p07 pediatric pelvis, aceta
TRANSCRIPT
![Page 1: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/1.jpg)
Fractures of the Pelvis and Acetabulum in Pediatric Patients
Steven Frick, MD
![Page 2: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/2.jpg)
Anatomy - Pelvis
• Iliac bone with iliac apophysis• Ischium with apophysis• Pubic bones – physeal connection at
ischiopubic junction• Sacrum – SI joint 2/3 synchondrosis, 1/3
synovial joint• Pubic symphysis - synchondrosis
![Page 3: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/3.jpg)
The Child’s Pelvis
• Fundamental Differences:– Bones more malleable– Cartilage capable of absorbing more energy– Joints more elastic– Triradiate Cartilage
![Page 4: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/4.jpg)
Elasticity of Joints
• Sacroiliac Joint and Pubic Symphysis more elastic
• Allows significant displacement• Allows for single break in the ring• Thick periosteum – apparent dislocations
may have a periosteal tube that heals like a fracture
![Page 5: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/5.jpg)
AcetabularAnatomy
• 3 Primary Ossification Centers:– Pubis– Ischium– Ilium
![Page 6: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/6.jpg)
Acetabular Anatomy
• These 3 distinct physes along all cartilage borders 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
![Page 7: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/7.jpg)
Infant Acetabulum
Triradiate Cartilage Complex
• Separates the Iliac bone, the Pubic bone and the Ischial Bone
![Page 8: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/8.jpg)
Infant Acetabulum
Histologic Section of Infant Acetabulum
• Acetabular Cartilage• Triradiate Cartilage• Labrum• Pulvinar• Capsule• Ilium
From Ponseti et al, JBJS
![Page 9: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/9.jpg)
Development of the Acetabulum
• Interstitial growth within the Triradiate cartilage complex allows enlargement
• Concavity = response to the femoral head
![Page 10: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/10.jpg)
Development of the Acetabulum
• 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.
![Page 11: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/11.jpg)
Puberty
• 3 Secondary Ossification center appear in the Hyaline Cartilage:– os acetabuli (epiphysis of the pubis)– acetabular epiphysis (epiphysis of the ilium)– secondary ossification center of the ischium
![Page 12: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/12.jpg)
Adolescent AcetabulumAdolescent’s Innominate
BoneSecondary Ossification Centers
• OA - Os Acetabuli
• AE - Acetabular Epiphysis
• PB - Pubic Bone
• SCI - Secondary Ossification Center of the Ischium
SCI
![Page 13: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/13.jpg)
Adolescent Acetabulum
• The Os Acetabuli forms the anterior wall of the acetabulum
• The Acetabular Epiphysis forms a good part of the superior wall of the acetabulum
• The secondary ossification center of the ischium develops into the ischial acetabular cartilage
![Page 14: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/14.jpg)
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
![Page 15: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/15.jpg)
Secondary Ossification Center
• Iliac Crest : first seen at age 13 to 15 and fuses at age 15 to 17 years
• 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)
![Page 16: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/16.jpg)
Weakness of Cartilage
• Avulsion fractures occur more often in children and adolescents through apophysis
• Fractures of the acetabulum into the triradiate cartilage may occur with less energy than adult acetabular fractures
![Page 17: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/17.jpg)
History and Associated Injuries
• Usually high energy injuries for pelvic ring and acetabular fractures
• Other associated injuries– Orthopaedic – long bone or spine fractures– Urologic – bladder rupture– Vascular – less frequent than in adults
![Page 18: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/18.jpg)
Physical Examination
• A, B, C’s• Trauma evaluation• Orthopaedic exam all extremities and spine• Systematic approach to the Pelvis
![Page 19: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/19.jpg)
Examination of the Pelvis
• Areas of contusion, abrasion, laceration, ecchymosis, or hematoma, especially in the perineal and pelvic areas, should be recorded.
• Landmarks such as the anterior superior iliac spine, crest of the ilium, sacroiliac joints, and symphysis pubis should be palpated.
• Carefully evaluate perineum/genital/rectal areas in fractures with significant displacement to rule out open fractures
![Page 20: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/20.jpg)
Examination of the Pelvis
• Provocative Tests (ie. Compressing 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
• Neurologic and vascular exam of the lower extremities
![Page 21: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/21.jpg)
Radiographic Evaluation
• Standard AP Pelvis• Judet views for acetabular involvement• Inlet/Outlet views for pelvic ring injuries• Computed tomography
– 2-d and 3-d reconstruction• Cystography and/or urography if blood at meatus
or on bladder catheterization
![Page 22: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/22.jpg)
Pelvic Avulsion Fracture Injuries
• At sites of muscle attachments through apophyses, caused by forceful contraction
• Iliac wing – tensor fascia lata• Anterior superior iliac spine – sartorius• Anterior inferior iliac spine – rectus femoris• Ischium – hamstrings• Lesser trochanter - iliopsoas
![Page 23: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/23.jpg)
Relative Percentages of Pelvic Avulsion Fracture Locations
![Page 24: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/24.jpg)
ASIS Avulsion Fracture
![Page 25: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/25.jpg)
Pelvic Ring Injuries
• Often high energy mechanism• MVC, pedestrian vs. car, fall from height• Often other fractures present• TBI, intraabdominal and urologic injuries
often associated• Neurologic and vascular injuries may occur
with severe disruptions
![Page 26: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/26.jpg)
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)
![Page 27: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/27.jpg)
Tile Classification(applicable to adolescents /
patients near skeletal maturity)
• Type A – stable• Type B – rotationally unstable, vertically
stable• Type C – rotationally and vertically
unstable
![Page 28: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/28.jpg)
Treatment Options
• Bedrest• Spica cast• Mobilization with restricted weightbearing• Skeletal traction• External fixation• ORIF
![Page 29: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/29.jpg)
Treatment Differences
• Pubic symphyseal and SI disruptions may be able to be treated closed because of potential for periosteal healing
• Children tolerate bedrest/traction/immobilization better than adults
• Operative fixation should spare growth plates when possible
• When not possible consider temporary (4-6 weeks) fixation across physes with smooth pins
![Page 30: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/30.jpg)
Treatment
• Most avulsion injuries, Tile A fractures treated with restricted or no weightbearing
• Most Tile B fractures treated nonoperatively unless major deformity
• Tile C fractures may need stabilization
![Page 31: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/31.jpg)
Treatment Caveats
• Older children and adolescents with pelvic injuries treated like adults
• Operative treatment in general for pelvic injuries where posterior ring disruptions are displaced or unstable
• May be able to stabilize anterior ring only, and for shorter time period if using external fixation
![Page 32: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/32.jpg)
13 Year Old, Bilateral Pubic Rami Fractures with Left SI DisruptionSubtrochanteric Femur Fracture
![Page 33: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/33.jpg)
Pediatric Acetabular Fractures
• Not common • Historically treated nonoperatively• Classification by injury pattern (shear or
compression), growth plate injury, or as in adults with Letournel
![Page 34: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/34.jpg)
Incidence of Triradiate Cartilage Injury
Review of the Literature: (0.8% - 15%)• 2/237 (0.8%) Jurkovskj 1945• 3/52 (6%) Bryan and Tullos (1 significant) 1979• 4/84 (5%) Reed 1976• 13/221 (11.9%) Ljubosic 1967• ~12% Bucholz et al 1982• 4/27 (15%) Heeg et al 1988
![Page 35: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/35.jpg)
Pubic ramus fractures and triradiate cartilage injury
OFTEN associated ring injury
![Page 36: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/36.jpg)
Triradiate Cartilage
Fractures through this physeal cartilage in children can ultimately cause:– growth arrest– leg-length discrepancy– faulty development of the acetabulum
![Page 37: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/37.jpg)
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 1982
![Page 38: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/38.jpg)
Triradiate Physeal Closure
• Can occur following nondisplaced or minimally displaced fractures
• Possible consequences are progressive acetabular dysplasia with shallow acetabulum and subluxation, thickening of medial acetabular wall, hypoplastic hemipelvis
![Page 39: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/39.jpg)
Classification of Injury
• Injuries to the triradiate cartilage constitute physeal trauma
• Two basic patterns:– Shearing Type (Salter-Harris Type 1 or 2)– Crushing or Impaction Type (Type 5)
![Page 40: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/40.jpg)
Bucholz et al: JBJS(A) 1982
![Page 41: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/41.jpg)
Shearing Pattern with Central Protrusio of Femoral Head
![Page 42: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/42.jpg)
CT Scan Shearing Type
![Page 43: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/43.jpg)
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 the
S-H Type II injuries
• 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
![Page 44: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/44.jpg)
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 unaffected
• Favorable prognosis for continued relatively normal growth and development of the acetabulum
![Page 45: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/45.jpg)
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
![Page 46: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/46.jpg)
Treatment Options
• Non-operative Treatment• Operative Treatment
– ORIF– Early Reconstruction– Late Reconstruction
![Page 47: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/47.jpg)
Non-operative Treatment
Majority in the LiteratureTreatment:
– Traction– Spica Cast– Bedrest– Protected mobilization
![Page 48: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/48.jpg)
• Bucholz et al reported 50% (4/8) rate of growth disturbance
• Only one with acetabular dysplasia– this patient injured at a young age
Bucholz et al 1982
![Page 49: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/49.jpg)
Non-operative Treatment
Conclusion:• Mixed Results• Results often poor, especially in cases with
comminution, incongruity and when traction does not improve position of fracture fragments
![Page 50: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/50.jpg)
Operative Treatment
• ORIF• Early Reconstruction (Physeal Bar excision)• Late Reconstruction (Pelvic Osteotomy)
![Page 51: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/51.jpg)
Acetabular Fractures in Children- Indications for ORIF
• Joint displacement > 2mm• Joint incongruity• Joint instability (fracture dislocations)• Able to undergo anesthetic
![Page 52: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/52.jpg)
Displaced Acetabular Fracute3D CT – Shows “Free Fragment”
![Page 53: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/53.jpg)
Post-Op- smooth Kwire across Triradiate cartliage
6 Weeks Post-Op
![Page 54: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/54.jpg)
3 Month Follow-up
![Page 55: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/55.jpg)
Literature Review: ORIF Pediatric Acetabular FractureAuthor Age at Injury Time of F/U Comment_____________________
Bucholz et al 6 18mo Asymptomatic; lost 15 degrees of IR1982 X-ray: Osseous Acetabular overgrowth
Brooks and 10 48mo Asymptomatic; full range of motionRosman X-ray: Normal1988
Heeg et al 9 72mo Skeletally Mature; pain-free, but walks1988 w/ severe limp; 25 degree fixed flx, 25 degrees fixed IR, 20 degrees fixed
adduct, 3 cm short X-ray: subluxation of femoral head
Operative Treatment-ORIF• Three Case Reports
– Bucholz et al: JBJS (A), 1982– Brooks and Rosman: J of T, 1988– Heeg et al: JBJS (B), 1988
![Page 56: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/56.jpg)
Pre-Op Post-Op
Bucholz et al 1982
![Page 57: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/57.jpg)
Bucholz et al 1982
At 18 months Post-Op
Osseous Acetabular Overgrowth
![Page 58: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/58.jpg)
Pre-Op Post-Op
Brooks and Rosman 1988
![Page 59: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/59.jpg)
Brooks and Rosman 1988
At 48 months Post-Op
?Osseous Bridge?
![Page 60: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/60.jpg)
Operative Treatment ORIF
Conclusion:– Early Results appear Good/Excellent– Intermediate results questionable– One case with Long-term follow-up shows
Poor results – Need longer followup
![Page 61: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/61.jpg)
Older child – displace posterior column through triradiate “scar” – ORIF with plate / lag screw on posterior column
![Page 62: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/62.jpg)
Heeg et al. CORR July 2000
• Retrospective, 29 patients, age 2-16 years• 14 year avg followup• ORIF 14, arthrotomy 2 , 13 nonoperative• All but one satisfactory function• Central fracture dislocation relatively poor
because of failure to achieve radiographic congruence, even with surgery
• Need longer followup
![Page 63: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/63.jpg)
Operative TreatmentEarly Reconstruction
• Hamlet and Robertson: JBJS(A)1997• Single Case Report• 14 year follow-up• Initial treatment = Non-operative• Physeal Bar Excision/Bone Wax
Interposition
![Page 64: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/64.jpg)
Operative TreatmentEarly Reconstruction
• 5 YO s/p MVA sustains a minimally displaced R acetabular fracture
![Page 65: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/65.jpg)
Operative TreatmentEarly Reconstruction
• At age 7, tomograms shows evidence of physeal bar formation
![Page 66: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/66.jpg)
Operative TreatmentEarly Reconstruction
• Age 7• S/p excision of
physeal bar (1982)• Bone wax
interposition• WBAT post-op day 5
![Page 67: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/67.jpg)
Operative TreatmentEarly Reconstruction
• At age 19, there is slight increase in width of acetabular wall and lateral displacement of femoral head.
• Suggests premature closure of triradiate cartilage
![Page 68: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/68.jpg)
Operative TreatmentEarly Reconstruction
• Conclusion:– Small physeal bars are amenable to excision– Premature closure of Triradiate still occurs
despite bar excision– Recommend: Early recognition and treatment
prior to premature closure of entire physis and permanent osseous deformity
![Page 69: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/69.jpg)
• “Theoretically, if the osseous bridge were removed surgically, growth would resume and the normal shape of the acetabulum might be preserved. However, the rapid development of the osseous bridge and progression to closure of the triradiate cartilage certainly suggest that resection of the bridge and implantation of fat… may not have much success.”
Bucholz et al, 1982
![Page 70: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/70.jpg)
Operative TreatmentLate Reconstruction (SALVAGE)
• Two Case Reports– Blair and Hanson: JBJS(A) 1979– Scuderi and Bronson: CORR 1987
• Conservative Management Initially• Premature closure of Triradiate Cartilage• Symptomatic treatment • Chiari Osteotomy at maturity
![Page 71: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/71.jpg)
Operative TreatmentLate Reconstruction (SALVAGE)
Conclusion:– Results Not KNOWN– Salvage procedure
Chiari Osteotomy
![Page 72: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/72.jpg)
Conclusion• Pediatric Acetabular fractures are rare• Potential complication = Triradiate Cartilage injury• Traumatic acetabular dysplasia
– growth arrest– faulty development of the acetabulum
• shallow acetabulum• femoral head subluxation/dislocation
– leg-length discrepancy
![Page 73: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/73.jpg)
Conclusion
• Risk factors include:– Age (<10 years)– S-H Type 5 injury pattern
• Diagnosis:– High level of suspicion– CT scan helpful
![Page 74: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/74.jpg)
Conclusion• Treatment:
– Non-operative (Majority)– Operative
• Acute ORIF – gaining favor, similar treatment principles as adults
• Reconstruction– Early – Late
• Results:– No Long-term follow-up
![Page 75: P07 pediatric pelvis, aceta](https://reader036.vdocuments.net/reader036/viewer/2022062412/587550aa1a28ab00528b4597/html5/thumbnails/75.jpg)
Conclusion
Recommendation:• Non/Min displaced fractures = Non-operative
– Patient treated non-operatively should be followed for at least one – two years
– Those that progress to premature triradiate cartilage fusion = consider Early Reconstruction
– Those presenting late with subluxation= Salvage Procedure
• Displaced fractures = ORIF
Return to Pediatrics Index