Trauma – Early management of pelvic injuries in children


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network


  • All children under 16 years of age with major trauma (including confirmed or highly suspected pelvic injury) should have ongoing management at Royal Children's Hospital. See State Trauma Guidelines

    In Victoria, the Paediatric Infant Perinatal Emergency Retrieval (PIPER) service is available to retrieve critically injured children from referral hospitals and provide safe, expert, emergency inter-hospital retrieval. The earlier contact is made with PIPER, the earlier assistance can be dispatched to the hospital.

    See also:

    Background

    Pelvic fractures are rare in children, but may occur in high-energy traumas.

    Assessment

    Assessment of the pelvis occurs during the primary survey.  Identification of major pelvic injury and the stabilisation of the pelvis should occur together at this stage.(see Major paediatric trauma).

    Key questions to answer early in the initial care of any child with a suspected or confirmed pelvic injury are:

    • Who needs a pelvic binder? This will assist in reducing blood loss from an unstable pelvic fracture, and may be life saving. Consider having a pelvic binder or sheets ready on the trolley when the patient arrives. The selection and application of a pelvic binder is detailed below.
    • Who needs blood products? Pelvic injuries may cause life-threatening haemorrhage. Consider early contact with the blood bank +/- activation of the Massive Transfusion procedure.
    • Do I need help? Children with pelvic injuries may require resource consuming and expert care. Please contact PIPER 1300 137 650 early to ensure optimal advice regarding initial care and transfer to the Royal Children’s Hospital.
      It is essential PIPER facilitate early consultation with RCH ED and Orthopaedic
      +/- other surgical specialties re timelymanagement of pelvic trauma.

    What features of the history make pelvic injury more likely?

    • high risk mechanism, often involving crush injury
      • high speed MVA (+/- ejection)
      • rollover
      • lateral (side) impact MVA
      • pedestrian vs. car, bicycle struck by car, etc.
    • fatalities in same collision

    Which features on examination make pelvic injury more likely?

    • abnormal pelvic examination, including suspected femur fracture
    • Inspect for bruising, wounds, asymmetry or obvious deformity of pelvis or lower limbs
    • Gently palpate for tenderness along the iliac crests, pubic symphysis, sacro-iliac joints, ischial tuberosities and lumbar-sacral spine
    • Assess for pelvic instability by gentle compression of the iliac crest – this should only be done once, preferably by the most senior clinician, and avoided altogether if there is obvious pelvic instability as you risk dislodging a clot and worsening bleeding.  Similarly, caution is required when log rolling the patient, and this examination should be deferred if there is risk of worsening an unstable pelvis.

    NB: Beware visceral injury: thorough examination for blood at the urethral meatus, vagina, scrotum, and rectum should be performed.  If there is suspicion of a urological injury, please consult early with RCH Paediatric Urology.

    Who needs a pelvic binder?

    • The primary role of a pelvic binder is to augment haemorrhage control in the haemodymically unstable (shocked) patient with a suspected or known pelvic injury.
    • Children without haemodynamic instability, but in whom the mechanism of injury or clinical assessment suggests a pelvic fracture (or is unreliable due to a reduced conscious state), may benefit from a pelvic binder until pelvic injury is excluded.  It is important to consider the need for a pelvic binder in all children, even if the patient arrives without one already in-situ.
    • There is little evidence favouring any one proprietary binder over another in different age groups.  Some binders may be cut to length (e.g. T-POD®; Prometheus Pelvic Splint); others come in a number of sizes (SAM Pelvic Sling™).
    • A folded sheet, wrapped around the child at the level of the greater trochanters and secured in place, may be appropriate if no other well-fitting binder is available.

    Trauma – Early management of pelvic injuries in children diagram

    How do I apply a pelvic binder to the patient?

    • The binder should be placed on the ED trolley if the mechanism of injury and pre-hospital findings are suggestive of possible pelvic injury and no sling/binder has been applied pre-hospital.
    • The binder should be placed at the level of the greater trochanters (NOT iliac crests, see Figure below).

    truma

    Figure greater trochanter and symphysis pubic region  

    • A misplaced binder may exacerbate a pelvic fracture if there is an injury through the iliac crest. When placed too high it will also obstruct access for laparotomy.
    • Tying the feet together will help maintain the anatomical position of the pelvis (unless there are also lower limb fractures) via internal rotation of the femurs.
    • The binder will not control arterial haemorrhage. Patients who do not improve haemodynamically following application of the pelvic binder may require urgent angio-embolization or operative intervention.
    • The binder should remain in place until the definitive stabilization procedure.

    What if I don’t have a bespoke pelvic binder, or the child is too young?

    • Circumferential pelvic sheeting is an option for all children, especially younger children. A folded sheet should be placed underneath the patient – between the iliac crests and greater trochanters. Two team members should cross the sheet across the pubic symphysis and pull the sheet firmly. Twist the ends together and secure with a plastic clamp where possible (metal artery clips can obscure plain x-rays and CT imaging).

       For further information please watch “Technique for temporary pelvic stabilization after trauma” video from the New England Journal of Medicine available at http://www.nejm.org/doi/full/10.1056/NEJMvcm1200383

    Who needs what pelvic imaging?

    • The decision-making guide below shows which patients need what imaging, and which patients can have imaging safely deferred

    Title: Trauma – Early management of pelvic injuries in children diagram 2

    • If CT imaging is being considered outside of RCH prior to transfer,  it is strongly recommended that it be first discussed with the relevant paediatric speciality teams through PIPER 1300 137 650. This may prevent unnecessary use of CT imaging and its associated risks. 

    Acute management of pelvic trauma

    • The management of paediatric pelvic fractures depends on the patient’s, haemodynamic status, stability of the pelvic ring, type of fracture and the patient’s age.

    Referral

    When to consider transfer to a tertiary centre:

    All paediatric major trauma patients ( <16 years old) need to be referred to the Royal Children’s Hospital in accordance with the Victorian State Trauma System.

    Please consult PIPER 1300 137 650 early to ensure optimal advice regarding initial care and transfer to the Royal Children’s Hospital. 

    PIPER will facilitate discussion with the RCH ED, Orthopaedic +/- other surgical specialties re optimal early management.