[size=20px]A ten-year old boy presents to the emergency department after being hit by a motor vehicle. He is tachycardic with abdominal distension, diffuse tenderness and a right thigh deformity. The initial radiographs in the trauma bay reveal pelvic and right femur fractures. When he becomes hemodynamically unstable, a massive transfusion protocol is initiated and his focused assessment with sonography for trauma (FAST) reveals a large amount of free fluid. He is placed in a pelvic binder appropriately centered at the greater trochanters without improvement. For this unstable patient with a pelvic fracture and free fluid, he is most appropriately transferred to the

 

A intensive care unit for additional resuscitation.

 

B radiology department for computerized tomography.

 

C radiology department for embolization.

 

D operating room for orthopedic fixation.

 

E operating room for laparotomy.[/size]

A

C

E

C

E

D

E

he is unstable he need a laparotomy and damage control if needed

, he should have got to the Ct while he was stable

correct answer

E operating room for laparotomy.

 

Due to skeletal immaturity, the amount of force required to fracture the pediatric pelvis is significant. As such, up to 97% of children with pelvic fractures will have associated injuries. Skeletal injuries are frequent with femur fractures being most common. Solid organ and head injuries are the most frequent cause of early mortality.

 

Although a pediatric pelvic fracture can cause significant blood loss - and in isolation is best treated with embolization - it rarely results in exsanguinating hemorrhage which is more likely due to intra-abdominal solid organ injury. Hak et al suggest that a FAST exam may be helpful in identifying free fluid. At laparotomy, intraperitoneal injuries can be addressed and the pelvis packed prior to embolization and/or fixation. Opening a contained pelvic hematoma can lead to disastrous results.

 

These patients may be best served in a hybrid operating room with general and orthopedic surgical and interventional radiology capabilities.