J Orthop Sci DOI 10.1007/s00776-014-0634-z
CASE REPORT
Fracture-dislocation of the sacroiliac joint with severely unstable fractures of the pelvis and femur in a 16-month-old patient: a case report Qiang Shi • Weiping Wu • Juan Han Shuangwu Dai • Wei Tan • Xu Li
•
Received: 9 January 2014 / Accepted: 6 August 2014 Ó The Japanese Orthopaedic Association 2014
Introduction Pelvic injuries combined with femoral fractures in children are uncommon lesions and often caused by high-energy trauma. Conservative treatment has been favored by surgeons because of the significant potential for union and remodeling in skeletally immature children [1] and the difficulty of surgery in small patients and risk of damage to growth plates in the pelvis. However, unstable or markedly displaced fractures of the pelvis in children are usually best managed surgically to improve alignment and outcomes. There are few literature reports of unstable pelvic fracture in infants \2 years old; however, Starr et al. [2] reported on a 20-month-old patient. In this study, we present a rare case of sacroiliac (SI) joint dislocation associated with acetabulum, femur, and pubic rami fractures in a 16-month-old patient, making reduction and fixation more difficult than in a case of simple anterior dislocation of the SI joint. After restorations by open means, healing of these lesions was achieved, with favorable clinical and radiological outcomes. Our case shows that even very young children with pelvic fractures can be treated surgically, and when appropriately managed with full consideration of their Q. Shi W. Wu J. Han S. Dai W. Tan X. Li (&) Department of Pediatric Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, People’s Republic of China e-mail: [email protected] Q. Shi e-mail: [email protected] Q. Shi W. Wu J. Han S. Dai W. Tan X. Li Academy of Orthopaedics, Guangdong Province, Guangzhou 510630, People’s Republic of China
small size, good outcomes could be achieved. The purpose of this report is to present the operative treatment of unstable pelvic and femoral fractures in a 16-month-old patient. To our knowledge, this is the youngest case treated surgically ever reported in the literature.
Case report A 16-month-old boy was run over on his way home by an low-velocity automobile. He was taken to a local hospital where systolic blood pressure (SBP) was reported normal; hemoglobin was 8.9 g/dl. Fluid resuscitation was begun with intravenously administered crystalloid, and 2 U of packed red blood cells was transfused immediately. Examination revealed no evidence of urethral injury or perineal laceration. A Foley catheter passed easily and drained clear urine. Computed tomography (CT) scans of the abdomen showed no intra-abdominal injury but revealed traumatic cryptorchidism. The patient was admitted to the intensive care unit. He was kept supine and a left femoral supracondylar traction device was applied for the femoral shaft fracture. Hemoglobin and hematocrit levels were checked every 6 h. Nine days later, the patient was transferred to our hospital. On arrival, pulse was 148 beats/min and respirations 28/min. He had abrasions on the left thigh and over his left iliac crest. The pelvic area was asymmetric, with the left side externally rotated. Palpation of the iliac wings was painful, and peripheral blood circulation of the involved limb was normal. Neurologic examination of the lower extremities was difficult due to the patient’s age and obvious pain with motion of the legs. He had active extension and flexion of bilateral ankles and toes and had intact sensation to touch. Pillows were used to support the patient’s legs and pelvis.
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Q. Shi et al. Fig. 1 a Plain films showing unstable pelvic fractures. b Three-dimensional computed tomography (CT) scan showing pubic symphysis diastasis. c Horizontal CT scan confirming displacement of the left ilium. d CT images of the abdomen showing a large pelvic hematoma (white arrow)
Fig. 2 a Postoperative simple anteroposterior radiograph of the pelvis showing satisfactory reduction of the lesion and fixation in the pelvis and femur. b Follow-up radiograph showing when the external fixator was removed 1 month after surgery
Plain films revealed disruption of the left sacroiliac joint, fractures of left pubic rami, fractures of left femoral shaft, and diastasis of symphysis pubis (Fig. 1a). Initial three-dimensional CT scan reconstruction (Fig. 1b) and representative horizontal CT scan (Fig. 1c) confirmed marked displacement of the left ilium; CT images of the abdomen showed a large pelvic hematoma (Fig. 1d). After getting the stabilized general condition, the patient accepted surgical treatment in general anesthetic. The pillows around the patient’s pelvis were removed. We first performed a closed reduction and intramedullary nailing fixation of the left femoral shaft fracture. Then, open
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reduction and internal fixation (ORIF) using the anterior approach was performed on the sacroiliac joint. After clearing the pelvic hematoma, the pubic symphysis was treated using ORIF with a plate (Fig. 2a). After surgery, the patient’s neurologic and vascular state remained unchanged, and the external fixator was removed 1 month after surgery (Fig. 2b). Then, the traumatic cryptorchidism was repaired surgically by a urology surgeon. Postoperative horizontal CT (Fig. 3a) and three-dimensional CT scan reconstruction (Fig. 3b) clearly manifested reduction of the left SI joint, pubic symphysis, and left femoral-shaft fracture. Three
Fracture-dislocation of the SI joint Fig. 3 a Postoperative horizontal CT clearly showing reduction of the left sacroiliac (SI) joint, pubic symphysis, and left femoral shaft fracture. b Postoperative CT scan showing excellent reduction of the left SI joint
Fig. 4 a Radiograph showing good reduction of the symphysis pubis, sacroiliac joint, and femur after a 12-month followup. b Anteroposterior radiograph 2 years after surgery at the last follow-up showing good bone union
months after surgery, the patient was able to walk and run normally and asymptomatically. Plates were removed from the pubic symphysis and SI joint to avoid SI joint or symphysis fusion. After a 12-month follow-up, radiography revealed good reduction and healing of the symphysis pubis, sacroiliac joint, and femur (Fig. 4a). The last follow-up was 24 months after surgery, at which time the patient had achieved full range motion and could walk and run with no problem (Fig. 4b). The patient’s parents were asked if data concerning the case could be submitted for publication, and they consented.
Discussion Pelvic fractures usually occur as a result of auto–pedestrian and crushing accidents in children [3, 4]. Mehmet reported that 68 % of pediatric pelvic-ring injuries is caused by auto–pedestrian accidents [5]. Pediatric pelvic fractures
often result from high-energy trauma and have etiologies very different from those of adult pelvic fractures [6]. The biomechanical stability of a child’s pelvis outweighs that of an adult pelvis [7]. Because of the greater plasticity of the pelvic bones and its thick periosteum, increased elasticity and flexibility of the symphysis pubis and sacroiliac joints, stronger ligaments, and the increased capacity for energy absorption in the cartilaginous area in children, lower incidences of pubic and sacroiliac diastasis were observed in children than in adults. This also implies that a greater comparative energy is needed to cause a similar fracture in child as in an adult [8–11]. Therefore, associated injuries as a result of severe pelvic fracture and neurological defect should be anticipated and investigated. Although this patient’s small size made it necessary to modify our standard treatment protocol, the principles of management remained the same: volume resuscitation, and provisional stabilization to prevent enlargement of the pelvic hematoma, followed by definitive reduction and stabilization. Pediatric pelvic fractures have been managed using conservative treatment, such as bed rest, pelvic slings,
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skeletal traction, or hip spica casting [12, 13]. The rationale for conservative treatment in children is the remarkable potential for union and remodeling and for stability resulting from a thick periosteum and high ligamentous strength. However, recent studies have demonstrated that conservative treatment of displaced unstable pelvic fractures can lead to long-term morbidity and functional problems. McDonald [14], reporting on conservative treatment of 15 skeletally immature children, concluded that unstable pelvic fractures that distort the immature skeletal pelvic ring can lead to significant residual long-term morbidity, including delayed union and SI fusion, hemipelvis undergrowth, and limblength discrepancy. Schwarz et al. [15] emphasized the importance of anatomic reduction of the pelvic ring and concluded that nonsurgical treatment of unstable injuries can lead to unacceptable, poor clinical outcomes as a result of pelvic asymmetry. Smith et al. [16] suggested that fractures in skeletally immature children associated with [1.1 cm of pelvic asymmetry after closed reduction should be treated promptly using ORIF to improve alignment and hence long-term functional outcomes. With regard to grossly unstable SI joints, we felt that the risks of conservative management outweighed the risks of surgery in this patient [2], and open reduction is often warranted in skeletally immature patients. Hoffmann et al. [17] described a unilateral SI hinge fixation in association with an anterior osteosynthesis to treat SI joint dislocation, achieving good clinical results. A recent biomechanical study [18] showed that no significant difference between this kind of fixation and iliosacral screws was noted. In our study, hinge fixation fixed SI joint dislocation solidly and avoided the risk of further iatrogenic neurologic damage, especially to the L5 nerve root. Importantly, implants in the SI joint should be removed between 3 and 4 months after surgery to prevent bony fusion or breakage of the internal fixation. In our opinion, resetting the SI joint should precede reduction and fixation of the symphysis diastasis, because the symphysis pubis is rich in symphyseal cartilage in young children, and we found it very difficult to distinguish normal anatomic landmarks. Furthermore, anterior dislocation of the SI joint would significantly hinder resetting of the symphysis diastasis. During the surgical reduction process, the Simpson approach was used, and the periosteum elevator was placed between the iliac wing and the sacrum. Then, the ilium was pried posterior to the sacrum until anatomical reduction. Reduction can be evaluated by palpation and direct observation. After SI joint and pubic symphysis fixation, an external fixator was used to reduce the risk of extensive blood loss and restore stability of the anterior pelvic ring destabilized by fractures of left pubic rami. We believe that CT scans are useful for evaluating any pelvic ring injury and can identify possible triradiate cartilage injury that might otherwise be missed. In addition to
123
being helpful in determining the need for surgery and assisting in surgical planning [19], CT is imperative in pediatric pelvic fracture cases to identify associated injuries. Scans of the hip to identify triradiate cartilage injuries are of particular importance, because such damage can result in premature growth-plate fusion, which can affect acetabular diametric growth [20]. From our point of view, this case was classified as type C2 according to the Tile classification system [21]. Although surgical treatment is rarely required in pediatric patients with pelvic fracture, the basic principles of management remain the same as in adult patients. This report illustrates that such principles can be employed successfully, even in very young patients. However, the study involved only one patient, and there was lack of long-term follow-up, so the effect of surgical treatment on outcomes remains to be established. Further studies with more cases and longer-term follow-up are necessary to confirm our experience.
Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Musemeche CA, Fischer RP, Cotler HB, Andrassy RJ. Selective management of pediatric pelvic fractures: a conservative approach. J Pediatr Surg. 1987;22:538–40. 2. Starr AJ, Ortega G, Reinert CM. Management of an unstable pelvic ring disruption in a 20-month-old patient. J Orthop Trauma. 2009;23:159–62. 3. Reichard SA, Helikson MA, Shorter N, White RI Jr, Shemeta DW, Haller JA Jr. Pelvic fractures in children-review of 120 patients with a new look at general management. J Pediatr Surg. 1980;15:727–34. 4. Rieger H, Brug E. Fracture of the pelvis in children. Clin Orthop Relat Res. 1997;336:226–39. 5. Subasi M, Arslan H, Necmioglu S, Onen A, Ozen S, Kaya M. Long-term outcomes of conservatively treated paediatric pelvic fractures. Injury. 2004;35:771–81. 6. Spiguel L, Glynn L, Liu D, Statter M. Pediatric pelvic fractures: a marker for injury severity. Am Surg. 2006;72:481–4. 7. Silber JS, Flynn JM, Koffler KM, Dormans JP, Drummond DS. Analysis of the cause, classification, and associated injuries of 166 consecutive pediatric pelvic fractures. J Pediatr Orthop. 2001;21:446–50. 8. Bircher M, Hargrove R. Is it possible to classify open fractures of the pelvis? Eur J Trauma. 2004;30:74–9. 9. Schmal H, Klemt C, Haag C, Bonnaire F. Complex pelvic injury in childhood. Unfallchirurg. 2002;105:748–54. 10. Smith WR, Oakley M, Morgan SJ. Pediatric pelvic fractures. J Pediatr Orthop. 2004;24:130–5. 11. Vitale MG, Kessler MW, Choe JC, Hwang MW, Tolo VT, Skaggs DL. Pelvic fractures in children: an exploration of practice patterns and patient outcomes. J Pediatr Orthop. 2005;25:581–7. 12. Blasier RD, McAtee J, White R, Mitchell DT. Disruption of the pelvic ring in pediatric patients. Clin Orthop Relat Res. 2000;376:87–95.
Fracture-dislocation of the SI joint 13. Watts HG. Fractures of the pelvis in children. Orthop Clin North Am. 1976;7:615–24. 14. McDonald GA. Pelvic disruptions in children. Clin Orthop Relat Res. 1980;151:130–4. 15. Schwarz N, Posch E, Mayr J, Fischmeister FM, Schwarz AF, Ohner T. Long-term results of unstable pelvic ring fractures in children. Injury. 1998;29:431–3. 16. Smith W, Shurnas P, Morgan S, Agudelo J, Luszko G, Knox EC, Georgopoulos G. Clinical outcomes of unstable pelvic fractures in skeletally immature patients. J Bone Joint Surg Am. 2005;87:2423–31. 17. Hoffmann E, Levassor N, Rillardon L, Lavelle G, Guigui P. Sacroiliac fixation: a new technique after pelvic trauma. Rev Chir Orthop Reparatrice Appar Mot. 2003;89:725–9.
18. Ilharreborde B, Breitel D, Lenoir T, Mosnier T, Skalli W, Guigui P, Hoffmann E. Pelvic ring fractures internal fixation: iliosacral screws versus sacroiliac hinge fixation. Orthop Traumatol Surg Res. 2009;95:563–7. 19. Lee DH, Park JW, Lee SH. A transepiphyseal fracture of the femoral neck in a child with 2 widely displaced Salter-Harris III fragments of the capital femoral epiphysis. J Orthop Trauma. 2010;24:125–9. 20. Banerjee S, Barry MJ, Paterson JM. Paediatric pelvic fractures: 10 years experience in a trauma centre. Injury. 2009;40:410–3. 21. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br. 1988;70:1–12.
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CASE REPORT
Fracture-dislocation of the sacroiliac joint with severely unstable fractures of the pelvis and femur in a 16-month-old patient: a case report Qiang Shi • Weiping Wu • Juan Han Shuangwu Dai • Wei Tan • Xu Li
•
Received: 9 January 2014 / Accepted: 6 August 2014 Ó The Japanese Orthopaedic Association 2014
Introduction Pelvic injuries combined with femoral fractures in children are uncommon lesions and often caused by high-energy trauma. Conservative treatment has been favored by surgeons because of the significant potential for union and remodeling in skeletally immature children [1] and the difficulty of surgery in small patients and risk of damage to growth plates in the pelvis. However, unstable or markedly displaced fractures of the pelvis in children are usually best managed surgically to improve alignment and outcomes. There are few literature reports of unstable pelvic fracture in infants \2 years old; however, Starr et al. [2] reported on a 20-month-old patient. In this study, we present a rare case of sacroiliac (SI) joint dislocation associated with acetabulum, femur, and pubic rami fractures in a 16-month-old patient, making reduction and fixation more difficult than in a case of simple anterior dislocation of the SI joint. After restorations by open means, healing of these lesions was achieved, with favorable clinical and radiological outcomes. Our case shows that even very young children with pelvic fractures can be treated surgically, and when appropriately managed with full consideration of their Q. Shi W. Wu J. Han S. Dai W. Tan X. Li (&) Department of Pediatric Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, People’s Republic of China e-mail: [email protected] Q. Shi e-mail: [email protected] Q. Shi W. Wu J. Han S. Dai W. Tan X. Li Academy of Orthopaedics, Guangdong Province, Guangzhou 510630, People’s Republic of China
small size, good outcomes could be achieved. The purpose of this report is to present the operative treatment of unstable pelvic and femoral fractures in a 16-month-old patient. To our knowledge, this is the youngest case treated surgically ever reported in the literature.
Case report A 16-month-old boy was run over on his way home by an low-velocity automobile. He was taken to a local hospital where systolic blood pressure (SBP) was reported normal; hemoglobin was 8.9 g/dl. Fluid resuscitation was begun with intravenously administered crystalloid, and 2 U of packed red blood cells was transfused immediately. Examination revealed no evidence of urethral injury or perineal laceration. A Foley catheter passed easily and drained clear urine. Computed tomography (CT) scans of the abdomen showed no intra-abdominal injury but revealed traumatic cryptorchidism. The patient was admitted to the intensive care unit. He was kept supine and a left femoral supracondylar traction device was applied for the femoral shaft fracture. Hemoglobin and hematocrit levels were checked every 6 h. Nine days later, the patient was transferred to our hospital. On arrival, pulse was 148 beats/min and respirations 28/min. He had abrasions on the left thigh and over his left iliac crest. The pelvic area was asymmetric, with the left side externally rotated. Palpation of the iliac wings was painful, and peripheral blood circulation of the involved limb was normal. Neurologic examination of the lower extremities was difficult due to the patient’s age and obvious pain with motion of the legs. He had active extension and flexion of bilateral ankles and toes and had intact sensation to touch. Pillows were used to support the patient’s legs and pelvis.
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Q. Shi et al. Fig. 1 a Plain films showing unstable pelvic fractures. b Three-dimensional computed tomography (CT) scan showing pubic symphysis diastasis. c Horizontal CT scan confirming displacement of the left ilium. d CT images of the abdomen showing a large pelvic hematoma (white arrow)
Fig. 2 a Postoperative simple anteroposterior radiograph of the pelvis showing satisfactory reduction of the lesion and fixation in the pelvis and femur. b Follow-up radiograph showing when the external fixator was removed 1 month after surgery
Plain films revealed disruption of the left sacroiliac joint, fractures of left pubic rami, fractures of left femoral shaft, and diastasis of symphysis pubis (Fig. 1a). Initial three-dimensional CT scan reconstruction (Fig. 1b) and representative horizontal CT scan (Fig. 1c) confirmed marked displacement of the left ilium; CT images of the abdomen showed a large pelvic hematoma (Fig. 1d). After getting the stabilized general condition, the patient accepted surgical treatment in general anesthetic. The pillows around the patient’s pelvis were removed. We first performed a closed reduction and intramedullary nailing fixation of the left femoral shaft fracture. Then, open
123
reduction and internal fixation (ORIF) using the anterior approach was performed on the sacroiliac joint. After clearing the pelvic hematoma, the pubic symphysis was treated using ORIF with a plate (Fig. 2a). After surgery, the patient’s neurologic and vascular state remained unchanged, and the external fixator was removed 1 month after surgery (Fig. 2b). Then, the traumatic cryptorchidism was repaired surgically by a urology surgeon. Postoperative horizontal CT (Fig. 3a) and three-dimensional CT scan reconstruction (Fig. 3b) clearly manifested reduction of the left SI joint, pubic symphysis, and left femoral-shaft fracture. Three
Fracture-dislocation of the SI joint Fig. 3 a Postoperative horizontal CT clearly showing reduction of the left sacroiliac (SI) joint, pubic symphysis, and left femoral shaft fracture. b Postoperative CT scan showing excellent reduction of the left SI joint
Fig. 4 a Radiograph showing good reduction of the symphysis pubis, sacroiliac joint, and femur after a 12-month followup. b Anteroposterior radiograph 2 years after surgery at the last follow-up showing good bone union
months after surgery, the patient was able to walk and run normally and asymptomatically. Plates were removed from the pubic symphysis and SI joint to avoid SI joint or symphysis fusion. After a 12-month follow-up, radiography revealed good reduction and healing of the symphysis pubis, sacroiliac joint, and femur (Fig. 4a). The last follow-up was 24 months after surgery, at which time the patient had achieved full range motion and could walk and run with no problem (Fig. 4b). The patient’s parents were asked if data concerning the case could be submitted for publication, and they consented.
Discussion Pelvic fractures usually occur as a result of auto–pedestrian and crushing accidents in children [3, 4]. Mehmet reported that 68 % of pediatric pelvic-ring injuries is caused by auto–pedestrian accidents [5]. Pediatric pelvic fractures
often result from high-energy trauma and have etiologies very different from those of adult pelvic fractures [6]. The biomechanical stability of a child’s pelvis outweighs that of an adult pelvis [7]. Because of the greater plasticity of the pelvic bones and its thick periosteum, increased elasticity and flexibility of the symphysis pubis and sacroiliac joints, stronger ligaments, and the increased capacity for energy absorption in the cartilaginous area in children, lower incidences of pubic and sacroiliac diastasis were observed in children than in adults. This also implies that a greater comparative energy is needed to cause a similar fracture in child as in an adult [8–11]. Therefore, associated injuries as a result of severe pelvic fracture and neurological defect should be anticipated and investigated. Although this patient’s small size made it necessary to modify our standard treatment protocol, the principles of management remained the same: volume resuscitation, and provisional stabilization to prevent enlargement of the pelvic hematoma, followed by definitive reduction and stabilization. Pediatric pelvic fractures have been managed using conservative treatment, such as bed rest, pelvic slings,
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Q. Shi et al.
skeletal traction, or hip spica casting [12, 13]. The rationale for conservative treatment in children is the remarkable potential for union and remodeling and for stability resulting from a thick periosteum and high ligamentous strength. However, recent studies have demonstrated that conservative treatment of displaced unstable pelvic fractures can lead to long-term morbidity and functional problems. McDonald [14], reporting on conservative treatment of 15 skeletally immature children, concluded that unstable pelvic fractures that distort the immature skeletal pelvic ring can lead to significant residual long-term morbidity, including delayed union and SI fusion, hemipelvis undergrowth, and limblength discrepancy. Schwarz et al. [15] emphasized the importance of anatomic reduction of the pelvic ring and concluded that nonsurgical treatment of unstable injuries can lead to unacceptable, poor clinical outcomes as a result of pelvic asymmetry. Smith et al. [16] suggested that fractures in skeletally immature children associated with [1.1 cm of pelvic asymmetry after closed reduction should be treated promptly using ORIF to improve alignment and hence long-term functional outcomes. With regard to grossly unstable SI joints, we felt that the risks of conservative management outweighed the risks of surgery in this patient [2], and open reduction is often warranted in skeletally immature patients. Hoffmann et al. [17] described a unilateral SI hinge fixation in association with an anterior osteosynthesis to treat SI joint dislocation, achieving good clinical results. A recent biomechanical study [18] showed that no significant difference between this kind of fixation and iliosacral screws was noted. In our study, hinge fixation fixed SI joint dislocation solidly and avoided the risk of further iatrogenic neurologic damage, especially to the L5 nerve root. Importantly, implants in the SI joint should be removed between 3 and 4 months after surgery to prevent bony fusion or breakage of the internal fixation. In our opinion, resetting the SI joint should precede reduction and fixation of the symphysis diastasis, because the symphysis pubis is rich in symphyseal cartilage in young children, and we found it very difficult to distinguish normal anatomic landmarks. Furthermore, anterior dislocation of the SI joint would significantly hinder resetting of the symphysis diastasis. During the surgical reduction process, the Simpson approach was used, and the periosteum elevator was placed between the iliac wing and the sacrum. Then, the ilium was pried posterior to the sacrum until anatomical reduction. Reduction can be evaluated by palpation and direct observation. After SI joint and pubic symphysis fixation, an external fixator was used to reduce the risk of extensive blood loss and restore stability of the anterior pelvic ring destabilized by fractures of left pubic rami. We believe that CT scans are useful for evaluating any pelvic ring injury and can identify possible triradiate cartilage injury that might otherwise be missed. In addition to
123
being helpful in determining the need for surgery and assisting in surgical planning [19], CT is imperative in pediatric pelvic fracture cases to identify associated injuries. Scans of the hip to identify triradiate cartilage injuries are of particular importance, because such damage can result in premature growth-plate fusion, which can affect acetabular diametric growth [20]. From our point of view, this case was classified as type C2 according to the Tile classification system [21]. Although surgical treatment is rarely required in pediatric patients with pelvic fracture, the basic principles of management remain the same as in adult patients. This report illustrates that such principles can be employed successfully, even in very young patients. However, the study involved only one patient, and there was lack of long-term follow-up, so the effect of surgical treatment on outcomes remains to be established. Further studies with more cases and longer-term follow-up are necessary to confirm our experience.
Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Musemeche CA, Fischer RP, Cotler HB, Andrassy RJ. Selective management of pediatric pelvic fractures: a conservative approach. J Pediatr Surg. 1987;22:538–40. 2. Starr AJ, Ortega G, Reinert CM. Management of an unstable pelvic ring disruption in a 20-month-old patient. J Orthop Trauma. 2009;23:159–62. 3. Reichard SA, Helikson MA, Shorter N, White RI Jr, Shemeta DW, Haller JA Jr. Pelvic fractures in children-review of 120 patients with a new look at general management. J Pediatr Surg. 1980;15:727–34. 4. Rieger H, Brug E. Fracture of the pelvis in children. Clin Orthop Relat Res. 1997;336:226–39. 5. Subasi M, Arslan H, Necmioglu S, Onen A, Ozen S, Kaya M. Long-term outcomes of conservatively treated paediatric pelvic fractures. Injury. 2004;35:771–81. 6. Spiguel L, Glynn L, Liu D, Statter M. Pediatric pelvic fractures: a marker for injury severity. Am Surg. 2006;72:481–4. 7. Silber JS, Flynn JM, Koffler KM, Dormans JP, Drummond DS. Analysis of the cause, classification, and associated injuries of 166 consecutive pediatric pelvic fractures. J Pediatr Orthop. 2001;21:446–50. 8. Bircher M, Hargrove R. Is it possible to classify open fractures of the pelvis? Eur J Trauma. 2004;30:74–9. 9. Schmal H, Klemt C, Haag C, Bonnaire F. Complex pelvic injury in childhood. Unfallchirurg. 2002;105:748–54. 10. Smith WR, Oakley M, Morgan SJ. Pediatric pelvic fractures. J Pediatr Orthop. 2004;24:130–5. 11. Vitale MG, Kessler MW, Choe JC, Hwang MW, Tolo VT, Skaggs DL. Pelvic fractures in children: an exploration of practice patterns and patient outcomes. J Pediatr Orthop. 2005;25:581–7. 12. Blasier RD, McAtee J, White R, Mitchell DT. Disruption of the pelvic ring in pediatric patients. Clin Orthop Relat Res. 2000;376:87–95.
Fracture-dislocation of the SI joint 13. Watts HG. Fractures of the pelvis in children. Orthop Clin North Am. 1976;7:615–24. 14. McDonald GA. Pelvic disruptions in children. Clin Orthop Relat Res. 1980;151:130–4. 15. Schwarz N, Posch E, Mayr J, Fischmeister FM, Schwarz AF, Ohner T. Long-term results of unstable pelvic ring fractures in children. Injury. 1998;29:431–3. 16. Smith W, Shurnas P, Morgan S, Agudelo J, Luszko G, Knox EC, Georgopoulos G. Clinical outcomes of unstable pelvic fractures in skeletally immature patients. J Bone Joint Surg Am. 2005;87:2423–31. 17. Hoffmann E, Levassor N, Rillardon L, Lavelle G, Guigui P. Sacroiliac fixation: a new technique after pelvic trauma. Rev Chir Orthop Reparatrice Appar Mot. 2003;89:725–9.
18. Ilharreborde B, Breitel D, Lenoir T, Mosnier T, Skalli W, Guigui P, Hoffmann E. Pelvic ring fractures internal fixation: iliosacral screws versus sacroiliac hinge fixation. Orthop Traumatol Surg Res. 2009;95:563–7. 19. Lee DH, Park JW, Lee SH. A transepiphyseal fracture of the femoral neck in a child with 2 widely displaced Salter-Harris III fragments of the capital femoral epiphysis. J Orthop Trauma. 2010;24:125–9. 20. Banerjee S, Barry MJ, Paterson JM. Paediatric pelvic fractures: 10 years experience in a trauma centre. Injury. 2009;40:410–3. 21. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br. 1988;70:1–12.
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