Keywords

Uncommon injury in children (represents 1–2 % of pediatric fractures). Often treated non-operatively depending on age and displacement. Surgery mainly needed for high-energy trauma or in older patients.

Overview

  • Low-energy mechanism: avulsion of apophysis

  • High-energy mechanism: motor vehicle accident or peds struck

  • More commonly lateral compression (vs. adults with more AP compression)

  • Higher rate of single-bone fractures

  • Lower rate of hemorrhage secondary to plasticity of bones, thicker cartilage

    • May be associated with: (requires co-evaluation with trauma team)

      • CNS or abdominal visceral injury

      • Femoral head fx/dislocation

      • GU injury

History

  • Mechanism of injury?

  • Other sites of pain (abdomen, back, extremities)?

Physical Exam

  • Skin intact, tenderness, ecchymosis

  • Full trauma survey (often done in conjunction with trauma team) including rectal/GU survey

  • Stability of pelvis to compression (AP, lateral, rotational)

  • LE neuro exam (Appendix A)

Diagnosis

Imaging

  • XR Pelvis: AP, inlet/outlet views

  • CT pelvis without contrast—often needed as radiographs may underestimate injuries

  • MRI—occasionally indicated to evaluate apophyseal injuries

Classification

Tile Classification—describing stability

  • Type A: stable (rotationally and vertically)

  • Type B: rotationally unstable; vertically stable

  • Type C: unstable (rotationally and vertically)

Torode/Zieg Classification—describing location

  • Type I: avulsion fx

  • Type II: iliac wing fx (usually from a direct blow)

  • Type III: ring fx with no segmental instability (pubic rami/symphysis fractures)

  • Type IV: ring fx with segmental instability (bilateral rami, straddle injuries, SI joint disruption)

    • Before closure of triradiate cartilage (14 in boys, 12 in girls), iliac wing is weaker than pelvic ligaments leading to more pubic rami and iliac wing fractures.

    • After closure , more likely to sustain fractures of acetabulum, diastasis of pubic symphysis, SI joint separation.

Treatment

Non-operative

  • Treatment: Protected weight bearing → physical therapy → gradual return to activities

    • Generally less than 2 cm of displacement

  • Indications: Generally indicated for most nondisplaced or type I/II injuries

  • Treatment: Bedrest

  • Indications: Type IV fracture with less than 2 cm of displacement

  • Treatment: Consider spica casting

    • May use skeletal or Buck’s traction

  • Indications: Young patients who have trouble with weight-bearing restrictions

Surgery

  • Treatment: Usually done in the first 24–48 h after injury

    • ORIF

    • External fixation—vertical shear patter with hemodynamic instability

  • Indications:

    • More than 2 cm of displacement, intra-articular, triradiate cartilage displacement

    • Older children, high-energy (comminuted/displaced) fractures, open fractures, neurovascular compromise, associated injuries