Open Pelvic Fracture with Vaginal Laceration and Arterial Injury in a Pediatric Patient Lisa K

(aspects of trauma)

Open Pelvic Fracture With Vaginal Laceration and Arterial Injury in a Pediatric Patient Lisa K. Cannada, MD, John F. Scovell, MD, Brent Bauer, MD, and David A. Podeszwa, MD

pen pelvic fractures occur Case Report was identified, and a palpable and in up to 3% to 5% of all An unrestrained backseat passenger, Doppler pulse was present proxi- adult pelvic fractures.1,2 a 3-year-old girl, was ejected during mally, but a significant change in the OThe incidence is even a collision of motor vehicles. She Doppler pulse was detected distally. lower in pediatric pelvic fractures. was transferred from the accident The middle portion of the vessel Open pelvic fractures in children are scene to our hospital. On arrival, appeared bruised. The iliac artery reported as small series or isolated she was awake and alert (Glasgow was opened distal to the middle por- case reports. Open pelvic fractures Coma Scale score, 15). An unstable tion, and a brisk back-flow from the are known to be associated with pelvis was noted. The patient had leg was noted. The injury to the ves- many other severe injuries.1-7 Pelvic a complicated wound involving the sel was 4 cm long. A No. 6 carotid fractures in pediatric patients differ right inguinal region extending to the shunt was used to bypass the injured significantly from those in adults.3,8 perineum. The wound was grossly zone of the vessel. Immediately, the The ability of the pediatric pelvis to contaminated with dirt and debris. right lower extremity became pink, deform plastically—a result of the The right lower extremity was cold and palpable pulses were present in elasticity of the pediatric bone and and pulseless. the right foot. Ischemic time was the presence of more cartilaginous During physical examination, approximately 1.5 hours from time structures—leads to its absorbing the patient could move the right of injury. significantly more energy before foot and had sensation in the right With blood flow restored to the breaking. Therefore, presence of a lower extremity. An anteroposterior right lower extremity, the orthopedic pelvic fracture in a pediatric trauma (AP) pelvic radiograph showed a team then addressed the pelvic dias- patient should heighten suspicion pubic diastasis of greater than 8 cm. tasis. We placed 4-mm stainless steel for other significant injuries. Fractures of the right pubic rami and half-pins into the superior crest of This is the first known English- ilium were also identified (Figure 1). the iliac wings bilaterally, and place- literature report of an open pelvic The bladder appeared normal, and ment was confirmed by fluoroscopy. fracture sustained with vaginal lacer- there was no extravasation when nor- An external fixation frame (Synthes, ation and internal iliac artery injury. mal saline was flushed through the Paoli, Pennsylvania) was construct- The patient’s guardians provided patient’s Foley catheter. ed, and the pelvis was reduced. written informed consent for print The patient was emergently taken With the external fixator in place, and electronic publication of this to the operating room. She received the pediatric surgeons proceeded case report. IV cefazolin 400 mg and IV gen- with the external iliac repair. A tamicin 40 mg. The femoral vessel 3.5 mm polytetrafluoroethylene graft Dr. Cannada is Associate Professor, on the right was identified and no was used to complete the repair. Department of Orthopaedic Surgery, pulse was present on direct examina- After vessel repair, the other inju- Saint Louis University, St. Louis, Missouri. Dr. Scovell is Orthopedic Surgeon, tion or Doppler signal. The proximal ries were addressed. A laparotomy Lubbock Sports Medicine, Lubbock, portion of the external iliac artery was performed, and a through-and- Texas. Dr. Bauer, at the time of this writing, was Orthopedic Resident, University of Texas Southwestern, Dallas, Texas. Dr. Podeszwa is Assistant Professor, University of Texas Southwestern.

Address correspondence to: Lisa K. Cannada, MD, Department of Orthopaedic Surgery, Saint Louis University, 3635 Vista Ave, 7th Floor, St. Louis, MO 63110 (tel, 314-577-8850; fax, 314-268-5121; e-mail, [email protected]).

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vehicle.3,4,7-9 It has been reported that symphysis widening is normally 10 mm to 12 mm within the first 3 years, compared with 2 mm to 4 mm in adults.4 Clearly, our patient had significantly more widening than what is considered a normal variant. In a 12-year review, Spiguel and colleagues5 found pelvic fractures Figure 2. Immediate postoperative radiograph shows pelvic reduction. in 13 of 2850 pediatric admissions. Eight of the 13 patients (62%) pre- through injury to the rectum and an sented with an associated injury, but injury to the rectal sphincter complex no patient had an open pelvic frac- Figure 3. Anteroposterior radiograph of were noted. These injuries required a pelvis at 29-month follow-up. ture. The pediatric pelvis is shal- diverting colostomy. Next, the exten- low compared with the adult pelvis sive wounds involving the perineum tive course. Clindamycin was used and offers less bony protection to were repaired. There was a lacera- to manage the drainage. When the the abdominal and pelvic system tion from the right crus of the clito- patient was discharged home with throughout. Thus, there may be an ral hood along the bulbocavernosus a peripherally inserted central cath- increased incidence of intra-abdom- muscle, in addition to a laceration eter on PTD 11, ESR was 49 mm/h, inal or intrapelvic injuries.5,10 along the edge of the introitus of CRP was 2.2 mg/dL, and there The largest series of pediatric the vagina, through the transverse were no clinical signs of infection. open pelvic fractures was reported perineal muscles and into the peri- For 8 weeks, the patient remained by Mosheiff and colleagues.2 In their neal body and along the right anal non–weight-bearing on the bilateral retrospective study, they identified sphincter. Digital examination dem- lower extremities. The pelvic external 15 patients treated over a 12-year onstrated a defect into the body of fixation was removed 8 weeks after period. Mortality of open pelvic the fourchette of the vagina, and this surgery. The colostomy was reversed fractures was 20%. Ten of the 15 was repaired. 4 months after injury. patients (67%) presented with unsta- The patient tolerated the proce- At the latest orthopedic follow-up, ble type III or type IV pelvic frac- dure well. After it was completed, she 29 months after injury (Figure 3), tures (Torode and Zieg classifica- was taken to the intensive care unit the patient’s mother reported that tion of pelvic fractures). Ten patients and remained intubated. She was in the girl had no complaints of pain, (67%) had severe superficial soft- stable condition. Postoperative radio- no activity limitation, and no geni- tissue injuries in the immediate area graphs showed the fracture reduc- tourinary complaints. The patient around the pelvis, and 12 patients tion (Figure 2). Heparin infusion for had normal gait and no leg-length (80%) had injuries in the anal-rectal- graft preservation was started, but discrepancy. She had symmetric hip genitourinary region. Concomitant the inpatient postoperative course range of motion with flexion of head, chest, and extremity injuries became complicated. Less than 24 more than 110°, internal rotation of are commonly associated with pelvic hours after surgery, hemoglobin level 45°, and external rotation of 65° and fractures; however, in this series of dropped to 4.9 g/dL. Heparin infu- abduction of 65°. open pelvic fractures, only 2 patients sion was discontinued, and the patient had additional injuries. was transfused. Reexploration of the Discussion Vaginal lacerations can occur in groin region revealed continued retro- Pelvic fractures in children are open or closed pelvic fractures. A peritoneal bleeding. The bleeding was not common. In a review of the 10-year retrospective review of 114 controlled. National Pediatric Trauma Registry, female patients with pelvic fractures The patient was extubated on the number of pediatric pelvic frac- found a 3.5% incidence of vaginal posttrauma day (PTD) 2. On PTD tures over a 5-year period was found lacerations.11 For most adult vaginal 6, there was copious serous drain- to represent 3% of pediatric trauma lacerations, management includes age from the right groin wound. patients, or half the frequency in debridement and primary surgi- The patient was afebrile but had adults.1 In many series of pediatric cal closure or vaginal packing with an elevated erythrocyte sedimenta- pelvic fractures, the open-book frac- antibiotic coverage. Complications tion rate (ESR) of 49 mm/h and ture is extremely rare, and often is of delayed management of unrecog- C-reactive protein (CRP) of 3.6 not even mentioned. The most com- nized vaginal lacerations in children mg/dL. White blood cell count mon mechanism of injury for pelvic have been reported to include vaginal remained stable, around 10,000/ fractures is blunt trauma; most fre- stricture, dyspareunia, osteomyelitis, mm3, throughout the postopera- quently, a child is struck by a motor and pelvic abscess.6

416 The American Journal of Orthopedics® www.amjorthopedics.com L. K. Cannada et al

There is a paucity of literature internal iliac artery injury in the frac- Authors’ Disclosure regarding long-term follow-up of tured pelvis of an 8-year-old patient. Statement pediatric pelvic fractures. In a pro- Hit by a motor vehicle, the child The authors report no actual or spective multicenter study of func- had sustained multiple fractures of potential conflict of interest in rela- tional outcomes, Signorino and col- the pelvis and femur along with a tion to this article. leagues12 found that, at 6 months, ruptured urethra. The fractures were the average functional outcomes closed and managed nonoperatively. References of pediatric pelvic fractures were One month after injury, the patient 1. Ismail N, Bellemare JF, Mollitt DL, DiScala C, nearing normal. In the past, many presented with a large pseudoaneu- Koeppel B, Tepas JJ III. Death from pelvic fracture: children are different. J Pediatr Surg. pediatric pelvic fractures, including rysm of the left internal iliac artery. 1996;31(1):82-85. unstable pelvic fractures, were man- Ligation of the internal iliac artery 2. Mosheiff R, Suchar A, Porat S, Shmushkevich aged nonoperatively. Historically, it was performed. A, Segal D, Liebergall M. The “crushed open was believed that the immature pel- Heinrich and colleagues17 pelvis” in children. Injury. 1999;30(suppl vis remodels after injury. However, described a case of open pelvic frac- 2):B14-B18. 3. Chia JP, Holland AJ, Little D, Cass DT. Pelvic 13 Smith and colleagues evaluated 23 ture with vaginal lacerations and dia- fractures and associated injuries in children. J skeletally immature unstable pelvic phragmatic rupture in a 4-year-old Trauma. 2004;56(1):83-88. fractures a mean of 6.5 years after child. The patient had other orthope- 4. Schlickwei W, Keck T. Pelvic and acetabular injury and found improved clinical dic injuries and, ultimately, the open fractures in childhood. Injury. 2005;36(suppl 1):A57-A63. and functional outcomes in those pelvic fracture was managed with 5. Spiguel L, Glynn L, Liu D, Statter M. Pediatric patients with pelvic asymmetry of an external fixator. Even though at pelvic fractures: a marker for injury severity. less than 1 cm. We restored our follow-up the patient had a malunion Am Surg. 2006;72(6):481-484. patient’s pelvic symmetry, though of the Malgaigne fracture and signif- 6. McDonald GA. Pelvic disruptions in children. there still was some increased dias- icant pelvic asymmetry, the clinical Clin Orthop. 1980;(151):130-134. 7. Reichard SA, Helikson MA, Shorter N, White tasis. outcome was good. RI Jr, Shemeta DW, Haller JA Jr. Pelvic frac- 14 Karunakar and colleagues tures in children—review of 120 patients with reported on 18 patients who were Conclusion a new look at general management. J Pediatr younger than age 16 and had unsta- Pelvic ring injuries with vaginal Surg. 1980;15(6):727-734. 8. Silber JS, Flynn JM. Changing patterns of ble pelvic fractures or acetabular frac- lacerations are not uncommon pediatric pelvic fractures with skeletal matura- tures with good operative manage- in themselves. What made our tion: implications for classification and man- ment results over a 7-year period. Of patient’s case unique is that it was agement. J Pediatr Orthop. 2002;22(1):22-26. the 18 patients, only 4 had skeletally an open unstable pelvic fracture of 9. Quick TJ, Eastwood DM. Pediatric fractures immature unstable pelvic fractures— the Young-Burgess anteroposterior and dislocations of the hip and pelvis. Clin Orthop. 2005;(432):87-96. again demonstrating the rarity of compression type, with an accompa- 10. Biffl WL, Smith WR, Moore EE, et al. Evolution this injury—and these were man- nying vascular injury. This fracture of a multidisciplinary clinical pathway for the aged with surgery. All these surgically pattern in this age group is extreme- management of unstable patients with pelvic treated, skeletally immature patients ly rare, and it was sustained in a fractures. Ann Surg. 2001;233(6):843-850. had a good outcome at short-term collision of motor vehicles instead 11. Niemi TA, Norton LW. Vaginal injuries in patients with pelvic fractures. J Trauma. follow-up (mean, 31 months). of in the typical pedestrian-versus- 1985;25(6):547-551. The anatomy of the immature skel- motor-vehicle accident.4,8,14 Our 12. Signorino PR, Densmore J, Werner M, et eton allows it to withstand a signifi- patient’s mechanism most likely was al. Pediatric pelvic injury: functional outout-- cantly stronger force before breaking. the impact of abducted feet against come at 6-month follow-up. J Pediatr Surg. 2005;40(1):107-112. Children’s blood vessels, particularly the front seat of her car, as she 13. Smith W, Shurnas P, Morgan S, et al. Clinical the arteries, undergo vasoconstric- was an unrestrained backseat pas- outcomes of unstable pelvic fractures in skel- tion—as opposed to the more fri- senger. The forces leading to her etally immature patients. J Bone Joint Surg able, arteriosclerotic vessels found in injury were significant. With her Am. 2005;87(11):2423-2431. adults. Children’s vessels are smaller pulseless extremity, suspicion of a 14. Karunakar MA, Goulet JA, Mueller KL, Bedi A, Le TT. Operative treatment of unstable pedi- and therefore easier to constrict to vascular injury from the open pelvic atric pelvis and acetabular fractures. J Pediatr create an occlusion. Constriction and fracture was high. The soft-tissue Orthop. 2005;25(1):34-38. occlusion reduce hemorrhaging and extent of the injury involving the 15. Bond SJ, Gotschall CS, Eichelberger MR. thereby prevent the coagulation pro- vaginal laceration and rectal injury Predictors of abdominal injury in children with pelvic fracture. J Trauma. 1991;31(8):1169- cess from becoming overwhelmed, was not fully realized before surgery. 1173. which results in life-threatening coag- Surgical management was required 16. Wali MA. Internal iliac artery injury in a frac- ulopathy.1,15 Although not common, for stability of this unstable pelvic tured pelvis. Ann Thorac Cardiovasc Surg. hemorrhage from a pelvic fracture fracture and for preventing further 2003;9(5):337-339. can have catastrophic effects if it goes damage to repaired structures. The 17. Heinrich SD, Sharps CH, Cardea JA, Gervin AS. Open pelvic fracture with vaginal lacera- unrecognized or is not managed in outcome was good, despite the rare, tion and diaphragmatic rupture in a child. J 16 a timely fashion. Wali reported an life-threatening injury. 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