Pediatric Pelvic Fracture andUrethral Injuries: A Review of the National Trauma Data Bank
Lauren Poniatowski, MD1, Niels Johnsen, MD2, Paul Merguerian, MD,MS1.
1Seattle Children's Hospital, Seattle, WA, USA, 2University of Washington, Seattle, WA, USA.
Pediatric Pelvic-Fracture Urethral Injuries: A Review of the National Trauma Data Bank
The association of traumatic pelvic fractures with urethral injuries has been well described in adults, occurring in approximately 2% of adult men with traumatic pelvic fractures. However, little is known about these injuries in terms of prevalence and associated injuries in pediatric patients. We sought to perform a descriptive analysis of pelvic fracture urethral injuries (PFUI) in pediatric patients utilizing a national dataset.
Using the National Trauma Data Bank (NTDB) for years 2007 to 2016, patients under the age of 18 with ICD-9 codes for traumatic pelvic fracture were identified. Those with associated urethral and/or bladder injuries were further isolated using specific Abbreviated Injury Scale (AIS) codes. Subject demographic and injury data were abstracted to determine presentation, associated injury, and outcome details during the index hospitalization. All analyses were completed with R statistical software (Vienna, Austria).
During the 10-year study period, 32,504 pediatric traumatic pelvic fracture patients were identified in the database, of which 49 (0.2%) had associated urethral injuries and 1,182 (3.6%) had associated bladder injuries. 9 urethral injury patients (18.4%) were coded to have concomitant bladder ruptures. 31 PFUI children (63.3%) were male with a median age of 16 years (IQR 15-16). The majority of PFUI was due to motor vehicle related injuries (81.6%) and was acutely managed at university-affiliated hospitals (73.5%).
Pelvic fracture patterns associated with PFUI were sacral fractures in 16 (32.7%), pubic bone fractures in 21 (42.9%), and multiple unspecified fractures of the pelvic ring in 22 (44.9%). Non-urologic injury patterns were notable for thoracic injuries in 44 (89.8%), intracranial injuries in 35 (71.4%), lower extremity fractures in 17 (34.7%), splenic injuries in 18 (36.7%), liver injuries in 15 (30.6%), and kidney injuries in 9 (18.4%).
Relative to children identified with traumatic bladder injuries from the database, PFUI patients, on average, had significantly higher Injury Severity Scores (39 vs 25, p<0.001), lower emergency department presentation Glasgow Coma Scores (3 vs 15, p<0.001), longer intensive care unit lengths of stay (5 vs 2 days, p<0.001), and higher mortality rates (22.5% vs 6.0%, p<0.001).
Urethral injuries in pediatric patients following traumatic pelvic fractures are rare and less common than reported in adults. These injuries, however, are often associated with a significantly elevated overall injury severity, multiple competing injuries, and substantial mortality risk. Most often occurring in teenagers and following motor vehicle accident, these data suggest that the mechanisms required for PFUI in pediatric patients are significant and likely associated with substantial high-velocity or high-impact traumas. While no established management protocols are in place at present for pediatric PFUI, prompt and appropriate urinary drainage are vital to minimize the negative impact of urinary tract injuries in otherwise severely injured patients.
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