Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October,...

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

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Page 1: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Fractures of the Pelvis and Acetabulum in Pediatric Patients

Joshua Klatt, MD

Revised - October, 2011

Created March 2004 by Steven Frick, MD

Page 2: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

The Child’s 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.

Page 3: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 4: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 5: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 6: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Triradiate Cartilage Complex

• Separates the ilium, the pubis and the ischium

Ponseti, I. J Bone Joint Surg Am. 1978.

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Infant Acetabulum

Histologic section of infant acetabulum

• Acetabular cartilage

• Triradiate cartilage

• Labrum

• Pulvinar

• Capsule

• Ilium

Ponseti, I. J Bone Joint Surg Am. 1978.

Page 8: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 9: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 10: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

Page 11: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

Page 12: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

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

Page 14: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

Page 15: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

Page 16: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Physical Examination

• A, B, C’s

• Trauma evaluation

• Orthopaedic exam of extremities and spine

• Systematic approach to the pelvis

Page 17: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

Page 18: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

Page 19: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

Page 20: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

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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.

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ASIS Avulsion Fracture

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Ischial Avulsion Fracture11 yr male sprinting

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CT of ischial avulsion fracture

Page 25: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

AIIS Avulsion Fracture13 yr female kicking a soccer ball

Page 26: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 27: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 28: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 29: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Treatment Options

• Bedrest

• Spica cast

• Restricted weight bearing

• Skeletal traction

• External fixation

• ORIF

Page 30: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 31: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Pelvic Ring Injuries

*Often crush mechanism and can have severe soft tissue injuries as well.

Page 32: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 33: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 34: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Plate Symphysis for Diastasis

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13 year old, bilateral pubic rami fractures with left SI disruptionsubtrochanteric femur fracture

Page 36: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

Page 37: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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;376:80–6.

Page 38: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Pediatric Acetabular FracturesClassification

• 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.

Page 39: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Pediatric Acetabular FracturesClassification

• 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.

Page 40: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Pediatric Acetabular FracturesClassification

• 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.

Page 41: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

• 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 FracturesClassification

Page 42: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9.

Page 43: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

•Pubic ramus fractures and triradiate cartilage injury

•OFTEN associated ring injury

•Watts Type B injury•Bucholz Shearing Type•Salter-Harris II

Page 44: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 45: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 46: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Shearing Pattern with Central Protrusio of Femoral Head

•Watts Type D injury•Bucholz Shearing Type

Page 47: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

CT ScanShearing Type

Page 48: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 49: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 50: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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.

Page 51: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Incidence of TriradiateCartilage 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, 0–11%)

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.

Page 52: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Triradiate Physeal Closure

• Can occur following nondisplaced or minimally displaced fractures

• Possible consequences are – Progressive acetabular dysplasia– Thickening of medial acetabular wall– Shallow acetabulum and subluxation– Hypoplastic hemipelvis

Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9.

Page 53: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

• Bucholz reported 56% (5/9) rate of growth disturbance (in injuries to triradiate)– All four of those with Salter-Harris type V – Only one with acetabular dysplasia

• Patient injured at a young age (2 yrs)

Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9.

Triradiate Physeal Closure

Page 54: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Treatment Options

• Unique nature of the developing hip joint necessitates an individualization of treatment for each pediatric acetabular fracture

• Agreed that functional outcome determined by– Age at the time of injury

– Articular displacement

– Congruency of the hip joint

Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9.

Page 55: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Treatment Options

• Non-operative treatment– Traction

– Spica Cast

– Bedrest

– Protected mobilization

• Operative treatment– ORIF

– Early reconstruction– Late reconstruction

Page 56: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Non-operative Treatment

• Mixed Results– Few articles give specific guidelines for

nonoperative versus operative treatment.

• Results often poor, especially in cases with – Comminution – Incongruity– When traction does not improve position of

fracture fragmentsLiporace, 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.

Page 57: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Operative Treatment

• ORIF– If hardware must cross triradiate cartilage,

consider smooth K-wires

• Early reconstruction (physeal bar excision)

• Late reconstruction (pelvic osteotomy)

Page 58: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Acetabular Fractures in Children Indications for ORIF

• Joint displacement > 2 mm• Joint incongruity• Joint instability (fracture dislocations)

• Fractures with posterior instability

• Persisting medial subluxation

• Central fracture-dislocations• Intra-articular fragments• Open fractures

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.

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Displaced Acetabular Fracture3D CT – Shows “Free Fragment”

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Post-op - smooth K-wire across triradiate cartilage

6 weeks post-op

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3 month follow-up

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Operative Treatment

• Three Case Examples– Bucholz. JBJS-Am, 1982– Brooks and Rosman, J Trauma, 1988– Heeg, JBJS-Br, 1988

Page 63: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Pre-op Post-op

Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9.

Page 64: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

18 months post-op

Osseous acetabular overgrowth

Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9.

Page 65: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Pre-op Post-op

Brooks E, Rosman M: Central fracture-dislocation of the hip in a child. J Trauma 28:1590-1592, 1988.

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48 months Post-Op

Osseous bridge?

Brooks E, Rosman M: Central fracture-dislocation of the hip in a child. J Trauma 28:1590-1592, 1988.

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Heeg M, de Ridder VA. Acetabular fractures in children and adolescents. Clin Orthop Relat Res 376:80–6, 2000.

Page 68: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Largest series of pediatric acetabular fractures

• Heeg & Ridder, Netherlands, 2000• Retrospective, 29 patients, age 2-16 years• 14 year avg follow-up• 14 ORIF, 2 arthrotomy, 13 nonoperative• 6 (21%) fair or poor results• Central fracture dislocation relatively poor

because of failure to achieve radiographic congruence, even with surgery

• Need longer follow-up

Heeg M, de Ridder VA. Acetabular fractures in children and adolescents. Clin Orthop Relat Res 376:80–6, 2000.

Page 69: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Operative Treatment

Conclusion:– Early results appear – Good/excellent– Intermediate results questionable– One case with long-term follow-up shows poor

results – Current evidence is poor quality

• Need longer follow-up

• Increased number of reports

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Older child – displaced posterior column through triradiate “scar”

ORIF with plate / lag screw on posterior column

Page 71: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Operative TreatmentEarly Reconstruction

• Peterson and Robertson, Mayo Clinic, 1997

• Single case report

• 14 year follow-up

• Initial treatment was non-operative

• Physeal bar excision/bone wax interposition

Peterson, et al. Premature partial closure of the triradiate cartilage treated with excision of a physical osseous bar. J Bone Joint Surg Am. 1997;79(5):767-70.

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Operative TreatmentEarly Reconstruction

• 5 yr s/p MVA sustains a minimally displaced R acetabular fracture

Peterson. J Bone Joint Surg Am. 1997.

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Operative TreatmentEarly Reconstruction

• At age 7, tomograms shows evidence of physeal bar formation

Peterson. J Bone Joint Surg Am. 1997.

Page 74: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Operative TreatmentEarly Reconstruction

• Age 7• Excision of physeal

bar (1982)• Bone wax

interposition• WBAT post-op day 5

Peterson. J Bone Joint Surg Am. 1997.

Page 75: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

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

Peterson. J Bone Joint Surg Am. 1997.

Page 76: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Operative TreatmentEarly Reconstruction

• Conclusion:– Small physeal bars are amenable to excision– Premature closure of triradiate can still occur

despite bar excision– Recommendation: Early recognition and

treatment prior to premature closure of entire physis and permanent osseous deformity

– Based on extremely limited data/experience

Peterson. J Bone Joint Surg Am. 1997.

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

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 2 to 3 years prior to

maturity

Page 79: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Operative TreatmentLate Reconstruction (Salvage)

Conclusion:– Long-term results unknown– Salvage procedure

Chiari Osteotomy

Page 80: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Conclusion• Pediatric acetabular fractures are rare

• Potential complication of triradiate cartilage injury

• Traumatic acetabular dysplasia– Growth arrest– Faulty development of the acetabulum

• Shallow acetabulum• Femoral head subluxation/dislocation

– Leg-length discrepancy

Page 81: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Conclusion

• Risk factors for bar/growth disturbance include:– Age (<10 years)– Salter-Harris type 5 injury pattern

• Diagnosis:– High level of suspicion– CT scan helpful

Page 82: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Conclusion

• Treatment– Non-operative (Majority)– Operative

• Acute ORIF – Gaining favor– Similar treatment principles as adults (>2 mm displacement)

• Reconstruction– Early – Late

• Results– No long-term follow-up in literature

Page 83: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Conclusion• Non/min displaced fractures = Non-operative

– Patient treated non-operatively should be followed for at least one to two years

– Those that progress to premature triradiate cartilage fusion = consider early reconstruction

– Those presenting late with subluxation = salvage procedure

• Displaced fractures– ORIF using adult principles– If hardware across triradiate required, use smooth wires

Page 84: Fractures of the Pelvis and Acetabulum in Pediatric Patients Joshua Klatt, MD Revised - October, 2011 Created March 2004 by Steven Frick, MD.

Bibliography• Blair W, Hanson C. Traumatic closure of the triradiate cartilage: report of a case. J Bone

Joint Surg Am 1979;61(1):144-5.• Brooks E, Rosman M. Central fracture-dislocation of the hip in a child. J Trauma

28:1590-1592, 1988.• Bucholz R, Ezaki M, Ogden J. Injury to the acetabular triradiate physeal cartilage. J

Bone Joint Surg Am 64(4):600-9, 1982.

• Delaere O, Dhem A. Prenatal development of the human pelvis and acetabulum. Acta Orthop Belg. 1999;65(3):255-60.

• Habacker TA, Heinrich SD, Dehne R. Fracture of the superior pelvic quadrant in a child. J Pediatr Orthop 15:69-72, 1995.

• Hall BB, Klassen RA. Acetabular fractures in children: A long-term follow-up study. Orthop Trans 6:353. 1982.

• Heeg M, Visser JD, Oostvogel HJM. Injuries of the acetabular triradiate cartilage and sacroiliac joint. J Bone Joint Surg Br 70:34-37,1988.

• Heeg M, Klasen HJ, Visser JD. Acetabular fractures in children and adolescents. J Bone Joint Surg-Br 71:418-421, 1989.

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Bibliography• Heeg M, de Ridder VA. Acetabular fractures in children and adolescents. Clin Orthop

Relat Res 376:80–6, 2000.• Holden CP, Holman J, Herman MJ. Pediatric pelvic fractures. J Am Acad Orthop Surg.

2007;15:172-7.• Judet, R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical

approaches for open reduction. J Bone Joint Surg Am 1964;46:1615-46.• Liporace F, Ong B, Mohaideen A, Ong A, Koval K. Development and injury of the

triradiate cartilage with its effects on acetabular development: review of the literature. J Trauma 2003;54(6):1245-9.

• Peterson HA, Robertson RC. Premature partial closure of the triradiate cartilage treated with excision of a physical osseous bar. Case report with a fourteen-year follow-up. J Bone Joint Surg Am. 1997;79(5):767-70.

• 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.

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Bibliography• Rossi F, Dragoni S. Acute Avulsion Fractures of the Pelvis in Adolescent

Competitive Athletes. Skeletal Radiol. 2001;30(3):127-31.• Schlickwei W, Keck T. Pelvic and acetabular fractures in childhood. Injury.

2005; 36(suppl 1):A57-A63.• Scuderi G, Bronson MJ. Triradiate cartilage injury. Report of two cases and

review of the literature. Clin Orthop Relat Res 1987;217:179-89.• Tile M. Acute Pelvic Fractures: I. Causation and Classification? J Am Acad

Orthop Surg. 1996;4(3):143-151.• Torode I, Zieg D. Pelvic fractures in children. J Pediatr Orthop 1985;5:76-84.• Watts HG. Fractures of the pelvis in children. Orthop Clin North Am

1976;7:615-624.

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