Aug. 12, 2021
In March 2021 in Iowa, an all-terrain vehicle (ATV) rolled, ejecting a 13-year-old girl. A 911 call quickly prompted a dispatcher to send a Mayo One helicopter to the scene. The flight team evaluated the teen and deemed her stable for ground transport, so an ambulance drove the girl to Saint Marys Hospital. A trauma team met the girl upon arrival, checking her trauma ABCs and then performing a massive transfusion protocol with whole blood. The staff also ordered diagnostic imaging. An X-ray identified a pelvic injury, prompting a subsequent pelvic CT scan. The patient also received CT scans of the chest, abdomen, cervical spine and head.
The patient not only suffered a severe pelvic fracture but also a mesenteric hematoma, a pulmonary contusion and rib fractures. Though Brandon J. Yuan, M.D., an orthopedic traumatologist at Mayo Clinic's campus in Rochester, Minnesota, usually treats pelvic fractures in adults, the trauma team called him in for this pediatric case because of his expertise with the injury. The patient received pelvic embolization for control of hemorrhage and subsequently surgical fixation of the pelvic ring injury by Dr. Yuan.
Dr. Yuan explains that pelvic fractures often accompany other visceral injuries and are associated with pelvic bleeding and hemorrhage, yet are uncommon in a child. "A pelvic fracture is rare in children; it's seen more frequently in adults," says Dr. Yuan. "This patient was skeletally immature, but kids aren't usually in this situation — it's not as frequent because of the plasticity and strength of bone in children."
Dr. Yuan says it's easy for a pelvic fracture to go unnoticed upon physical exam. However, patients may report pain, bringing a pelvic fracture to the attention of providers. For the young patient involved in the ATV crash, Dr. Yuan credits smart deduction by her caregivers, prompting them to order imaging to identify any pelvic region injury.
"The trauma team did a good job getting the pelvic X-ray done," he says. "I imagine the reason for the decision was the patient's mechanism of injury."
Less than seven weeks after the crash in Iowa, the patient started walking again. Dr. Yuan reports she was doing fine when he saw her a month later at Mayo Clinic.
Tips from this patient's case for trauma professionals
Dr. Yuan says there are several lessons trauma professionals can learn from this case for best outcomes in similar cases:
Since a pelvic fracture, even a severe one, may be elusive, providers should have a low threshold for imaging patients involved in high-speed crashes or when the patient reports pain. Other medical facilities in southern Minnesota typically refer pediatric patients to Mayo Clinic in Rochester, Minnesota, so this imaging often takes place on the Mayo campus. Dr. Yuan recommends that providers send adult patients for pelvic X-rays locally if warranted due to the injury's mechanism of action or through patient-reported pain. Of note, Foley catheters should not be placed until the urethra has been evaluated.
Patients who report pain or have demonstrable significant injury need pain management.
If a patient needs to be sent to a hospital that offers a higher level of care, Dr. Yuan suggests doing it as soon as possible. In the young girl's case, Dr. Yuan applauds how quickly the EMS providers transferred her to the Level 1 Pediatric Trauma Center at Mayo Clinic.
Using spine precautions is wise, especially if imaging results warrant precautions. With a suspected pelvic fracture, in particular, Dr. Yuan says sometimes providers use pelvic binders. While binders are an essential part of stabilization for the patient who has experienced blunt trauma and is in shock or who's hypotensive with signs of shock, binders are not always necessary, says Dr. Yuan. In fact, pelvic binders may be painful to the patient and cause discomfort and anxiety.
Overall, Dr. Yuan maintains that a suspicious mindset is critical to pinpoint pelvic injuries. "Probably the main issue is to have a high index of suspicion for blunt pelvic injury or a patient reporting pain," he explains. "The worst case is if you don't do imaging due to concerns about exposing the child to radiation and the child has an unstable injury not recognized until a day later."