ped trauma prof 1

7/31/2019 Ped Trauma Prof 1

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Pediatric Trauma

#1 Killer of children after neonatal period

Priorities same as adult ABCs

Children not small adults


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Pediatrics

Many other healthcare providers often have:

Limited pediatric patient contacts

Limited knowledge, training, and experience

specifically directed towards pediatrics


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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


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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


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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


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Mechanisms of Pediatric

Injury

Waddells Triad


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Mechanisms of Pediatric

Injury


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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


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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


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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!


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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


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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)


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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


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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


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Physeal Injuries

The physis is the primary center for growth of

the skeleton.

The physes appear to be the weakest area inchildrens 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.


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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 bedeferred 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.


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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 ofinfection as long as intravenous antibiotics are started

on presentation to the emergency department.


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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.


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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, thegreater 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.


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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.


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Pediatric Trauma

pediatric fractures of the upper extremity

pediatric fractures of the lower extremity

pediatric fractures of pelvic

pediatric fractures of spine


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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.


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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


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Pediatric fractures of the upper

extremity

The vast majority of pediatric fractures of the upperextremity can and should be treated with closed

reduction, immobilization, and close follow-up.


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Closed reduction, immobilization

Pediatric fractures of the upper extremity


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Closed reduction, immobilization

Historically, almost all forearm fractures in

skeletally immature patients were treated

nonoperatively.



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Closed reduction and immobilization in an

above-the-elbow cast

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


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Traction



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Intramedullary nail

Intramedullary Fixation

with closed or open reduction is ideal for unstable

transverse fractures



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Intramedullary nail



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Plate and screws



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Plate and screws



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Plate Fixation

Patients with a comminuted fracture or less

than one year of skeletal growth remaining are

candidates for plate-and screw fixation withuse of standard techniques.



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Closed reduction and

percutaneous pinning



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Screw fixation

Non-union of lateral condyle

Reduced and fixed with screws



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Screw fixation

SC, IC fracture of humerus

Reduced and fixed with screws



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Fracture of the olecranon and radial neck.

open reduction and internal fixation of the olecranon

with two smooth pins and a tension band wire.



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Cubitus varus is a cosmetic problem that

occurs in 5% to 10% of patients with a

supracondylar humeral fracture.



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Cubitus vulgus is a cosmatic problem that

occurs with non union of lateral condyle

fracture.


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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


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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.


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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 lessthan

Femoral Shaft Fracture


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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

Fl ibl I t d ll


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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

Ri id I t d ll


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Rigid Intramedullary

Nail Fixation

Rigid, antegrade intramedullary nail

fixation offers maximum stability and

load-sharing.

O R d ti d


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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

Mi i ll i i l t


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Minimally invasive plate

osteosynthesis

Minimally invasive plate osteosynthesis was

used to treat a comminuted transverse

diaphyseal femoral fracture


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F t f th Tibi


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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 evenminor 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.


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Nearly all closed tibial and fibular shaft

fractures in children can be managed by

nonoperative techniques. Closed treatment is appropriate

for all undisplaced fractures.


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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.


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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 andinternal fixation with a tension-band technique is recommended for

ractures displaced more than 2 to 3 mm.


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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.


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Tibial Shaft Fractures

Diaphyseal fractures of the tibia are the most

common lower-extremity fractures in children.

Following a reduction, the limits of acceptablepositioning are 10 mm of shortening;


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Distal Tibial and Ankle


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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 soft-

tissue interposition prevents reduction.

Success of trauma


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Success of trauma

management

Team work

Together everyone achieves more

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