Updated: 4/15/2020

Pediatric Pelvis Trauma Radiographic Evaluation

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 Normal Anatomy
 Ossification
 Ossification of the pelvis
 Osteology & Attachments
  • Anterior view
  • Posterior view
  • Lateral view
 Radiographic Views
 AP view
  • Positioning
    • patient
      • supine
      • legs IR 15-20°
    • beam
      • aim midway between ASIS + pubic symphysis
  • Indications
    • pelvic/acetabular fractures
      • assess 6 lines
        • posterior rim (1) = posterior wall/column
          • posterior horn of acetabulum
          • more lateral + horizontal line
        • anterior rim (2) = anterior wall/column
          • inferior margin of superior pubic ramus
          • more medial + horizontal line
        • sourcil (3) = anterior/posterior column
          • acetabular roof = superior weight-bearing portion
          • normal 45-60° arc
        • teardrop (4) = anterior/posterior column
          • external/lateral limb = inferior anterior acetabular wall + outer cotyloid fossa
          • lower border = ischiopubic/acetabular notch + superior obturator foramen
          • internal/medial limb = outer wall of obturator canal + quadrilateral surface
          • internal + external limbs = not in same coronal plane but usually parallel + forms U
        • ilioischial line (5) = posterior column
          • pelvic brim + quadrilateral surface + posterior obturator foramen + ischiopubic ramus
          • always superimposed on teardrop = disruption 2/2 rotation vs. quadrilateral surface Fx
        • iliopectineal line (6) = anterior column
          • anterior ¾ = pelvic brim, pubic symphysis to ilioischial line
          • posterior ¼ = lower ½ of sciatic buttress to roof of greater sciatic notch
  • Critique
    • no pelvic tilt
      • coccyx located 2cm above pubic symphysis
    • no rotation of pelvis
      • sacrum in midline
      • symmetrical greater trochanters + obturator foramen
    • no visualization of lesser trochanters
    •  
      • too much external rotation of leg leads to increased visualization of lesser trochanter
      • if lesser trochanters are visible, they should be of symmetrical size and shape
 Lateral view
  • Positioning
    • patient
      • supine vs. lateral decubitus
    • beam
      • aim 5cm above greater trochanters
  • Critique
    • no superimposition of femurs + pubic arch
      • achieve via leg extension
    • superimposition of femurs + acetabulum
    • superimposition of posterior ischium/ilium
 Axial/Chassard-Lapine view 
  • Positioning
    • patient
      • seated + leaning forward
      • pelvis tilted anteriorly 45° + hips abducted
    • beam
      • aim between greater trochanters
  • Indications
    • assess relationship of femoral head + acetabulum
    • measurement of horizontal/bi-ischial diameter
  • Critique
    • symmetrical greater trochanters
    • equal distance between greater trochanters + sacrum
 Inlet view
  • Positioning
    • patient
      • supine
      • legs IR 15-20°
    • beam
      • aim at ASIS + 40° caudad
  • Indications
    • AP displacement + IR/ER of hemipelvis
    • rotational stability of pelvis
    • SI joint widening
    • sacral Fx
  • Critique
    • superimposition of S1 + S2 body
 Outlet view 
  • Positioning
    • patient
      • supine
      • legs IR 15-20°
    • beam
      • aim 5cm below pubic symphysis
      • til 20-35° cephalad if male, 30-45° cephalad if female
  • Indications
    • vertical displacement + flexion/extension of hemipelvis
    • SI joint widening
    • sacral Fx
  • Critique
    • superimposition of pubic symphysis + S2 body
    • open obturator foramen
 Judet view
  • Positioning
    • patient
      • iliac oblique = semi-lateral 45° on ipsilateral side
      • obturator oblique = semi-lateral 45° on contralateral side
    • beam
      • aim 5cm medial + inferior to ASIS
  • Indications
    • iliac oblique = anterior wall + posterior column
    • obturator oblique = posterior wall + anterior column
  • Critique
    • iliac oblique = visualization of iliac wing
    • obturator oblique = open obturator foramen
 Normal Radiographic Findings
    • female pelvis
      • wider in the mediolateral dimension
      • suprapubic angle > 90°
    • male pelvis
      • wider in AP dimension
      • suprapubic angle < 90°
  • Normal variants
    • phleboliths
      • calcifications in walls of veins
      • usually found laterally around bladder
      • can be symmetrical
      • can occur in clusters
    • os acetabuli
      • located at anterosuperior margin of acetabulum
      • round in shape with concave lateral border and convex medial border
      • may be bilateral and partially fused to the acetabulum
    • paraglenoidal sulcus
      • groove at insertion of anterior SI ligament
      • commonly seen in multiparous females
      • associated with osteitis condensans ilii

  • Risser staging (based on ossification of iliac crest)
  • Risser staging classification
 Radiographic Clinical Pearls
 Pelvic Avulsion Fracture
  • More common in pediatric patients
    • occurs at apophysis

MUSCLE
NON-OP TREATMENT CRITERIA
 
Iliac crest
abdominal muscles
always
ASIS
sartorius + TFL < 3 cm displacement
AIIS
rectus femoris
always
Ischial tuberosity
hamstrings (ST, SM, long head of biceps femoris) 1 tendon + < 2 cm displacement
Pubic symphysis
adductors + gracilis always

 

 Pediatric Pelvic Ring Fracture 
  • Classification = Torode & Zieg
    Torode/Zieg Classification
    Type I  • Avulsion injuries
     
    Type II  • Fractures of the iliac wing

    Type III  • Fractures of the ring with no segmental instability
    Type IV  • Fracture of the ring with segmental instability
  • Recommended views (only detects 50% of pediatric pelvic fractures)
    • AP
    • inlet/outlet
    • judet views if suspected acetabular njury
  • Treatment criteria
    • nonoperative treatment acceptable if 
      • type I avulsion injuries with < 2 cm displacement
      • type II iliac wing fractures with < 2 cm displacement
      • type III pelvic ring fractures without segmental instability
    • ORIF vs. ex-fix if 
      • type I avulsion injuries with > 2-3 cm displacement
      • type II iliac wing fractures with > 2-3 cm displacement
      • type III pelvic ring with displaced acetabular fractures > 2mm
      • type IV pelvic ring with instability and > 2 cm pelvic ring displacement
 Pediatric Acetabular Fracture 
  • Classification = Bucholz
    Bucholz Classification
    Shearing   • Salter Harris I or II
    Blow to pubis/ischial ramus/proximal femur leads to injury at interface of 2 superior arms of triradiate cartilage and metaphyses of ilium.
    A triangular medial metaphyseal fragment (Thurston-Holland fragment) is often seen in SH II injuries.
      
    Crushing/Impaction  • Salter Harris V
    Difficult to see on initial radiographs. May detect narrowing of triradiate space. Leads to premature triradiate cartilage closure. The earlier the closure, the greater the eventual deformity. 

  • Recommended views
    • AP
    • judet
    • inlet/outlet views if suspected pelvic ring injury
  • Findings
    •  displacement of growth plates
    • disruption of iliopectineal line
    • asymmetric teardrop
  • Treatment criteria
    • nonoperative treatment acceptable if minimally displaced
    • ORIF if
      • comminuted acetabular fracture when traction does not improve the position of fragments
      • joint displacement >2mm
      • joint incongruity 
      • intra-articular fragments
      • joint instability (persistent medial subluxation or posterior subluxation)
      • central fracture dislocation
      • open fractures
 

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