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Long-term results of unstable pelvic ring fractures in children
Injury Vol. 29, No. 6, pp. 431-433, 0 1998 Elsevier ELSEVIER
1998 Science Ltd. All rights reserved Printed in Great Britain 0020-1383/98 $19.00+0.00
PII: SOO20-1383(98)00074-6
Long-term in children N. Schwarz’,
results of unstable
pelvic ring fractures
E. Posch’, J. Mayr”, F. M. FischmeisteelP, A. F. Schwarz5 and T. 6hner”
‘Trauma Hospital, Klagenfurt, Austria, 2Trauma Hospital ‘Meidling’, Vienna, Austria, 3Department of Pediatric Surgery, University of Graz, Graz, Austria, “Trauma Hospital, Linz, Austria, “Trauma Hospital, Salzburg, Austria and hTrauma Hospital, ‘Lorenz Bohler’, Vienna, Austria
Seventeen patients less than 12 years old sustained unstable pelvic ring fractures and were treated non-operatively. They were followed for 2 to 25 years. The subjective long-term results depended on the presence or absenre of low back pain. This eorrelated strongly with pelvic asymmetry. Five patients complained about chronic back pain, two were functionally impaired by severe pelvic asymmetry. Healing of an unstable pelvic fracture in malposition with asymmetry causes poor results and must be prevented. 0 1998 Elsevier Science Ltd. All rights reserved.
Injury, Vol. 29, No. 6,431-433, 1998
Introduction Stable pelvic ring fractures treated non-operatively heal perfectly’. In unstable fractures, non-operative treatment is often recommendedz, although the limitations of this therapy are known” and there is a paucity of information on the long-term results. Nierenberg et al.’ suggest an ‘aggressive conservative approach’, doubting that the results of surgery could be superior. This study was aimed at evaluating long-term results of non-operative therapy of unstable pelvic ring fractures in children, the data being used in reconsideration of the therapeutic approach to such fractures.
Patients and methods In a retrospective multicentre-study, children who suffered an unstable pelvic ring fracture between 1967 and 1992 were investigated. There were 32 patients, all less than 12 years old at the time of injury, with a minimum follow-up of 2 years. Seventeen of the 32 patients were available for a clinical and radiographic examination. The results refer to these 17 patients.
Patients There were 13 boys and four girls. The age at the time of injury was less than 6 years in six patients, 6 to 10 years in nine, and 11 to 12 years in two. Twelve children were injured in road traffic accidents and four by a fall from height. One child was buried alive. Only four children had no injuries in addition to their pelvic fracture. Among 13 patients, there were four urinary bladder ruptures, one rectal rupture, one vaginal tear, six femoral shaft fractures, two fractures of the tibiae and two of the forearm, two craniocerebral injuries, one splenic rupture, one thoracic injury, and one renal tear.
Classification Only unstable fractures of the pelvic ring were investigated. There are, according to Tile”, Type B (fractures of the pelvic ring with rotational instability) and Type C (fractures of the pelvic ring with additional vertical instability). Isolated disruptions of the symphysis were not included, since in contrast to the adult instability remains unclear due to the stronger ligaments when young. Disruption of the SI joints was only considered if the joint space of the injured joint was distinctly wider than that of the opposite site or if there was an additional fracture in the adjacent bone. Nine fractures were of type B (five Bl open-book injuries and three lateral compression injuries), eight were of type C (five unilateral, one bilateral incomplete, and two bilateral complete posterior arch disruptions). The pelvic lesions consisted of nine symphyseal disruptions, 39 fractures of the pubic rami, 17 sacroiliac joint disruptions, two fractures of the iliac wing, and five lesions of the Y-suture of the acetabulum.
432
Injury: International
Follow-up
examination
A clinical examination included muscular strength, gait, inclination of the pelvis while standing, scoliosis of the lumbar spine, Trendelenburg’s sign and range of motion of both hip joints. Radiographic examination was limited to an AP-view. Only in the case of special questions were additional radiographs or CAT-scans carried out. An AI’-view of the lumbar spine while standing was done in the presence of a clinical leg length difference. Leg length was measured clinically by determining the distance between the anterior superior iliac spine and the ankle joint. This was called ‘functional leg length difference’ for the fact that a difference between right and left could be caused by both pelvic asymmetry and pre-existing asymmetry of the lower extremities. A neurological examination was not carried out in all patients, and if so, it was not done by the same examiners. Therefore no results are given. Follow up was a minimum of 2 years, but was 10 to 25 years in nine patients. At the time of the last examination nine patients were older than 15 years and thus were fully grown.
Treatment Primary therapy was bed rest in 11 and femoral traction in three cases. Three patients were treated in a pelvic hammock (i.e. a 50 x 20 cm large sling of cotton tissue which is applied around the pelvis, crossed in front of the patient and pulled with two strings on each end of the cotton stripe with 3 kg each in order to compress the pelvic ring); one of these patients had additional femoral traction. Treatment was continued for 2 to 8 weeks. In one multiply injured patient an external fixateur was applied 10 weeks after injury for persistant malposition of the pelvic ring.
Journal of the Care of the Injured Vol. 29, No. 6,1998
Results (Table I) All fractures healed. In one patient, a disrupture of the Y-suture led to premature growth arrest and subsequently to a posttraumatic acetabular dysplasia with a poor clinical result after 6 years. Two patients had a widening of the symphysis from 2 to 3 cm without symptoms. One patient with a remaining vertical dislocation of the symphysis of 20 mm was pain free. Three patients, two males and one female, had an ossification of the symphysis which caused pain in the female, but not in the males. There was no functional leg length difference in five patients. Nine patients had differences of up to 3 cm. One patient had a 5 cm difference which in part was due to pelvic asymmetry and in part to femoral shortening after a shaft fracture. In two patients no measurements were done. Lumbar scoliosis was found in 10 patients. Pain was almost exclusively located at the lumbo-sacral junction and was in all but one patient correlated with lumbar scoliosis. Of 10 patients with a leg length difference of 1 cm or less, two had low back pain. However, of the remaining five patients with a leg length difference of more than 1 cm, three complained of low back pain. Hip joint mobility was normal bilaterally in 11 patients. In one patient one hip joint moved freely, the other was restricted due to avascular femoral head necrosis (AVN) following pertrochanteric fracture. In one patient both sides were restricted, one without obvious cause, the other because of AVN. Spastic plegia was the cause of limited range of motion of both hip joints in another patient. One patient had a limited range of motion due to the malrotated position of one half of the pelvis. In two patients no information could be obtained. The pelvic ring showed no or only slight asymmetry in nine patients, moderate asymmetry in
Table I. Patient’s initials GT RS AK NS RU CK DP
CG GK CA t: ZLs GC
Age” --__
Sexb
4y5m llylm 7y6m 5y4m 4y6m 3y3m 4y5m 6y2m 5y3m 9y4m
f m m f m m m m f m m m m m m f f
12Y 8y9m lly9m 7y6m 9y7m 6y2m 7y8m
“y, years; m, months. bm, male; f, female. + slight scoliosis; + + marked
Vertical instability no
ves ves yes no no
ves yes no no no no yes
ves yes no no
scoliosis.
Follow-up years 16 22 3 14 6 3 2 2 12 11 3 13 6 II 15 25 4
Radiographic asymmetry (modest or severe only)
++
++ ++ ++ ++ ++ ++
Leg length discrepancy (cm)
2 ? 1 1 1
Lumbar scoiiosis +i + ++
i ++ ? ++ ++ ++ ++ ++
Low back pain no yes yes yes no no no no no no no
ves yes no yes no
Schwarz
et al.: Long-term
results of unstable
pelvic ring fractures
six and severe asymmetry in two. A pelvic ring that was found to be radiographically symmetrical at the end of the treatment was so at follow-up, in no case did asymmetry correct itself over the years. In two severely multiply injured patients the pelvic fractures were neglected and therefore healed Both had enormous with major malformation, functional problems and pain due to their pelvic asymmetry. Two patients had a permanent bladder cystic fistula; one of these suffered from an additional rectal sphincter paralysis.
Discussion Stable pelvic ring fractures in children usually yield good results; but it is difficult to distinguish between stable and unstable fractures and classification is often subjective. The joint space of %-joints is primarily wider in children, and additional fractures of the related bones as proof of a joint lesion are seldom seen. Only a yawning joint cavity or a vertical dislocation proves an injury of an %-joint. In children, tense ligaments may keep pelvic ring fractures stable, even if there is more than one fracture through the pelvic ring. Retrospectively, instability is proven by increasing displacement but, on the other hand lack of displacement is no evidence for stability. Dislocated double ring fractures must be vertically unstable. This was the case in eight of our patients. Rotational instability was assumed in nine patients, but could not be absolutely proven in all cases. It is difficult to assessthe three-dimensional form of the bony pelvis even by advanced radiographic methods; therefore, asymmetry remains a somewhat subjective consideration. Healing in a defective position inevitably causes asymmetry of the pelvis, and in some patients this was aggravated by impaired growth. Disturbance of growth (as well as potential spontaneous correction, which is probably rather limited’), can only be caught by radiographic follow-up at regular intervals; in our series this was only performed in exceptional cases for its retrospective and multicentre character. Asymmetry of the pelvis causes functional leg length difference and deviation of the spine and subsequently low back pain. No patient with a symmetrical pelvis complained about low back pain, independently of the follow-up time. Nierenberg et al.’ reported good results even in cases of remaining deformation of the pelvis; we cannot duplicate this. A functional length length difference of more than 1 cm will probably cause low back pain in the longterm. The outcome of pelvic fractures in children mainly depends on the symmetry of the pelvic ring
433
in children
maintained or achieved by treatment. It also depends on the location and pattern of injury and, indirectly, on the stability of fixation”. Therefore, Kershishyan et al.” advocate the application of an external fixateur in complex pelvic fractures, and Gordon et al.” also suggest an external fixateur or ORIF for children over 8 years of age. However, both papers lack sufficient data to support the treatment proposed. From our results, we propose the following principle of treatment: pelvic ring fractures in children should be reduced as perfectly as possible to secure healing in an anatomical position and to avoid asymmetry of the pelvic ring. By non-operative means this goal was achieved in only some of the patients in our series. In half of the cases the results of non-operative therapy were less than satisfactory. Non-operative treatment seems to be insufficient in the multiply injured child. Faced with the danger to the child’s life, the severe orthopaedic problems that may arise later are underestimated. In these rare cases, open reduction and internal fixation of the pelvic ring fracture should be considered as soon as the child is in a stable condition. For the time being it is unknown whether the outcome of pelvic ring fractures in children can be improved by operation. Healing in malposition with asymmetry of the pelvis causespoor results and must be prevented. However, which patients may benefit from operative reduction has to be clarified by studies to be undertaken.
References 1 Nierenberg G., Volpin G., Bialik V. and Stein H. Pelvic fractures in children: a follow-up in 20 children treated conservatively. ] P&i&v Orthop 1993; 1: 140. 2 Lane-O’Kelly A., Foharty E. and Dowling F. The pelvic fracture in childhood - a report supporting nonoperative management.I~~jur~1995;26: 327. 3 Keshishyan R. A., Rozinov V. M. and Malakhov 0. A. etal. Pelvic polyfractures in children. CIilj Orthop 1995; 320:28. 4 Tile M. Pelvic ring fractures: should they be fixed?. ] Boflc /oiut Surcy (BY) 1988; 70: 1.
5 Gordon R. G., Karpik K., Hardy S. and Mears, D. C. Techniquesof operative reduction and fixation of pediatric and adolescent pelvic fractures. Opmtiur TK~II~~IICS irl Orthopdics
1995; 5: 95.
Paper accepted 27 January 1998. Recpsts @ rqwirzts shouldbc nddrmcd to: N. Schwarz, M.D., Professor of Traumatology, Unfallkrankenhaus, Waidmannsdorferstr. 35, Klagenfurt A-9021,Austria.
1998 Science Ltd. All rights reserved Printed in Great Britain 0020-1383/98 $19.00+0.00
PII: SOO20-1383(98)00074-6
Long-term in children N. Schwarz’,
results of unstable
pelvic ring fractures
E. Posch’, J. Mayr”, F. M. FischmeisteelP, A. F. Schwarz5 and T. 6hner”
‘Trauma Hospital, Klagenfurt, Austria, 2Trauma Hospital ‘Meidling’, Vienna, Austria, 3Department of Pediatric Surgery, University of Graz, Graz, Austria, “Trauma Hospital, Linz, Austria, “Trauma Hospital, Salzburg, Austria and hTrauma Hospital, ‘Lorenz Bohler’, Vienna, Austria
Seventeen patients less than 12 years old sustained unstable pelvic ring fractures and were treated non-operatively. They were followed for 2 to 25 years. The subjective long-term results depended on the presence or absenre of low back pain. This eorrelated strongly with pelvic asymmetry. Five patients complained about chronic back pain, two were functionally impaired by severe pelvic asymmetry. Healing of an unstable pelvic fracture in malposition with asymmetry causes poor results and must be prevented. 0 1998 Elsevier Science Ltd. All rights reserved.
Injury, Vol. 29, No. 6,431-433, 1998
Introduction Stable pelvic ring fractures treated non-operatively heal perfectly’. In unstable fractures, non-operative treatment is often recommendedz, although the limitations of this therapy are known” and there is a paucity of information on the long-term results. Nierenberg et al.’ suggest an ‘aggressive conservative approach’, doubting that the results of surgery could be superior. This study was aimed at evaluating long-term results of non-operative therapy of unstable pelvic ring fractures in children, the data being used in reconsideration of the therapeutic approach to such fractures.
Patients and methods In a retrospective multicentre-study, children who suffered an unstable pelvic ring fracture between 1967 and 1992 were investigated. There were 32 patients, all less than 12 years old at the time of injury, with a minimum follow-up of 2 years. Seventeen of the 32 patients were available for a clinical and radiographic examination. The results refer to these 17 patients.
Patients There were 13 boys and four girls. The age at the time of injury was less than 6 years in six patients, 6 to 10 years in nine, and 11 to 12 years in two. Twelve children were injured in road traffic accidents and four by a fall from height. One child was buried alive. Only four children had no injuries in addition to their pelvic fracture. Among 13 patients, there were four urinary bladder ruptures, one rectal rupture, one vaginal tear, six femoral shaft fractures, two fractures of the tibiae and two of the forearm, two craniocerebral injuries, one splenic rupture, one thoracic injury, and one renal tear.
Classification Only unstable fractures of the pelvic ring were investigated. There are, according to Tile”, Type B (fractures of the pelvic ring with rotational instability) and Type C (fractures of the pelvic ring with additional vertical instability). Isolated disruptions of the symphysis were not included, since in contrast to the adult instability remains unclear due to the stronger ligaments when young. Disruption of the SI joints was only considered if the joint space of the injured joint was distinctly wider than that of the opposite site or if there was an additional fracture in the adjacent bone. Nine fractures were of type B (five Bl open-book injuries and three lateral compression injuries), eight were of type C (five unilateral, one bilateral incomplete, and two bilateral complete posterior arch disruptions). The pelvic lesions consisted of nine symphyseal disruptions, 39 fractures of the pubic rami, 17 sacroiliac joint disruptions, two fractures of the iliac wing, and five lesions of the Y-suture of the acetabulum.
432
Injury: International
Follow-up
examination
A clinical examination included muscular strength, gait, inclination of the pelvis while standing, scoliosis of the lumbar spine, Trendelenburg’s sign and range of motion of both hip joints. Radiographic examination was limited to an AP-view. Only in the case of special questions were additional radiographs or CAT-scans carried out. An AI’-view of the lumbar spine while standing was done in the presence of a clinical leg length difference. Leg length was measured clinically by determining the distance between the anterior superior iliac spine and the ankle joint. This was called ‘functional leg length difference’ for the fact that a difference between right and left could be caused by both pelvic asymmetry and pre-existing asymmetry of the lower extremities. A neurological examination was not carried out in all patients, and if so, it was not done by the same examiners. Therefore no results are given. Follow up was a minimum of 2 years, but was 10 to 25 years in nine patients. At the time of the last examination nine patients were older than 15 years and thus were fully grown.
Treatment Primary therapy was bed rest in 11 and femoral traction in three cases. Three patients were treated in a pelvic hammock (i.e. a 50 x 20 cm large sling of cotton tissue which is applied around the pelvis, crossed in front of the patient and pulled with two strings on each end of the cotton stripe with 3 kg each in order to compress the pelvic ring); one of these patients had additional femoral traction. Treatment was continued for 2 to 8 weeks. In one multiply injured patient an external fixateur was applied 10 weeks after injury for persistant malposition of the pelvic ring.
Journal of the Care of the Injured Vol. 29, No. 6,1998
Results (Table I) All fractures healed. In one patient, a disrupture of the Y-suture led to premature growth arrest and subsequently to a posttraumatic acetabular dysplasia with a poor clinical result after 6 years. Two patients had a widening of the symphysis from 2 to 3 cm without symptoms. One patient with a remaining vertical dislocation of the symphysis of 20 mm was pain free. Three patients, two males and one female, had an ossification of the symphysis which caused pain in the female, but not in the males. There was no functional leg length difference in five patients. Nine patients had differences of up to 3 cm. One patient had a 5 cm difference which in part was due to pelvic asymmetry and in part to femoral shortening after a shaft fracture. In two patients no measurements were done. Lumbar scoliosis was found in 10 patients. Pain was almost exclusively located at the lumbo-sacral junction and was in all but one patient correlated with lumbar scoliosis. Of 10 patients with a leg length difference of 1 cm or less, two had low back pain. However, of the remaining five patients with a leg length difference of more than 1 cm, three complained of low back pain. Hip joint mobility was normal bilaterally in 11 patients. In one patient one hip joint moved freely, the other was restricted due to avascular femoral head necrosis (AVN) following pertrochanteric fracture. In one patient both sides were restricted, one without obvious cause, the other because of AVN. Spastic plegia was the cause of limited range of motion of both hip joints in another patient. One patient had a limited range of motion due to the malrotated position of one half of the pelvis. In two patients no information could be obtained. The pelvic ring showed no or only slight asymmetry in nine patients, moderate asymmetry in
Table I. Patient’s initials GT RS AK NS RU CK DP
CG GK CA t: ZLs GC
Age” --__
Sexb
4y5m llylm 7y6m 5y4m 4y6m 3y3m 4y5m 6y2m 5y3m 9y4m
f m m f m m m m f m m m m m m f f
12Y 8y9m lly9m 7y6m 9y7m 6y2m 7y8m
“y, years; m, months. bm, male; f, female. + slight scoliosis; + + marked
Vertical instability no
ves ves yes no no
ves yes no no no no yes
ves yes no no
scoliosis.
Follow-up years 16 22 3 14 6 3 2 2 12 11 3 13 6 II 15 25 4
Radiographic asymmetry (modest or severe only)
++
++ ++ ++ ++ ++ ++
Leg length discrepancy (cm)
2 ? 1 1 1
Lumbar scoiiosis +i + ++
i ++ ? ++ ++ ++ ++ ++
Low back pain no yes yes yes no no no no no no no
ves yes no yes no
Schwarz
et al.: Long-term
results of unstable
pelvic ring fractures
six and severe asymmetry in two. A pelvic ring that was found to be radiographically symmetrical at the end of the treatment was so at follow-up, in no case did asymmetry correct itself over the years. In two severely multiply injured patients the pelvic fractures were neglected and therefore healed Both had enormous with major malformation, functional problems and pain due to their pelvic asymmetry. Two patients had a permanent bladder cystic fistula; one of these suffered from an additional rectal sphincter paralysis.
Discussion Stable pelvic ring fractures in children usually yield good results; but it is difficult to distinguish between stable and unstable fractures and classification is often subjective. The joint space of %-joints is primarily wider in children, and additional fractures of the related bones as proof of a joint lesion are seldom seen. Only a yawning joint cavity or a vertical dislocation proves an injury of an %-joint. In children, tense ligaments may keep pelvic ring fractures stable, even if there is more than one fracture through the pelvic ring. Retrospectively, instability is proven by increasing displacement but, on the other hand lack of displacement is no evidence for stability. Dislocated double ring fractures must be vertically unstable. This was the case in eight of our patients. Rotational instability was assumed in nine patients, but could not be absolutely proven in all cases. It is difficult to assessthe three-dimensional form of the bony pelvis even by advanced radiographic methods; therefore, asymmetry remains a somewhat subjective consideration. Healing in a defective position inevitably causes asymmetry of the pelvis, and in some patients this was aggravated by impaired growth. Disturbance of growth (as well as potential spontaneous correction, which is probably rather limited’), can only be caught by radiographic follow-up at regular intervals; in our series this was only performed in exceptional cases for its retrospective and multicentre character. Asymmetry of the pelvis causes functional leg length difference and deviation of the spine and subsequently low back pain. No patient with a symmetrical pelvis complained about low back pain, independently of the follow-up time. Nierenberg et al.’ reported good results even in cases of remaining deformation of the pelvis; we cannot duplicate this. A functional length length difference of more than 1 cm will probably cause low back pain in the longterm. The outcome of pelvic fractures in children mainly depends on the symmetry of the pelvic ring
433
in children
maintained or achieved by treatment. It also depends on the location and pattern of injury and, indirectly, on the stability of fixation”. Therefore, Kershishyan et al.” advocate the application of an external fixateur in complex pelvic fractures, and Gordon et al.” also suggest an external fixateur or ORIF for children over 8 years of age. However, both papers lack sufficient data to support the treatment proposed. From our results, we propose the following principle of treatment: pelvic ring fractures in children should be reduced as perfectly as possible to secure healing in an anatomical position and to avoid asymmetry of the pelvic ring. By non-operative means this goal was achieved in only some of the patients in our series. In half of the cases the results of non-operative therapy were less than satisfactory. Non-operative treatment seems to be insufficient in the multiply injured child. Faced with the danger to the child’s life, the severe orthopaedic problems that may arise later are underestimated. In these rare cases, open reduction and internal fixation of the pelvic ring fracture should be considered as soon as the child is in a stable condition. For the time being it is unknown whether the outcome of pelvic ring fractures in children can be improved by operation. Healing in malposition with asymmetry of the pelvis causespoor results and must be prevented. However, which patients may benefit from operative reduction has to be clarified by studies to be undertaken.
References 1 Nierenberg G., Volpin G., Bialik V. and Stein H. Pelvic fractures in children: a follow-up in 20 children treated conservatively. ] P&i&v Orthop 1993; 1: 140. 2 Lane-O’Kelly A., Foharty E. and Dowling F. The pelvic fracture in childhood - a report supporting nonoperative management.I~~jur~1995;26: 327. 3 Keshishyan R. A., Rozinov V. M. and Malakhov 0. A. etal. Pelvic polyfractures in children. CIilj Orthop 1995; 320:28. 4 Tile M. Pelvic ring fractures: should they be fixed?. ] Boflc /oiut Surcy (BY) 1988; 70: 1.
5 Gordon R. G., Karpik K., Hardy S. and Mears, D. C. Techniquesof operative reduction and fixation of pediatric and adolescent pelvic fractures. Opmtiur TK~II~~IICS irl Orthopdics
1995; 5: 95.
Paper accepted 27 January 1998. Recpsts @ rqwirzts shouldbc nddrmcd to: N. Schwarz, M.D., Professor of Traumatology, Unfallkrankenhaus, Waidmannsdorferstr. 35, Klagenfurt A-9021,Austria.