General Principles of Pediatric Trauma

I. Child with Multiple Injuries

A. Incidence of Injuries

1. Trauma—Trauma is the most common cause of death in children and adolescents in the United States and costs over $1 billion annually. Traumatic injuries account for 20,000 deaths, 600,000 hospital admissions, and 16 million visits to the emergency room. Mechanisms of injury include child abuse, falls, and motor-vehicle accidents (either in them or hit by them). Head injury is the most common reason for death from trauma in children; the ratio of boys to girls is 2:1. Death occurs most often from blunt trauma. Alcohol plays an increasingly important role in the injury of adolescents.

2. Fractures—Fractures are common in children with multiple injuries. About 9% of fractures in such children are open.

                3.      Child abuse—The annual incidence of child abuse in the United States is 15 to 42 cases per 1,000 children; the incidence is increasing (or cases are being better recognized). More than 2 million children each year are victims of physical abuse or neglect, and over 150,000 suffer serious injury or impairment (Neglect is more common than physical abuse.) Children of all socioeconomic backgrounds suffer physical abuse or neglect; however, the incidence does appear to be related to family income. (Children in homes with a family income of less than $15,000 per year are 25 times more likely to suffer abuse compared with children in homes with a family income greater than $30,000 per year.)
    Children with the highest risk for abuse include first-born children, unplanned children, premature children, and stepchildren. Children with an increased risk for abuse include children in a single-parent home, children of parents who abuse drugs, children of parents who were abused, children of unemployed parents, and children of families of lower economic status.
    Approximately one-third of abused children are eventually seen by an orthopaedic surgeon. A clear and thorough history and physical examination should be performed. Knowledge of a child’s social environment, age, injury pattern, and stated mechanism of injury are all important factors in the evaluation.
    Knowledge of injury patterns suggestive of nonaccidental trauma in children is essential. Child abuse must be suspected in all cases of multiple injuries in children younger than 2 years if there is no obvious witnessed explanation for the trauma. Skeletal injuries that have a high specificity for child abuse include posterior rib fractures, sternal fractures, spinous process avulsion fractures, and scapular fractures. Skeletal injuries that have a moderate specificity for child abuse include multiple fractures, fractures in various stages of healing, vertebral compression fractures, and epiphyseal separations. Long-bone fractures are commonly seen in cases of child abuse, but have a low specificity. Some authors have suggested that the most common fracture seen in child abuse is a single transverse fracture of the femur or humerus. (Other authors disagree.)
    The differential diagnosis in cases of suspected child abuse includes true accidental injury, osteogenesis imperfecta, and metabolic bone disease.
    A skeletal survey is a useful initial imaging modality and may be repeated 2 to 3 weeks after the child’s initial presentation. Nuclear medicine bone scanning may be helpful when the skeletal survey is negative.
    The most important aspect of management is the establishment of the diagnosis of child abuse. (The history of injury must be clearly detailed, documented, and understood.) An instrument for detection of nonaccidental trauma called the screening index for physical child abuse (SCIPA) has been validated; it can assist with diagnosis. By law, all suspected cases of child abuse must be reported to Child Protective Services.

B. Initial Resuscitation—Resuscitation can be cost effective and adequately provided at a general level I trauma center. The ABCs of trauma are the same as those for an adult.

1. Cervical spine—The cervical spine must be stabilized. Special transport spine boards are recommended for children younger than 6 years. Other (“distracting”) injuries such as long-bone fractures, abdominal injuries, and crush injuries can mask cervical spine injuries.

2. Intravenous access—In the child, intravenous access may be difficult; intraosseous fluid infusion can be considered.

3. Blood pressure—A child’s blood pressure must be maintained at an adequate level because death is more common in children than in adults if hypovolemic shock is not quickly reversed. (Injuries are usually internal.) Attention to volume administration in a child with a severe head injury is paramount unless hypotension is present from obvious internal or external blood loss. Adolescent girls with traumatic shock have significantly decreased risk of death as compared to boys.

4. Aggressive fluid replacement—Aggressive fluid replacement may lead to internal fluid shifts and thus decrease blood oxygenation levels secondary to interstitial pulmonary edema.

C. Evaluation and Assessment—After initial resuscitation and stabilization, a thorough check for other injuries is initiated.

1. Injury Severity Score (ISS)—The ISS is a valid, reproducible method for pediatric multitrauma. It classifies injuries as moderate, severe, serious, critical, and fatal for each of the five major body systems. Each level of severity is given a numerical code (1 to 5). Systems include general, head and neck, chest, abdomen, and extremities. The ISS is the sum of the squares of the three most injured body systems. The range of severity is from 0 to 75. The New Injury Severity Score (NISS) has been shown to be a better predictor of outcome in severely injured patients.

2. Glasgow Coma Scale (GCS)—Head injury is rated using the GCS. For further details, see Chapter 1.

3. Abdominal examination

4. Extremity examination—Every joint is palpated, and range of motion is assessed. A neurovascular examination is performed.

5. Open fractures

• Assessment—The nature and extent of the open wound is assessed without probing. The patient should not be subjected to multiple examinations. The injury is then provisionally stabilized. Neurovascular status is checked after stabilization.

• Treatment—If there is profuse bleeding, a compression dressing or a tourniquet should be applied. Tetanus prophylaxis and an initial dose of broad-spectrum intravenous antibiotics should be given to prevent early wound sepsis. After appropriate radiographic studies and other lifesaving measures have been performed, the patient should be quickly taken to the operating room for a formal irrigation and debridement and skeletal stabilization.

6. Imaging studies

• Plain radiographs—In the trauma cervical spine series (lateral from C1 to the top of T1, anteroposterior [AP], open-mouth odontoid views), the clinician should watch for pseudosubluxation of C2 on C3 or of C3 on C4, which are normal variants. An AP chest, AP pelvis, and appropriate extremity films should also be obtained.

• Computed tomography (CT)—CT of the head is performed without contrast if warranted.

• Retrograde urethrography—Retrograde urethrography is performed if there is urethral obstruction. Urethral injury is common with pelvic fractures.

• Magnetic resonance imaging (MRI)—If spinal cord injury is suspected, MRI can be valuable, especially in children who have signs and symptoms of compromise without radiographic abnormality.

• Ultrasonography—Ultrasonography is a fast and accurate way of detecting hemoperitoneum. In some centers, it has replaced laparoscopy and diagnostic peritoneal lavage, but accuracy depends on user experience.

D. Nonorthopaedic Conditions

1. Head injury

• Recovery—Head injury is the leading cause of morbidity and mortality in pediatric trauma patients. Recovery from significant head injury, however, is substantially better in children than in adults. Even in children with severe head injuries, full functional recovery is likely. Poor oxygenation on arrival to the emergency department and a low GCS at 72 hours after head injury have been correlated with a poorer functional result and a greater neurologic deficit. Failure to treat orthopaedic injuries in a child with a head injury is inappropriate. It must be assumed that a full functional recovery will occur, and optimal orthopaedic care should be provided when the child is able to undergo surgery.

• Complications—Abundant callus forms in fractures of patients with head injuries. Other complications after head injury include spasticity, contractures, and the formation of heterotopic ossification.

2. Thoracic injuries—Thoracic trauma has a mortality rate of 25% in children less than 5 years of age. When there is concomitant head trauma, children with chest trauma have significantly higher morbidity and mortality. Rib fractures are less frequent due to their intrinsic flexibility, and chest contusions can occur without external evidence of trauma.

3. Injuries to abdominal viscera—Injuries to both solid and hollow abdominal viscera are often associated with multiple skeletal injuries. Liver and spleen injuries together comprise 75% of abdominal injuries in children. Multiple pelvic fractures correlate strongly (80%) with abdominal or genitourinary injury. Abdominal trauma should not delay fracture care if the child’s medical condition is stable.

4. Fat embolism syndrome—Fat embolism syndrome is unusual in children, but it presents the same as it does in adults. Radiographic changes of pulmonary infiltrates that appear within several hours of a long-bone fracture, axillary petechiae, and hypoxemia should indicate the diagnosis, even in a child.

5. Nutritional requirements—Nutritional requirements can be determined based on the patient’s weight and age. The daily nitrogen requirement in the acute phase of injury for a child is approximately 250 mg/kg.

E. Orthopaedic Management—Orthopaedic injuries are rarely life threatening in children, and skeletal stabilization is initially accomplished with a splint.

1. Closed fractures—Early skeletal stabilization can decrease the risk of acute respiratory distress syndrome in children with multiple injuries. Specific guidelines for operative fixation (e.g., intramedullary fixation, compression plate fixation, and external fixation) are beyond the scope of this chapter. Skeletal injury should be stabilized to facilitate mobilization and management of the patient.

2. Open fractures

• Classification (Table 29-1)

• Treatment

(a) Stages

• Emergency treatment—Emergency treatment includes tetanus prophylaxis, appropriate antibiotics, a compression dressing to stop bleeding, and application of a splint.

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