Pelvic injuries should be assessed and managed by an orthopaedic surgeon. The following is a guide should an orthopaedic surgeon not be present initially

Beware! Paediatric patients are not always tachycardic at presentation. Apply a pelvic splint if there is suspicion of potential injury.

The initial management aims to:

• splint the pelvis to provide tamponade and prevent movement
• detect the presence of a pelvic fracture with an early X-ray / CT
• differentiate between pelvic and intra-abdominal bleeding.

The following is the standard operating procedure:

• Apply pelvic binder with history of blunt trauma and hypotension (see below).
• Pelvic binder can be applied even if lateral compression injury is suspected.
• The binder should be placed around the trochanters, not the iliac crests.
• If binder applied pre-hospital leave it. Check position and X-ray.
• If hypotensive, begin fluid resuscitation.
• Do NOT examine the pelvis for mechanical stability.
• Do NOT logroll the patient until the pelvis is cleared.
• Obtain an early pelvic X-ray (or immediate CT) to clear the pelvis.

If this X-ray is normal, the pelvis is cleared: remove binder and then consider repeating the X-ray. (An AP compression – openbook – injury can be perfectly reduced by the binder so that the plain X-ray and CT scan is normal. A check X-ray after removal of the binder will identify this problem.) If there is haemodynamic instability, replace the binder.

If a pelvic fracture is present:

• You can leave binder in place for up to 24 hours unless patient has severe neurological deficit (eg. paraplegia).
• Examine carefully for open wounds, especially in the perineum.
• If there is an open wound, including vaginal lacerations, antibiotics must be administered. Unless contraindicated, Augmentin, Gentamycin and Metronidazole are recommended.
• How essential is the logroll?
• If unilateral pelvic injury: log-roll to opposite side.
• If bilateral pelvic injury: avoid log-roll if at all possible.
• Female patient: catheterise if able. See catheterisation guidance below.
• Male patient: refer to catheterisation guidance below.

Adequate examination of the perineum, vaginal and rectum in paediatric patients will probably require an examination under anaesthesia. If so this needs to be co-ordinated with the orthopaedic team to ensure that the patient is moved in an appropriate manner to allow examination of the perineum, whilst reducing movement and preventing exacerbation of the pelvic injury.

Potential urethral injuries

If there are any concerning features present, then the case should be discussed with the on-call paediatric surgical consultant or one of the consultant paediatric urologists prior to catheterising the child.

Concerning features in a child with a pelvic fracture are:

• blood at the meatus
• haematuria since injury

In the absence of any concerning features, in particular blood at the meatus, or any history of haematuria since the accident, a single, gentle attempt at passing a urinary catheter may be undertaken. Sterile technique must be used and the procedure performed by an experienced surgeon or urologist – this is not the time to teach the technique.

• If clear urine drains, then all is good.
• If there is any element of blood staining in the fluid draining from the catheter, then a contrast study (retrograde cystogram) is mandated.

If there is any blood at the meatus prior to catheterisation, or any history of haematuria since accident, then a retrograde urethrogram is indicated before attempts at catheterisation.

• Urethrogram positive: call consultant paediatric surgeon and/or paediatric urologist. Decisions now very difficult. If a suprapubic catheter is needed suggest discussion with the pelvic and acetabular surgeons as this will have major implications for any internal fixation.
• Urethrogram negative: catheterise. If haematuria present, perform a retrograde cystogram.