptably low.
In the operating room, a systematic approach to irrigation and débridement is helpful. A sample for culture is usually obtained, but there is controversy about the importance of the result of this culture with regard to determining the later treatment of the wound. The edges of the wound are excised, and the wound is extended to allow for a more complete exploration. The hematoma is evacuated, and any necrotic soft tissue is excised. The ends of the proximal and distal fracture fragments are inspected. During this exploration of the wound, a pulsatile irrigation system is used to gently debride both the soft tissues and the ends of the bone. It is customary to use ten liters of fluid for irrigation of each open fracture. Reduction of the fracture is then completed under direct vision, and the fracture is assessed to determine the reconstruction options for stabilization. After the fracture is stabilized, the portion of the wound that was incised in the operating room is closed and the wound associated with the open fracture is left open. When the fracture is type I, a small drain is left in the wound for two days. Cefazolin, administered intravenously at a dosage of twenty-five milligrams per kilogram of body weight every eight hours, is generally used for a total of three days. A longer course of appropriate antibiotics, based on the results of culture and sensitivity studies, is used if additional problems with the wound occur.
Timing of Treatment of Multiple Closed Fractures
It is standard practice in adult trauma centers to stabilize fractures of the long bones within twenty-four hours after the injury in order to decrease the risk of pulmonary and other medical complications. There is much less concern about pulmonary disease developing in children after multiple injuries, unless the child has sustained severe trauma to the chest or multiple fractures of the ribs. In addition, children who have multiple injuries were typically active and healthy before the trauma.
Generally, closed fractures of the long bones should be treated expeditiously. Treatment of fractures within seventy-two hours after the time of the multiple injuries, as opposed to more than seventy-two hours after the injuries, usually results in a shorter stay in the hospital, a shorter stay in the intensive-care unit, and a shorter period of ventilatory assistance. Children who have earlier operative management have fewer complications24. General anesthesia does not have a negative effect on the brain of a comatose child, and early fixation of fractures facilitates evaluation and care of the other injured organ systems28.
Indications for External or Internal Fixation of Fractures
Indications for operative treatment of long-bone fractures have to be examined individually in each child with multiple injuries, as the combination of organ-system injuries is seldom fully predictable. Nonetheless, there are some relatively frequent clinical situations in which it is best to treat fractures by either external or internal fixation. These situations include a displaced and shortened fracture of a long bone in a comatose child, an open or closed fracture associated with a large wound or loss of skin, a fracture associated with vascular injury, a fracture associated with compartment syndrome necessitating fasciotomy, a so-called floating joint (long-bone fractures on both sides of the joint), and a displaced pelvic fracture in a preteenager or teenager.
Internal Fixation of Fractures
The techniques used for internal fixation of fractures in children differ somewhat from those used in adults. The main types of internal fixation in children are Kirschner wires or Steinmann pins, flexible intramedullary rods, and AO plates. The primary purposes of internal fixation in children are to align the fracture fragments enough to allow healing, to facilitate the care of other injured organ systems, and to prevent complications that may be associated with immobilization of the extremity. Since nonunion of fractures is unusual in children, the fixation does not need to be as rigid as it needs to be in adults. As stiffness of adjacent joints caused by immobilization is not an important risk in most children, casts or splints can be used to supplement the internal fixation while healing rapidly occurs. In addition, intramedullary fixation with reaming should be avoided in order to prevent iatrogenic injury to the open growth plates.
Radial or Ulnar Fractures
Most closed fractures of the forearms of children who are less than ten years of age should be treated with closed reduction and the application of a cast. In certain situations—such as when the fracture is open or irreducible or is unstable after closed reduction—intramedullary rod fixation, currently the most common form of internal fixation used for the treatment of fractures of the forearm, is indicated22. In these children and young adolescents, flexible intramedullary implants are useful for providing sufficient stability to allow healing. These implants have included Steinmann pins, Rush rods, and, more recently, the new flexible titanium implants of two to four millimeters in diameter. The type of device that is used for fixation depends on the surgeon's experience and on the size of the child's bone. Steinmann pins are used in the ulna to provide stabilization of this straight bone, but they are less applicable to the radius. Rush rods can be used in both the ulna and the radius, with the implant contoured to accommodate the bow of the radius when it is inserted in that bone. Flexible titanium nails have a slightly hooked end that facilitates passage across the site of the fracture, and they can be inserted either straight into the ulna or with a contoured bow into the radius.
When intramedullary implants are used for fractures of the forearm, the ulna is stabilized first. The point of entry into the ulna is at the olecranon or in the proximal ulnar metaphysis. Once entry into the medullary canal is achieved, the implant should be inserted by hand, not with a power drill, particularly if the end of the implant is sharp. The implant is advanced with fluoroscopic control while the fracture is held in the reduced position. After the ulna is stabilized, fluoroscopic examination is done to assess the adequacy of the reduction of the radial fracture. If the stability provided by the ulnar implant has allowed satisfactory reduction of the radius, a cast is applied without additional operative stabilization of the radius. If the radius is not adequately reduced after the ulna is stabilized, an intramedullary rod is placed in the radius as well.
The standard point of entry of the intramedullary implant into the radius is the distal metaphysis, just proximal to the distal physis. Patients who have a closed fracture of the middle or proximal part of the radius are good candidates for intramedullary fixation, as these fractures are more difficult to control with closed reduction and a cast. Here again, the implant is manually advanced across the site of the fracture under fluoroscopic guidance. In the proximal aspect of the radius, limited operative exposure of the fracture may be necessary to align the fracture fragments, particularly if the pinning is being done several days after the initial fracture.
An operative alternative to the use of an intramedullary rod in the forearm is the use of an AO plate36. Generally, AO plates used in preteenagers can be shorter and can have a smaller number of sites of cortical fixation than those needed in teenagers or adults, as a splint or cast is applied postoperatively for preteenagers. A second operative procedure is needed to remove the plate, and, even in children and teenagers, there is a risk of refracture through the empty screw-holes for approximately six weeks after the plate and the screws are removed.
Humeral Fractures
Nonoperative treatment is preferred for most fractures of the proximal aspect of the humerus; substantial angulation and displacement can be accepted because the bone remodels excellently after this fracture, even in teenagers. If open reduction is needed because of the presence of interposed soft tissue, fixation with Steinmann pins is sufficient to provide stability for healing. Fixation with an AO plate is usually used for diaphyseal fractures in a teenager or when there is a special circumstance, such as a floating elbow with associated fracture of the forearm. Recently available flexible intramedullary nails can also be used in this setting, without the risk of injuring the radial nerve during either insertion of the plate or its subsequent removal. Fixation with smooth pins is generally sufficient for distal fractures in preteenagers. In adolescents, as in adults, T condylar fractures need to be treated with open reduction and the insertion of a contoured AO reconstruction plate.
Tibial Fractures
Internal fixation is not often used for diaphyseal fractures of the tibia; it is more common for this bone to be treated operatively with pins and an external fixation device when operative stabilization is needed. The primary use of internal fixation is for stabilization after reduction of physeal fractures. A Salter-Harris type-I fracture in the proximal aspect of the tibia can be stabilized with the percutaneous insertion of smooth Steinmann pins in a crossed fashion between the epiphysis and metaphysis. Fixation of fractures in this manner usually negates the need for an extreme reduction position in a cast and allows for care of arterial injury, which is often associated with this type of fracture. An above-the-knee cast is used to protect the fracture reduction for four weeks, after which time the pins are removed.
A Salter-Harris type-III fracture is temporarily stabilized with two Kirschner wires inserted into the epiphysis, parallel to the joint surface, under fluoroscopic imaging. Two parallel cannulated screws are then inserted over the Kirschner wires for permanent stabilization, and the Kirschner wires are removed. A washer is frequently used to prevent the screw from being buried into the epiphysis as it is tightened. A similar technique of temporary stabilization with a Kirschner wire followed by permanent fixation with cannulated screws is used for Salter-Harris type-II and type-IV fractures with a sizable metaphyseal fragment. The cannulated screws used in this setting must avoid crossing the physis and are inserted parallel to the joint line and to the physis. When either Steinmann pins or cannulated screws are used for fixation of a physeal fracture, it is necessary to use an above-the-knee cast as well until the fracture has healed.
Reaming to insert an intramedullary fixation device, an approach often used to treat a tibial fracture in an adult, is avoided in skeletally immature patients because of the possibility of a recurvatum deformity developing as a result of iatrogenic injury to the anterior part of the proximal tibial physis. Flexible intramedullary nails, entering the proximal metaphysis, will likely be used more in the future, but currently their use is more popular in other long bones.
Femoral Fractures
Femoral fractures commonly are treated with operative stabilization in children with multiple injuries. As in the tibia, distal physeal fractures in the femur can be stabilized with smooth Steinmann pins or cannulated screws, depending on the amount of displacement and the type of fracture.
Physeal growth arrest is rather common after any distal femoral physeal fracture. Nonetheless, with Salter-Harris type-I fractures, percutaneous smooth Steinmann pins can be inserted in a crossed fashion to hold the fracture fragments securely enough to allow for placement of a cast or splint with slight flexion of the knee. With Salter-Harris type-II fractures, the insertion of cannulated screws through the metaphyseal fragment, parallel to the physis, provides adequate stability of the fracture reduction to allow placement of a cast or splint. Supracondylar distal femoral fractures are usually best reduced with the knee flexed to relax the pull of the gastrocnemius muscle. However, with the knee in this position it is not possible to easily recognize varus or valgus malalignment of the fracture reduction. Percutaneous crossed Steinmann pins are useful to hold the reduction in a position to allow full extension of the knee and to provide the opportunity to accurately assess for varus or valgus malalignment.
There may be a small risk of physeal injury from the use of Steinmann pins, but it is better to achieve excellent alignment of the fracture here than to avoid the insertion of smooth pins across the physis because of this risk. These pins are left protruding through the skin and are removed on an outpatient basis three to four weeks after insertion. Cannulated screws are used commonly for Salter-Harris type-III fractures of the distal epiphysis and for Salter-Harris type-II and type-IV fractures with a large enough metaphyseal fragment to allow for internal fixation without physeal damage. All patients who have treatment of a distal femoral physeal fracture must be followed carefully to look for subsequent longitudinal or angulatory growth disturbance.
It is the operative treatment of the femoral diaphyseal fracture that remains controversial8. Intramedullary rods inserted in any fashion after reaming are used in teenagers and adults. In children between five and twelve years of age, the primary choice of operative stabilization is external fixation, retrograde flexible intramedullary fixation, or fixation with AO plates.
Open reduction with AO plate fixation has been shown to be successful in treating femoral fractures in children who have multiple injuries21. This is a particularly effective technique when there is an injury of the femoral artery needing repair adjacent to the fracture. Prompt stabilization of the fracture is achieved through the same wound that is used for exploration of the artery; with the internal fixation, an external fixation frame, which can make the arterial repair more cumbersome, is unnecessary. A disadvantage of fixation with a plate is that a second operative procedure is needed in order to remove the plate. Also, there is possibly more subsequent femoral overgrowth than occurs with other treatment methods, although a recent study demonstrated a mean of only nine millimeters of overgrowth after fixation with an AO plate in children21.
An increasingly popular method of internal fixation of femoral fractures in children is the use of flexible retrograde intramedullary nails that range in diameter from two to four millimeters15,17. I prefer this method for stabilization of femoral fractures in children who are six to twelve years of age. Two intramedullary implants are inserted at the medial and lateral metaphyseal areas just proximal to the distal femoral physis. The implant is bent into a gentle C-shape and is inserted through a drill-hole. The implant is then manually advanced proximally across the site of the fracture under fluoroscopic imaging. The second implant that is used is generally five millimeters smaller than the first to facilitate passage across the fracture site. The curved tip of one nail should end in the femoral neck and that of the other should end in the region of the greater trochanter to improve the rotational stability. The distal ends of the nails are cut off one to two centimeters from the surface of the bone to facilitate later removal of the implants. Although general anesthesia is needed for a brief time, the implants are removed easily through the distal insertion wounds once fracture-healing is complete.
The use of standard techniques of antegrade femoral intramedullary nailing in children who are less than twelve years of age remains controversial8. Interference with the appositional growth of the proximal aspect of the femoral neck leads to narrowing of the femoral neck in some preteenagers. The appearance of avascular necrosis of the femoral head following treatment of fractures of the femoral shaft with antegrade nails has suggested that injury to the circumflex artery near the piriformis fossa is the most likely cause of the necrosis. Implants recently have been designed to enter from the tip of the greater trochanter to avoid this problem of avascular necrosis, but follow-up information regarding these new implants is incomplete to date.
External Fixation of Fractures
As is the case with internal fixation, external fixation of fractures of the long bones can greatly facilitate the overall care of children with multiple injuries2,4,12,19,29-32. Although the technique is applicable to any fracture of a long bone, external fixation is used primarily to treat fractures of the lower extremities in children. The main reason to use external fixation in the upper extremity of a comatose child may be to lengthen a bone that has shortened excessively. The placement of pins for external fixation has more potential for causing iatrogenic injury to the peripheral nerves in the arm and forearm than it has in the lower extremity. In some patients, it may be safer to place certain pins (for example, those in the distal aspect of the humerus) under direct vision through a limited incision in order to avoid nerve injury. Familiarity with the cross-sectional anatomy of the forearm is essential if external fixation is used there.
In contrast, external fixation is a widely used, valuable method for the stabilization of fractures of the lower extremities of children. Most orthopaedists can apply the pins and the external fixator frame relatively quickly. Unlike the use of pins for external fixation in the upper extremity, placement of the pins in the lower extremity is associated with a low risk of iatrogenic neurovascular problems. External fixation is the preferred method for treatment of open fractures of the femur and tibia. The external fixator can be used to bridge the knee or ankle joint to achieve stability of metaphyseal fractures as well as to avoid the use of pins inside large wounds. It is my preferred technique of operative stabilization for fractures of the tibial shaft and for spiral or oblique femoral fractures in preteenagers.
Usually a unilateral frame provides sufficient stabilization of tibial and femoral fractures. A number of fixators are commercially available, and each has its relative merits. All require that at least two pins be placed in the proximal and distal fragments of the fracture. When pins are to be placed in a skeletally immature patient, the sites of insertion should be predrilled. Half-pins, inserted through a stab wound and engaging both bone cortices but not exiting the skin on the opposite side of the thigh or leg, are used routinely. These half-pins are inserted laterally in the femur and either anteriorly or medially in the tibia. The size of the pin that should be used varies with the size of the bone and the age of the child, but the diameter of the pin should be less than 30 percent of the diameter of the bone in order to minimize the risk of fracture through the site of the pin. The most distal and proximal pins should be placed at least one to two centimeters away from the physis to avoid physeal injury from insertion of the pin and later from infections at the sites of the pins. Weight-bearing is encouraged after the child has recovered from the other injuries and walking is permitted. If a rigid frame is used, some of the connectors of the pins to the frame are loosened a few weeks before removal of the pins and the frame to allow weight-bearing forces to pass through the bone rather than through the external fixator. This process, which has been termed dynamization, appears to strengthen the bone at the site of the fracture and to decrease the prevalence of refracture after removal of the pins and the frame.
There are several potential problems with the use of pins and an external fixator in children. The most commonly encountered problem is pin-track infection. The risk of such an infection can be decreased by ensuring that there is no skin tension at the sites of entry of the pins and by meticulous care of the pin sites; hydrogen-peroxide-soaked swabs should be used twice daily to remove any crusted material. This home care may be augmented at times with whirlpool cleansing. If local erythema and seropurulent drainage occurs, the oral administration of broad-spectrum antibiotics, usually cephalexin at a dosage of fifty milligrams per kilogram of body weight per day in four divided doses, will suffice to control the local infection and allow for continued use of the external fixator. If radiographs demonstrate progressive lucency around a pin with drainage, the pin needs to be removed and the pin track must be debrided with curettage and irrigation in the operating room and the patient under general anesthesia. In the case of established osteomyelitis, intravenous antibiotic therapy is generally used initially in conjunction with the operative curettage and irrigation to control the infection. At first, cefazolin at a dosage of twenty-five milligrams per kilogram of body weight is given every eight hours, but other antibiotics may be used if the cultures indicate that the bacteria are more susceptible to them. Although many patients have some wound drainage during the course of treatment, the prevalence of deep bone infection is very low in children.
The use of external fixation can lead to delayed healing of a fracture, particularly a transverse fracture in a teenager. Use of a rigid frame and a lack of dynamization of a frame also lead to a delay in fracture-healing. Early weight-bearing should be encouraged. In preteenagers in whom femoral overgrowth is expected after a fracture heals, bayonet apposition with 0.5 to 1.0 centimeter overriding allows faster healing of a transverse fracture than if it is reduced anatomically. In reports on external fixation of fractures of the lower extremity, rates of refracture have ranged from zero of twenty-seven30 to three of fourteen31, with refractures occurring either through the site of the old fracture or through the pin track. The use of a flexible frame, the loosening of the connectors of the pins to the rods to allow weight-bearing through the fractured bone before removal of the pin and rod, bayonet apposition of the fracture ends, and the use of pins of appropriate size all minimize the rate of refracture after removal of the fixator.
Overgrowth of a limb usually amounts to a few millimeters after treatment of a solitary closed fracture of the femoral shaft. It is primarily a concern in a preteenager who has had anatomical reduction of the femoral fracture and who has also had associated extensive soft-tissue injury in the ipsilateral extremity. Use of bayonet apposition for preteenagers who have a femoral fracture helps to eliminate this problem with limb length and possibly decreases the time to healing. Joint stiffness is unusual, even if the external fixator is used to bridge a joint, unless there is marked soft-tissue injury adjacent to the joint. Malalignment of the fracture in the frontal plane should be preventable, as the frame can be adjusted to correct malalignment quite readily. Rotational alignment of the femur is more difficult to judge at the time of placement of the fixator pins. The use of an anteroposterior radiograph to view both ends of the bone helps to ensure correct alignment when pins are placed, thus avoiding malalignment, which most often results from internal rotation of the distal femoral fragment.
Treatment of Floating Joints
A floating joint, an injury involving a fracture of a long bone on each side of a joint, is a special injury that requires operative stabilization of at least one of the fractures5,23. This injury most commonly involves the long bones adjacent to the knee and the elbow. Although floating joints are sometimes treated nonoperatively in children who are less than ten years of age5, I prefer some operative stabilization even in young children. Treatment of floating joints in teenagers and of those involving fractures in the juxta-articular position has poorer results than treatment of fractures of the midpart of the shaft and those in children who are less than ten years of age5. If there is swelling of the involved joint, I prefer to stabilize both fractures in order to evaluate the joint for ligamentous instability or another injury of bone or cartilage and in order to institute joint motion earlier. The primary difference between treatment of a floating joint in children and treatment of this injury in adults is that the fixation usually can be less rigid in children and skeletally immature adolescents; AO plates are used less often, and external fixation or fixation with an intramedullary rod is generally employed.
High-energy trauma often leads to pelvic fractures as a part of the multiple-system injury. Injuries to the pelvis and spine are associated with the longest hospital stays, the most admissions to the intensive-care unit, and the highest rates of mortality among patients with multiple injuries7. It has been demonstrated that associated head and abdominal injuries should be strongly suspected when a pelvic fracture and at least one other fracture are present, so careful examination of other systems is essential35. Trauma to viscera and soft-tissue structures adjacent to the osseous pelvis can cause life-threatening injuries, so resuscitation of the child initially takes precedence over stabilization of the pelvic fracture. Although at times a pelvic fracture may need to be stabilized immediately to help to control hemorrhage, it appears that the death of children who have a pelvic fracture usually results from a head injury, not the visceral or vascular injuries associated with the pelvic fracture27. However, while soft-tissue and visceral injuries are of high priority, incompletely treated orthopaedic injuries of the pelvis may lead to more permanent disability. Thus, these displaced fractures, like those of the long bones, need to be treated definitively and expeditiously, with the assumption that the child will eventually recover fully from any head injury that has occurred.
Pubic and Ischial Injuries
A fracture of the pubic or ischial ramus needs little orthopaedic treatment if it is the only osseous injury present in the pelvis. However, care needs to be taken to assess two primary areas: the posterior aspect of the pelvic ring and the genitourinary system. If the child is awake, examination for tenderness at the sacroiliac joints is indicated, and, if tenderness is present, a computed axial tomography scan of this area is needed. As most genitourinary injuries that occur with pelvic fractures are associated with those of the anterior aspect of the pelvic ring3, it is necessary to ensure that a urethral injury is not missed in a patient who has this type of fracture. If this is the only fracture of the pelvis, the patient should be managed with analgesics and bed rest until the pain is sufficiently relieved to allow weight-bearing. Full weight-bearing after a fracture of the pubic or ischial ramus will not displace the fracture, but the patient usually walks with crutches until the pain resolves, after which time full weight-bearing is resumed.
Bilateral fracture of the pubic and ischial rami is a more severe injury, with more potential for injury to the adjacent soft-tissue structures, especially the urethra. Urological consultation should be arranged in the emergency room soon after admission to assess the patient for a possible urethral injury. Although a bilateral fracture of the rami is relatively stable, there is often an associated injury of the posterior aspect of the pelvic ring or of the sacroiliac joint (a Malgaigne fracture). Because of this possibility, a computed axial tomography examination of the pelvis is needed to assess for injuries of the posterior sacroiliac joint or the ilium and to provide more information for the formulation of treatment plans. External fixation has been used29, but operative stabilization is usually not needed in children and preteenagers, as healing is expected to occur quickly in these patients. Guidelines for internal stabilization of an injury of the posterior aspect of the pelvis in a teenager are similar to those for stabilization of this injury in adults. An injury of the posterior aspect of the pelvis in a child or a preteenager usually can be treated adequately with four weeks of bed rest to allow enough bone-healing for the commencement of weight-bearing. If there is no posterior injury, weight-bearing can begin when the pain subsides and the other injuries have healed sufficiently.
Diastasis of the pubic symphysis involves injury to the sacroiliac joints or the adjacent posterior part of the pelvic ring. Again, urological consultation should be obtained in the emergency room or shortly after admission to the hospital to assess the patient for a possible urethral injury. The degree of injury of the posterior aspect of the pelvic ring is related to the degree of spread of the pubis anteriorly. Bed rest, with the patient lying either supine or on the side, is used for mild diastasis until the pain is gone, at which point walking is begun. In more severe cases, an external fixator placed anteriorly can be used to close the diastasis34. If a wide diastasis is left unreduced, the child will walk with increased external rotation of the lower limbs but should not have other functional problems.
Acetabular Injuries
An acetabular injury in a child usually occurs from the extension of an adjacent fracture into the acetabular region and usually is stable. Fractures of the pubic and ischial rami can extend into the triradiate cartilage and may lead to premature closure with cessation of the centrifugal growth of the triradiate cartilage. A fracture of the iliac wing may extend into the superior aspect of the acetabulum. If plain radiographs suggest extension of a fracture into the acetabulum or the triradiate cartilage, computed axial tomography scans should be made to define the injury more completely. If the acetabular fracture is displaced, open reduction and internal fixation is recommended to restore joint congruity.
Vertical Shear Fractures
A vertical shear fracture is the most serious type of pelvic injury in children. These fractures are unstable and are associated with visceral and other soft-tissue injuries6. The immediate problem associated with these fractures is bleeding, which can be either retroperitoneal from the fracture or intraperitoneal from injured abdominal organs18. Of the different types of pelvic fracture, bilateral anterior and posterior fractures are the most likely to cause severe hemorrhage25. The initial treatment usually involves replacement of blood volume and stabilization of the child's overall condition. While adults often die from the loss of blood associated with severe pelvic fracture, it is much less common for a child to do so27. There may be instances in which a child needs external fixation of the pelvis to control hemorrhage, but children need such treatment far less often than adults do29. Although an anterior external fixation frame that is attached with pins to the iliac wings does not anatomically reduce a vertical shear fracture, the stability provided by the fixator appears to help to limit motion of the posterior aspect of the pelvis and, in this way, aid in controlling retroperitoneal hemorrhage.
Once lost blood has been replaced and blood loss has been controlled, imaging studies of the abdomen and pelvis should be performed to define the degree of injury. Plain radiography is used first, but it is nearly always necessary to perform a computed axial tomography scan of the abdomen and pelvis. At times, a three-dimensional reconstruction of the computed axial tomography scan of the osseous pelvis is helpful to better visualize the extent of the injuries26. Stabilization with internal fixation is not usually needed in a young child with a vertical shear pelvic fracture, as these fractures heal even if they are moderately displaced. All children and preteenagers who do not have internal or external fixation of the pelvic fracture should be managed with skeletal traction, with use of a Steinmann pin in the distal aspect of the femur, to prevent further cephalad migration of the hemipelvis. If there is a concomitant femoral fracture, either external fixation or traction is used to reduce the femoral fracture to full length or the femur is slightly overlengthened to compensate for the approximately one centimeter of shortening of the lower extremity that occurs with cephalad displacement of the hemipelvis. In teenagers who have a vertical shear fracture, posterior reduction and plate-and-screw internal fixation is used in the same way as it is used in adults.
Nonorthopaedic Injuries Associated with Pelvic Fractures
Nonorthopaedic injuries associated with pelvic fractures are common; in one series, they occured in twenty-four (67 percent) of thirty-six patients and eleven (30 percent) of these thirty-six patients had long-term morbidity or died13.
Neurological injuries: Displacement of the hemipelvis or the iliac wing posteriorly can result in local neurological deficits, either from injury to the sciatic nerve at the sciatic notch or from nerve-root avulsion at the lumbosacral level. The level of injury can be partially determined with a clinical examination, but it may be necessary to perform other imaging studies to assess the feasibility of treating this injury operatively. Myelography with computed axial tomography can be used to diagnose nerve-root avulsions by visualizing small meningoceles at the level of the injured nerve roots. If no nerve-root avulsion is noted and there is no clinical or electromyographic evidence of recovery in six to nine months after the injury, exploration of the sciatic nerve is probably indicated in children before adolescence. The younger the child is, the better the outlook is for success of nerve-grafting for an injury of the sciatic nerve, if such a repair is possible. Operative repair of nerve-root avulsion or of injury of the proximal aspect of the sciatic nerve generally is not recommended for teenagers because the distance between the injured area and the motor end plate in the muscles ennervated by these neural elements is too great to expect functional return.
Vascular injuries: Retroperitoneal hemorrhage may be a severe problem in children who have a pelvic fracture, but, as a rule, it is less of a problem in children than in adults. I do not recommend exploration of the retroperitoneal area. Blood replacement, external compression devices, and, at times, external fixation of the pelvis should allow control of the bleeding. If there is marked cephalad displacement of the hemipelvis, the superior and inferior gluteal arteries at the sciatic notch can be injured, which may lead to local soft-tissue necrosis. Unless there is an open fracture involving the anterior aspect of the pelvic ring, injury of the iliac artery or femoral artery is uncommon.
Urological injuries: Most urological injuries occur from fractures of the anterior aspect of the pelvic ring. The injury is most common at the bulb of the urethra, but the bladder, the prostate, and other portions of the urethra also can be injured. When the trauma is severe, injury to a kidney is also possible, but most urological injuries associated with pelvic fractures occur in the lower genitourinary tract distal to the ureters1.
Gynecological injuries: Vaginal tears and fistulae between the vagina and the bladder may occur from severe injuries of the anterior aspect of the pelvic ring. Other fractures that displace the ilia or change the shape of the pelvic ring can lead to later problems associated with narrowing of the birth canal. The rate of cesarean section is substantially higher for young women who have had a pelvic fracture than in those who have not10. In children and adolescents, pelvic fractures heal in a predictable way, and nonunions are unusual, so it is very important that, in girls, the fracture be reduced at least to the degree needed to allow freedom from later complications during pregnancy and delivery.
Late Orthopaedic Sequelae of Pelvic Fractures
There are few late orthopaedic effects of pelvic fractures that have been appropriately treated initially. Limb-length discrepancy may result from vertical shear-type fractures, with cephalad migration of one hemipelvis. This discrepancy is usually mild, but if it is more than two centimeters consideration can be given to contralateral epiphyseodesis at the appropriate time to allow for equality of the limb lengths at maturity. Premature closure of the triradiate cartilage may result from a fracture that extended into this area, usually from the region of the pubic ramus. If the child is young when this occurs, the acetabulum will not develop its normal depth and hip dysplasia will occur in early adolescence. Operative procedures to increase acetabular coverage of the femoral head may be needed at a later date.