Pediatric emergency medicine trisk 3486 3486
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compared to the adult trauma patient. A high index of suspicion for the presence
of potential pelvic fractures should be maintained for high-energy injury
mechanisms, including motor vehicle collisions, pedestrians hit by a motor
vehicle, and significant falls. As the physical examination has moderate
sensitivity for pelvic fractures, those with abnormal pelvis and hip examinations
with instability, pain on palpation of the pelvis, or the inability to walk due to
pelvic pain should be evaluated for possible pelvic fractures.
Triage considerations . Most pelvic fractures are stable; however, those with
abnormal vital signs indicating trauma-related hemorrhage require immediate
resuscitative measures.
Clinical assessment . Mechanism of injury and any comorbid conditions should
be emphasized in the history.
The initial assessment should include the vital signs and a thorough
examination of the abdomen, pelvis, lower extremities, skin, genitourinary, and
neurologic systems. Vital signs must be closely monitored and appropriate fluid
and/or blood product resuscitation should be administered if tachycardia and/or
hypotension are present. Anterior and lateral compression of the pelvis should be
performed to assess pelvic stability.
Management . Pelvis and hip radiographs are the initial diagnostic test of choice.
If further evaluation of the pelvis is needed, CT may be considered to further
visualize the fracture(s). Immediate orthopedic consultation is required for all
pelvic fractures except for minor avulsion fractures. The emergent application of
an external fixator or a pneumatic antishock garment in the ED compresses the
pelvis, leading to a tamponade effect to decrease the bleeding in some pelvic
fractures. If commercial devices are not available, wrapping the pelvis in a sheet
can provide temporary stability. Pelvic fractures can be categorized as (1)
avulsion fractures, (2) pelvic ring fractures, and (3) acetabular fractures.
AVULSION FRACTURES . Sports are the most common mechanism causing
avulsion fractures as they can result in strong, active contractions of the muscular
attachments against resistance to the secondary centers of ossification (anteriorsuperior iliac spine, anterior-inferior iliac spine, and ischial tuberosity) ( Fig.
111.31 ). The patient usually presents with localized pain and tenderness over the
ossification sites ( Fig. 111.32 ). The typical treatment is crutches with partial or
no weight bearing for 4 to 6 weeks with a slow resumption of activities. The
patient should be referred for outpatient orthopedic follow-up.
