Pediatric Trauma

#1 Killer of children after neonatal period Priorities same as adult ABCs Children not small adults

Pediatrics

Many other healthcare providers often have:

Limited pediatric patient contacts Limited knowledge, training, and experience specifically directed towards pediatrics

How Does Serious Injury Occur in Children?

Function of Age & Development

Does not yet understand harm or risk Does not yet understand cause and effect Feeling of invincibility

Injury is the leading cause of death in children and young adults 1/2 of the injuries result from motor vehicles

Common Emergencies By Age

Neonate: Infection, Neglect Infant: Infection, Neglect, Abuse Toddler: Poisoning, Fall Preschool: Poisoning, Fall, Pedestrian School Age: Pedestrian; Fall, Recreation Adolescent: MV, OD/Poison, Recreation

Pediatric Trauma

Traumatic injuries often involve blunt trauma to the head

Drowning leading cause of death < 4 years Pedestrian leading cause of death 5 - 9 years

Injuries from Falls, Motorized vehicles, Bicycles, Sports Mechanism & Kinematics are critical
serious injuries in a child may not be evident initially

Mechanisms of Pediatric Injury

Waddells Triad

Mechanisms of Pediatric Injury

First Impression

Consider the possibility of serious injury if:

the injured child has altered mental status or appears behaving inappropriately initially there is significant mechanism regardless of whether there are obvious injuries the injured child has evidence of poor systemic perfusion

Pediatric Assessment: Initial Assessment

Pediatric Assessment Triangle

Appearance - AVPU Breathing - airway open, effort, sounds, rate, central color Circulation - pulse rate/strength, skin color/temp, cap refill, BP ( use at early ages)

Circulation

General Assessment

Observations of the child, family and environment are critical! Form a first impression of the childs status Maintain distance Talk to parents. Keep child with parent Is the behavior appropriate for the childs age? Mental status and ABCs are critical!

Focused Exam

Vitals signs are age dependent

Use pediatric vital signs charts

Systemic perfusion
Best evaluated by presence and volume of peripheral pulses and mental status Low output shock: weak, thready, narrow PP High output shock: bounding, wide PP Loss of central pulses is a premorbid sign

Focused History & Exam

History of the Present Injury

Family/Witness/Caretaker Older child

Pertinent Past Medical History

Often none or not obtainable

Immediately Treat Life-Threats

Some exceptions (epiglottitis, febrile seizure)

Extremity Trauma

Never severe enough to warrant attention before head, chest, abdominal injury Priorities remain with ABCs Pliant bones absorb/ dissipate significant force
Greenstick fractures common Treat painful, tender, guarded extremities as fractures

Extremity Trauma

Epiphyseal plate frequently involved 50% have growth abnormalities Neurovascular injury - most common injury
Humerus Femur

Assess distal pulse, skin color, temp, cap refill, motor/sensory function

Physeal Injuries

The physis is the primary center for growth of the skeleton. The physes appear to be the weakest area in childrens bones. Physeal injuries - occur in approximately 30% of long bone fractures in children The distal end of the radius, distal end of the tibia, and phalanges of the fingers
frequent site of physeal injury.

Open fracture

In children often have a better prognosis than similar injuries in adults treatment may be different from that for adults Emergent administration of appropriate antibiotics is essential to decrease the risk of infection. Stabilization of unstable fractures is usually beneficial, although children may require less rigidity than adults. If viability of soft tissue is in doubt, dbridement should be deferred until a later operation, as the superior healing potential of young children may produce unexpected recovery. Associated injuries are common with open fractures in children, and serial examinations over time often uncover these injuries.

Open fracture

Timing of Surgery Traditional teaching is that open fractures must be operated on within six to eight hours after the injury. Irrigation and dbridementof open fractures in children can be performed within the first twenty-four hours after injury without increasing the risk of infection as long as intravenous antibiotics are started on presentation to the emergency department.

Open fracture

Irrigation and Dbridement After the wound is extended and irrigated and areas of gross contamination are removed, the tourniquet (if used) is deflated to identify tissue viability. Muscle that bl Periosteum in young children can reconstitute bone even when there is bone loss. Devitalized bone stripped of all soft-tissue attachments usually should be removed in an adult, whereas this bone may be left in place and will usually incorporate in young children. The incised area can be gently reapproximated with simple nylon or Prolene (polypropylene) sutures, while the traumatic wound can be closed over a drain or left open.

Open fracture

Stabilization of open fractures is essential, although, depending on the fracture site, rigid fixation is not always as importantin children as it is in certain settings in adults. As a general principle, the more extensive the soft-tissue damage, the greater the need for stable fixation to account for delayed fracture-healing and allow earlier mobility to prevent stiffness. A corollary is that older children whose biological capacity for healing approaches that of adults may need more rigid fixation than do young children. Fracture stabilization facilitates rehabilitation, decreases pain, and protects soft tissues. Bone grafting is rarely necessary in young children, except those with substantial bone loss. Surviving periosteum has a remarkable ability to regenerate bone in young children, even when there is considerable bone loss.

Traumatic Amputations

Traumatic amputation is the most severe form of open injury. When amputation is required, the physis should be preserved with as much length as possible. Even a stump that initially appears very short after a traumatic amputation in a growing child may achieve substantial length by skeletal maturity if the physis is preserved. Children have remarkable regenerative potential that allows replantation of some amputated parts that would not be salvageable in adults.

Pediatric Trauma

pediatric fractures of the upper extremity pediatric fractures of the lower extremity pediatric fractures of pelvic pediatric fractures of spine

General Principles

As with all fractures, the basic principle is to accurately align, both axially and rotationally, the distal fracture fragments with the proximal fragments and maintain this position until the fracture has healed.

Paediatric spinal injury

SCIWORA Spinal Cord Injury Without Radiologic Abnormality (10 -20% of SCI) Incompletely calcified vertebrae may transiently deform Marked by transient or migratory neurologic deficit MRI is the imaging modality of choice Steroids for Children with Spine Injury?
Area of controversy

Pediatric fractures of the upper extremity

The vast majority of pediatric fractures of the upper extremity can and should be treated with closed reduction, immobilization, and close follow-up.

Closed reduction, immobilization

Pediatric fractures of the upper extremity

Closed reduction, immobilization

Historically, almost all forearm fractures in skeletally immature patients were treated nonoperatively.

Pediatric fractures of the upper extremity

Closed reduction and immobilization in an above-the-elbow cast

is recommended for any acute injury with obvious deformity and >15 to 20 of angulation

Traction

Pediatric fractures of the upper extremity

Intramedullary nail

Intramedullary Fixation
with closed or open reduction is ideal for unstable transverse fractures

Pediatric fractures of the upper extremity

Intramedullary nail

Pediatric fractures of the upper extremity

Plate and screws

Pediatric fractures of the upper extremity

Plate and screws

Pediatric fractures of the upper extremity

Plate Fixation

Patients with a comminuted fracture or less than one year of skeletal growth remaining are candidates for plate-and screw fixation with use of standard techniques.

Pediatric fractures of the upper extremity

Closed reduction and percutaneous pinning

Pediatric fractures of the upper extremity

Closed reduction and percutaneous pinning

Pediatric fractures of the upper extremity

Closed reduction and percutaneous pinning

Screw fixation

Non-union of lateral condyle

Reduced and fixed with screws

Pediatric fractures of the upper extremity

Screw fixation

SC, IC fracture of humerus

Reduced and fixed with screws

Pediatric fractures of the upper extremity

Fracture of the olecranon and radial neck. open reduction and internal fixation of the olecranon with two smooth pins and a tension band wire.

Pediatric fractures of the upper extremity

Cubitus varus is a cosmetic problem that occurs in 5% to 10% of patients with a supracondylar humeral fracture.

Pediatric fractures of the upper extremity

Cubitus vulgus is a cosmatic problem that occurs with non union of lateral condyle fracture.

pediatric fractures of the lower extremity

The majority can and should be treated with closed reduction, immobilization, and close follow-up. Surgical management is being used
to maintain optimal alignment, to allow early motion, or to facilitate mobilization

Femoral Shaft Fractures

A femoral fracture is the most common major pediatric injury treated by orthopaedic surgeons. A spica cast applied early is a very effective treatment for most children who are less than six years old.

Femoral Shaft Fracture

Operative Decision-Making Indications for operative management of pediatric femoral fractures are Based on a sound understanding of remodeling after fracture union. Remodeling potential is greatest in children less than

Femoral Shaft Fracture

External Fixation

External fixation can be thought of as a form of portable traction for a pediatric femoral fracture. An excellent method
for restoring the length of the limb achieving satisfactory alignment without long incisions, exposureof the fracture site, major blood loss,or the risk of physeal injury or osteonecrosis

Flexible Intramedullary Nail Fixation

Flexible intramedullary nail fixation

as an internal splint maintains length and alignment but permits sufficient motion at the fracture site to generate excellent callus formatio

Rigid Intramedullary Nail Fixation

Rigid, antegrade intramedullary nail fixation offers maximum stability and load-sharing.

Open Reduction and Plate Fixation

Plate fixation is an effective treatment for pediatric femoral fractures. Advantages

familiarity of the technique and widely available equipment as well as rigid fixation in anatomic alignment that allows rapid mobilization

Disadvantage
large incision, greater blood loss, refractures, hardware failure and issues regarding hardware removal

Minimally invasive plate osteosynthesis

Minimally invasive plate osteosynthesis was used to treat a comminuted transverse diaphyseal femoral fracture

Fractures of the Tibia and Fibula

Fractures About the Knee Fractures about the knee have important implications for growth. They also necessitate accurate reduction, since even minor angulation at the knee produces visible deformity. Even in children, stiffness and articular degeneration may follow if cartilage or muscle damage has occurred31. Finally, the surgeon should remember that ligament injuries may coexist with physeal fractures about the knee.

Nearly all closed tibial and fibular shaft fractures in children can be managed by nonoperative techniques. Closed treatment is appropriate for all undisplaced fractures.

Displaced closed fractures require closed reduction If the tibia fracture is oblique or comminuted, maintenance of length may be difficult, and surgical treatment may need to be considered.

Patellar Fractures Patellar fractures are rare in children, presumably because of their decreased body mass and increased resistance to impact56. One unique feature in this age-group is the relatively thick layer of unossified cartilage (the patella is completely cartilaginous until about the age of four years)57. Therefore, a small rim of bone avulsed from the inferior pole of the patella in a young child represents a large cartilaginous and softtissue injury. This pattern has been termed a sleeve fracture.58 Treatment of an undisplaced patellar fracture in a cylinder cast for six weeks is advised. There is usually no problem with regaining motion. Open reduction and internal fixation with a tension-band technique is recommended for ractures displaced more than 2 to 3 mm.

Tibial Shaft and Ankle Fractures Proximal Tibial Metaphyseal Fractures Fractures involving the proximal tibial metaphysis in children commonly occur between the ages of two and eight years59. Occasionally, soft-tissue interposition blocks the reduction and the soft tissue must be removed from the fracture site. Fractures that cannot be reduced may require an open reduction60,61. A valgus deformity of the tibia may occur after these fractures.

Tibial Shaft Fractures

Diaphyseal fractures of the tibia are the most common lower-extremity fractures in children. Following a reduction, the limits of acceptable positioning are 10 mm of shortening; <10 of varus, valgus, or recurvatum; and no malrotation.

Distal Tibial and Ankle Fractures

Salter-Harris type-I and II fractures account for approximately 15% and 40% of fractures of the distal tibial physis, respectively. These fractures can almost always be treated closed, except in the rare instance in which softtissue interposition prevents reduction.

Success of trauma management

Team work Together everyone achieves more