Pelvic Trauma in Children

Dr Nigel Moore
Royal Children’s Emergency
6th October, 2010
 Overview
Patterns of paediatric pelvic injury

Pelvic binders

Pelvic examination

Unstable pelvic fracture management

 Question 1

What is the usual pattern of pelvic fracture

in children?

How does it differ from adult pelvic injury?

Pelvic fractures relatively rare in immature
skeletons

Require large amount of force

Mortality 5-15% but often assoc with other

injuries ie they are a marker of severe trauma

Severe haemorrhage from pelvic injury

uncommon in children
 Different anatomy
Bones less brittle, covered with thick
periosteum

Post ligaments relatively stronger than

adjacent bone

Bone growth centres present

Pelvic volume relatively shallow

 Implications
Greater amount of energy to cause
fracture

Single fractures occur more commonly due

to ligament laxity (in adults rare to have
single fracture)

Shallowness and flexibility of paediatric

pelvis allows damage to intrapelvic viscera
without obvious fracture
Mechanism of injury
 Lateral Compression ~50% injuries
– MVA - car is broadsided
– or pedestrian struck from side

Anteroposterior compression ~25%

- head on MVA

Vertical Shear ~5%

– Fall/jump from height

Rest of injuries made up of a combination

 Fracture Types
Double breaks in pelvic ring
– Hemipelvis unstable and displaced cephalad
– High incidence of complications, including genitourinary, abdo
and vascular injuries

Single breaks in pelvic ring

– Symphysis pubis diastasis
– Sup and inf pubic rami #s
– Straddle fractures

Avulsion fractures
– Usually sporting injuries – cartilage weaker than bone

Acetabular fractures
– Rare
– Often assoc with hip dislocation
 Question 2
What type(s) of pelvic binders are
available in our department?

– Demonstrate how to use

– What’s the evidence for use of pelvic binders?
– When are they indicated?
– Once applied, when should they be removed?
Functions of the pelvic binder

To splint the bony pelvis to reduce haemorrhage

from bone ends and venous disruption.

To reduce pain and movement during transfers.

To provide some integrity to the pelvis when

operative packing of the pelvis is necessary.

To provide stabilization of the pelvis until

definitive stabilization can be achieved.
 Indications
Absolute
– Haemodynamically unstable patient with a
mechanically unstable pelvis.
– Haemodynamically unstable patient with a
suspected pelvic fracture.

Relative
– Haemodynamically normal patients with
unstable pelvic fractures, for pain control and
reducing movement during transfers
 Pelvic binders
Analagous to C-spine collar
– Should be used where pelvic injury is suspected before definitive
imaging performed

Pelvis does not fill with blood like water poured into a cone-shaped
bucket - haemorrhage spreads through disrupted tissue planes

'Closing the pelvis' does not prevent this and the binder is not used
to reduce the volume of the pelvis or achieve perfect anatomical
alignment.

The pelvic binder is used to splint the bony pelvis.

– approximates bone ends
– reduces low-pressure bleeding - bone ends and disrupted veins.
– possible to exacerbate certain injury patterns if excessive force
is applied, esp severe lateral compression or vertical shear
injuries.
 Practical aspects
Should be placed over the greater trochanters
– provides best mechanical stability
– If too high may exacerbate a pelvic fracture if iliac crest injury.
Also obstructs access for laparotomy.

Binder will not control arterial haemorrhage

– If no improvement may require angio or operative intervention
– Should allow easy access to the groins or abdomen

Should remain in place until the definitive stabilization procedure

– may be > 24 hours, so important that belt material and
construction does not induce pressure necrosis.

The binder should be removed as soon as possible

Emergency external fixation has no benefit over the pelvic binder

– should not be removed only to be replaced by an emergency fixator.
 The ‘ideal’ binder
Suitable for pre-hospital and emergency department
– light and easily applied, ideally by one person

Allow access to the abdomen for laparotomy, and to the

groins for angioembolisation

Soft material that will be comfortable and not induce

pressure ulceration.

Allow access to the perineum and anus for examination.

Must fit various sizes of patients (including children), or

different sizes be available.

Should be washable or cheap enough to be disposable

 What is available?
London pelvic binder
Pelvigrip
Sam-sling
T-POD
Sheet wrap
 So what do we have?

Volunteer Demonstration
 Do They Work?
2007 study in American Journal of Surgery
Looked at early placement of pelvic binder (T-
POD) and effect on transfusion requirement and
mortality
Retrospective chart study in pelvic fractures with
1or more risk factors for haemorrhage (unstable
#, age>55, first SBP<90)
118 pts with binders vs 119 without (in year
before binders used)
No difference in need for embolisation,
transfusion requirement or mortality
 Question 3
Should ‘pelvic springing’ be done as part
of the secondary survey in the trauma
patient?

How do you examine the pelvis? Justify

your opinion.
Traditionally, in multitrauma pts pelvis is
assessed by manipulation for tenderness and
stability, as well as being imaged as part of
trauma series.

This approach based on adult models, where

pelvic injury more common, and also more likely
to be complicated by haemorrhage

Perpetuated by ATLS/EMST teaching

Is this appropriate in paediatric patients?

 Pelvic ‘springing’
Not done any more – potentially dangerous
in terms of dislodging clot if unstable #

Not good at detecting fractures in general.

2009 study retrospective chart review

(adults)
– Pelvic stablility exam (springing) only 8%
sensitive in detecting #, 99.9% specific
 Pelvic tenderness

If tenderness elicited on palpation of pelvis

in pts with GCS>13, sensitivity of 100% for
unstable #s (adult pop)

So, how should we examine?

 My approach
Inspect for obvious deformity/open
fracture/perineal bruising consistent with #

If these present, no need for exam – Xray

If normal inspection, palpate for tenderness (not

stability)

?PR/PV
 Should we Xray?

Pelvic Xrays advocated as routine for

paediatric trauma pts by
EMST/ATLS/APLS and RCH guidelines

Do we need them?
2001 Paediatric Radiology study
347 trauma pts who had pelvic xrays

Only one #, which was clinically apparent

(gross haematuria)

Suggest routine pelvic Xrays not needed

as screening tool
 Question 4
Scenario

An adolescent male pt (60kg) presents

after high-speed trail bike accident and has
diastasis of pubic symphysis with widening
of posterior iliosacral joint. He is
hypotensive
How do you delineate between intra-abdominal
injury which may require laparotomy versus
primarily pelvic source for bleeding which may
need other treatment?

Important distinction between stable v unstable

If stable then good case for CT

If haemodynamically unstable and obvious

unstable pelvic # then FAST can help delineate
between abdo vs pelvic bleeding
 FAST
What does it stand for?

Focused assessment with sonography for

trauma

4 views – pericardial, RUQ (Morrison’s

pouch), LUQ, pelvis

What is it for?
 Only two applications
– to detect presence of free fluid in abdomen in trauma
– To detect pericardial fluid/diagnose tamponade

Fast, bedside test. Able to be carried out by

relatively unskilled personnel (ED physicians)

NOT intended as a screening or diagnostic tool

for intra-abdo injury
NOT intended to replace CT
NOT good for retroperitoneal blood, bowel
injury, solid organ injury with encapsulated
haemorrhage
Sensitivity for free fluid variable 55-80%.
Specificity greater 80-95%%

Numerous studies done focused on role of

FAST as a screening test in
haemodynamically stable pts ie trying to
avoid CT scans – results disappointing.

This is not its role. If a patient needs a

CT, negative FAST does not stop them
needing one.
If the source is thought to be bleeding
related to the pelvic # - is first line
management OT for pelvic packing,
orthopaedic involvement for application of
external fixators in ED or in OT, or IR to
arrange embolisation?
Reducing and splinting fractures with pelvic
binders should reduce low pressure
bleeding from fractures and venous injury
Pelvic binders have replaced Ex-fix in ED
Ex-fix only if adjudged definitive procedure
(in OT)
If remain haemodynamically unstable
despite pelvic binder and adequate
resuscitation choice is pelvic packing vs
angiography and embolisation
Angiography clearly better if readily available and
no abdo injury. Survival benefit only if within 3
hrs of admission

Isolated pelvic injuries with massive

haemorrhage rare in paediatric patients, with
most bleeding coming from associated visceral
injuries

Therefore, pelvic packing often performed along

with laparotomy and external fixation, before
proceeding to angiography if still needed
What else do you do to manage this
unstable pt?
ABC
Stabilise pelvis
Keep warm (warmed fluids, room, space
blanket etc)
Activate massive transfusion protocol –
early use of blood and blood products
(FFP, platelets) to limit coagulopathy
Early notification and involvement of
orthopaedic and IR colleagues +/- surgical
 How is interventional radiology
arranged at RCH?

Decision to involve IR should occur as early

as possible

Early consult with orthopaedic and

radiology consultant

Paediatric radiologist will then liaise with

on-call IR at RBWH
 References
RCH Trauma Guidelines (3rd edition, Jan 2010)

Paediatric pelvic fractures: 10 years experience in a trauma centre. Injury

International Journal for Care of the Injured 2009. 40: 410-413

The screening pelvic radiograph in paediatric trauma. Paediatric Radiology 2001

31: 497-500

Haemodynamically unstable pelvic fractures. Injury International Journal for Care of

the Injured 2009. 40: 1023-1030

Death from pelvic fracture: children are different. Journal of Paediatric Surgery
1996. 31(1): 82-85

Focused assessment with sonography for trauma: the FAST scan. Trauma 2008.
10: 93-101

The efficacy of focused abdominal sonography for trauma (FAST) as a screening

tool in the assessment of injured children. Journal of Paediatric Surgery 1999.
34: 44-47
Preliminary experience with focused abdominal sonography for trauma (FAST) in
children: is it useful? Journal of Paediatric Surgery 1999. 34: 48-54

Interventional radiology for paediatric trauma. Paediatric Radiology 2009. 39: 506-
515

How (un)useful is the pelvic ring stability exam in diagnosing mechanically unstable
pelvic fractures in blunt trauma patients? Journal of Trauma 2009. 66: 815-820

Immediate application of improvised pelvic binder as first step in extended

resuscitation from life-threatening hypovolaemic shock in conscious patients
with unstable pelvic injuries. Injury International Journal for Care of the Injured
2007. 38: 125-128

The ideal pelvic binder. Trauma.org

Management of exsanguinating pelvic haemorrhages. Trauma.org

Pelvic ring injuries. Trauma 2006. 8: 95-110

Effects of early use of external pelvic compression on transfusion requirements and

mortality in pelvic fractures. The American Journal of Surgery 2007. 194: 720-
723