Caring for injured children is central to the mission of pediatric orthopaedics. Someday, they may invent a drug or genetic treatment that completely cures a syndrome or genetic deficiency that causes musculoskeletal deformity or disease. But they will never stop kids from hurting themselves: jumping out of trees, tackling friends on the trampoline, or skateboarding down the hill through traffic. NEWSFLASH! The pediatric orthopaedist who treats injuries will never go out of business. Understanding and avoiding the common pitfalls in caring for the injured child is central to the wisdom a pediatric orthopaedist gains over the years in practice.

Trauma is the leading cause of mortality in children. The outcome from the injuries is primarily related to the severity and management of the head and musculoskeletal injuries. It’s important to listen carefully to the story of the injury (from the child and from the family whenever possible). Most pediatric fractures are isolated injuries, but be on the lookout for associated injuries on initial evaluation, especially after high falls, bike and vehicle crashes, and kids hit by cars. Recognize that certain injuries are sentinels for other types of injuries. Examples of this include rib fractures, pelvic fractures, facial injuries, and a lap belt sign (Fig. 5-1) on the anterior aspect of the abdomen or chest.

The value of mobilizing injured children is increasingly being appreciated, especially by busy families not prepared for their 5-year-old to be in a spica cast for 6 weeks. The vast majority of pediatric fractures can be treated successfully with cast immobilization. However, in the 21st century, we’ve seen a dramatic paradigm shift to internal fixation of pediatric fractures, often with improved outcomes, but not always with improved outcomes. Essential to the art of pediatric orthopaedics is understanding where surgery for a fracture gives a better outcome and where surgery just gives a temporarily better X-ray.

In an era in which families share stories and X-rays on social media and families Google an injury as soon as the emergency department (ED) doc gives it a name, there is often parental pressure to “put the puzzle back together perfectly” in the operating room. They may not want to deal with a spica cast for 6 weeks when Dr. Google says that maybe their 2-year-old could have a metal plate put on the femur, making the X-ray perfect, and have their toddler walking in a few days. All it takes is that rare infection, or intraoperative complication, or that second operation to remove the plate from the 2-year-old femur, before the seasoned orthopedist knows to use her judgment and convince the family that nature does a better job healing the fracture than a surgeon. NEWSFLASH! With operative treatment of fractures in young children, just because you can, doesn’t mean you should.

A major source of trouble in caring for multiply injured children results from the family’s perspective and expectations. When they arrive with their injured child, the family may be overwhelmed and shocked by the traumatic event. The relationship with the health care team is quickly established. As the surgeon, you may find yourself cast in one of two lights: part of the problem or part of the solution. Some families quickly look for someone to blame for the calamity, and if there is no one outside the hospital, they look for someone inside the hospital—and who better than the surgeon, the captain of the ship. The surgeon becomes solely responsible for “making it all like it was before the accident” and anything different is grounds for a malpractice suit. To stay out of trouble, use those first few minutes with the family to establish the optimal relationship—a partnership that is you and the family against the injury (Fig. 5-2).

It is fair for you to describe the extent of the problem in graphic detail, the outcome if untreated, the prolonged length of recovery (yes, many children do limp for a year or more after a serious lower extremity injury), and the numerous complications that have been described in the literature. Remember: you’ve been summoned to rescue this child and the family from the injury. The injury is not your fault. You are going into battle against it. It is wise to paint the worst possible picture, offer reassurance that often things go much better than that, and then at each stage express relief that the treatment and the healing is going fairly well. An example might be a Salter-Harris II distal femur fracture: explain that it is the fastest-growing growth plate that will give much of the remaining leg length in the teenager, and that studies have shown a growth arrest rate ranging from 30% to 40%, and surgery does not necessarily change this because the growth plate was damaged at the moment of injury. Then in the months that follow, as the fracture heals and the boy returns the soccer field, and there is no growth arrest, the family will feel blessed and appreciative, and you will be a hero. When rescuing a child from their injury, begin dark and end sunny; it’s best for everyone involved. The more untrusting the family, the more you should see them, both inpatient and outpatient. After many weekly clinic visits, such families often thank you, rather than complain about the hassle of such close follow-up.

There are certain anatomic and physiologic differences that make a child’s injury unique and may alter treatment. Ligaments may attach to the epiphysis. Because the ligaments are stronger than the physis, a force to such a joint leads to physeal injury rather than ligamentous disruption.

Plastic deformation is an important and unique type of fracture in children. Plastic deformation can lead to loss of motion or deformity, such as in a diaphyseal forearm fracture, or make reduction of an associate fracture difficult, such as in a type III Monteggia fracture. The ulnar border should be “ruler straight.” A plastically deformed fibula can challenge tibia fracture reduction. Plastic deformation
can be improved with operative reduction using a slow, steady (and significant) force, particularly in the forearm.

The two primary causes of death in pediatric trauma victims are head injury and intraabdominal hemorrhage. One of the most important ways to stay out of trouble as an orthopaedist caring for severely injured children is establishing a good relationship with your trauma team. Children have a smaller blood volume and become hypovolemic quite quickly. This is particularly problematic in femur fractures associated with splenic injury or other internal bleeding. Because of their amazing ability to compensate with an increased pulse, children may not show a drop in blood pressure due to hypovolemia until they are in a very critical range; this insight may be lost on the junior anesthesia resident covering your trauma case, so stay alert. Blood loss is easily underestimated because most pediatric trauma is blunt and the bleeding is internal. Partnering with a general surgeon and a neurosurgeon and using a careful physical examination with liberal use of imaging (Fig. 5-3) are valuable ways to optimally collaborate care when there are both skeletal injuries and multiple internal injuries.