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Clinical Outcomes of Unstable Pelvic Fractures in Skeletally Immature Patients

¹ Department of Orthopaedic Surgery, Denver Health Medical Center, MC 0188, 777 Bannock Street, Denver, CO 80204. E-mail address for W. Smith: wsmith{at}dhha.org
² The Columbia Orthopedic Group, 400 Keene Street, P.O. Box 0, Columbia, MO 65201
³ Department of Orthopaedic Surgery, University of Arizona, 1609 North Warren Street, #110, Tucson, AZ 85719
⁴ Regional Health Care, #3 Medical Plaza, Mountain Home, AR 72653
⁵ Department of Orthopaedic Surgery, The Children's Hospital, 1056 East 19th Street, Denver, CO 80218

Investigation performed at the Department of Orthopaedic Surgery, Denver Health Medical Center, and The Children's Hospital, Denver, Colorado

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Methods: A retrospective review of all patients with open triradiate cartilages and an unstable pelvic (Tile type-B or C) fracture treated, from 1986 to 2000, at one of two level-I trauma centers was performed. Patients were evaluated with a review of their medical records, the Modified Injury Severity Score (MISS), standardized physical examination, standardized radiographic evaluation, and the Short Musculoskeletal Function Assessment Questionnaire (SMFA). The outcomes were then used to assess the difference between patients who had been treated operatively and those who had been treated nonoperatively.

Results: Of 230 pelvic fractures treated during the study period, twenty-three in twenty-three patients were unstable. Of the twenty-three patients, twenty, with a mean age of 9.5 years at the time of injury, were evaluated. The mean duration of follow-up was 6.5 years. There were four type-B and sixteen type-C fractures according to the Tile classification system. The four patients with a type-B fracture had a mean of 1.4 cm of pelvic asymmetry at the time of union and the last follow-up, whereas the sixteen patients with a type-C fracture had a mean of 1.5 cm of pelvic asymmetry at those times. Pelvic asymmetry did not remodel even in younger patients. Eighteen patients were treated operatively with external fixation, internal fixation, or a combination of both, and pelvic asymmetry of 1 cm was achieved in ten of them. Patients who had 1 cm of pelvic asymmetry had no lumbar or sacroiliac pain, no or mild sacroiliac tenderness, no Trendelenburg sign, no lumbar scoliosis, and lower (better) bother and dysfunction scores on the SMFA compared with patients with more pelvic asymmetry. All patients with 1.1 cm of pelvic asymmetry had three or more of the following: nonstructural scoliosis, lumbar pain, a Trendelenburg sign, or sacroiliac joint tenderness and pain. Patients with fewer associated injuries and pelvic asymmetry of 1 cm had better clinical results.

Conclusions: Unstable pelvic fractures in children can result in long-term morbidity and functional problems. Fractures associated with 1.1 cm of pelvic asymmetry following closed reduction should be treated with open reduction and internal or external fixation in order to improve alignment and the long-term functional outcome.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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