Computer and magnetic resonance imaging for pelvic fractures in children

Introduction. Fractures of pelvic bones in children are rare and make up from 0.3 to 4% of all childhood trauma, 20% of children with polytrauma have pelvic ring injuries. Comparative studies of diagnostic capabilities of MRI and CT in sacral and acetabular fractures showed that about 37% of CT were missed, therefore the authors recommended MRI as the best method in visualizing pelvic fractures.

Aim of this study is to show the capabilities of CT and MRI to improve recognition of pelvic fractures.

Material and methods. In the period 2010–2019, 790 children with pelvic fractures as part of polytrauma were studied. The age of children was from 8.5 to 17 years, average 10.14 ± 1.4. Computed tomography with three-phase contrast was performed in all 790 patients on Brilliance 16 scanners. MRI was performed (n = 63) on a 3 T tomograph with obtaining multiplanar STIR, T1-, T2- and PD weighted images (VI) with signal suppression factor of adipose tissue, as well as 3D isotropic images.

Results. On the polytrauma severity scale (ISS), the assessment of the condition of 790 children ranged from 23.54 to 27.5 (mean 25.77) points. The main mechanism of pelvic injury was road traffic accidents (pedestrian + passenger – 63.54% (n = 502), catatrauma was in second place – 32.66% (n = 258), followed by compression – 2.15% (n = 17) , sports injury – 0.38% (n = 3), other injury – 3.43% (n = 27). 73.26% (n = 578) had multiple pelvic fractures, 20.5% (n = 162) – complicated, – 22.3% (n = 176) unstable In 63 patients with damage to the anterior pelvic ring, according to CT, MRI revealed fractures of the posterior pelvic ring in 79.36% (n = 50).

Conclusion. Children with polytrauma must undergo computed tomography to exclude not only all non-muscular-skeletal injuries, but also combined pelvic fractures. We believe that for the detection and assessment of bone fractures and concomitant injuries of other tissues and organs of the pelvis, in most cases, multiphase CT with intravenous contrast is a sufficient method. MRI is important for evaluating pelvic soft tissue structures such as tendons, ligaments, nerves and fascia, as well as detecting hidden / fine bone lesions.

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

2. Ismail N., Bellemare J.F., Mollitt D.L., DiScala C., Koeppel B., Tepas J.J. 3rd. Death from pelvic fracture: children are different. J. Pediatr. Surg. 1996; 31 (1): 82– 85. https://doi.org/10.1016/s0022-3468(96)90324-3

3. Demetriades D., Karaiskakis M., Velmahos G.C., Alo K., Murray J., Chan L. Pelvic fractures in pediatric and adult trauma patients: are they different injuries? J. Trauma. 2003; 54 (6): 1146–1151. https://doi.org/10.1097/01.ta.0000044352.00377.8f.

4. Gansslen A., Hildebrand F., Heidari N., Weinberg A.M. 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. https://doi.org/10.1007/s00590-012-1102-0

5. Holden C.P., Holman J., Herman M.J. Pediatric pelvic fractures. JAAOS J. Am. Acad. Orthopaed. Surg. 2007; 15 (3): 172–177. https://doi.org/10.5435/00124635-200703000-00007

6. Banerjee S., Barry M.J., Paterson J.M.H. Paediatric pelvic fractures: 10 years experience in a trauma centre. Injury. 2009; 40 (4): 410–413. https://doi.org/10.1016/j.injury.2008.10.019

7. Silber J.S., Flynn J.M., Koffler K.M., Dormans J.P., Drummond D.S. Analysis of the cause, classification, and associated injuries of 166 consecutive pediatric pelvic fractures. J. Pediatr. Orthopaed. 2001; 21 (4): 446–450. https://doi.org/10.1097/01241398-200107000-00006

8. Lyuboshits N.A. Closed fractures of the pelvic bones in children. Moscow: Medicine, 1968. (In Russian)

9. Widmann R. Fractures of the Pelvis Rockwood CA WK. Philadelphia: Lippincott Williams & Wilkins, 2006.

10. Giannoudis P.V., Grotz M.R.W., Tzioupis C., Dinopoulos H., Wells G.E., Bouamra O., Lecky F. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J. Trauma Acute Care Surg. 2007; 63 (4): 875–883. https://doi.org/10.1097/01.ta.0000242259.67486.15

11. Flint L., Cryer H. G. Pelvic fracture: the last 50 years. J. Trauma Acute Care Surg. 2010; 69 (3): 483–488. https://doi.org/10.1097/ta.0b013e3181ef9ce1

12. Marmor M., Elson J., Mikhail C., Morshed S., Matityahu A. Short-term pelvic fracture outcomes in adolescents differ from children and adults in the National Trauma Data Bank. J. Child. Orthopaedics. 2015; 9 (1): 65–75. https://doi.org/10.1007/s11832-015-0634-3

13. Stahel P.F., Hammerberg E.M. History of pelvic fracture management: a review. Wld J. Emerg. Surg. 2016; 11 (1): 18. https://doi.org/10.1186/s13017-016-0075-4

14. Mosheiff R., Suchar A., Porat S., Shmushkevich A., Segal D., Liebergall M. The “crushed open pelvis” in children. Injury. 1999; 30: 14–18. https://doi.org/10.1016/s0020-1383(99)90003-7

15. Smith W., Shurnas P., Morgan S., Agudelo J., Luszko G., Knox E.C., Georgopoulos G. Clinical outcomes of unstable pelvic fractures in skeletally immature patients. JBJS. 2005; 87 (11): 2423–2431. https://doi.org/10.2106/00004623-200511000-00008

16. Junkins Jr. E.P., Nelson D.S., Carroll K.L., Hansen K., Furnival R.A. A prospective evaluation of the clinical presentation of pediatric pelvic fractures. J. Trauma Acute Care Surg. 2001; 51 (1): 64–68. https://doi.org/10.1097/00005373-200107000-00010

17. Kuznetsov L.E. Pelvic fractures in children (morphology, biomechanics, diagnostics). Moscow: Folium, 1994. (In Russian)

18. Coccolini F., Stahel P.F., Montori G., Biffl W., Horer T.M., Catena F., Kluger Y., Moore E.E., Peitzman A.B., Ivatury R., Coimbra R., Fraga G.P., Pereira B., Rizoli S., Kirkpatrick A., Leppaniemi A., Manfredi R., Magnone S., Chiara O., Solaini L., Ceresoli M., Allievi N., Arvieux C., Velmahos G., Balogh Z., Naidoo N., Weber D., Abu-Zidan F., Sartelli M., Ansaloni Luca. Pelvic trauma: WSES classification and guidelines. Wld J. Emerg. Surg. 2017; 12 (1): 1–18. https://doi.org/10.1186/s13017-017-0117-6

19. Hermans E., Cornelisse S.T., Biert J., Tan E.C.T.H., Edwards M.J.R. Paediatric pelvic fractures: how do they differ from adults? J. Child. Orthopaed. 2017; 11 (1): 49–56. https://doi.org/10.1302/1863-2548-11-160138

20. Sheikh Z.V., Arablinskyi A.V., Karmazanovsky G.G., Donchenko S.V., Alekseev D.V., Klimko S.V. Radiography and MSCT in the Diagnostic of Acetabular Fractures. Medical Visualization. 2016; 1: 113–122. (In Russian)

21. Cerva Jr. D.S., Mirvis S.E., Shanmuganathan K., Kelly I.M., Pais S.O. Detection of bleeding in patients with major pelvic fractures: value of contrast-enhanced CT. Am. J. Roentgenol. 1996; 166(1): 131–135. https://doi.org/10.2214/ajr.166.1.8571861.

22. Genin G., Rode A. Imagerie du polytraumatisé. Masson, 1992.

23. Hunter J.C., Brandser E.A., Tran K.A. Pelvic and acetabular. Radiol. Clin. N. Am. 1997; 35 (3): 559–590.

24. Gänsslen A., Heidari N., Weinberg A.M. Fractures of the pelvis in children: a review of the literature. Eur. J. Orthopaed. Surg. & Traumatol. 2013; 23 (8): 847–861. https://doi.org/10.1007/s00590-012-1102-0

25. Amorosa L.F., Kloen P., Helfet D.L. High-energy pediatric pelvic and acetabular fractures. Orthoped. Clin. 2014; 45 (4): 483–500. https://doi.org/10.1016/j.ocl.2014.06.009.

26. Foex B.A., Russell A. BET 2: CT versus MRI for occult hip fractures. Emerg. Med. J. 2018; 35 (10): 645. https://doi.org/10.1136/emermed-2018-208093.3.

27. Rehman H., Clement R.G.E., Perks F., White T.O. Imaging of occult hip fractures: CT or MRI? Injury. 2016; 47 (6): 1297–1301. https://doi.org/10.1016/j.injury.2016.02.020.

28. Eggenberger E., Hildebrand G., Vang S., Ly A., Ward C. Use of CT vs. MRI for Diagnosis of Hip or Pelvic Fractures in Elderly Patients After Low Energy Trauma. Iowa Orthop. J. 2019; 39 (1): 179.

29. Gaeta M., Minutoli F., Scribano E., Ascenti G., Vinci S., Bruschetta D., Magaudda L., Blandino A. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005; 235 (2): 553–561. https://doi.org/10.1148/radiol.2352040406

30. Nüchtern J.V., Hartel M.J., Henes F.O., Groth M., Jauch S.Y., Haegele J., Briem D., Hoffmann M., Lehmann W., Rueger J.M., Großterlinden L.G. Significance of clinical examination, CT and MRI scan in the diagnosis of posterior pelvic ring fractures. Injury. 2015; 46 (2): 315–319. https://doi.org/10.1016/j.injury.2014.10.050

31. Vaccaro A.R., Kim D.H., Brodke D.S., Harris M., Chapman J.R., Schildhauer T., Routt M.L., Sasso R.C. Diagnosis and management of sacral spine fractures. Instr. Course Lect. 2004; 86 (1): 166–175. https://doi.org/10.2106/00004623-200401000-00027

32. Schicho A., Schmidt S.A., Seeber K., Olivier A., Richter P.H., Gebhard F. Pelvic X-ray misses out on detecting sacral fractures in the elderly–Importance of CT imaging in blunt pelvic trauma. Injury. 2016; 47 (3): 707–710. https://doi.org/10.1016/j.injury.2016.01.027

33. Durkin A., Sagi H.C., Durham R., Flint L. Contemporary management of pelvic fractures. Am. J. Surg. 2006; 192 (2): 211–223. https://doi.org/10.1016/j.amjsurg.2006.05.001

34. Kos S., Gutzeit A., Hoppe H., Liu D.M., Jacob A.L. Diagnosis and therapy of acute hemorrhage in patients with pelvic fractures. Seminars in musculoskeletal radiology. – Thieme Medical Publishers. 2013; 17 (4): 396–406. https://doi.org/10.1055/s-0033-1356469

35. Cabarrus M.C., Ambekar A., Lu Y., Link T.M. MRI and CT of insufficiency fractures of the pelvis and the proximal femur. Am. J. Roentgenol. 2008; 191 (4): 995–1001. https://doi.org/10.2214/ajr.07.3714

36. Torode I., Zieg D. Pelvic fractures in children. J. Pediatr. Orthopaed. 1985; 5 (1): 76–84. https://doi.org/10.1097/01241398-198501000-00014

37. Tile M. Pelvic ring fractures: should they be fixed? The Journal of bone and joint surgery. Br. Vol. 1988; 70 (1): 1–12. https://doi.org/10.1302/0301-620x.70b1.3276697

38. Chia J.P.Y., Holland A.J.A., Little D., Cass D.T. Pelvic fractures and associated injuries in children. J. Trauma Acute Care Surg. 2004; 56 (1): 83–88. https://doi.org/10.1097/01.ta.0000084518.09928.ca

39. Moore N., Mills T.J. Pelvic Fracture in Emergency Medicine. Medscape, 2017.

40. Burlew C.C., Moore E.E., Stahel P.F., Geddes A.E., Wagenaar A.E., Pieracci F.M., Fox C.J., Campion E.M., Johnson J.L., Mauffrey C. Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J. Trauma Acute Care Surg. 2017; 82 (2): 233. https://doi.org/10.1097/ta.0000000000001324

41. Caillot M., Hammad E., Le Baron M., Villes V., Leone M., Flecher X. Pelvic fracture in multiple trauma: a 67-case series. Orthop. Traumatol. Surg. Res. 2016; 102 (8): 1013–1016.

42. Andrich S., Haastert B., Neuhaus E., Neidert K., Arend W., Ohmann C., Grebe J., Vogt A., Jungbluth P., Thelen S., Windolf J., Icks A. Excess mortality after pelvic fractures among older people. J. Bone Mineral Res. 2017; 32 (9): 1789–1801. https://doi.org/10.1002/jbmr.3116

43. Scott S.T., Watt I. Gas at the symphysis pubis: a sign of occult pelvic trauma. Br. J. Radiol. 1984; 57 (674): 173–176. https://doi.org/10.1259/0007-1285-57-674-173