Pelvic injuries in children

Anatomical features and classification

The specific nature of pelvic injuries in children is due to the structure of the growing organism. The pelvic ring is characterized by high flexibility. The ilium, pubis, and ischium are separated by voluminous cartilaginous layers, and the ligamentous apparatus in the pubic symphysis and sacroiliac joint is relatively weak.

In traumatology, 4 main types of pelvic injuries are distinguished:

1. Marginal fractures (bones do not participate in the formation of the pelvic ring).
2. Pelvic ring fractures without disruption of its continuity.
3. Fractures with disruption of the pelvic ring continuity.
4. Acetabular fractures.

Severe injuries are usually associated with high-energy mechanisms: falls from a height, motor vehicle accidents, and crush injuries from collapses.

Marginal fractures

These injuries are characteristic of older children and adolescents. The main cause is the disproportion between the rapid development of muscle mass and the not-yet-matured (unfused) apophyseal ossification centers of the innominate and ischial bones.

• Avulsion fractures: frequently occur with inadequate athletic loads. For example, a sharp attempt to do the splits or a long jump in a 13–14-year-old adolescent can lead to an avulsion of the ischial tuberosity.
• Direct trauma: typical for injuries of the sacrum and coccyx (in children older than 10 years).

Key radiological feature: on initial radiographs, injury to the growth plate is often not visualized. The diagnosis can only be confirmed radiologically several weeks or months later, when the shadow of the ossification appears in the soft tissues.

Treatment is conservative in most cases (bed rest on a firm mattress with relaxation of the target muscles). Surgery is indicated only for significant displacement of the ischial tuberosity fragment (open reduction and fixation). For dislocations and fractures of the coccyx, strict bed rest in the prone position is prescribed for a period of 2 weeks.

Fractures without ring disruption

This group includes isolated or bilateral fractures of the ischial and pubic bones, as well as their various combinations. The clinical picture and diagnostic principles are similar to those in adults, but the physician must carefully compare fracture lines with the natural location of the pelvic growth plates.

The main stage of conservative treatment is high-quality analgesia using Shkolnikov-Selivanov intra-pelvic blockade. A 0.25% novocaine solution is used for the procedure. The volume of the administered anesthetic strictly depends on the child's age:

• from 3 to 6 years — 30–40 ml;
• from 6 to 9 years — 40–60 ml;
• from 9 to 12 years — 60–70 ml;
• from 12 to 15 years — 70–100 ml.

Further treatment consists of strict bed rest until complete bone union.

Injuries with ring disruption

Severe diagonal, multiple fractures, and Malgaigne fractures are accompanied by massive destruction of pelvic integrity. In children, instead of bone fractures, kinetic energy more frequently causes disruptions of the pubic symphysis, sacroiliac joint, and puboischial synchondrosis.

Diagnostics: Trauma is often complicated by the development of shock, so anti-shock measures and infusion therapy are initiated immediately. Checking load-bearing symptoms is strictly prohibited. To avoid additional trauma during transportation and repositioning, radiography is performed on-site using a portable device.

Principles of treatment:

• Without displacement: the child is placed in the Volkovich position. Duration of bed rest: 3 weeks for children aged 8–10 years, 4 weeks for older patients.
• With displacement (external fragment shifts superiorly): skeletal traction is applied via the tibial metaepiphysis along with adhesive skin traction on the injured leg. The limb is given an atypical position: 100° abduction relative to the bispinal line and 15–20° flexion in the joints (this helps align the axis of the displaced fragment with the traction vector).

To calculate the weight, the formula is used: 0.5 kg per 1 year of life. The total weight is distributed as follows: 2/3 of traction goes to the femur, 1/3 to the lower leg. As counter-traction, the foot of the bed is elevated by 20–30°.

Class and exam questions

What else to study on this topic

• Acetabular fractures in children
• Technique of the Shkolnikov-Selivanov intra-pelvic blockade
• Infusion-transfusion shock therapy in multiple pelvic trauma
• Volkovich position: biomechanics and effect on muscle tone

Other topics in the section "Specifics of bone and joint injuries in children"

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