Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD

Download Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD

Post on 23-Dec-2015

214 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

<ul><li> Slide 1 </li> <li> Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD </li> <li> Slide 2 </li> <li> The Childs Pelvis Fundamental differences: Bones are more malleable Cartilage is capable of absorbing more energy SI joint and symphysis are more elastic Triradiate Cartilage Injury causing growth arrest may lead to significant deformity Schlickwei W, Keck T. Pelvic and acetabular fractures in childhood. Injury. 2005; 36(suppl 1):A57-A63. </li> <li> Slide 3 </li> <li> Elasticity of Joints Sacroiliac joint and pubic symphysis are more elastic Allows significant displacement before fx Allows for single break in the ring Thick periosteum Apparent dislocations may have a periosteal tube that heals like a fracture Schlickwei W, Keck T. Pelvic and acetabular fractures in childhood. Injury. 2005; 36(suppl 1):A57-A63. </li> <li> Slide 4 </li> <li> Pelvic Anatomy 3 primary ossification centers: Ilium appears at 9 wks Ischium appears at 16 wks Pubis appears at ~20 wks Endochonral ossification, just like long bones Delaere O, Dhem A. Prenatal development of the human pelvis and acetabulum. Acta Orthop Belg. 1999;65(3):255-60. </li> <li> Slide 5 </li> <li> Acetabular Anatomy The 3 distinct physes of each bone making up the triradiate cartilage allow hemispheric growth of both the acetabulum and pelvis. The 3 ossification centers meet and fuse at the triradiate cartilage at age 13-16 years Ponseti, I. Growth and development of the acetabulum in the normal child. Anatomical, histological, and roentgenographic studies. J Bone Joint Surg Am. 1978;60(5):575-85. </li> <li> Slide 6 </li> <li> Triradiate Cartilage Complex Separates the ilium, the pubis and the ischium Ponseti, I. J Bone Joint Surg Am. 1978. </li> <li> Slide 7 </li> <li> Infant Acetabulum Histologic section of infant acetabulum Acetabular cartilage Triradiate cartilage Labrum Pulvinar Capsule Ilium Ponseti, I. J Bone Joint Surg Am. 1978. </li> <li> Slide 8 </li> <li> Development of the Acetabulum Interstitial growth within the horizontal flange of the triradiate cartilage contributes to the normal growth of the distal third of the ilium. Enlargement of the acetabulum during growth is likely the result of interstitial growth within the triradiate cartilage. Ponseti, I. J Bone Joint Surg Am. 1978. </li> <li> Slide 9 </li> <li> Development of the Acetabulum Development of concavity is a response to pressure from the femoral head In DDH with a dislocation the acetabulum will not develop appropriately Depth of the acetabulum results from: Interstitial growth in the acetabular cartilage Appositional growth of the periphery of this cartilage Periosteal new bone formation at the acetabular margin. </li> <li> Slide 10 </li> <li> Puberty 3 secondary ossification centers appear in the hyaline cartilage of the acetabulum Os acetabuli Epiphysis of the pubis Forms most of anterior wall Acetabular epiphysis Epiphysis of the ilium Forms most of superior acetabulum Secondary ossification center of the ischium Forms much of posterior wall </li> <li> Slide 11 </li> <li> Secondary Ossification Centers OA - Os Acetabuli AE - Acetabular Epiphysis PB - Pubic Bone SCI Secondary ossification center of ischium Ossification centers appear at age 8 to 9 yrs and fuse around 17 18 yrs Ponseti, I. J Bone Joint Surg Am. 1978. SCI </li> <li> Slide 12 </li> <li> Anatomy Other secondary ossification centers of the pelvis Iliac crest Ischial apophysis Anterior inferior iliac spine Pubic tubercle Angle of the pubis Ischial spine Lateral wing of the sacrum </li> <li> Slide 13 </li> <li> Secondary Ossification Center Iliac Crest : first seen at age 13 to 15 and fuses at age 15 to 17 years Used in Risser staging Ischium : first seen at age 15 to 17 and fuses at age 19 to 25 years ASIS : first seen about age 14 and fusing at age 16 *Important to know these secondary ossification centers so they will not be confused with avulsion fractures </li> <li> Slide 14 </li> <li> Weakness of Cartilage Avulsion fractures occur more often in children and adolescents through an apophysis Fractures of the acetabulum into the triradiate cartilage may occur with less energy than adult acetabular fractures </li> <li> Slide 15 </li> <li> History and Associated Injuries Pelvic ring and acetabular fractures usually involve high energy injuries Associated injuries Orthopaedic long bone or spine fractures Urologic bladder rupture Vascular less frequent than in adults, rarely life threatening </li> <li> Slide 16 </li> <li> Physical Examination A, B, Cs Trauma evaluation Orthopaedic exam of extremities and spine Systematic approach to the pelvis </li> <li> Slide 17 </li> <li> Examination of the Pelvis Areas of contusion, abrasion, laceration, ecchymosis, or hematoma, especially in the perineal and pelvic areas, should be noted Rule out open fractures in perineum/genital/rectal areas Palpate landmarks Anterior superior iliac spine Crest of the ilium Sacroiliac joints Symphysis pubis </li> <li> Slide 18 </li> <li> Examination of the Pelvis Neurologic and vascular exam of the lower extremities Provocative Tests Compress the pelvic ring with anterior-posterior and lateral compression stress The range of motion of the extremities, especially of the hip joint, should be determined </li> <li> Slide 19 </li> <li> Radiographic Evaluation There is no standard algorithm for which films to obtain in children AP pelvis Judet views for acetabular involvement Inlet/Outlet views for pelvic ring injuries Computed tomography 2D and possibly 3D reconstruction Cystography/urography if blood at meatus or on bladder catheterization </li> <li> Slide 20 </li> <li> Pelvic Avulsion Fractures Caused by forceful contraction at sites of muscle attachments through apophyses Iliac wing tensor fascia lata Anterior superior iliac spine sartorius Anterior inferior iliac spine rectus femoris Ischium hamstrings Lesser trochanter - iliopsoas </li> <li> Slide 21 </li> <li> Relative Percentages of Pelvic Avulsion Fracture Locations Ischial tuberosity 54% AIIS 22% ASIS 19% Pubic Symphysis 3% Iliac Crest 1% http://crashingpatient.com Rossi F, Dragoni S. Acute Avulsion Fractures of the Pelvis in Adolescent Competitive Athletes. Skeletal Radiol. 2001;30(3):127-31. </li> <li> Slide 22 </li> <li> ASIS Avulsion Fracture </li> <li> Slide 23 </li> <li> Ischial Avulsion Fracture 11 yr male sprinting </li> <li> Slide 24 </li> <li> CT of ischial avulsion fracture </li> <li> Slide 25 </li> <li> AIIS Avulsion Fracture 13 yr female kicking a soccer ball </li> <li> Slide 26 </li> <li> Pelvic Ring Injuries Often high energy mechanism MVA Auto-pedestrian Fall from height Often other fractures present Traumatic brain injury (TBI) Intra-abdominal injuries Urologic injuries Neurologic and vascular injuries may occur with severe disruptions Torode I, Zieg D. Pelvic fractures in children. J Pediatr Orthop 1985;5:76-84. </li> <li> Slide 27 </li> <li> Classification of Pelvic Injuries in Children Torode and Zieg modification of Watts classification Type I avulsion fractures Type II - Iliac wing fractures Type III stable pelvic ring injuries Type IV any fracture pattern creating a free bony fragment (unstable pelvic ring injuries) Torode I, Zieg D. Pelvic fractures in children. J Pediatr Orthop 1985;5:76-84. </li> <li> Slide 28 </li> <li> Tile Classification Applicable in patients near skeletal maturity More often adult type patterns Type A Stable Type B Rotationally unstable, vertically stable Type C Rotationally and vertically unstable Tile M. Acute Pelvic Fractures: I. Causation and Classification? J Am Acad Orthop Surg. 1996;4(3):143-151. </li> <li> Slide 29 </li> <li> Treatment Options Bedrest Spica cast Restricted weight bearing Skeletal traction External fixation ORIF </li> <li> Slide 30 </li> <li> Treatment Differences Children tolerate bedrest/traction/immobilization better than adults Pubic symphyseal and SI disruptions may be able to be treated closed because of potential for periosteal healing Operative fixation should spare growth plates when possible When not possible consider temporary (4-6 weeks) fixation across physes with smooth pins or early hardware removal Holden C, et al. Pediatric pelvic fractures. J Am Acad Orthop Surg. 2007;15:172-7. </li> <li> Slide 31 </li> <li> Pelvic Ring Injuries *Often crush mechanism and can have severe soft tissue injuries as well. </li> <li> Slide 32 </li> <li> Treatment Most avulsion injuries and Tile A fractures treated with restricted or no weight bearing Most Tile B fractures treated nonoperatively unless major deformity Tile C fractures may need stabilization Holden C, et al. Pediatric pelvic fractures. J Am Acad Orthop Surg. 2007;15:172-7. </li> <li> Slide 33 </li> <li> Treatment Caveats Treat older children and adolescents with pelvic injuries like adults In general, pelvic injuries where posterior ring disruptions are displaced or unstable need operative treatment Only anterior ring may need stabilization And for shorter time period, if using external fixation Holden C, et al. Pediatric pelvic fractures. J Am Acad Orthop Surg. 2007;15:172-7. </li> <li> Slide 34 </li> <li> Plate Symphysis for Diastasis </li> <li> Slide 35 </li> <li> 13 year old, bilateral pubic rami fractures with left SI disruption subtrochanteric femur fracture </li> <li> Slide 36 </li> <li> Pediatric Acetabular Fractures Constitute only 1% to 15% of pelvic fractures in children Much more common after the triradiate cartilage closes (12 yrs in girls, 14 yrs in boys) Mechanism of injury similar to that in adults Force transmitted through femoral head Position of leg relative to pelvis and location of impact determine fracture pattern </li> <li> Slide 37 </li> <li> Pediatric Acetabular Fractures Often associated with hip dislocation The distribution of types is different than adults More often transverse than both column Historically treated nonoperatively Achieving congruent reduction with closed, conservative treatment is difficult and often impossible Many think that the role of surgical treatment in children is expanding Heeg M, de Ridder VA. Acetabular fractures in children and adolescents. Clin Orthop Relat Res 2000;376:806. </li> <li> Slide 38 </li> <li> Pediatric Acetabular Fractures Classification Growth plate injury Use Salter-Harris classification Bucholz suggested that there are common injury patterns Letournel system most frequently used Same as used for adults Watts classification also sometimes used Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9. </li> <li> Slide 39 </li> <li> Pediatric Acetabular Fractures Classification Letournel system Type A Single wall or column Type B Fractures involving 2 columns Type C Fractures involve both columns and separate dome fragment from axial skeleton Judet, et al. Fractures of the acetabulum: classification and surgical approaches for open reduction. J Bone Joint Surg Am 1964;46:1615-46. </li> <li> Slide 40 </li> <li> Pediatric Acetabular Fractures Classification Watts classification Type A Small fragments that most often occur with hip dislocation Type B Stable linear fractures without displacement in association with pelvic fractures Type C Linear fractures with hip joint instability Type D Fractures secondary to central fracture- dislocation of the hip Watts HG. Fractures of the pelvis in children. Orthop Clin North Am 1976;7:615-624. </li> <li> Slide 41 </li> <li> Injuries to the triradiate cartilage constitute physeal trauma Bucholz Classification Two basic patterns Shearing Type (Salter-Harris Type I or II) Crushing or Impaction Type (Type IV) Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9. Pediatric Acetabular Fractures Classification </li> <li> Slide 42 </li> <li> Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9. </li> <li> Slide 43 </li> <li> Pubic ramus fractures and triradiate cartilage injury OFTEN associated ring injury Watts Type B injury Bucholz Shearing Type Salter-Harris II </li> <li> Slide 44 </li> <li> Shearing Type Blow to the pubic or ischial ramus or the proximal end of the femur Injury at the interface of the 2 superior arms of the triradiate cartilage and the metaphysis of the ilium A triangular medial metaphyseal fragment (Thurston-Holland sign) may be seen in Salter- Harris Type II injuries Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9. </li> <li> Slide 45 </li> <li> Shearing Type Effectively splits the acetabulum into superior (main weight-bearing) one-third and inferior (non- weight-bearing) two-thirds Germinal zones contained within the physes often unaffected Favorable prognosis for continued relatively normal growth and development of the acetabulum Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9. </li> <li> Slide 46 </li> <li> Shearing Pattern with Central Protrusio of Femoral Head Watts Type D injury Bucholz Shearing Type </li> <li> Slide 47 </li> <li> CT Scan Shearing Type </li> <li> Slide 48 </li> <li> Crushing or Impaction Type Difficult to detect on initial radiographs Narrowing of the triradiate space suggests this injury pattern (rarely seen) Premature closure of the triradiate cartilage appears to be the usual outcome The earlier in life the premature closure occurs, the greater the eventual acetabular deformity Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9. </li> <li> Slide 49 </li> <li> Triradiate Cartilage Fractures through this physeal cartilage in children can ultimately cause: Growth arrest Leg-length discrepancy Faulty development of the acetabulum Heeg, et al. Injuries of the acetabular triradiate cartilage and sacroiliac joint. J Bone Joint Surg Br 70:34-37,1988. </li> <li> Slide 50 </li> <li> Age is a significant risk factor in the development of post-traumatic acetabular dysplasia. Children younger than ten years of age at the time of injury are at greatest risk Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9. </li> <li> Slide 51 </li> <li> Incidence of Triradiate Cartilage Injury Of pediatric patients with pelvic trauma, between 1% and 15% of patients sustain an acetabular fracture In pediatric patients with acetabular fractures, resulting premature closure of the triradiate cartilage has an overall incidence of less than 5% (range, 011%) Liporace, et al. Development and injury of the triradiate cartilage with its effects on acetabular development: review of the literature. J Trauma 2003;54(6):1245-9. </li> <li> Slide 52 </li> <li> Triradiate Physeal Closure Can occur following nondisplaced or minimally displaced fractures Possible consequences are Progressive acetabular...</li></ul>