Pelvic Fractures and Associated Urogenital Injuries in Children: A Systematic Review.

Introduction: Traumatic pelvic injuries are potentially life-threatening and disabling injuries that often result from high-energy impact. It is well established in the orthopaedic literature that adult pelvic fractures can result in urologic injury, especially posterior urethral injury. Pelvic trauma and associated injuries in children are less characterized than in adults and extrapolated from an older population although there are significant anatomic differences between the skeletally mature and immature pelvis. In this context, long-term urogenital sequelae of pelvic fractures, specifically in children, are not clearly and comprehensively represented in the literature. Therefore, we conducted this systematic review with 3 main objectives: (1) to identify characteristics of pediatric pelvic fractures and urogenital injuries, (2) to understand the relationship between pelvic fractures and associated urogenital injuries with their outcomes, and (3) to elucidate treatment modalities for orthopaedic pelvic injuries.

Methods: A comprehensive literature search of PubMed, Medline, SCOPUS, and Cochrane databases was conducted following the PRISMA guidelines with predefined criteria on September 1st, 2024, yielding 595 papers. The papers were screened using Rayyan QCRI and studies included for data analysis were confirmed by at least 2 reviewers. The final full manuscript review was conducted for 29 studies, encompassing a total of 838 pediatric patients with documented pelvic ring fractures and concurrent urogenital injury.

Results: Of the papers reporting on the mechanism of injury, the most common mechanism was motor vehicle collision (325/562 patients, 58%), followed by motor vehicle versus pedestrian collision (215/562, 38%), and fall (22/562, 4%). Among 161 cases where the pelvic fracture was classified, 86 (53%) had rotational or segmental instability of the pelvis, correlating to Torode and Zieg type IV and Tile-type B and C classifications. Forty-eight (30%) patients had multisite pelvic fractures. The most commonly reported urogenital injuries included urethral injury (725/807, 90%), bladder/bladder neck injury (53/807, 6.6%), and vaginal/vulvar laceration (29/807, 3.6%). Among cases where the entire urologic management of the patient was described, nonoperative management was utilized in patients rarely, (38/683, 5.5%), early urethral realignment and repair was utilized (337/683, 49%) and was the most common form of post-traumatic intervention, followed by delayed urethroplasty [284/683 (42%)].

Discussion: Many cases of pediatric pelvic fractures, ranging from 2.4% to 7.5%, present with concomitant urogenital injuries, particularly posterior urethral and bladder injuries. These urogenital injuries were more frequently reported in high-energy pelvic injuries characterized by rotational instability, multisite pelvic fractures, and pelvic ring disruptions. Generally, fractures were conservative unless surgery was indicated. In those cases, surgical fixation and plating were utilized in stabilizing the pelvic ring. Early urethral realignment and repair was the most reported surgical intervention for these associated urologic injuries, followed by cystostomy with delayed urethroplasty (generally 3 mo after injury), but the optimal time to surgery is still debated in the literature. While historically delayed repair has been favored due to the increased risk of incontinence and erectile dysfunction associated with early primary repair, endoscopic techniques have decreased the risk profile of early intervention, thus increasing its popularity.