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Predicting Internal Bleeding with Pelvic Fractures in Children

Posted on: 11/30/1999
Orthopedic Surgeons from Children's Hospital in Boston (associated with Harvard Medical School) offer some important modifications to a classification system used to rate the seriousness of pelvic fractures in children. They say their proposed changes can potentially save children's lives, reduce blood loss, and reduce the number of days children with these types of injuries are in the hospital.

Pelvic fractures are serious business because they often come with major trauma from either a car or pedestrian accident. In many cases, there are other injuries as well affecting the head, face, arms, legs, and/or spine. And when the bones of the pelvis are broken, the soft tissues and organs in the belly and pelvis are left unprotected. In up to five per cent of these injuries, the child dies.

So you can see there is a need to quickly identify anyone at risk for blood loss or mortality (death). These surgeons took the traditionally used Torode classification scheme and tweaked it just a bit. This classification method uses X-rays to identify the specific area(s) of the pelvic bones that are broken, the type of fracture, and the severity of the injury.

Torode fractures are placed in one of four groups labeled I, II, III, or IV. As you might guess, Type I are the least serious injuries and Type IV the most serious. Type IV fractures are considered unstable and include disruption of the pelvic anatomy, hip dislocations, and/or more than one fracture affecting the pelvis and hip.

The modified groups break down Type III into Type IIIA and Type IIIB. This separation helps to identify fractures that are more like Type II (labeled Type IIIA) or more like Type IV (labeled Type IIIB). This distinction is helpful because it tells the surgeon that children with Type IIIB are more serious, more likely to need a blood transfusion, and more likely to need a longer hospital stay.

The authors include a drawing to help us understand the classification categories. Torode I and II pelvic fractures are avulsion (piece of bone breaks off) somewhere along the pelvic crest. With a Type I fracture, a separation occurs in the growth plate, which is still cartilaginous. Type I is much smaller in size than Type II.

Type III fractures affect the lower portion of the pelvis that bear our weight when we sit down. The symphysis pubis (where the two pelvic bones meet in the front of the body) may be involved. This part of the pelvis helps form a bony ring and pelvic "bowl" that support the bladder. The new Type III A/B designation gives an A if just the front or anterior portion of the ring is broken. Type IIIB indicates both the front (anterior) and back (posterior) portions of the ring are fractured.

The drawing of a Type IV fracture shows multiple different locations for pelvic bone fractures. All involve complete disruption of the bone, nearby joints, and/or the hip (dislocation).

To elaborate just a bit more on the modifications made to the traditional Torode classifications, Type III pelvic fractures are stable but the B subgroup are more involved injuries. They require more attention early on after the accident.

For example, children with Type IIIB pelvic fractures are two and a half times more likely to hemorrhage internally and need a blood transfusion. They are also much more likely to have additional injuries. They are twice as likely to need hospitalization compared with the Type IIIA group.

The authors conclude by pointing out that high-energy traumatic injuries to the pelvis resulting in pelvic fractures are potentially very serious and require careful evaluation. The modified Torode classification system they developed and tested can help predict children who will need close management and early intervention. Often, the nature of the other injuries (e.g., head trauma) leaves the pelvis for later treatment but the risk of internal bleeding that can lead to death must be recognized and treated immediately.

References:
Benjamin J. Shore, MD, FRCSC, et al. Pediatric Pelvic Fracture: A Modification of a Preexisting Classification. In Journal of Pediatric Orthopaedics. March 2012. Vol. 32. No. 2. Pp. 162-168.

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