POSTGRADUATE ORTHOPEDIC INSTRUCTION - IMAGING

Case Resolution

Bibiana Dello Russo,* Mónica Galeano,** Florencia D’ Adamo^#

^*Orthopedics and Traumatology Service

^**Diagnostic Imaging Service

^#Non-Accidental Trauma Care Team

Hospital Nacional de Pediatría “Prof. Dr. Juan P. Garrahan”, Autonomous City of Buenos Aires, Argentina

Case Presentation on page 499.

ABSTRACT

We present the case of an 18-month-old boy with a displaced pelvic fracture and hip epiphysiolysis resulting from non-accidental trauma, after being dragged down a flight of stairs by his caregiver. The radiological protocol used in our institution for suspected non-accidental trauma is described, along with the diagnostic process and the orthopedic and social management implemented.

Keywords: Non-accidental trauma; pelvic fracture; hip epiphysiolysis; children.

Level of Evidence: IV

RESUMEN

Se presenta el caso de un niño de 18 meses con una fractura desplazada de pelvis y epifisiólisis de cadera producidas por un trauma no accidental al ser arrastrado por las escaleras, por su cuidadora. Se define el protocolo radiológico utilizado en nuestra institución para los casos de trauma no accidental, su diagnóstico y los tratamientos ortopédico y social.

Palabras clave: Trauma no accidental; fractura de pelvis; epifisiólisis de cadera; niños.

Nivel de Evidencia: IV

Diagnosis: Multiple pelvic and hip fractures due to non-accidental trauma in an 18-month-old child.

DISCUSSION

Puncture-aspiration was performed under anesthesia to assess the degree of epiphyseal displacement¹ and to evacuate the joint hematoma.² Then, using a small amount of contrast medium, an arthrogram was performed, which confirmed the displacement and its instability. Magnetic resonance imaging is another modality to reach the diagnosis when instability is suspected; however, an MRI scanner should be available near or within the operating room to perform it during the same anesthetic procedure (Figures 4 and 5).

Using the Parsch technique³ via a minimal Hueter approach,⁴ the displacement of the femoral head was reduced, and a screw and a pin were placed through a minimal lateral approach under fluoroscopic guidance.

Once the hip had been drained and stabilized, another cannulated screw was inserted percutaneously to stabilize the large fragment avulsed from the iliac wing. The patient was immobilized with a hip spica cast to control the open-book component, and soft-tissue traction was applied; the patient was then placed in postoperative traction. Traction was continued for 3 weeks, and anatomical reduction of the fractures was achieved (Figures 6-8).

Figures 9 and 10 show the imaging follow-up at 6 and 24 months after removal of the osteosynthesis material.

Although the pelvis of an 18-month-old child contains a large amount of cartilage, which provides increased elasticity and resistance to torsional and shear forces, this same cartilage has high remaining growth potential. Therefore, this type of high-energy trauma can cause permanent damage to the pelvic girdle, the hip joint due to injury mainly to the triradiate cartilage, and in this case, to the proximal femur.⁵

For the reasons described above, stabilization of the femoral epiphysiolysis and of the iliac wing physis was chosen using minimally invasive techniques in order to avoid additional periosteal stripping or damage to the regional blood supply.

When treating a pelvic fracture in children, the instability pattern and the degree of displacement, together with the associated growth-plate injury, must be considered. The belief that anatomical deformities will not cause problems in adulthood is unacceptable.

Vertically displaced unstable type C pelvic fractures can progress to clinically significant pelvic deformity, as well as sacroiliac fusion, scoliosis, and lower-limb length discrepancy.⁶

We must therefore make every effort to ensure that our reduction maneuvers are precise and avoid further stress on the cartilage, especially in the region of the triradiate cartilage or, as in this case, the Risser cartilage.7 Otherwise, the growth of the pelvic ring will be inhibited, and growth-plate arrest will lead to pelvic asymmetry.

In the treatment of transphyseal fracture of the proximal femur, once instability was confirmed, priority was given to achieving stability by placing a central screw, which was removed at 4 months to prevent physeal arrest per se.⁸

REFERENCES

1. Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg 1963;45(3):587-622. Available at: https://journals.lww.com/jbjsjournal/citation/1963/45030/Injuries_Involving_the_Epiphyseal_Plate.19.aspx/1000

2. Chung SMK. The arterial supply of the developing proximal end of the human femur. J Bone Joint Surg Am 1976;58(7):961-70. PMID: 977628

3. Parsch K, Weller S, Parsch D. Open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis. J Pediatr Orthop 2009;29(1):1-8. https://doi.org/10.1097/BPO.0b013e31818f0ea3

4. Hueter C. Fünfte abtheilung: die verletzung und krankheiten des hüftgelenkes, neunundzwanzigstes capitel. In: Hueter C (ed). Grundriss der chirurgie. 2nd ed. Leipzig: F.C.W. Vogel; 1883, p. 29-200.

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

6. Schlickewei W, Keck T. Pelvic and acetabular fractures in childhood. Injury 2005;36(Suppl 1):A57-63. https://doi.org/10.1016/j.injury.2004.12.014

7. Oransky M, Arduini M, Tortora M, Roa Zoppi A. Surgical treatment of unstable pelvic fracture in children: Long term results. Injury 2010;41(11):1140-4. https://doi.org/10.1016/j.injury.2010.08.002

8. Juanto M, Fernández E, Ramacciotti A, Fernández M, Franzolini M, Mussolini E. Osteosíntesis en pediatría. ¿Cuándo y por qué? Orthotips 2015;11(1):7-14. Available at: https://www.medigraphic.com/pdfs/orthotips/ot-2015/ot151b.pdf

M. Galeano ORCID ID: https://orcid.org/0000-0002-3904-3783

F. D’Adamo ORCID ID: https://orcid.org/0009-0006-9700-0999

Received on October 5th, 2024. Accepted after evaluation on December 12th, 2024 • Dr. Bibiana Dello Russo • bibianadellorusso@gmail.com • https://orcid.org/0000-0001-6487-4418

How to cite this article: Dello Russo B, Galeano M, D’Adamo F. Postgraduate Orthopedic Instruction – Imaging. Case Resolution. Rev Asoc Argent Ortop Traumatol 2025;90(6):604-608. https://doi.org/10.15417/issn.1852-7434.2025.90.6.2043

Article Info

Identification: https://doi.org/10.15417/issn.1852-7434.2025.90.6.2043

Published: December, 2025

Conflict of interests: The authors declare no conflicts of interest.

License: This article is under Attribution-NonCommertial-ShareAlike 4.0 International Creative Commons License (CC-BY-NC-SA 4.0).