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Orthopaedics & Traumatology: Surgery & Research xxx (xxxx) xxx

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Orthopaedics & Traumatology: Surgery & Research

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Original article

Therapeutic effect of an external fixator in the treatment of unstable

pelvic fractures in children
Danjiang Zhu , Dingwu Liu , Baojian Song , Wei Feng , Xuejun Zhang , Qiang Wang ∗
Department of Orthopaedics, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nalishi Road, 100045
Beijing, China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Unstable pelvic fractures in children are serious and complex injuries, and the optimal
Received 14 January 2021 method to manage these injuries is controversial.
Accepted 18 November 2021 Hypothesis: We hypothesized that an external fixator would be a satisfactory method of treating unstable
Available online xxx
pelvic fractures in children.
Patients and Methods: We retrospectively reviewed 40 pediatric patients with unstable pelvic fractures
Keywords: who were treated with an external fixator in Beijing Children’s Hospital from June 2006 to June 2016.
Children
Postoperative follow-up was 12 to 108 months, with an average of 26 months. One year after the oper-
Pelvic fracture
External fixator
ation, fracture healing, pelvic asymmetry, and deformity index were assessed by X-ray. Pelvic function
was evaluated with the Cole evaluation standard, and daily cognitive and motor functions were evaluated
by weeFIM. Patient complications were recorded.
Results: The average age of the 40 patients was 5.9 ± 3.1 years (2 to 14.5), including 25 boys and 15 girls.
Among these cases, 37 (92.5%) had injuries caused by traffic accidents and 3 (7.5%) had injuries caused
by falling from height. Based on the Tile classification, there were 18 cases of class B (14 class B2 and 4
class B3) and 22 cases of class C (15 class C1, 6 class C2, and 1 class C3). The X-rays showed good fracture
healing at the 1-year postoperative follow-up. The pelvic asymmetry was reduced from 1.13 cm before
the operation to 0.88 cm after (p < 0.05), and the deformity index was decreased from 0.09 before to 0.05
after the operation (p < 0.05). At the 1-year postoperative follow-up, 36 patients had excellent Cole scores,
and 4 had good Cole scores, with a good or excellent rate of 100%. According to the weeFIM, 28 patients
had complete independence, 11 had basic independence, and 1 had conditional independence. Three
patients (7.5%) had complications, all of which were postoperative pin-site infections.
Discussion: For children with horizontally unstable pelvic fractures, an external fixator can be used alone.
For children with horizontally and vertically unstable pelvic fractures, after external fixator placement
and reduction, lower extremity traction can be performed to achieve better reduction and maintain
stability, and the therapeutic effect is satisfactory.
Level of evidence: IV, retrospective observational cohort study.
© 2021 Elsevier Masson SAS. All rights reserved.

1. Introduction
Pelvic fractures in children are the most serious and complex
fractures in pediatric orthopedic trauma [1]. Most of them are
caused by high-energy injuries such as traffic accidents or falling
from a building, and their incidence is less than 1% [2,3]. Most
children with stable pelvic fractures can be treated conservatively,
while unstable pelvic fractures are often treated with surgery [4].
Closed reduction and external fixation is commonly used for an
unstable anterior pelvic ring, while for an unstable posterior pelvic
ring, the current common surgical methods include posterior pedi-
cle screw fixation, anterior plate fixation, and sacroiliac joint screw
fixation [1,5]. However, the optimal surgical treatment method is
controversial.
In this study, we reviewed the cases of unstable pelvic fractures
in children treated with closed reduction and external fixation,
and hypothesized that this treatment would be safe and lead to
acceptable clinical outcomes.
2. Patients and Methods

This study was approved by the ethics committee of our hospi-

∗ Corresponding author. tal. A retrospective chart review was performed to identify patients
E-mail address: wangqiangmd@163.com (Q. Wang). with unstable pelvic fractures who underwent surgical treatment

https://doi.org/10.1016/j.otsr.2021.103150
1877-0568/© 2021 Elsevier Masson SAS. All rights reserved.

Please cite this article as: D. Zhu, D. Liu, B. Song et al., Therapeutic effect of an external fixator in the treatment of unstable pelvic
fractures
Descargado in children,
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D. Zhu, D. Liu, B. Song et al.
Fig. 1. The pelvic asymmetry measurement method. x and y show the lower edge
of the ilium of the sacroiliac joint and the medial center of the contralateral acetab-
ulum, respectively, and the difference between x and y was the asymmetry of the
pelvis. (x-y)/(x + y) was the deformity index of the pelvis.
in our hospital from June 2006 to June 2016. The inclusion criteria
were: patients aged < 18 years, those with unstable pelvic fractures
(Tile classification: class B or C), and those who underwent closed
reduction and unilateral external fixation. The exclusion criteria
included: patients with previous pelvic surgery, those with con-
comitant severe injury to the lower extremities, inability to assess
pelvic function, and patients with a follow-up time less than 12
months.
A total of 40 patients met the criteria, including 25 boys and 15
girls. The clinical and imaging data of patients, including age, gen-
der, injury mechanism, fracture type, triradiate cartilage closure
state, operative time, intraoperative blood loss, pelvic asymme-
try and deformity index, functional status, and complications were
reviewed. The pelvic asymmetry and deformity index used the
method proposed by Keshishyan et al. [6], as shown in Fig. 1.
The Tile classification was adopted for fractures. The pelvic func-
tion was evaluated using the Cole scoring criteria, including the
following four grades: excellent, good, normal, and poor. Excellent
grade: equal length of the limbs, no rotation of the lower limbs, nor-
mal gait, no pain at the affected area; Good grade: unequal length
of the limbs < 2 cm, no rotation of the lower limbs, basically normal
gait, no pain at the affected area; Normal grade: unequal length
of the limbs of 2–4 cm, rotation of the lower limbs < 15◦ , slightly
lame in walking, and slight pain at the affected area; Poor grade:
unequal length of the limbs > 4 cm, rotation of the lower limbs > 15◦ ,
obviously lame, pain at the affected area. The quality of life was
evaluated by WeeFIM (The Functional Independence Measure for
Children, WeeFIM). The pelvic symmetry was evaluated pre- and
postoperatively. The pelvic symmetry and function were evaluated
at 1 year postoperatively.
2.1. Surgical Procedure
Patients were placed supine on the traction bed after satisfactory
anesthesia. The pin insertion point was determined on the anterior
superior iliac crest. A Kirschner wire was placed on the anterior
superior iliac spine, and its position was confirmed radiographi-
cally. The Schanz pin was then inserted, and the position of the
pin was confirmed radiographically. The detailed radiographical
method is described below. First, the start position was confirmed
with the C-arm using the obturator outlet or teardrop view that
profiles the external and internal iliac walls. The radiographic tech-
nician marked the C-arm angles to allow a quicker return to the
correct position. A No. 15 blade was used to make a small stab
incision at the expected pin site to reduce soft tissue tension after
reduction. A blunt instrument (such as a hemostat) was used to
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Orthopaedics & Traumatology: Surgery & Research xxx (xxxx) xxx
spread the soft tissue until bone was reached. A 1.25-mm K-wire
was inserted with a cannulated drill. A short K-wire was used to
allow room for the C-arm. The obturator outlet, obturator inlet,
and iliac oblique views were used to confirm the trajectory and
advance the K-wire or redirect it as needed. The K-wire was then
removed and a 3- or 4-mm diameter Schanz pin with a T-handle
was inserted to the ilium. This procedure was repeated on the
contralateral side. The diameter of the Schanz pin was chosen in
accordance with the patient’s bone measurements on preoperative
CT. As the 4.0-mm cannulated screw proved to be adequate for sta-
bilizing a small pelvis, this size was chosen in most cases. A 3.0-mm
diameter Schanz pin was used if the ilium was too small to per-
mit the use of a 4.0-mm cannulated screw in the supra-acetabular
region.
All Schanz pins were placed in the middle of the two cortices
of the iliac bone, and the insertion depth was more than half of
the iliac bone without exceeding the sacroiliac joint. When the
Schanz pin position was confirmed to be satisfactory under fluo-
roscopic guidance, the external fixation clamp was placed to hold
the external fixation pins for reduction. The order of reduction was
as follows. For type B fracture, the operator corrected the rota-
tional displacement by holding the external fixation clamp while
the assistant corrected the horizontal displacement by pushing the
bilateral iliac bones. For type C fracture, table traction was used to
pull the lower limbs to correct the vertical displacement; an exter-
nal fixation clamp was then used to hold the external fixation pins
to correct the rotational displacement; lastly, the operator used
both hands to push the bilateral iliac bones toward the patient’s
midline to correct the horizontal displacement. All reductions were
performed under C-arm fluoroscopic guidance. After reduction, the
displacement of the posterior sacroiliac joint was evaluated, and
if there was displacement, adjustment and reduction was neces-
sary. Intraoperative fluoroscopy of the inlet and outlet positions
was performed. Pelvic asymmetry of less than 1 cm on AP view was
considered an acceptable reduction, and pelvic asymmetry of less
than 0.4 cm was considered a good reduction. When the reduction
was acceptable, the metal connecting rod was placed with adequate
room for the abdomen, and the outer frame was locked and fixed.
Schanz pins and metal connecting rods were provided by Stryker
(Stryker, Kalamazoo, Michigan, USA).
Postoperative lower limb traction was used to manage vertical
instability, as the anterior external fixator alone was used to fix
the fracture and a cannulated screw was not used in the sacroiliac
joint. This lower limb traction strengthened and maintained the
stability in the vertical direction to counter the muscle pull that
occurred after the patients awoke from anesthesia. The traction
weight was 10% 12% of the body weight. The contralateral side was
given antagonistic limb traction, with a traction weight the same
as that of the affected side. The traction lasted 8 to 12 weeks.
Follow-ups were performed at 4 weeks, 8 weeks, 12 weeks, 6
months, and 1 year after the operation. Patients received pelvic
X-rays, their hip joint movements were inspected, and functional
scores were obtained. The external fixators were taken out after
complete healing of the fractures. The clinical criteria used to define
fracture healing were: a blurred or absent fracture line on X-ray, a
negative result on the pelvic separation and compression test, and
the ability to walk without substantial pain.
2.2. Statistical Analysis
The SPSS 18.0 (SPSS Inc., Chicago, IL, USA) statistical software
package was used for statistical analyses. The pelvic asymmetry
and deformity index before the operation and at the 1-year follow-
up were compared with a paired t-test. An ␣ level of bilateral 0.05
was used to indicate statistical significance.
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Table 1
Assessment of pelvic asymmetry and degree of deformity.
Before the operation 1-year follow-up p-value
Pelvic asymmetry (cm) 1.43 ± 0.42 0.68 ± 0.33 < 0.001
Pelvic deformity index 0.11 ± 0.04 0.05 ± 0.02 < 0.001
Table 2
Mean pelvic asymmetry according to tile fracture type.
Pelvic asymmetry (cm)
Fracture type Before the operation After the operation 1-year follow-up
Tile B 1.20 ± 0.47 0.55 ± 0.39 0.49 ± 0.36
Tile C 1.62 ± 0.46 0.92 ± 0.42 0.83 ± 0.38
3. Results
The 40 patients ranged in age from 2 to 14.5 years; there were
22 patients aged 2–6 years, eight aged 6.1–8 years, six aged 8.1–10
years, and four aged 10.1 years or older. The median age was 4.8
years, with an average of 5.9 ± 3.1 years. Among these patients,
35 (92.5%) had injuries caused by traffic accidents and 5 (7.5%)
had injuries caused by falling from height. Nine patients had frac-
tures of other parts of the body, including three cases of upper limb
fractures and eight cases of lower limb fractures. Additionally, 34
patients had head or chest and abdominal injuries, including 10
cases of head injuries, 15 cases of chest injuries, and 30 cases of
abdominal injuries. Pelvic fractures involved the anterior pelvic
ring in 19 cases, the posterior pelvic ring in 1 case, and both the
anterior and posterior pelvic rings in 20 cases. There were two open
fractures and 38 closed fractures. Based on Tile classification, there
were 18 cases of class B and 22 of class C. Among class B, 14 were
class B2 and 4 were class B3. There were 15 cases of class C1, 6 of
class C2, and 1 of class C3. Fractures involved the left side in 7 cases,
the right side in 4 cases, and both sides in 29 cases. Before the oper-
ation, the triradiate cartilage was open in 37 cases and closed in 3
cases.
Six patients underwent lower extremity fracture operations and
two underwent upper extremity fracture operations. The average
operative time was 62 min (range 30 to 120 ) only for the pelvic
fracture treatment, and the average surgical blood loss was 4 mL
(range 1 to 10 ) only for the external blood loss through the small
incision and pin canal. After the operation, 21 patients underwent
lower extremity traction, with an average traction time of 9.2 weeks
(8 to 12).
The follow-up time ranged from 12 to 108 months, with an
average of 26 months. All pelvic fractures healed well at the 1-
year follow-up. The pelvic asymmetry was reduced from 1.43 cm
before operation to 0.68 cm at the 1-year follow-up (p < 0.05), and
the improvement rate was 22%. The deformity index was decreased
from 0.11 before the operation to 0.05 at the 1-year follow-up
(p < 0.05), as shown in Table 1. The mean asymmetry associated
with type B fracture was 1.2 cm at the time of injury and 0.49 cm
at 1-year follow-up. The mean asymmetry associated with type C
fracture was 1.62 cm at the time of injury and 0.83 cm at 1-year
follow-up (Table 2).
All 40 included patients could not walk independently before
surgery, indicating that their preoperative Cole scores were poor. At
the 1-year postoperative follow-up, 36 patients had excellent Cole
scores and 4 had good Cole scores, with a good or excellent rate of
100%. At the 1-year follow-up, according to the weeFIM, 28 patients
had complete independence, 11 had basic independence, and 1 had
conditional independence (Table 3). A typical case is shown in Fig. 2.
Complications occurred in three cases (7.5%), all of which were
infections around the pin site. After regular disinfection around the
pin site, administration of oral antibiotics, and Schanz pin removal,
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Orthopaedics & Traumatology: Surgery & Research xxx (xxxx) xxx
Table 3
weeFIM according to tile fracture type.
weeFIM (n)
Fracture Type Complete Basic Conditional
independence independence independence
B (n = 18) 15 3 0
C (n = 22) 13 8 1
the wounds healed well. No cases of nonunion, deep infection, or
injury of the lateral femoral cutaneous nerve occurred.
4. Discussion
Our results for the primary outcome measure confirm our
hypothesis that external fixation is a satisfactory method for treat-
ing unstable pelvic fractures in children. Unstable pelvic fractures
are rare in children [2,3]. They are often caused by high-energy col-
lisions and are frequently associated with injuries to other parts of
the body, as well as a high mortality rate [1]. In the past, conserva-
tive treatment was often used for pelvic fractures in children, but
this can lead to more complications, such as nonunion, malunion,
pelvic asymmetry, and scoliosis [7–10]. Therefore, surgical treat-
ment of unstable pelvic fractures has been increasingly performed
and reported in the literature [1,4,5,11,12]. This is probably due to
improved understanding of pelvic instability and the consequences
of non-operative treatment in such cases, and to the development
of minimally invasive and navigation-guided techniques [11].
Because the external fixator is easy to use and can be used
to obtain reliable fixation of pelvic fractures, it has been recom-
mended for emergency early fixation of unstable pelvic fractures to
control fracture displacement, reduce bleeding, and prevent shock
[6,13–15]. With the increasing application of external fixation, it
has been recommended for routine use for horizontally unstable
Tile B pelvic fractures in many reports, and good surgical outcomes
have been achieved [1,5,16]. In this study, an external fixator was
used to treat Tile B pelvic fractures. After treatment, the pelvic sym-
metry was satisfactorily restored and the function was recovered
well. Although the posterior pelvic rings had Tile B2 and B3 injuries,
adjustment of the external fixator restored the anterior and poste-
rior rings well and maintained their position. In 2017, Kenawey
et al. [5] treated 29 cases of unstable pelvic fractures (6 type B
cases and 23 type C cases) in children. Among them, eight patients
were treated simply with Schanz screw external fixation through
the upper edge of the acetabulum, and all of them achieved fusion
and good pelvic reduction.
The surgical treatment of type C fractures remains controversial.
According to some reports, anterior ring external fixation alone was
not adequate to maintain the stability of the posterior pelvic ring
[17,18]. When the posterior displacement exceeds 5 mm, combined
anterior and posterior fixation should be used [19]. Jean et al. [20]
used an external fixator if there was a risk of growth disturbance in
children with type C pelvic fracture. In 2014, Guimarães et al. [18]
reported that for pelvic fractures in children with immature bones,
when sacroiliac joint dislocation occurred, combined external fixa-
tion and sacroiliac screw fixation achieved a better reduction effect.
Thus, they concluded that external fixation alone could not con-
trol the posterior structure of the pelvis. In 2003, Ginger et al. [21]
reported on children with anterior and posterior compression frac-
tures and bilateral sacral fractures who were treated with anterior
external fixation. During the 2-year follow-up, their function recov-
ered well despite unsatisfactory pelvic symmetry. In 2005, Smith
et al. [1] retrospectively evaluated 20 cases of unstable pelvic frac-
tures in children (4 type B cases and 16 type C cases) and compared
two groups of patients who underwent external fixation alone and
external fixation combined with sacroiliac fixation. They found that
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D. Zhu, D. Liu, B. Song et al.
Fig. 2. A boy, 2 years 5 months old, hit by a car, sustained a Tile type-C1 pelvic ring injury. Anterior injury was a fracture of two rami and posterior was a left ilium wing
fracture (a, b); c, CT scan revealing fracture and dislocation in left sacroiliac joints; d, postoperative X-ray, AP view showing supra-acetabular external fixation; e, AP pelvis
radiograph 7 years after injury; f, his hip flexion greater than 90◦ 7 years after surgery.
the pelvic asymmetry dropped from 3.2 cm before the operation to
2.7 cm at the last follow-up in the external fixation alone group,
and it dropped from 2.9 cm before the operation to 0.7 cm at the
last follow-up in the group with external fixation combined with
sacroiliac fixation. In this study, we performed lower limb skin
traction for 8 to 12 weeks postoperatively to assist with stabiliza-
tion for patients with preoperative vertical instability. Although
pelvic symmetry was worse than in type B patients at 1 year after
the operation, the postoperative pelvic symmetry was still better
than before the operation, and pelvic function recovered satisfacto-
rily. We believe that pelvic fractures in children are different from
adults for the following reasons: first, sacroiliac joint dislocations
are generally sacroiliac ligament complex tears in adults, while they
are often iliac wing transepiphyseal fractures in children; second,
because children have underdeveloped skeletal muscle strength,
by adjusting the position and depth of the Schanz pins and the
overall compression through the external fixator combined with
femoral traction, it is often possible to achieve good alignment and
maintain reduction. Therefore, for patients with vertical instability
combined with posterior ring injury, external fixation combined
with postoperative traction of the lower extremity is a treatment
option.
In recent years, sacroiliac screws have achieved a satisfactory
outcome in the treatment of vertically unstable pelvic fractures. In
patients with pelvic fracture without obvious sacroiliac joint dis-
placement, percutaneous sacroiliac screw implantation achieves
a good result via a small incision. Sacroiliac screw implantation
assisted by 3D navigation or a surgical robot to treat posterior pelvic
ring fracture results in less trauma, shorter operation time, and less
blood loss than implantation without assistance. Although internal
fixation with sacroiliac screws avoids long-term traction in patients
with vertical instability, this method requires open reduction that
leads to more severe destruction of soft tissue and more blood
loss in children, especially for children with concomitant visceral
injuries or open fractures. In addition, most reports of sacroiliac
screw implantation involved children older than 10 years. It is
extremely difficult to implant sacroiliac screws in children, espe-
cially those younger than 5 years. The technique of external fixation
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with traction may avoid the need for more incisions while achieving
a comparable functional outcome to internal fixation.
If the external fixator is used for treatment, the complication
of shallow pin site infection cannot be avoided. However, after
periodic disinfection, deep infections rarely occur, and the infec-
tion often completely resolves after the outer frame is removed.
Few deep infections have been reported in the literature, and none
occurred in our series. In addition, relevant literature has reported
a high incidence of symptoms of lateral femoral cutaneous nerve
injury, but this did not occur in the patients in this study.
In addition to the conventional external fixator, built-in pelvic
anterior fixators have been reported in recent years, which are fixed
with pedicle screws, and the fixator is placed under the skin [14,22].
A biomechanical study showed that an internal fixator combined
with sacroiliac screws achieves good stability and low displace-
ment [23]. Although this technique can be used to effectively treat
unstable pelvic fractures, it is mainly applicable to adults, especially
obese individuals [22,24]. Children have a small torso and a small
anterior subcutaneous volume of the pelvis, so this technique is not
applicable to them.
The use of an external fixator to manage pelvic fractures in chil-
dren has certain limitations. For type C fractures, it is hard to achieve
anatomical reduction of the sacroiliac joint using an external fixa-
tor alone. Furthermore, the force of lower limb traction to maintain
the stability of the sacroiliac joint is not comparable to that of the
sacroiliac screw, especially in adolescents whose bone develop-
ment approximates that of adults. Therefore, sacroiliac screws may
be a better choice than an external fixator for patients in whom
the triradiate cartilage is closed or the pelvic symmetry cannot be
corrected to less than 1 cm intraoperatively.
This study has the following limitations. First, no control group
was established, so external fixator treatment could not be com-
pared with other treatment measures. Second, because of the
short follow-up time, the sexual or reproductive side effects of the
patients into adulthood could not be evaluated.
In conclusion, for children with horizontally unstable pelvic
fractures, an external fixator can be used alone. For children with
horizontally and vertically unstable pelvic fractures, after external
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D. Zhu, D. Liu, B. Song et al.
fixation and reduction, lower extremity traction can be performed
to achieve better reduction and maintain stability. With these treat-
ments, appropriate imaging results and functional recovery can be
achieved, with a low incidence of complications.
Data are from the experience of a single surgical team, and
should therefore interpreted with caution. The choice of the treat-
ment is also related to the availability of the frame, and the clinical
status of the patient.
Disclosure of interest
The authors declare that they have no competing interest.
Funding
This research was supported by the National Key R&D Program
of China [grant number 2020YFC1107604].
Contributions of each author
Qiang Wang and Danjiang Zhu conceived and designed the
study, acquired the data, and analysed and interpreted the data.
Dingwu Liu, Baojian Song, and Wei Feng drafted the manuscript
and revised it critically for important intellectual content.
Qiang Wang gave final approval of the version to be submitted.
Xuejun Zhang performed the statistical analyses.
Qiang Wang performed the surgical procedures.
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