Pelvic Trauma in ChildrenPelvic Trauma in Children

Dr Nigel MooreDr Nigel Moore

Royal Children’s EmergencyRoyal Children’s Emergency

66thth October, 2010 October, 2010

OverviewOverview

Patterns of paediatric pelvic injuryPatterns of paediatric pelvic injury

Pelvic binders Pelvic binders

Pelvic examinationPelvic examination

Unstable pelvic fracture managementUnstable pelvic fracture management

Question 1Question 1

What is the usual pattern of pelvic fracture What is the usual pattern of pelvic fracture in children?in children?

How does it differ from adult pelvic injury?How does it differ from adult pelvic injury?

Pelvic fractures relatively rare in immature Pelvic fractures relatively rare in immature skeletonsskeletons

Require large amount of forceRequire large amount of force

Mortality 5-15% but often assoc with other Mortality 5-15% but often assoc with other injuries ie they are a marker of severe traumainjuries ie they are a marker of severe trauma

Severe haemorrhage from pelvic injury Severe haemorrhage from pelvic injury uncommon in childrenuncommon in children

Different anatomyDifferent anatomy

Bones less brittle, covered with thick Bones less brittle, covered with thick periosteumperiosteum

Post ligaments relatively stronger than Post ligaments relatively stronger than adjacent boneadjacent bone

Bone growth centres presentBone growth centres present

Pelvic volume relatively shallowPelvic volume relatively shallow

ImplicationsImplicationsGreater amount of energy to cause Greater amount of energy to cause fracturefracture

Single fractures occur more commonly due Single fractures occur more commonly due to ligament laxity (in adults rare to have to ligament laxity (in adults rare to have single fracture)single fracture)

Shallowness and flexibility of paediatric Shallowness and flexibility of paediatric pelvis allows damage to intrapelvic viscera pelvis allows damage to intrapelvic viscera without obvious fracturewithout obvious fracture

Mechanism of injuryMechanism of injury

Lateral Compression ~50% injuriesLateral Compression ~50% injuries– MVA - car is broadsided MVA - car is broadsided – or pedestrian struck from sideor pedestrian struck from side

Anteroposterior compression ~25%Anteroposterior compression ~25%- head on MVA- head on MVA

Vertical Shear ~5%Vertical Shear ~5%– Fall/jump from heightFall/jump from height

Rest of injuries made up of a combinationRest of injuries made up of a combination

Fracture TypesFracture TypesDouble breaks in pelvic ringDouble breaks in pelvic ring– Hemipelvis unstable and displaced cephaladHemipelvis unstable and displaced cephalad– High incidence of complications, including genitourinary, abdo High incidence of complications, including genitourinary, abdo

and vascular injuriesand vascular injuries

Single breaks in pelvic ringSingle breaks in pelvic ring– Symphysis pubis diastasisSymphysis pubis diastasis– Sup and inf pubic rami #sSup and inf pubic rami #s– Straddle fracturesStraddle fractures

Avulsion fracturesAvulsion fractures– Usually sporting injuries – cartilage weaker than boneUsually sporting injuries – cartilage weaker than bone

Acetabular fracturesAcetabular fractures– RareRare– Often assoc with hip dislocationOften assoc with hip dislocation

Question 2Question 2

What type(s) of pelvic binders are What type(s) of pelvic binders are available in our department?available in our department?

– Demonstrate how to useDemonstrate how to use– What’s the evidence for use of pelvic binders?What’s the evidence for use of pelvic binders?– When are they indicated?When are they indicated?– Once applied, when should they be removed?Once applied, when should they be removed?

Functions of the pelvic binderFunctions of the pelvic binder

To splint the bony pelvis to reduce haemorrhage To splint the bony pelvis to reduce haemorrhage from bone ends and venous disruption. from bone ends and venous disruption.

To reduce pain and movement during transfers.To reduce pain and movement during transfers.

To provide some integrity to the pelvis when To provide some integrity to the pelvis when operative packing of the pelvis is necessary. operative packing of the pelvis is necessary.

To provide stabilization of the pelvis until To provide stabilization of the pelvis until definitive stabilization can be achieved.definitive stabilization can be achieved.

IndicationsIndications

AbsoluteAbsolute– Haemodynamically unstable patient with a Haemodynamically unstable patient with a

mechanically unstable pelvis. mechanically unstable pelvis. – Haemodynamically unstable patient with a Haemodynamically unstable patient with a

suspected pelvic fracture. suspected pelvic fracture.

RelativeRelative– Haemodynamically normal patients with Haemodynamically normal patients with

unstable pelvic fractures, for pain control and unstable pelvic fractures, for pain control and reducing movement during transfersreducing movement during transfers

Pelvic bindersPelvic bindersAnalagous to C-spine collarAnalagous to C-spine collar– Should be used where pelvic injury is suspected before definitive Should be used where pelvic injury is suspected before definitive

imaging performedimaging performed

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

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

The pelvic binder is used to splint the bony pelvis.The pelvic binder is used to splint the bony pelvis.– approximates bone endsapproximates bone ends– reduces low-pressure bleeding - bone ends and disrupted veins. reduces low-pressure bleeding - bone ends and disrupted veins. – possible to exacerbate certain injury patterns if excessive force possible to exacerbate certain injury patterns if excessive force

is applied, esp severe lateral compression or vertical shear is applied, esp severe lateral compression or vertical shear injuriesinjuries..

Practical aspectsPractical aspectsShould be placed over the greater trochanters Should be placed over the greater trochanters – provides best mechanical stabilityprovides best mechanical stability– If too high may exacerbate a pelvic fracture if iliac crest injury. If too high may exacerbate a pelvic fracture if iliac crest injury.

Also obstructs access for laparotomy. Also obstructs access for laparotomy.

Binder will not control arterial haemorrhageBinder will not control arterial haemorrhage– If no improvement may require angio or operative interventionIf no improvement may require angio or operative intervention– Should allow easy access to the groins or abdomen Should allow easy access to the groins or abdomen

Should remain in place until the definitive stabilization procedure Should remain in place until the definitive stabilization procedure – may be > 24 hours, so important that belt material and may be > 24 hours, so important that belt material and

construction does not induce pressure necrosis. construction does not induce pressure necrosis.

The binder should be removed as soon as possibleThe binder should be removed as soon as possible

Emergency external fixation has no benefit over the pelvic binderEmergency external fixation has no benefit over the pelvic binder– should not be removed only to be replaced by an emergency fixator. should not be removed only to be replaced by an emergency fixator.

The ‘ideal’ binderThe ‘ideal’ binderSuitable for pre-hospital and emergency departmentSuitable for pre-hospital and emergency department– light and easily applied, ideally by one personlight and easily applied, ideally by one person

Allow access to the abdomen for laparotomy, and to the Allow access to the abdomen for laparotomy, and to the groins for angioembolisationgroins for angioembolisation

Soft material that will be comfortable and not induce Soft material that will be comfortable and not induce pressure ulceration. pressure ulceration.

Allow access to the perineum and anus for examination. Allow access to the perineum and anus for examination.

Must fit various sizes of patients (including children), or Must fit various sizes of patients (including children), or different sizes be available.different sizes be available.

Should be washable or cheap enough to be disposable Should be washable or cheap enough to be disposable

What is available?What is available?

London pelvic binderLondon pelvic binder

PelvigripPelvigrip

Sam-slingSam-sling

T-PODT-POD

Sheet wrapSheet wrap

So what do we have?So what do we have?

Volunteer DemonstrationVolunteer Demonstration

Do They Work?Do They Work?2007 study in American Journal of Surgery2007 study in American Journal of Surgery

Looked at early placement of pelvic binder (T-Looked at early placement of pelvic binder (T-POD) and effect on transfusion requirement and POD) and effect on transfusion requirement and mortalitymortality

Retrospective chart study in pelvic fractures with Retrospective chart study in pelvic fractures with 1or more risk factors for haemorrhage (unstable 1or more risk factors for haemorrhage (unstable #, age>55, first SBP<90) #, age>55, first SBP<90)

118 pts with binders vs 119 without (in year 118 pts with binders vs 119 without (in year before binders used)before binders used)

No difference in need for embolisation, No difference in need for embolisation, transfusion requirement or mortalitytransfusion requirement or mortality

Question 3Question 3

Should ‘pelvic springing’ be done as part Should ‘pelvic springing’ be done as part of the secondary survey in the trauma of the secondary survey in the trauma patient?patient?

How do you examine the pelvis? Justify How do you examine the pelvis? Justify your opinion.your opinion.

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

This approach based on adult models, where This approach based on adult models, where pelvic injury more common, and also more likely pelvic injury more common, and also more likely to be complicated by haemorrhageto be complicated by haemorrhage

Perpetuated by ATLS/EMST teachingPerpetuated by ATLS/EMST teaching

Is this appropriate in paediatric patients?Is this appropriate in paediatric patients?

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

Not good at detecting fractures in general. Not good at detecting fractures in general.

2009 study retrospective chart review 2009 study retrospective chart review (adults)(adults)– Pelvic stablility exam (springing) only 8% Pelvic stablility exam (springing) only 8%

sensitive in detecting #, 99.9% specificsensitive in detecting #, 99.9% specific

Pelvic tendernessPelvic tenderness

If tenderness elicited on palpation of pelvis If tenderness elicited on palpation of pelvis in pts with GCS>13, sensitivity of 100% for in pts with GCS>13, sensitivity of 100% for unstable #s (adult pop)unstable #s (adult pop)

So, how should we examine?So, how should we examine?

My approachMy approach

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

If these present, no need for exam – XrayIf these present, no need for exam – Xray

If normal inspection, palpate for tenderness (not If normal inspection, palpate for tenderness (not stability)stability)

?PR/PV?PR/PV

Should we Xray?Should we Xray?

Pelvic Xrays advocated as routine for Pelvic Xrays advocated as routine for paediatric trauma pts by paediatric trauma pts by EMST/ATLS/APLS and RCH guidelinesEMST/ATLS/APLS and RCH guidelines

Do we need them?Do we need them?

2001 Paediatric Radiology study2001 Paediatric Radiology study

347 trauma pts who had pelvic xrays347 trauma pts who had pelvic xrays

Only one #, which was clinically apparent Only one #, which was clinically apparent (gross haematuria)(gross haematuria)

Suggest routine pelvic Xrays not needed Suggest routine pelvic Xrays not needed as screening toolas screening tool

Question 4Question 4ScenarioScenario

An adolescent male pt (60kg) presents An adolescent male pt (60kg) presents after high-speed trail bike accident and has after high-speed trail bike accident and has diastasis of pubic symphysis with widening diastasis of pubic symphysis with widening of posterior iliosacral joint. He is of posterior iliosacral joint. He is hypotensivehypotensive

How do you delineate between intra-abdominal How do you delineate between intra-abdominal injury which may require laparotomy versus injury which may require laparotomy versus primarily pelvic source for bleeding which may primarily pelvic source for bleeding which may need other treatment?need other treatment?

Important distinction between stable v unstableImportant distinction between stable v unstable

If stable then good case for CTIf stable then good case for CT

If haemodynamically unstable and obvious If haemodynamically unstable and obvious unstable pelvic # then FAST can help delineate unstable pelvic # then FAST can help delineate between abdo vs pelvic bleedingbetween abdo vs pelvic bleeding

FASTFAST

What does it stand for?What does it stand for?

Focused assessment with sonography for Focused assessment with sonography for traumatrauma

4 views – pericardial, RUQ (Morrison’s 4 views – pericardial, RUQ (Morrison’s pouch), LUQ, pelvispouch), LUQ, pelvis

What is it for?What is it for?

Only two applicationsOnly two applications– to detect presence of free fluid in abdomen in traumato detect presence of free fluid in abdomen in trauma– To detect pericardial fluid/diagnose tamponadeTo detect pericardial fluid/diagnose tamponade

Fast, bedside test. Able to be carried out by Fast, bedside test. Able to be carried out by relatively unskilled personnel (ED physicians)relatively unskilled personnel (ED physicians)

NOT intended as a screening or diagnostic tool NOT intended as a screening or diagnostic tool for intra-abdo injuryfor intra-abdo injuryNOT intended to replace CTNOT intended to replace CTNOT good for retroperitoneal blood, bowel NOT good for retroperitoneal blood, bowel injury, solid organ injury with encapsulated injury, solid organ injury with encapsulated haemorrhagehaemorrhage

Sensitivity for free fluid variable 55-80%. Sensitivity for free fluid variable 55-80%. Specificity greater 80-95%%Specificity greater 80-95%%

Numerous studies done focused on role of Numerous studies done focused on role of FAST as a screening test in FAST as a screening test in haemodynamically stable pts ie trying to haemodynamically stable pts ie trying to avoid CT scans – results disappointing.avoid CT scans – results disappointing.

This is not its role. If a patient needs a This is not its role. If a patient needs a CT, negative FAST does not stop them CT, negative FAST does not stop them needing one.needing one.

If the source is thought to be bleeding If the source is thought to be bleeding related to the pelvic # - is first line related to the pelvic # - is first line management OT for pelvic packing, management OT for pelvic packing, orthopaedic involvement for application of orthopaedic involvement for application of external fixators in ED or in OT, or IR to external fixators in ED or in OT, or IR to arrange embolisation?arrange embolisation?

Reducing and splinting fractures with pelvic Reducing and splinting fractures with pelvic binders should reduce low pressure binders should reduce low pressure bleeding from fractures and venous injurybleeding from fractures and venous injury

Pelvic binders have replaced Ex-fix in EDPelvic binders have replaced Ex-fix in ED

Ex-fix only if adjudged definitive procedure Ex-fix only if adjudged definitive procedure (in OT)(in OT)

If remain haemodynamically unstable If remain haemodynamically unstable despite pelvic binder and adequate despite pelvic binder and adequate resuscitation choice is pelvic packing vs resuscitation choice is pelvic packing vs angiography and embolisationangiography and embolisation

Angiography clearly better if readily available and Angiography clearly better if readily available and no abdo injury. Survival benefit only if within 3 no abdo injury. Survival benefit only if within 3 hrs of admissionhrs of admission

Isolated pelvic injuries with massive Isolated pelvic injuries with massive haemorrhage rare in paediatric patients, with haemorrhage rare in paediatric patients, with most bleeding coming from associated visceral most bleeding coming from associated visceral injuriesinjuries

Therefore, pelvic packing often performed along Therefore, pelvic packing often performed along with laparotomy and external fixation, before with laparotomy and external fixation, before proceeding to angiography if still neededproceeding to angiography if still needed

What else do you do to manage this What else do you do to manage this unstable pt?unstable pt?

ABCABC

Stabilise pelvisStabilise pelvis

Keep warm (warmed fluids, room, space Keep warm (warmed fluids, room, space blanket etc)blanket etc)

Activate massive transfusion protocol – Activate massive transfusion protocol – early use of blood and blood products early use of blood and blood products (FFP, platelets) to limit coagulopathy(FFP, platelets) to limit coagulopathy

Early notification and involvement of Early notification and involvement of orthopaedic and IR colleagues +/- surgicalorthopaedic and IR colleagues +/- surgical

How is interventional radiology How is interventional radiology arranged at RCH?arranged at RCH?

Decision to involve IR should occur as Decision to involve IR should occur as early as possibleearly as possible

Early consult with orthopaedic and Early consult with orthopaedic and radiology consultantradiology consultant

Paediatric radiologist will then liaise with Paediatric radiologist will then liaise with on-call IR at RBWHon-call IR at RBWH

ReferencesReferences

RCH Trauma Guidelines (3RCH Trauma Guidelines (3rdrd edition, Jan 2010) edition, Jan 2010)

Paediatric pelvic fractures: 10 years experience in a trauma centre. Paediatric pelvic fractures: 10 years experience in a trauma centre. Injury Injury International Journal for Care of the Injured 2009.International Journal for Care of the Injured 2009. 40: 410-413 40: 410-413

The screening pelvic radiograph in paediatric trauma. The screening pelvic radiograph in paediatric trauma. Paediatric RadiologyPaediatric Radiology 20012001 31: 497-50031: 497-500

Haemodynamically unstable pelvic fractures. Haemodynamically unstable pelvic fractures. Injury International Journal for Care of Injury International Journal for Care of the Injured 2009. the Injured 2009. 40: 1023-103040: 1023-1030

Death from pelvic fracture: children Death from pelvic fracture: children areare different. different. Journal of Paediatric Surgery Journal of Paediatric Surgery 19961996. 31(1): 82-85. 31(1): 82-85

Focused assessment with sonography for trauma: the FAST scan. Focused assessment with sonography for trauma: the FAST scan. Trauma 2008. Trauma 2008. 1010: 93-101: 93-101

The efficacy of focused abdominal sonography for trauma (FAST) as a screening The efficacy of focused abdominal sonography for trauma (FAST) as a screening tool in the assessment of injured children. tool in the assessment of injured children. Journal of Paediatric Surgery 1999. Journal of Paediatric Surgery 1999. 34: 44-4734: 44-47

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

Interventional radiology for paediatric trauma. Interventional radiology for paediatric trauma. Paediatric Radiology 2009.Paediatric Radiology 2009. 39: 506- 39: 506-515515

How (un)useful is the pelvic ring stability exam in diagnosing mechanically unstable How (un)useful is the pelvic ring stability exam in diagnosing mechanically unstable pelvic fractures in blunt trauma patients? pelvic fractures in blunt trauma patients? Journal of Trauma 2009.Journal of Trauma 2009. 66: 815-820 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 Injury International Journal for Care of the Injured 2007. 2007. 38: 125-12838: 125-128

The ideal pelvic binder. Trauma.orgThe ideal pelvic binder. Trauma.org

Management of exsanguinating pelvic haemorrhages. Trauma.orgManagement of exsanguinating pelvic haemorrhages. Trauma.org

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

Effects of early use of external pelvic compression on transfusion requirements and Effects of early use of external pelvic compression on transfusion requirements and mortality in pelvic fractures. mortality in pelvic fractures. The American Journal of Surgery 2007. The American Journal of Surgery 2007. 194: 720-194: 720-723723