Treatment of children with pelvic polytrauma with minimally invasive and combined osteosynthesis techniques

Introduction Pelvic fractures in children are rare but extremely severe injuries associated with a significant threat to life. The search for new rational tactics of their surgical treatment based on a combination of various minimally invasive osteosynthesis techniques and instruments for its implementation remains relevant.

The aim of the work was to evaluate the results of staged treatment and a combination of minimally invasive osteosynthesis techniques at different periods of traumatic disease in children with combined and multiple pelvic injuries.

Materials and methods An analysis of 48 cases of treating pelvic ring fractures in children who sustained combined and multiple injuries within the period of 2000 to 2023 was carried out. The study group included 23  children treated at the pediatric polytrauma center of the Amur Regional Children's Clinical Hospital, in whom the author's methods and instruments were used for anti-shock and final osteosynthesis of the pelvic ring. The comparison group included 25 patients treated at the Republican Scientific Center for Emergency Medical Care (Tashkent). The comparison group was divided into three subgroups based on the treatment method: conservative treatment, osteosynthesis with pins, osteosynthesis with an external fixation device (EFD). Pelvic fractures were classified according to AO/ASIF; the severity of polytrauma was assessed according to the ISS scale. Anatomical and functional treatment results were evaluated using the methods of I.L. Shlykov and S.A. Majeed.

Results In patients of the main study group, residual displacement was observed by 57.6 % less frequently than  in  the  subgroup with conservative treatment, by 32.6 % than in the subgroup with wire osteosynthesis and  by  15.9 % than in the subgroup with osteosynthesis with an external fixation device (EFD). The  functional  treatment result of patients in the main study group was significantly better than in the subgroups of conservative treatment and wire osteosynthesis of the comparison group, with no significant difference when compared with the subgroup of EFD osteosynthesis.

Discussion Staged combined treatment using developed techniques and metal structures for osteosynthesis allows better reduction and stabilization of pelvic ring fractures and achieves good functional results. Not all problems of pelvic surgery can be solved with EFD; a number of injuries require the use of internal osteosynthesis for more accurate reduction. Disintegrating pelvic injuries accompanied by complete bilateral instability should be operated using temporary transpedicular fixation, since there is no alternative to this method.

Conclusion The combination of external fixation with internal osteosynthesis provides accurate reduction and reliable stabilization of pelvic ring fragments. Staged specialized care including internal bleeding arrest and  fixation with an anti-shock device at the first stage and final stabilization of pelvic ring fragments at the second stage is the most rational tactical approach to polytrauma in children. External fixation can be used not only as a reliable and simple anti-shock fixation, but also as a method of final osteosynthesis.

1. Hermans E, Cornelisse ST, Biert J, et al. Paediatric pelvic fractures: how do they differ from adults? J Child Orthop. 2017;11(1):49-56. doi: 10.1302/1863-2548-11-160138.

2. Shaath MK, Koury KL, Gibson PD, et al. Analysis of pelvic fracture pattern and overall orthopaedic injury burden in children sustaining pelvic fractures based on skeletal maturity. J Child Orthop. 2017;11(3):195-200. doi: 10.1302/1863-2548.11.160266.

3. Kruppa CG, Khoriaty JD, Sietsema DL, et al. Pediatric pelvic ring injuries: How benign are they? Injury. 2016;47(10):2228-2234. doi: 10.1016/j.injury.2016.07.002.

4. Schlickewei W, Keck T. Pelvic and acetabular fractures in childhood. Injury. 2005;36 Suppl 1:A57-63. doi: 10.1016/j.injury.2004.12.014.

5. Sridharan SS, You D, Ponich B, et al. Outcomes following pelvic ring fractures in the paediatric population: A systematic review. J Clin Orthop Trauma. 2020;11(6):963-969. doi: 10.1016/j.jcot.2020.10.005.

6. Mulder MB, Maggart MJ, Yang WJ, et al. Outcomes of Pediatric Pelvic Fractures: A Level I Trauma Center's 20-Year Experience. J Surg Res. 2019;243:515-523. doi: 10.1016/j.jss.2019.07.011.

7. Heeg M, de Ridder VA, Tornetta P 3rd, de Lange S, Klasen HJ. Acetabular fractures in children and adolescents. Clin Orthop Relat Res. 2000;(376):80-86. doi: 10.1097/00003086-200007000-00012.

8. Nguyen ATM, Drynan DP, Holland AJA. Paediatric pelvic fractures - an updated literature review. ANZ J Surg. 2022;92(12):3182-3194. doi: 10.1111/ans.17890.

9. Gänsslen A, Hildebrand F, Heidari N, Weinberg AM. Pelvic ring injuries in children. Part I: Epidemiology and primary evaluation. A review of the literature. Acta Chir Orthop Traumatol Cech. 2012;79(6):493-498. doi: 10.55095/achot2012/071.

10. Shaath MK, Koury KL, Gibson PD, Adams MR, Sirkin MS, Reilly MC. Associated Injuries in Skeletally Immature Children with Pelvic Fractures. J Emerg Med. 2016;51(3):246-251. doi: 10.1016/j.jemermed.2016.05.031.

11. Amorosa LF, Kloen P, Helfet DL. High-energy pediatric pelvic and acetabular fractures. Orthop Clin North Am. 2014;45(4):483-500. doi: 10.1016/j.ocl.2014.06.009.

12. Holden CP, Holman J, Herman MJ. Pediatric pelvic fractures. J Am Acad Orthop Surg. 2007;15(3):172-177. doi: 10.5435/00124635-200703000-00007.

13. McIntyre RC Jr, Bensard DD, Moore EE, et al. Pelvic fracture geometry predicts risk of life-threatening hemorrhage in children. J Trauma. 1993;35(3):423-429. doi: 10.1097/00005373-199309000-00015.

14. Quinby WC Jr. Fractures of the pelvis and associated injuries in children. J Pediatr Surg. 1966;1(4):353-364. doi: 10.1016/0022-3468(66)90338-1.

15. Demetriades D, Karaiskakis M, Velmahos GC, et al. Pelvic fractures in pediatric and adult trauma patients: are they different injuries? J Trauma. 2003;54(6):1146-1451; discussion 1151. doi: 10.1097/01.TA.0000044352.00377.8F.

16. de la Calva C, Jover N, Alonso J, Salom M. Pediatric Pelvic Fractures and Differences Compared With the Adult Population. Pediatr Emerg Care. 2020;36(11):519-522. doi: 10.1097/PEC.0000000000001411.

17. Silber JS, Flynn JM. Changing patterns of pediatric pelvic fractures with skeletal maturation: implications for classification and management. J Pediatr Orthop. 2002;22(1):22-26.

18. Spiguel L, Glynn L, Liu D, Statter M. Pediatric pelvic fractures: a marker for injury severity. Am Surg. 2006;72(6):481-484.

19. Banerjee S, Barry MJ, Paterson JM. Paediatric pelvic fractures: 10 years experience in a trauma centre. Injury. 2009;40(4):410-413. doi: 10.1016/j.injury.2008.10.019.

20. Grisoni N, Connor S, Marsh E, Thompson GH, Cooperman DR, Blakemore LC. Pelvic fractures in a pediatric level I trauma center. J Orthop Trauma. 2002;16(7):458-463. doi: 10.1097/00005131-200208000-00003.

21. Leonard M, Ibrahim M, Mckenna P, et al. Paediatric pelvic ring fractures and associated injuries. Injury. 2011;42(10):1027-1030. doi: 10.1016/j.injury.2010.08.005.

22. Tile M. Acute Pelvic Fractures: I. Causation and Classification. J Am Acad Orthop Surg. 1996;4(3):143-151. doi: 10.5435/00124635-199605000-00004.

23. Борозда И.В., Воронин Н.И., Волков С.П. Устройство для репозиции и фиксации переломов костей таза. Патент РФ на изобретение № 2159091. 20.11.2000. Бюл. № 32. Доступно по: https://www.fips.ru/registers-doc-view/fips_servlet?DB=RUPAT&rn=5898&DocNumber=2159091&TypeFile=html. Ссылка активна на 28.11.2024.

24. Епифанцев А.В., Борозда И.В., Воронин Н.И. Устройство для репозиции и фиксации переломов костей таза. Патент РФ на изобретение № 2234277. 20.08.2004. Бюл. № 23. Доступно по: https://www.fips.ru/registers-doc-view/fips_servlet?DB=RUPAT&rn=9688&DocNumber=2234277&TypeFile=html. Ссылка активна на 28.11.2024.

25. Борозда И.В., Воронин Н.И., Воронцов В.Н., Епифанцев А.В. Способ комбинированного остеосинтеза нестабильного повреждения таза с разрывом крестцово-подвздошного сочленения. Патент РФ на изобретение № 2306895. 27.09.2007. Бюл. № 23. Доступно по: https://www.fips.ru/registers-doc-view/fips_servlet?DB=RUPAT&rn=7422&DocNumber=2306895&TypeFile=html. Ссылка активна на 28.11.2024.

26. Борозда И.В., Воронин Н.И., Бушманов А.В. Способ чрескостного остеосинтеза нестабильного повреждения таза с вертикальным переломом крестца. Патент РФ на изобретение № 2306896. 27.09.2007. Бюл. № 27. Доступно по: https://www.fips.ru/registers-doc-view/fips_servlet?DB=RUPAT&rn=7422&DocNumber=2306896&TypeFile=html. Ссылка активна на 28.11.2024.

27. Борозда И.В., Канивец Д.В., Николаев Р.В. и др. Способ чрескостного остеосинтеза односторонних нестабильных повреждений таза. Патент РФ на изобретение № 2457805. 10.08.2012. Бюл. № 27. Доступно по: https://www.fips.ru/registers-doc-view/fips_servlet?DB=RUPAT&rn=7967&DocNumber=2457805&TypeFile=html. Ссылка активна на 28.11.2024.

28. Борозда И.В., Ганжуров Н.А., Капустянский А.А. Чрескостный модуль для репозиции и фиксации задних отделов таза. Патент РФ на изобретение № 2559739. 10.08.2015. Бюл. № 22. Доступно по: https://www.fips.ru/registers-doc-view/fips_servlet?DB=RUPAT&rn=5080&DocNumber=2559739&TypeFile=html. Ссылка активна на 28.11.2024.

29. Шлыков И.Л. Оперативное лечение больных с последствиями повреждений тазового кольца: автореф. дис. ... канд. мед. наук. Курган; 2004:28. Доступно по: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://new-disser.ru/_avtoreferats/01004067514.pdf. Ссылка активна на 28.11.2024.

30. Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg Br. 1989;71(2):304-306. doi: 10.1302/0301-620X.71B2.2925751.

31. Борозда И.В. Комплексная диагностика сочетанных повреждений таза, проектирование и управление аппаратами внешней фиксации: дис. ... д-ра мед. наук. Якутск, 2009:279. Доступно по: https://www.dissercat.com/content/kompleksnaya-diagnostikasochetannykh-povrezhdenii-taza-proektirovanie-i-upravlenie-apparata. Ссылка активна на 28.11.2024.