Abstract
While many of the same principles of musculoskeletal management apply equally to adult and pediatric populations, significant or even subtle differences may impact the diagnosis and treatment of children. Conceptual shifts are involved in the management of child abuse as well as physeal fractures. Additionally, specific injury conditions are explored. Pediatric bony injuries generally tend to tolerate more deformity due to their healing potential. However, certain minor deformities must be corrected to prevent adverse consequences in the growing child.
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Keywords
- Avulsion fractures
- Casting and immobilization
- Child abuse-non-accidental trauma (NAT)
- Distal humerus physeal separation
- Distal femur physeal fracture
- Pediatric hip dislocation
- Pediatric hip fracture
- Humeral shaft fractures
- Lateral condyle fracture
- Medial epicondyle fracture
- Pediatric ankle fractures
- Pediatric forearm fracture
- Pediatric clavicle fracture
- Pediatric distal radius fracture
- Pediatric femur fracture
- Pediatric Galeazzi fracture
- Pediatric Monteggia fracture
- Pediatric pelvic fracture
- Pediatric proximal humerus fracture
- Sedation for the pediatric patient
- Radial head subluxation
- Radial neck fracture
- Salter-Harris classification
- Slipped capital femoral epiphysis
- Septic hip
- Transient synovitis
- Supracondylar humerus fracture
- Tibial tubercle fracture
- Tibial eminence fracture
- Toddler’s fracture
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
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Low-energy mechanism: avulsion of apophysis
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High-energy mechanism: motor vehicle accident or peds struck
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More commonly lateral compression (vs. adults with more AP compression)
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Higher rate of single-bone fractures
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Lower rate of hemorrhage secondary to plasticity of bones, thicker cartilage
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May be associated with: (requires co-evaluation with trauma team)
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CNS or abdominal visceral injury
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Femoral head fx/dislocation
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GU injury
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History
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Mechanism of injury?
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Other sites of pain (abdomen, back, extremities)?
Physical Exam
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Skin intact, tenderness, ecchymosis
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Full trauma survey (often done in conjunction with trauma team) including rectal/GU survey
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Stability of pelvis to compression (AP, lateral, rotational)
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LE neuro exam (Appendix A)
Diagnosis
Imaging
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XR Pelvis: AP, inlet/outlet views
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CT pelvis without contrast—often needed as radiographs may underestimate injuries
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MRI—occasionally indicated to evaluate apophyseal injuries
Classification
Tile Classification—describing stability
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Type A: stable (rotationally and vertically)
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Type B: rotationally unstable; vertically stable
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Type C: unstable (rotationally and vertically)
Torode/Zieg Classification—describing location
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Type I: avulsion fx
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Type II: iliac wing fx (usually from a direct blow)
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Type III: ring fx with no segmental instability (pubic rami/symphysis fractures)
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Type IV: ring fx with segmental instability (bilateral rami, straddle injuries, SI joint disruption)
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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.
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After closure , more likely to sustain fractures of acetabulum, diastasis of pubic symphysis, SI joint separation.
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Treatment
Non-operative
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Treatment: Protected weight bearing → physical therapy → gradual return to activities
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Generally less than 2 cm of displacement
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Indications: Generally indicated for most nondisplaced or type I/II injuries
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Treatment: Bedrest
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Indications: Type IV fracture with less than 2 cm of displacement
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Treatment: Consider spica casting
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May use skeletal or Buck’s traction
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Indications: Young patients who have trouble with weight-bearing restrictions
Surgery
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Treatment: Usually done in the first 24–48 h after injury
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ORIF
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External fixation—vertical shear patter with hemodynamic instability
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Indications:
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More than 2 cm of displacement, intra-articular, triradiate cartilage displacement
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Older children, high-energy (comminuted/displaced) fractures, open fractures, neurovascular compromise, associated injuries
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References
Banerjee S et al. Paediatric pelvic fractures: 10 years experience in a trauma centre. Injury. 2009;40(4):410–3.
Holden CP et al. Pediatric pelvic fractures. J Am Acad Orthop Surg. 2007;15(3):172–7.
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© 2017 Springer International Publishing Switzerland
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Makhni, M.C., Makhni, E.C., Swart, E.F., Day, C.S. (2017). Pelvic Fracture. In: Makhni, M., Makhni, E., Swart, E., Day, C. (eds) Orthopedic Emergencies. Springer, Cham. https://doi.org/10.1007/978-3-319-31524-9_101
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DOI: https://doi.org/10.1007/978-3-319-31524-9_101
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