What is the initial management for an 8-year-old child with a pelvic fracture from a road traffic accident?

Initial Management of Pelvic Fracture in an 8-Year-Old Child

Immediately apply a commercial pelvic binder around the greater trochanters as soon as pelvic fracture is suspected, then rapidly assess hemodynamic stability to determine whether the child requires immediate hemorrhage control interventions or can proceed directly to CT imaging. 1

Immediate Prehospital/Emergency Department Actions

Apply Pelvic Binder First

• Place a commercial pelvic binder around the greater trochanters (not the iliac crests) immediately upon suspicion of pelvic fracture 1
• This single intervention directly reduces transfusion requirements, ICU length-of-stay, and provides compression equivalent to surgical C-clamp 1
• Do not use sheet wrapping as it provides no benefit 1

Assess Hemodynamic Status

• Check for signs of hemorrhagic shock: systolic blood pressure <90 mmHg (adjust for pediatric norms), altered consciousness, ongoing bleeding 1
• Reassess vital signs frequently as children can compensate initially then decompensate rapidly 2
• Pelvic instability on examination confirms high-risk injury 1

Algorithm Based on Hemodynamic Stability

If Hemodynamically UNSTABLE (Shock Present)

Obtain pelvic X-ray immediately upon arrival to confirm fracture pattern 1

Perform E-FAST within 30 minutes to identify intra-abdominal bleeding source (97% positive predictive value for intra-abdominal hemorrhage) 1, 3

Administer antibiotics within 3 hours of injury:

• Use cefazolin (or clindamycin if beta-lactam allergic) 4
• Add gram-negative coverage (aminoglycoside or piperacillin-tazobactam) if open fracture suspected 4
• Continue for maximum 48-72 hours unless proven infection exists 4

Proceed to hemorrhage control based on bleeding source:

• If intra-abdominal bleeding present on E-FAST: Immediate laparotomy with concomitant external pelvic fixation, followed by angiography if pelvic arterial bleeding persists 3

• If no intra-abdominal bleeding: Transfer to angiography within 45-60 minutes of arrival for embolization 1, 3

  • Steel coils or Gelfoam suspension are optimal embolic agents 3
  • Angioembolization is highly effective for arterial bleeding, particularly with sacroiliac joint disruption 1

External fixation timing:

• Should not exceed 60 minutes from hospital admission 5
• Use external fixator for Tile C fractures and Tile B1/B3 fractures with ring disruption 2
• Place anteriorly and inferiorly to allow potential laparotomy 2

If Hemodynamically STABLE

Skip pelvic X-ray (Grade 2- recommendation against X-ray in stable patients) 1

Proceed directly to CT scan with IV contrast of entire pelvis 1

• CT identifies fracture pattern, associated injuries, and active arterial extravasation ("blush") 1
• Delayed sequences assess for urinary tract injuries when hemodynamically possible 2

Look for markers of occult hemorrhage on CT:

• Active arterial extravasation (CT "blush") 1
• Pelvic hematoma volumes >500 ml 1
• Anterior-posterior or vertical shear deformations 1

Special Considerations for Open Pelvic Fractures

If open fracture identified (perineal wounds, buttock wounds):

• Transfer immediately to referral center with multidisciplinary capabilities as mortality exceeds 50% 2, 5, 4

• Four management priorities in order: 2

  1. Bleeding control (primary cause of death)
  2. Cleaning and debridement of wound
  3. Identification of associated injuries (bladder, urethra, rectum)
  4. Treatment of pelvic fracture

• Perform sigmoidoscopy to rule out rectal injury in all open pelvic fractures 5

• Consider early colostomy for buttock or perineal wounds as delaying this is associated with near-universal pelvic sepsis 5

• Achieve definitive wound coverage within 7 days to reduce infection risk 5, 4

Associated Injuries Requiring Immediate Recognition

Bladder injuries occur in 4-15% of unstable pelvic fractures, particularly intraperitoneal ruptures requiring early surgical closure 5

Posterior urethral injuries present in 4-19%, especially with bilateral pubic rami fractures and sacroiliac dislocation 5

Perform delayed CT sequences (when stable) to assess urinary contrast excretion for suspected urinary injuries 2

Transport Considerations

All severe pelvic trauma patients must be transported to a Level I trauma center with 24/7 availability of trauma surgery, interventional radiology, and orthopedic surgery 1

• This approach decreases mortality by 15-30% compared to non-specialized facilities 1

Critical Pitfalls to Avoid

Do not delay antibiotic administration beyond 3 hours as infection risk increases exponentially 5, 4

Do not exceed 60 minutes from admission to bleeding control intervention as this increases mortality 5

Do not remove pelvic packs before 48 hours to lower re-bleeding risk 1

Do not perform non-therapeutic laparotomy in patients with isolated pelvic fractures as this may increase mortality 1

Do not delay colostomy in patients with perineal contamination 5

Do not extend antibiotics beyond 72 hours without documented infection 5, 4