Abstract
Purpose
To explore the clinical characteristics of pediatric pelvic fracturs caused by traffic accidents and to analyze the accompanying injuries and complications.
Methods
A total of 222 cases involved traffic accidents was enrolled in this case-control study. The data of children with pelvic fractures caused by traffic accidents who were admitted to our hospital from January 2006 to December 2021 were analyzed retrospectively. Sex, age, Tile classification, abbreviated injury scale score, injury severity score, mortality, and accompanying injuries were studied. The ANOVA was used for measurement data, and the non-parametric rank sum test was used for non-normally distributed data. The Fisher's exact probability method was used for the count data.
Results
Of all enrolled cases, 140 are boys and 82 are girls, including 144 cases aged < 6 years, 65 aged between 6 and 12 years, and 13 aged > 12 years. Depending on the injury mechanism, there are 15 cases involving pedestrians vs. motorcycles (PVM), 91 cases involving pedestrians vs. passenger cars (PVC), 78 cases involving pedestrians vs. commercial vehicles (PVV), and 38 cases involving motor vehicles vs. motor vehicles (MVM). Associated injuries are reported in 198 cases (89.2%), primarily involving the abdomen injury in 144 cases (64.9%), and lower limb injury in 99 cases (44.6%). PVV injury involves longer hospital stay (p = 0.004). Intensive care unit admission rate is significantly higher in the MVM group than in other groups (p = 0.004). Head injury (p = 0.001) and face injury (p = 0.037) are more common in the MVM group, whereas abdominal injury (p = 0.048) and lower limb injury (p = 0.037) are more common in the PVV group. In the MVM group, the brain injury (p = 0.004) and femoral neck injury (p = 0.044) are more common. In the PVM group, the mediastinum (p = 0.004), ear (p = 0.009), lumbar vertebrae (p = 0.008), and spinal cord (p = 0.011) are the most vulnerable regions, while in the PVV group, the perineum (p < 0.001), urethra (p = 0.001), rectum (p = 0.006), anus (p = 0.004), and lower limb soft tissues (p = 0.024) are the most vulnerable regions. Children aged > 12 years have higher pelvic abbreviated injury scale scores (p = 0.019). There are significant differences in the classification of pelvic fractures among children < 6, 6 – 12, and > 12 years of age, with Tile C being more likely to occur in children > 12 years of age (p = 0.033). Children aged > 12 years are more likely to sustain injuries to the spleen (p = 0.022), kidneys (p = 0.019), pancreas (p < 0.001), lumbar vertebrae (p = 0.013), and sacrum (p = 0.024). The MVM group has the highest complication rate (p = 0.003).
Conclusion
PVC is the leading cause of the abdomen and lower extremities injury and has the most concomitant injuries. Different traffic injuries often lead to different associated injuries. Older children are more likely to sustain more severe pelvic fractures and peripelvic organs injuries. The MVM group has the highest extent of injury and complication rates.
Keywords: Children, Pelvic fractures, Complications, Traffic injuries
1. Introduction
Pediatric pelvic fractures are relatively rare and are often caused by high-energy injuries1, such as motor vehicle accidents, fall from height, and crush injuries2. Traffic accidents account for the highest percentage of these injuries, of which the mechanisms usually involve high force or impact, such as being hit by a motor vehicle (range from 24% to 71%) or being an occupant in a motor vehicle collision (range from 13% to 53%).3 Pelvic fractures have multiple associated injuries, often severe. In children, the mortality rate due to pelvic fractures ranges from 0.5% to 20%4, and the combined head and intrapelvic injuries increase the mortality risk1,5. Thus, the mortality in children with multiple traumas are impacted significantly on pelvic fractures.2 In motor vehicle traffic accidents, children often act as pedestrians resulting in different injury patterns depending on the height of the child and the type of motor vehicle.
There are many reports on pelvic fractures in children; however, there are no corresponding studies on concomitant injuries and complications of different types of traffic injuries. Therefore, we reviewed 222 children with pelvic fractures due to traffic injuries. We aim to analyze the injury mechanism, concomitant injuries, and comorbidities during hospitalization in children with pelvic fractures due to different traffic injury types.
2. Methods
Patients in Beijing Children's Hospital aged < 18 years and diagnosed with pelvic fractures based on the international classification of diseases classification (9th and 10th editions; codes: 808.0–808.9; S30–39) between January 1, 2006, and December 31, 2021, were included in the study. Statistical analysis was performed by searching through our electronic case query system and the picture archiving and communications system. The study was approved by the ethics committee of our hospital (2021-E−070-R). The inclusion criteria were as follows: (1) initial visit after injury, (2) pelvic imaging available for evaluation from the time of injury, and (3) complete medical records. The exclusion criterion was non-traffic accident injuries.
A uniform survey form was developed to collect data on the following epidemiological factors: age, sex, cause of injury, Tile classification of the pelvic fracture, length of hospitalization, mortality, 2008 abbreviated injury scale (AIS08) score, injury severity score (ISS), associated injuries, and comorbidities during hospitalization. Associated injuries were classified by the AIS08 and further detailed by site of injury, including the head, neck, face, chest, abdomen, spine, upper extremities, and lower extremities. Data were analyzed through the AIS08 classification system by physicians with 10 years of experience. Complications during hospitalization included shock, acute respiratory failure, acid-base balance disorders, electrolyte disorders, traumatic coagulopathy, and blood clots.
The pelvic fracture was classified according to the Tile classification. The patients were categorized based on age into 3 groups: aged < 6 years, 6 – 12 years, and > 12 years. The injury mechanism was divided into 4 groups according to the cause of the traffic injury and the type of motor vehicle as follows.
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Pedestrian vs. motorbike accident (PVM): traffic accidents involving motorcycles or electric 2- or 3-wheeler and pedestrians.
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Pedestrian vs. passenger car accident (PVC): traffic accidents involving small motor vehicles with or fewer seats and pedestrians.
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Pedestrian vs. commercial vehicle accident (PVV): traffic accidents involving automobiles with more than seats or large motor vehicles, such as buses, trucks, and pedestrians.
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Motor vehicle vs. motor vehicle accident (MVM): traffic accidents involving being an occupant in a motor vehicle collision.
Statistical analysis was performed using the statistical package for the social sciences, version 19.0 (IBM Corp., Armonk, NY, USA), with measurements expressed as percentages and counts as rates or composition ratios. The ANOVA was used for measurement data, and the non-parametric rank sum test was used for non-normally distributed data. The Fisher's exact probability method was used for the count data. A non-parametric Mann-Whitney U test was performed for skewed continuous data. Statistical significance was set at a 2-tailed p value < 0.05.
3. Results
During the 16-year study period, 222 pediatric patients with pelvic fractures caused by traffic accidents were included. The study included 140 boys (63.1%) and 82 girls (36.9%) with a mean age of (5.54 ± 3.15) years (ranging from 0.4 to 15.7 years). The mean hospitalization was (17.23 ± 19.26) days. Of all enrolled cases, 44 (19.8%) were admitted to the intensive care unit (ICU).
The most common mechanism of injury was in the PVC group (91 cases, 41.0%), followed by the PVV group (78 cases, 35.1%), the MVM group (38 cases, 18.1%), and the PVM group (15 cases, 6.8%). There was no difference between the fracture subtypes and causes of injury (p = 0.411). There was a difference in AIS scores by the mechanism of injury (p = 0.020), with MVM having a significantly higher AIS score (15.47 ± 12.28) than those of the other groups (Table 1). There was an age difference between injury mechanisms (p = 0.011), with a maximum age of (7.00 ± 3.60) years in the MVM group. The age in the remaining 3 groups was similar to the overall mean age (Table 1). There was a difference in the hospitalization between injury mechanisms (p = 0.004), and a longer hospital stay was found in the PVV group. There was a significant difference between injury types admitted to the ICU ward (p = 0.004), and 14 injuries (36.8%) required ICU admission in the MVM group, significantly higher than those in other groups (Table 1).
Table 1.
Comparison of clinical presentation of pediatric pelvic fractures based on the mechanism of injury.
| Variables | Total cases (n = 222) | PVM (n = 15) | PVC (n = 91) | PVV (n = 78) | MVM (n = 38) | p value |
|---|---|---|---|---|---|---|
| Age (year) | 5.54 ± 3.15 | 4.49 ± 1.62 | 5.42 ± 3.08 | 5.17 ± 3.05 | 7.00 ± 3.60 | 0.011a |
| Male sex | 140 (63.1) | 10 (66.7) | 60 (65.9) | 51 (65.4) | 19 (50.0) | 0.338 |
| AIS score | 11.79 ± 8.75 | 10.53 ± 5.82 | 10.29 ± 7.44 | 11.99 ± 8.15 | 15.47 ± 12.28 | 0.020a |
| ISS | 16.44 ± 11.80 | 15.00 ± 10.54 | 15.03 ± 11.11 | 16.58 ± 11.37 | 20.08 ± 14.17 | 0.161 |
| Hospitalization (day) | 17.23 ± 19.26 | 24.13 ± 21.77 | 13.23 ± 12.11 | 22.49 ± 26.57 | 13.26 ± 8.82 | 0.004a |
| Blood transfusion | 79 (35.6) | 7 (46.7) | 18 (19.8) | 33 (42.3) | 21 (55.3) | < 0.001a |
| ICU stay | 44 (19.8) | 3 (20.0) | 11 (12.1) | 16 (20.5) | 14 (36.8) | 0.017a |
| Mortality | 11 (5.0) | 0 (0) | 3 (3.3) | 5 (6.4) | 3 (7.9) | 0.537 |
| In-hospital complication | 59 (26.6) | 5 (33.3) | 13 (14.3) | 25 (32.1) | 16 (42.1) | 0.003a |
PVM: pedestrian vs. motorcycle; PVC: pedestrian vs. passenger car; PVV: pedestrian vs. commercial vehicle; MVM: motor vehicle vs. motor vehicle, AIS: abbreviated injury scale; ISS: injury severity score; ICU: intensive care unit.
Data presented as n (%) or mean ± SD.
Indicates statistical significance.
The combined associated pelvic fracture injury rate was 89.2% (198 cases), with most injuries occurring in the abdomen (64.9%) and lower extremities (44.6%), followed by the chest (36.5%) and the head (29.3%) (Table 2). The associated injuries required surgical treatment in 114 (51.4%) cases. Regarding specific organs, the highest number of injuries occurred in the lungs (72, 32.4%), followed by the skull (38, 17.1%), which also had the most severe injuries, and the urethra (31, 14.0%). The highest fracture occurrence in the extremities was in the femur (42, 18.9%), followed by the tibia (24, 10.8%), and the femoral neck (21, 9.5%). There were differences in the injury mechanisms for the associated injuries at each site (Table 2). Head (p = 0.001) and facial (p = 0.037) injuries occurred more often in the MVM group, whereas abdominal (p = 0.048) and lower extremity (p = 0.037) injuries occurred more often in the PVV group. The sites of combined injury caused by MVM were the cranium (p = 0.004), ear (p = 0.009), and femoral neck (p = 0.044), the sites caused by PVM were the mediastinum (p = 0.004), lumbar spine (p = 0.008), and spinal cord (p = 0.011), and the sites caused by PVV were the perineum (p < 0.001), urethra (p = 0.001), rectum (p = 0.006), anus (p = 0.004), and lower-extremity soft tissue (p = 0.024) (Table 2).
Table 2.
Specific injury situations and different injury mechanisms of each part.
| Parameters | Overall | PVM | PVC | PVV | MVM | p value |
|---|---|---|---|---|---|---|
| Tile classification | 0.411 | |||||
| Tile A | 147 (66.2) | 11 (73.3) | 65 (71.4) | 44 (56.4) | 27 (71.1) | |
| Tile B | 24 (10.8) | 1 (6.7) | 10 (11.0) | 9 (11.5) | 4 (10.5) | |
| Tile C | 51 (23.0) | 3 (20.0) | 16 (17.6) | 25 (32.1) | 7 (18.4) | |
| Pelvic AIS score | 2.85 ± 1.71 | 2.87 ± 1.51 | 2.64 ± 1.41 | 3.19 ± 2.11 | 2.63 ± 1.422 | 0.166 |
| Management | 0.108 | |||||
| Conservative | 162 (73.0) | 10 (66.7) | 71 (78.0) | 50 (64.1) | 31 (81.6) | |
| Surgery | 60 (27.0) | 5 (33.3) | 20 (22.0) | 28 (35.9) | 7 (18.4) | |
| Associated injuries | ||||||
| Head | 65 (29.3) | 5 (33.3) | 28 (30.8) | 12 (15.4) | 20 (52.6) | 0.001a |
| Simple scalp trauma | 21 (9.5) | 2 (13.3) | 7 (7.7) | 6 (7.7) | 6 (15.8) | 0.384 |
| Simple skull fracture | 6 (2.7) | 1 (6.7) | 4 (4.4) | 0 (0) | 1 (2.6) | 0.137 |
| Craniocerebral injury | 38 (17.1) | 2 (13.3) | 17 (18.7) | 6 (7.7) | 13 (34.2) | 0.004a |
| Facial | 45 (20.3) | 5 (33.3) | 16 (17.6) | 11 (14.1) | 13 (34.2) | 0.037a |
| Face | 27 (12.2) | 3 (20.0) | 11 (12.1) | 6 (7.7) | 7 (18.4) | 0.241 |
| Eye | 21 (9.5) | 1 (6.7) | 7 (7.7) | 6 (7.7) | 7 (18.4) | 0.258 |
| Nose | 1 (0.5) | 0 (0) | 0 (0) | 0 (0) | 1 (2.6) | 0.239 |
| Ear | 7 (3.2) | 2 (13.3) | 2 (2.2) | 0 (0) | 3 (7.9) | 0.009a |
| Oral cavity and upper and lower jaw | 8 (3.6) | 0 (0) | 4 (4.4) | 2 (2.6) | 2 (5.3) | 0.838 |
| Neck | 2 (0.9) | 1 (6.7) | 0 (0) | 1 (1.3) | 0 (0) | 0.100 |
| Chest | 81 (36.5) | 4 (26.7) | 32 (35.2) | 28 (35.9) | 17 (44.7) | 0.610 |
| Lung | 72 (32.4) | 3 (20.0) | 30 (33.0) | 23 (29.5) | 16 (42.1) | 0.420 |
| Rib | 18 (8.1) | 0 (0) | 9 (9.9) | 6 (7.7) | 3 (7.9) | 0.794 |
| Mediastinum | 2 (0.9) | 2 (13.3) | 0 (0) | 0 (0) | 0 (0) | 0.004a |
| Abdomen | 144 (64.9) | 8 (53.3) | 53 (58.2) | 60 (76.9) | 23 (60.5) | 0.048a |
| Liver | 28 (12.6) | 0 (0) | 13 (14.3) | 9 (11.5) | 6 (15.8) | 0.460 |
| Spleen | 18 (8.1) | 0 (0) | 7 (7.7) | 7 (9.0) | 4 (10.5) | 0.735 |
| Kidney | 18 (8.1) | 1 (6.7) | 8 (8.8) | 4 (5.1) | 5 (13.2) | 0.446 |
| Pancreas | 11 (5.0) | 0 (0) | 2 (2.2) | 4 (5.1) | 5 (13.2) | 0.079 |
| Perineum | 40 (18.0) | 3 (20.0) | 10 (11.0) | 26 (33.3) | 1 (2.6) | <0.001a |
| Bladder | 12 (5.4) | 0 (0) | 7 (7.7) | 3 (3.8) | 2 (5.3) | 0.631 |
| Urethra | 31 (14.0) | 2 (13.3) | 6 (6.6) | 21 (26.9) | 2 (5.3) | 0.001a |
| Small intestine | 11 (5.0) | 2 (13.3) | 3 (3.3) | 4 (5.1) | 2 (5.3) | 0.362 |
| Colon | 4 (1.8) | 0 (0) | 1 (1.1) | 2(2.6) | 1 (2.6) | 0.742 |
| Rectum | 7 (3.2) | 0 (0) | 0 (0) | 7 (9.0) | 0 (0) | 0.006a |
| Anus | 15 (6.8) | 0 (0) | 2 (2.2) | 12(15.4) | 1 (2.6) | 0.004a |
| Spine | 33 (14.9) | 5 (33.3) | 10 (11.0) | 11 (14.1) | 7 (18.4) | 0.133 |
| Cervical vertebra | 8 (3.6) | 0 (0) | 3 (3.3) | 5 (6.4) | 0 (0) | 0.393 |
| Thoracic vertebra | 8 (3.6) | 0 (0) | 4 (4.4) | 2 (2.6) | 2 (5.3) | 0.837 |
| Lumbar vertebra | 9 (4.1) | 3 (20.0) | 2 (2.2) | 1 (1.3) | 3 (7.9) | 0.008a |
| Sacral spine | 36 (16.2) | 2 (13.3) | 14 (15.4) | 9 (11.5) | 11 (28.9) | 0.132 |
| Spinal cord | 6 (2.7) | 2 (13.3) | 0 (0) | 2 (2.6) | 2 (5.3) | 0.011a |
| Upper extremity | 43 (19.4) | 4 (26.7) | 18 (19.8) | 11 (14.1) | 10 (26.3) | 0.326 |
| Clavicle | 15 (6.8) | 1 (6.7) | 7 (7.7) | 3 (3.8) | 4 (10.5) | 0.472 |
| Humerus | 12 (5.4) | 2 (13.3) | 6 (6.6) | 2 (2.6) | 2 (5.3) | 0.261 |
| Radius | 4 (1.8) | 1 (6.7) | 1(1.1) | 1 (1.3) | 1 (2.6) | 0.299 |
| Ulna | 2 (0.9) | 0 (0) | 0(0) | 1 (1.3) | 1 (2.6) | 0.293 |
| Hand | 1 (0.5) | 0 (0) | 1 (1.1) | 0 (0) | 0 (0) | 1 |
| Lower limbs | 99 (44.6) | 4 (26.7) | 33 (36.3) | 43 (55.1) | 19 (50.0) | 0.037a |
| Femoral neck | 21 (9.5) | 0 (0) | 5(5.5) | 8 (10.3) | 8 (21.1) | 0.044a |
| Femur | 42 (18.9) | 4 (26.7) | 15 (16.5) | 17 (21.8) | 6 (15.8) | 0.637 |
| Tibia | 24 (10.8) | 0 (0) | 10 (11.0) | 10 (12.8) | 4 (10.5) | 0.653 |
| Fibula | 15 (6.8) | 0 (0) | 8 (8.8) | 4 (5.1) | 3 (7.9) | 0.668 |
| Foot | 7 (3.2) | 0 (0) | 1 (1.1) | 6 (7.7) | 0 (0) | 0.076 |
| Soft tissues of the lower extremities | 39 (17.6) | 1 (6.7) | 10 (11.0) | 22 (28.2) | 6 (15.8) | 0.024a |
| Lower limb vascular injury | 5 (2.3) | 0 (0) | 1 (1.1) | 3 (3.8) | 1 (2.6) | 0.652 |
AIS: abbreviated injury scale score; ISS: injury severity score; ICU: intensive care unit; PVM: pedestrian vs. motorcycle; PVC: pedestrian vs. passenger car; PVV: pedestrian vs. commercial vehicle; MVM: motor vehicle vs. motor vehicle.
Data is presented as n (%) or mean ± SD.
Indicates statistical significance.
Blood transfusion was performed in 79 (35.6%) patients. No significant difference was observed in the classifications of pelvic fractures between the groups (p = 0.776) (Table 3). However, there was a difference in the requirement for blood transfusion between injury mechanisms (p < 0.001), and the percentage of transfusions was significantly higher in the MVM group (21, 55.3%) than in the other groups (Table 1). There was no difference in the mean hospitalization between the fracture subtypes (p = 0.135). There were no differences in the pelvic injury subtypes and injury sites between the groups (Table 3).
Table 3.
Comparison of clinical presentations and outcomes of pediatric pelvic fractures based on the Tile classification.
| Variables | Tile A | Tile B | Tile C | p value |
|---|---|---|---|---|
| Male sex | 96 (65.3) | 13 (54.2) | 31 (60.8) | 0.536 |
| Age (year) | 5.66 ± 3.08 | 4.40 ± 2.56 | 5.72 ± 3.54 | 0.170 |
| AIS | 11.21 ± 9.24 | 12.96 ± 10.05 | 12.90 ± 6.30 | 0.389 |
| ISS | 16.69 ± 12.31 | 16.63 ± 12.10 | 15.63 ± 10.24 | 0.857 |
| Hospitalization (day) | 15.84 ± 19.52 | 17.17 ± 17.18 | 21.24 ± 19.23 | 0.228 |
| Blood transfusion | 53 (36.1) | 7 (29.2) | 19 (37.3) | 0.776 |
| ICU stay | 29 (19.7) | 4 (16.7) | 11 (21.6) | 0.903 |
| Mortality | 6 (4.1) | 1 (4.2) | 4 (7.8) | 0.504 |
| Associated injuries | ||||
| Head | 47 (32.0) | 7 (29.2) | 11 (21.6) | 0.372 |
| Face | 32 (21.8) | 6 (25.0) | 7 (13.7) | 0.398 |
| Neck | 2 (1.4) | 0 (0) | 0 (0) | 1 |
| Chest | 57 (38.8) | 5 (20.8) | 19 (37.3) | 0.237 |
| Abdomen | 90 (61.2) | 18 (75.0) | 36 (70.6) | 0.263 |
| Spine | 21 (14.3) | 2 (8.3) | 10 (19.6) | 0.450 |
| Upper extremity | 32 (21.8) | 3 (12.5) | 8 (15.7) | 0.508 |
| Lower extremity | 61 (41.5) | 14 (58.3) | 24 (47.1) | 0.282 |
| Management | ||||
| Conservative | 143 (97.3) | 9 (37.5) | 10 (19.6) | <0.001a |
| Surgery | 4 (2.7) | 15 (62.5) | 41 (80.4) | |
| In-hospital complications | 37 (25.2) | 8 (33.3) | 14 (27.5) | 0.694 |
AIS: abbreviated injury scale score; ISS: injury severity score; ICU: intensive care unit.
Data is presented as n (%) or mean ± SD.
Indicates statistical significance.
The number of injury sites is summarized in Table 4. Two injuries had the highest occurrence (30.2%), followed by a single injury (26.1%) and 4 injuries (16.7%). Regarding the proportion of combined multi-regional injuries, the highest proportion was for simple abdominal injuries (13.1%), followed by abdominal and lower extremity injuries (12.6%) and simple pelvic fractures (7.2%). Other common types of combined injuries were lower extremity (5.9%), chest and abdomen (4.5%), head (2.7%), face and abdomen (2.3%), chest and abdomen and upper extremity and lower extremity (2.3%), and abdomen and upper extremity (1.8%). There was a correlation between the number of injured areas and the occurrence of complications, blood transfusion, and ICU stay (p < 0.001).
Table 4.
The summary of the cases with different number of injury sites, n = 222.
| Variables | 0 | 1 | 2 | 3 | 4 | 5 | 6 and 7 | p value |
|---|---|---|---|---|---|---|---|---|
| Number of injury sites | 16 (7.2) | 58 (26.1) | 67 (30.2) | 27 (12.2) | 37 (16.7) | 14 (6.3) | 3 (1.4) | |
| ICU | 0 (0) | 4 (6.9) | 11 (16.4) | 7 (25.9) | 13 (35.1) | 7 (50.0) | 3 (100) | < 0.001a |
| Mortality | 0 (0) | 1 (1.7) | 3 (4.5) | 1 (3.7) | 4 (10.8) | 2 (14.3) | 0 (0) | 0.280 |
| Blood transfusion | 0 (0) | 7 (12.1) | 22 (32.8) | 13 (48.1) | 22 (59.5) | 12 (85.7) | 3 (100) | < 0.001a |
| In-hospital complications | 0 (0) | 9 (15.5) | 15 (22.4) | 8 (29.6) | 16 (43.2) | 8 (57.1) | 3 (100) | < 0.001a |
ICU: intensive care unit.
Indicates statistical significance.
Associated injuries, classified into 3 groups according to the children's age, are presented in Table 5. The pelvic AIS score was higher in children aged > 12 years (p = 0.019). There was a difference between the 3 age groups in terms of pelvic injury typing (p = 0.033), with those aged > 12 years more likely to have Tile C fractures, those aged 6 – 12 years more likely to have Tile A fractures, and those < 6 years more likely to have Tile B fractures (Fig. 1). Patients < 6 years of age were more likely to have injuries to the small intestine (p = 0.042). There were no differences in complications among the different age groups. Children aged > 12 years were more likely to sustain injuries to the spleen (p = 0.022), kidneys (p = 0.019), pancreas (p < 0.001), lumbar spine (p = 0.013), and sacral spine (p = 0.024) (Table 5).
Table 5.
Age group and associated injuries.
| Variables | < 6 years | 6 – 12 years | > 12 years | p value |
|---|---|---|---|---|
| Tile classification | 0.033a | |||
| Tile A | 90 (62.5) | 51 (78.5) | 6 (46.2) | |
| Tile B | 20 (13.9) | 3 (4.6) | 1 (7.7) | |
| Tile C | 34 (23.6) | 11 (16.9) | 6 (46.2) | |
| Males | 89 (61.8) | 45 (69.2) | 6 (46.2) | 0.262 |
| AIS | 11.12 ± 7.76 | 12.46 ± 10.27 | 14.75 ± 9.78 | 0.133 |
| ISS | 16.01 ± 11.72 | 16.58 ± 11.90 | 19.00 ± 11.59 | 0.426 |
| Pelvic AIS | 2.87 ± 1.62 | 2.58 ± 1.67 | 4.08 ± 2.39 | 0.019a |
| hospitalization (day) | 17.78 ± 20.83 | 15.38 ± 13.46 | 19.75 ± 26.89 | 0.599 |
| Blood transfusion | 51 (35.4) | 22 (33.8) | 6 (46.2) | 0.729 |
| ICU stay | 27 (18.8) | 14 (21.5) | 3 (23.1) | 0.809 |
| Mortality | 6 (4.2) | 4 (6.2) | 1 (7.7) | 0.472 |
| Direction of cars | 0.017a | |||
| Forward | 111 (77.1) | 50 (76.9) | 8 (61.5) | |
| Backup | 11 (7.6) | 0 (0) | 0 (0) | |
| Turn | 4 (7.6) | 0 (0) | 0 (0) | |
| Between motor vehicles | 18 (12.5) | 15 (23.1) | 5 (38.5) | |
| Associated injuries | 0.930 | |||
| Head | 37 (25.7) | 23 (35.4) | 5 (38.5) | 0.250 |
| Face | 28 (19.4) | 13 (20.0) | 4 (30.8) | 0.589 |
| Neck | 1 (0.7) | 1 (1.5) | 0 (0) | 0.574 |
| Chest | 49 (34.0) | 24 (36.9) | 8 (61.5) | 0.139 |
| Abdomen | 90 (62.5) | 47 (72.3) | 7 (53.8) | 0.249 |
| Spine | 21 (14.6) | 7 (10.8) | 5 (38.5) | 0.048a |
| Upper extremity | 29 (20.1) | 12 (18.5) | 2 (15.4) | 0.957 |
| Lower extremity | 61 (42.4) | 33 (50.8) | 5 (38.5) | 0.474 |
| Management | 0.214 | |||
| Conservative | 102 (70.8) | 52 (80.0) | 8 (61.5) | |
| Surgery | 42 (29.2) | 13 (20.0) | 5 (38.5) | |
| In-hospital complications | 38 (26.4) | 16 (24.6) | 5 (38.5) | 0.583 |
| Head | ||||
| Simple scalp trauma | 10 (6.9) | 8 (12.3) | 3 (23.1) | 0.093 |
| Simple skull fracture | 4 (2.8) | 2 (3.1) | 0 (0) | 1 |
| Craniocerebral | 23 (16.0) | 13 (20.0) | 2 (15.4) | 0.797 |
| Facial | ||||
| Face | 18 (12.5) | 7 (10.8) | 2 (15.4) | 0.784 |
| Eye | 14 (9.7) | 6 (9.2) | 1 (7.7) | 1 |
| Nose | 1 (0.7) | 0 (0) | 0 (0) | 1 |
| Ear | 5 (3.5) | 2 (3.1) | 0 (0) | 1 |
| Oral cavity and upper and lower jaw | 4 (2.8) | 2 (3.1) | 2 (15.4) | 0.091 |
| Chest | ||||
| Lung | 42 (29.2) | 23 (35.4) | 7 (53.8) | 0.167 |
| Rib | 12 (8.3) | 4 (6.2) | 2 (15.4) | 0.397 |
| Mediastinum | 2 (1.4) | 0 (0) | 0 (0) | 1 |
| Abdomen | ||||
| Liver | 19 (13.2) | 8 (12.3) | 1 (7.7) | 1 |
| Spleen | 9 (6.3) | 5 (7.7) | 4 (30.8) | 0.022a |
| Kidney | 7 (4.9) | 8 (12.3) | 3 (23.1) | 0.019a |
| Pancreas | 1 (0.7) | 8 (12.3) | 2 (15.4) | < 0.001a |
| Perineum | 28 (19.4) | 11 (16.9) | 1 (7.7) | 0.611 |
| Bladder | 7 (4.9) | 3 (4.6) | 2 (15.4) | 0.269 |
| Urethra | 17 (11.8) | 14 (21.5) | 0 (0) | 0.071 |
| Small intestine | 11 (7.6) | 0 (0) | 0 (0) | 0.042a |
| Colon | 2 (1.4) | 2 (3.1) | 0 (0) | 0.682 |
| Rectum | 4 (2.8) | 2 (3.1) | 1 (7.7) | 0.483 |
| Anus | 9 (6.3) | 3 (4.6) | 3 (23.1) | 0.076 |
| Spine | ||||
| Cervical vertebra | 6 (4.2) | 1 (1.5) | 1 (7.7) | 0.286 |
| Thoracic vertebra | 3 (2.1) | 4 (6.2) | 1 (7.7) | 0.213 |
| Spinal cord | 6 (4.2) | 0 (0) | 0 (0) | 0.256 |
| Lumbar vertebra | 5 (3.5) | 1 (1.5) | 3 (23.1) | 0.013a |
| Sacral spine | 21(14.6) | 9 (13.8) | 6 (46.2) | 0.024a |
| Upper extremity | ||||
| Clavicle | 11 (7.6) | 3 (4.6) | 1 (7.7) | 0.657 |
| Humerus | 8 (5.6) | 4 (6.2) | 0 (0) | 1 |
| Radius | 2 (1.4) | 2 (3.1) | 0 (0) | 0.678 |
| Ulna | 2 (1.4) | 0 (0) | 0 (0) | 1 |
| Hand | 1 (0.7) | 0 (0) | 0 (0) | 1 |
| Lower limbs | ||||
| Femoral neck | 12 (8.3) | 7 (10.8) | 2 (15.4) | 0.461 |
| Femur | 28 (19.4) | 13 (20.0) | 1 (7.7) | 0.706 |
| Tibia | 13 (9.0) | 9 (13.8) | 2 (15.4) | 0.401 |
| Fibula | 7 (4.9) | 7 (10.8) | 1 (7.7) | 0.190 |
| Foot | 5 (3.5) | 2 (3.1) | 0 (0) | 1 |
| Soft tissues of the lower extremities | 25 (17.4) | 12 (18.5) | 2 (15.4) | 0.957 |
| Lower limb vascular injury | 3 (2.1) | 2 (3.1) | 0 (0) | 0.746 |
AIS: abbreviated injury scale score; ISS: injury severity score; ICU: intensive care unit.
Data is presented as n (%) or mean ± SD.
Indicates statistical significance.
Fig. 1.
Age group and Tile classification.
Eleven deaths occurred in 222 patients, with a mortality rate of 5.0%. The causes of death were severe head trauma (5 patients), iliac vessel rupture and severe pelvic fracture (1 patient), closed abdominal trauma (1 patient), multiple organ failure (3 patients), and pulmonary complications (1 patient). There was no correlation between death and the number of injury sites (p = 0.280) (Table 4). Based on the injury mechanism, 3 deaths were due to PVC, 5 deaths were due to PVV, and 3 deaths were due to MVM (Table 1). There were no differences in mortality rates according to injury types (Table 1) or pelvic injury subtypes (Table 3).
Fifty-nine patients (26.6%) experienced complications during hospitalization (Table 6). Complications included 26 cases (11.7%) of shock, 21 cases (9.5%) of hepatic impairment, 20 cases (9.0%) of myocardial impairment, and 20 cases (9.0%) of electrolyte disturbance. Among the 26 patients with shock, 21 had hemorrhagic shock and 5 had traumatic shock. There were 33 cases of acute respiratory failure, including 14 cases of central respiratory failure and no cases of acute respiratory distress syndrome. Complication occurrence was mainly related to the injury mechanism, and the complication rate was significantly higher with increased ISS and AIS scores. Regarding complications during hospitalization, there were differences in injury mechanisms between the groups (p = 0.003), with the highest complication rate in the MVM group (16, 42.1%). Acute respiratory failure (p < 0.001), myocardial damage (p = 0.031), hypoproteinemia (p = 0.046), and stress ulcers (p = 0.004) had the highest incidence in the MVM group. Skin soft tissue infections (p = 0.031) had the highest incidence in the PVV group (Table 6).
Table 6.
Comparison of in-complications based on the cause of the injury.
| Type of complication | PVM | PVC | PVV | MVM | p value |
|---|---|---|---|---|---|
| In-hospital complications | 5 (33.3) | 13 (14.3) | 25 (32.1) | 16 (42.1) | 0.003a |
| Shock | 2 (13.3) | 6 (6.6) | 11 (14.1) | 7 (18.4) | 0.156 |
| Acute respiratory failure | 2 (13.3) | 2 (2.2) | 1 (1.3) | 9 (23.7) | 0.000a |
| Hypoxic encephalopathy | 0 (0) | 0 (0) | 1 (1.3) | 1 (2.6) | 0.278 |
| Liver function damage | 1 (6.7) | 6 (6.6) | 6 (7.7) | 8 (21.1) | 0.089 |
| Renal function damage | 0 (0) | 0 (0.0) | 0 (0) | 0 (0) | |
| Myocardial damage | 1 (6.7) | 4 (4.4) | 7 (9.0) | 8 (21.1) | 0.031a |
| Malignant arrhythmia | 0 (0) | 0 (0.0) | 0 (0.0) | 1 (2.6) | 0.237 |
| Electrolyte disorder | 1 (6.7) | 4 (4.4) | 8 (10.3) | 7 (18.4) | 0.072 |
| Stress hyperglycemia | 0 (0) | 3 (3.3) | 3 (3.8) | 1 (2.6) | 1.000 |
| Acid-base balance disorder | 0 (0) | 3 (3.3) | 2 (2.6) | 3 (7.9) | 0.480 |
| Dysfunction of blood coagulation | 1 (6.7) | 2 (2.2) | 4 (5.1) | 3 (7.9) | 0.346 |
| Traumatic coagulopathy | 0 (0) | 0 (0) | 3 (3.8) | 1 (2.6) | 0.251 |
| Thrombosis | 0 (0) | 0 (0) | 1 (1.3) | 1 (2.6) | 0.278 |
| Osteofascial compartment syndrome | 0 (0) | 0 (0) | 1 (1.3) | 1 (2.6) | 0.278 |
| Hypoproteinemia | 0 (0) | 2 (2.2) | 7 (9.0) | 5 (13.2) | 0.046a |
| Rhabdomyolysis | 0 (0) | 2 (2.2) | 6 (7.7) | 1 (2.6) | 0.346 |
| systemic capillary leak syndrome | 1 (6.7) | 0 (0) | 0 (0) | 0 (0) | 0.067 |
| Stress ulcer | 1 (6.7) | 0 (0) | 0 (0) | 3 (7.9) | 0.004a |
| Skin necrosis | 0 (0) | 0 (0) | 3 (3.8) | 0 (0) | 0.241 |
| Sepsis | 1 (6.7) | 0 (0) | 2 (2.6) | 1 (2.6) | 0.104 |
| Septic meningitis | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Pneumonia | 1 (6.7) | 4 (4.4) | 5 (6.4) | 2 (5.3) | 0.906 |
| Urinary tract infection | 0 (0) | 1 (1.1) | 0 (0) | 0 (0) | 1 |
| Skin soft tissue infection | 0 (0) | 0 (0) | 5 (6.4) | 0 (0) | 0.031a |
PVM: pedestrian vs. motorcycle; PVC: pedestrian vs. passenger car; PVV: pedestrian vs. commercial vehicle; MVM: motor vehicle vs. motor vehicle.
Data is presented as n (%) unless otherwise stated.
Indicates statistical significance.
4. Discussion
In this single-center study, we analyzed the clinical characteristics, injury patterns, and complications of 222 children with pelvic injuries caused by traffic accidents hospitalized in Beijing Children's Hospital, Capital Medical University. The main findings of this study are that (1) PVC is the primary cause of pelvic injury in the pediatric population, (2) abdominal and lower extremity injuries have the highest incidence of concomitant injuries and older children were more likely to have severe pelvic fractures and peripelvic organs injuries, and (3) the MVM group had the highest extent of injury and complication rates.
Pelvic fractures are usually the result of high-energy injuries, most commonly traffic injuries. PVC is the most common injury mechanism in traffic accidents, similar to adult patients with pelvic fractures, which has been reported in several previous studies.6,7 However, children are more likely than adults to be involved in traffic accidents, usually when they are struck from the side by a car and thus suffer lateral compression injury. In contrast, in adult-related traffic injuries, patients most often suffer direct frontal-impact injuries, which typically results in “open book” fractures or even more severe soft tissue injuries. The highest extent of injury and complication rates occurred in the MVM group, which is related to the injury mechanism. Traffic accidents in the MVM group tend to be direct collisions, with higher energy at the time of the collision, which is more likely to result in serious injuries. Some children are injured more severely because they are not wearing a seatbelt or are being held by a parent.
Blood transfusion was required in 35.6% of patients, with a significantly higher percentage in the MVM group. AIS scores were significantly higher in the MVM group. No differences were observed in the pelvic fracture classification or blood transfusion rate between the groups. Thus, no significant hemorrhage occurred in children with pelvic fractures due to traffic injuries, and hemorrhage was mainly related to the extent of injury (systemic injury), similar to previous reports.8 A previous study comparing pelvic fractures in children and adults, reported that Tile C fractures were more frequent and might result in major hemorrhage.9 Another study concluded that hemodynamic instability in children arises more from disruption of the visceral rather than the pelvic vascular system.2 Moreover, pelvic fractures in children were not a major contributor to blood loss and death.2,10 Previous literature has reported that adults with pelvic fractures are more likely to have Tile C fractures and a higher frequency of blood instability during emergency room visits.9 Our data revealed that Tile C fractures and the need for blood transfusions occurred at a higher rate in patients aged > 12 years than in the other 2 groups, which suggested that pelvic fractures in children approaching maturity should be managed using the same principles used for adult pelvic fracture as their pelvic injury patterns closely resemble those of adults.
Associated injuries occurred in 89.2% of our patients, indicating that patients with pelvic fractures caused by high-energy injuries often had more combined injuries, similar to previous studies.11, 12, 13 Injuries to the abdomen and lower extremities were most common, followed by injuries to the chest and head. The rate of associated injuries was slightly higher in our study than in previous studies6,13,14, possibly because there were more patients with severe injuries in the emergency room of our pediatric medical center. In this study, 67.7% of the patients had more than 2 sites of injury, with most of the associated injuries being in the abdominal and lower extremities and related to the site of impact at the time of injury. The tibia, fibula, femur, pelvis, rib cage, cervical spine, and head were primarily affected in collision injuries related to adult and small motor vehicles. Tibiofibular fractures and head injuries are most common, along with fractures of the femur, pelvis, ribs, and cervical spine.15 According to our medical records, the highest incidence of organ injuries was in the lungs at 32.4%, followed by the brain at 17.1% which was also the most severe, and the urethra at 14.0%. The highest incidence of fractures of the extremities was in the femur, tibia, and femur neck at 18.9%, 10.8%, and 9.5%, respectively. According to previous studies, the height of a typical automobile hood is 85 cm, and thus, for an adult, a fracture may occur when the front bumper of a small car collides with a pedestrian's lower leg, or the upper end of the femur collides with the front edge of the hood.7,9,16 In contrast, children are more likely to sustain abdominal and lower extremity injuries along with combined pelvic fractures.
Based on different mechanisms of injuries, MVM is more likely to cause head and facial injuries because of the lack of immobilization of the head and neck. Although MVM injury is caused by high-energy; the incidence of cervical spine injury in children is significantly lower than that in adults, which may be related to children's anatomical structures. PVV is more likely to cause abdominal and lower extremity injuries, among which perineal, urethral, rectal, anal, and lower-extremity soft tissues are more common. The heavy weight of the commercial vehicle and long braking distance, crush injuries are more likely to occur. Therefore, PVV patients are more likely to have open injuries around the pelvis and lower extremities. PVM is more likely to involve injuries to the mediastinum, lumbar spine, and spinal cord due to the concentration of force at the point of impact.
According to our patient data, children aged < 12 years had higher pelvic AIS scores and were more likely to have Tile C fractures. In contrast, Tile A fractures occurred between the ages of 6 and 12 years, and Tile B fractures were more likely to occur in children aged < 6 years. This is related to the maturation of the pelvis, which has been previously reported in the literature.13 As the pelvis matures, the mechanical properties change and lose elasticity, making children with more mature skeletal more susceptible to severe pelvic fractures.17 From our data, children aged < 12 years were more likely to have spleen, kidney, pancreas, lumbar spine, and sacral spine injuries, which might be related to reduced pelvic elasticity and lower cushioning energy of the abdominal organs. Due to the vehicle's blind spot, backing and turning accidents often occur in children aged < 6 years. The incidence rate of injury for children aged > 12 years was higher in motor vehicle accidents.
Children with combined pelvic fractures caused by a car accident are at increased risk for complications such as shock and acute respiratory failure during hospitalization.18, 19, 20 Although postoperative complications such as acute respiratory distress syndrome, venous thromboembolism, and multiorgan failure are less common in children than in adults, according to a previous study; however, severe complications often affect survival rates in children.19 We reviewed our data and discovered that the complication rate during hospitalization was relatively high, reaching 26.6%, in which MVM was more likely to lead to complications due to the high-energy of impact. The statistical mortality rate in our study is 0.5% similar to that reported in previous studies.2,13,18,21,22 The mortality rate of children with pelvic fractures was not directly correlated with the severity of the fractures. Instead, the deaths were primarily caused by accompanying injuries, which were in line with the severity of the initial injury. This finding is consistent with earlier research findings.7,10 A previous study discovered that the injury type was associated with the severity. According to our medical records, head injury was one of the leading causes of death in patients, followed by multiple organ failure.23
Our study has some limitations. First, it is a retrospective study and may be subject to selection bias and confounding factors. Second, all data were obtained from a single medical facility in a city and the results may not be applicable to the entire population of children. Third, only vehicle type was considered for the study, and other relevant factors such as speed were not taken into account. A study of relevant other transportation data might lead to more reliable conclusions.
In conclusion, this study reveals that high-energy injuries often cause pelvic fractures in children. PVC was the leading cause of these injuries, and the abdomen and lower extremities had the highest occurrence of concomitant injuries. Furthermore, different traffic injuries often lead to different associated injuries. Older children were more likely to sustain more severe pelvic fractures and peripelvic organ injuries, and the MVM group had the highest extent of injury and complication rates.
Funding
This research was supported by the National Key R&D Program of China [grant number: 2020YFC1107604]. The funding source was not involved in the study design; data collection, analysis, and interpretation; the writing of the report; or the decision to submit the article for publication.
Ethical statement
The study was approved by the Ethics Committee of Beijing Children's Hospital, Capital Medical University. (2021-E−070-R).
Declaration of competing interest
The authors declare that they have no competing interest.
Author contributions
Bao-Jian Song: Manuscript preparation, study design, collection and analysis of data.
Qiang Wang: Study design, Manuscript preparation.
Wei Feng: Study design, Manuscript preparation.
Dan-Jiang Zhu: Study design, Manuscript preparation.
Xue-Jun Zhang: Manuscript preparation, study design, analysis of data.
Footnotes
Peer review under responsibility of Chinese Medical Association.
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