Associated injuries and complications in pediatric pelvic fractures requiring hospitalization: A series of 315 cases

Dear Editor,

I read with great interest the article titled “Associated Injuries and Complications in Pediatric Pelvic Fractures Requiring Hospitalization: A Series of 315 Cases” by Song et al., published in the March 2024 issue of your journal. ¹ The authors conducted a retrospective analysis of associated injuries in pediatric pelvic fractures using a large case series. I would like to commend them for this important contribution to the field.

In their article, the authors note, “Although there are many reports on pelvic fractures in children, there are no studies providing detailed information on associated injuries and complications.” In this context, I would like to refer to our study published in 2004, which assessed the mechanisms of injury, and associated injuries based on fracture types, as well as the relationship between injury severity, complications, and long-term outcomes in pediatric pelvic fractures. Our study focused on outcomes across orthopedics, urology, and psychiatry.^2,3

In our study, we evaluated the long-term outcomes of 58 children with unstable pelvic fractures who were treated conservatively. The majority of fractures (81%) were caused by motor vehicle accidents, and 14% resulted from falls from heights. All patients had one or more associated injuries. Of the 58 fractures, 34 were classified as Tile type B and 24 as type C. Urethral injuries were found in 41 patients (71%), a rate significantly higher than that typically reported in the literature. We hypothesize that this high incidence reflects the exclusion of patients with type A fractures from our study, as well as the referral of patients with multiple injuries to our clinic.

Furthermore, 21 patients (36%) sustained head injuries, with 6 having type B fractures and 15 having type C fractures. Femoral fractures were the most commonly associated orthopedic injury. Three patients (5%) with type C fractures died within the first 3 days post-trauma, two due to head trauma and multiple injuries, and one due to head trauma and uncontrolled bleeding. The average MISS (Morbidity and Mortality in Severe Trauma) score was 22 (range: 14–41) for all patients, 19 (range: 14–34) for type B fractures, and 23 (range: 14–41) for type C fractures. The difference in MISS scores between the two groups was statistically significant (p = 0.036).

All pelvic fractures in our cohort were treated non-operatively with bed rest, pelvic slings, hip spica casts, or skeletal traction. After an average follow-up of 7.4 years (ranging from 2 to 17 years), we observed the following long-term complications: In the type B group, 2 patients had a leg length discrepancy of 1 cm, 1 patient had limited knee motion due to an open knee wound, and 2 patients experienced low back pain. In the type C group, 4 patients had low back pain, 3 had gait abnormalities, 1 had sacroiliac ankylosis, and 2 had symphyseal ossification. Urethral strictures were noted in 11 patients, urinary incontinence in 6, and erectile dysfunction in 6. Psychiatric disorders were diagnosed in 31 patients (41 total), including dysthymic disorder, social phobia, post-traumatic stress disorder, and major depression. These psychiatric issues, which have not been widely reported in the literature, may be associated with concurrent organ injuries and lead to significant emotional distress, including suicidal ideation. Low self-esteem, arising from physical deformities such as limping and the long-term consequences of urological therapy, further compounded the mental health burden.

From an orthopedic perspective, non-operative treatment of pediatric pelvic fractures can lead to successful outcomes. However, from a holistic viewpoint, it is important to recognize the potential for psychological complications, especially with extended hospital stays (as reported in the authors’ study, up to 159 days) and repeated surgeries, particularly those related to urological injury. In-hospital educational support would be beneficial to prevent school-age children from falling behind academically. Moreover, close collaboration with psychiatric specialists is essential to mitigate both acute and chronic psychological complications. Social support organizations may also help address logistical challenges such as treatment costs and employment difficulties for affected families.

As the authors point out, the treatment and outcomes of pediatric pelvic fractures differ significantly from those in adults. Achieving a satisfactory outcome goes beyond fracture union; it requires the restoration of the child’s pre-injury functional capacity. All systemic complications related to the fracture or its treatment must be thoroughly evaluated.

I believe that the authors’ long-term follow-up of this large cohort will provide valuable insights into the management of pediatric pelvic fractures and contribute significantly to the literature.

Sincerely,

Supplemental Material

sj-pdf-1-cho-10.1177_18632521251330458 – Supplemental material for Associated injuries and complications in pediatric pelvic fractures requiring hospitalization: A series of 315 cases

Supplemental material, sj-pdf-1-cho-10.1177_18632521251330458 for Associated injuries and complications in pediatric pelvic fractures requiring hospitalization: A series of 315 cases by Mehmet Subasi in Journal of Children’s Orthopaedics