FIGURE 5-1 Temporary cervical spine stabilization is imperative in any child with multitrauma, especially those who are unconscious or complain of neck pain.

Fluid Replacement

Once an adequate airway is established, the amount of hemorrhage from the injury, either internally or externally, is assessed. This blood loss is replaced initially with intravenous (IV) crystalloid solution. In younger children, rapid IV access may be difficult. In this situation, the use of intraosseous fluid infusion via a large bore needle into the tibial metaphysis can usually be placed within 1 to 2 minutes and has been found safe and effective for IV fluids and drug delivery during resuscitation. Bielski et al.,¹⁶ in a rabbit tibia model, likewise demonstrated no adverse effects on the histology of bone or the adjacent physis with intraosseous injection of various resuscitation drugs and fluids.

Because death is common if hypovolemic shock is not rapidly reversed, the child’s blood pressure must be maintained at an adequate level for organ perfusion. Most multiply injured children have sustained blunt trauma rather than penetrating injuries, and most of the blood loss from visceral injury or from pelvic and femoral fractures is internal and may be easily underestimated at first. The “triad of death,” consisting of acidosis, hypothermia, and coagulopathy, has been described in trauma patients as a result of hypovolemia and the systemic response to trauma.²¹² Peterson et al.¹⁴² reported that an initial base deficit of eight portends an increased mortality risk.

Despite the need to stabilize the child’s blood pressure, caution needs to be exercised in children with head injuries so that overhydration is avoided because cerebral edema is better treated with relative fluid restriction. Excessive fluid replacement also may lead to further internal fluid shifts, which often produce a drop in the arterial oxygenation from interstitial pulmonary edema, especially when there has been direct trauma to the thorax and lungs. In some instances, to accurately assess the appropriate amount of fluid replacement, a central venous catheter is inserted during initial resuscitation. A urinary catheter is essential during the resuscitation to monitor urine output as a means of gauging adequate organ perfusion.

EVALUATION AND ASSESSMENT

Key Concepts

• Trauma rating systems have two functions: To aid in triage, and to predict outcomes.

• There are many rating systems, each with strengths and weaknesses.

• Of the commonly used systems, both the Injury Severity Score (ISS) and Glasgow Coma Score have predictive value for prognosis.

• The secondary survey is a systematic examination of the patient from head to toe.

• It includes a complete history, physical examination, focused radiographs, and adjunctive imaging studies such as CT and MRI scans.

Trauma Rating Systems

After initial resuscitation has stabilized the injured child’s condition, it is essential to perform a quick but thorough check for other injuries. At this point in the evaluation, a trauma rating is often performed. The purpose of the trauma rating is twofold: To aid in triage, and to predict outcomes. Several trauma rating systems have been validated for the pediatric population,^{5,21,34,54,147,149,167,168,178,193} but the most commonly utilized are the Glasgow Coma Scale (GCS), the Injury Severity Score (ISS), and the Pediatric Trauma Score (PTS). Each of the scoring systems has strengths and weaknesses. The ISS is a valid, reproducible rating system that can be widely applied in the pediatric polytrauma setting (Table 5-1).²¹¹ It is an ordinal, not a linear scale (i.e., a score of 40 is not twice as bad as a score of 20). It has been found to be a valid predictor of mortality, length of hospital stay, and cost of care.²⁴ Another injury rating system for children that has been shown to be valid and reproducible is the PTS (Table 5-2).²¹¹ It has good predictive value for injury severity, mortality, and the need for transport to a pediatric trauma center; however, it is a poor predictor of internal injury in children with abdominal blunt trauma.¹⁶⁰ The injury rating system chosen varies among trauma centers, but whether the ISS or PTS is used, each allows an objective means to assess mortality risk at the time of initial treatment, as well as allowing some degree of prediction of future disability.^138,186,218

Head injury is most often evaluated and rated by the GCS, which evaluates eye opening (1 to 4 points), motor function (1 to 6 points), and verbal function (1 to 5 points) on a total scale of 3 to 15 points (Table 5-3).¹⁹² There are some limitations in the use of the GCS in children who are preverbal or who are in the early verbal stages of development, but in other children this rating system has been a useful guide for predicting early mortality and later disability. A relative head injury severity scale (RHISS) has been validated⁴⁴ and is available in trauma registries, thus is useful for comparative studies of large populations. As a rough guide in verbal children, a GCS score of less than 8 points indicates a significantly worse chance of survival for these children than for those with a GCS of more than 8. The GCS should be noted on arrival in the trauma center and again 1 hour after the child arrives at the hospital. Serial changes in the GCS correlate with improvement or worsening of the neurologic injury. Repeated GCS assessments over the initial 72 hours after injury may be of prognostic significance. In addition to the level of oxygenation present at the initial presentation to the hospital, the 72-hour GCS motor response score has been noted to be very predictive of later permanent disability as a sequel to the head injury.^70,125,219

Physical Assessment

The secondary survey starts with a full history and physical examination. In a child with multiple injuries, a careful abdominal examination is essential to allow early detection of injuries to the liver, spleen, pancreas, or kidneys. Ecchymosis on the abdominal wall must be noted, because this is often a sign of significant visceral or spinal injury.^29,175 In one series, 48% (22/46) of children with such ecchymosis required abdominal exploration,²⁹ whereas in another series 23% (14/61) of children were noted to have spine fractures.¹⁷⁵

Swelling, deformity, or crepitus in any extremity is noted, and appropriate imaging studies are arranged to evaluate potential extremity injuries more fully. If extremity deformity is present, it is important to determine whether the fracture is open or closed. Sites of external bleeding are examined, and pressure dressings are applied if necessary to prevent further blood loss. A pelvic fracture combined with one or more other skeletal injuries has been suggested to be a marker for the presence of head and abdominal injuries.²⁰⁶ Major arterial injuries associated with fractures of the extremity are usually diagnosed early by the lack of a peripheral pulse. However, abdominal venous injuries caused by blunt trauma are less common and are less commonly diagnosed before exploratory laparotomy. About half of abdominal venous injuries have been reported to be fatal, so the trauma surgeon needs to consider this diagnosis in children who continue to require substantial blood volume support after the initial resuscitation has been completed.⁵⁹

Initial splinting of suspected extremity fractures is routinely done in the field. However, once the injured child is in the hospital, the orthopedist should personally inspect the extremities to determine the urgency with which definitive treatment is needed. Most important are whether a vascular injury has occurred, whether the fracture is open or closed. The back and spine should be carefully examined. If there is noopen fracture and if the peripheral vascular function is normal, there is less urgency in treating the fracture and splinting will suffice until the other organ system injuries are stabilized.

Splinting decreases the child’s pain while the child is resuscitated and stabilized and minimizes additional trauma to the soft tissue envelope surrounding the fracture. Splinting also facilitates transport of the child within the hospital while the trauma workup, including appropriate imaging studies, is completed. If the child is to be transferred to a trauma center, splints are invaluable for patient comfort and safety during transfer.

Any evident neurologic deficit is noted to document the extremity function before any treatment. It is important to remember that a detailed neurologic examination may not be possible because these are often young and scared children who are in pain and may have a central nervous system injury. The inability to obtain a reliable examination should also be documented.

Head injuries and extreme pain in certain locations can result in some injuries being missed initially. In a series of 149 pediatric polytrauma patients, 13 injuries were diagnosed an average of 15 days following the initial accident, including five fractures (one involving the spine), four abdominal injuries, two aneurysms, one head injury, and one facial fracture.^85,109 Given this 9% incidence of delayed diagnosis, it is imperative that polytrauma patients be reexamined once they are more comfortable to reassess for potential sites of injury. In some cases, despite careful inpatient reevaluations, some pediatric injuries escape detection until later follow-up visits. In addition, children with head injuries need to be reassessed once they awaken enough to cooperate with reexamination. Families and patients need to be informed of the frequency of delayed diagnosis of some injuries in polytrauma patients so that they can partner with the medical team in recognizing such injuries (often evident as previously undetected sites of pain or dysfunction).

Imaging Studies

Radiographs

Imaging studies should be obtained as quickly as possible after the initial resuscitation and physical examination. Any extremity suspected of having a significant injury should be examined on radiograph. Primary screening radiographs classically consist of a cross-table lateral cervical spine, anteroposterior chest, and anteroposterior pelvis.^53,150 In some centers, a lateral cervical spine radiograph is obtained only if the child has a head injury or if neck pain is noted on physical examination. Some centers evaluate the cervical spine with a CT scan in children with polytrauma who have neck pain, a traumatic brain injury (TBI), or who have been drinking alcohol.¹⁶¹ Further workup with cervical spine magnetic resonance imaging (MRI) is necessary before cervical spine clearance in those who have persistent neck pain or tenderness despite normal plain films and CT, and should be considered in patients who remain obtunded (see “Magnetic Resonance Imaging”).

If a cervical spine injury is present, the lateral radiograph of this area will detect it in 80% of cases.¹⁰⁵ If there is suspicion of a cervical spine injury on the neutral lateral view, a lateral flexion radiograph of the cervical spine taken in an awake patient will help detect any cervical instability. The cervical spine of a young child is much more flexible than the cervical spine in an adult. Under the age of 12 years, the movement of C1 on C2 during flexion of the neck can normally be up to 5 mm, whereas in adults, this distance should be less than 3 mm. Likewise in this young age group, the distance between C2 and C3 is up to 3 mm. No forward movement of C2 on C3 should be present in a skeletally mature individual when the neck is flexed. This so-called pseudosubluxation of C2 on C3 in a child should not be diagnosed as instability that requires treatment because this is a normal finding in young children.³³ Because it is difficult to detect a fracture of the thoracic or lumbar spine clinically, radiographs of this area, primarily a lateral view, should be carefully evaluated, particularly in a comatose child.

Computed Tomography

CT is essential in evaluating a child with multiple injuries. If a head injury is present, CT of the head will detect skull fractures and intracranial bleeding. With abdominal swelling, pain, or bruising, CT of the abdomen with IV contrast provides excellent visualization of the liver and spleen and allows quantification of the amount of hemorrhage present. Because most hepatic and splenic lacerations are treated nonoperatively,^29,79,155 the CT scan and serial hematocrit levels are used to determine whether surgical treatment of these visceral lacerations is needed.

CT of the pelvis is more sensitive for pelvic fractures than is a screening pelvic radiograph (Fig. 5-2). In one study, a screening pelvic radiograph demonstrated only 54% of pelvic fractures identified on CT scan.⁶⁶ CT also is useful for thoroughly evaluating fracture configuration and determining appropriate treatment options, both surgical and nonsurgical. If abdominal CT is being done to evaluate visceral injury, it is simple to request that the abdominal CT be extended distally to include the pelvis. CT of a fractured vertebra will provide the information needed to classify the fracture as stable or unstable and determine whether operative treatment is needed.

Intravenous Pyelography

There is a strong correlation of urologic injury with anterior pelvic fractures, as well as with liver and spleen injury. Although CT and ultrasonography are used to evaluate renal injuries, the IV pyelogram still has a role in helping to diagnose bladder and urethral injuries.¹³⁶ Regardless of the methods of imaging, the anatomy of the urethral disruption often cannot be accurately demonstrated preoperatively.⁴

Radionuclide Scans

Bone scans have a limited role in the acute evaluation of a child with multiple injuries. In conjunction with a skeletal survey, a technetium-99m bone scan is sometimes used in children with suspected child abuse to detect previously undetected new or old fractures.^75,94,123

Heinrich et al.⁷⁵ reported that bone scans in 48 children with multiple injuries often demonstrated an unsuspected injury. Nineteen previously unrecognized fractures were identified by obtaining radiographs of the areas with increased isotope uptake. In addition, there were 66 false-positive areas of increased uptake in the 48 patients. Of their 48 patients, six had a change in their orthopedic care as a result of this bone scan, although this treatment was usually simple cast immobilization of a nondisplaced fracture. In some instances, the bone scan can be useful to differentiate a normal variation in skeletal ossification (normal uptake) from a fracture (increased uptake), particularly in an extremity or a spinal area where pain is present. Areas of increased uptake require further imaging studies to determine if orthopedic treatment is required.

Magnetic Resonance Imaging

MRI is used primarily for the detection of injury to the brain or the spine and spinal cord. In young children, the bony spine is more elastic than the spinal cord. As a result, a spinal cord injury can occur without an obvious spinal fracture in children with multiple injuries, particularly in automobile accidents.^9,22,57 In the spinal cord injury without radiographic abnormality (SCIWORA) syndrome, MRI is valuable in demonstrating the site and extent of spinal cord injury and in defining the level of injury to the disks or vertebral apophysis. A fracture through the vertebral apophysis is similar to a fracture through the physis of a long bone and may not be obvious on planar radiographs. MRI in obtunded and intubated pediatric trauma patients has been reported to lead to a quicker cervical spine clearance with a resulting decrease in hospital stay and cost.⁶¹

MRI is also useful in evaluating knee injuries,¹¹⁸ particularly when a hemarthrosis is present. If blood is present on knee arthrocentesis, MRI can assist in diagnosing an injury to the cruciate ligaments or menisci. In addition, a chondral fracture that cannot be seen on routine radiographs may be demonstrated by MRI.

Ultrasonography

Ultrasound evaluation has been shown to be an accurate means of detecting hemopericardium and intraperitoneal fluid following injury. Some trauma centers have replaced peritoneal lavage and laparoscopy with serial ultrasound evaluations to monitor liver, spleen, pancreas, and kidney injury in children with multiple injuries.^27,79,155 The protocol most typically used is called “Focused Assessment with Sonography for Trauma” (FAST). FAST consists of a rapid ultrasound examination of four areas: The right upper abdominal quadrant, the left upper abdominal quadrant, the subxiphoid area, and the pelvis. The role of FAST in the evaluation of pediatric trauma patients is still being established.^{39,55,80,81,184} As a result, CT is more often used for assessment and monitoring of visceral injury in children sustaining multiple injuries. Comparisons of CT and ultrasonography have demonstrated the superiority of CT for diagnosing visceral injury in children with polytrauma,^{39,131,152,187} but there is evidence that hemodynamically unstable children with a positive FAST should be taken for laparotomy rather than for CT scanning.¹¹³

NONORTHOPEDIC CONDITIONS IN THE MULTIPLY INJURED CHILD

Key Concepts

• Head injury severity is the principle determinant of morbidity and mortality in a multiply injured child.

• Children often make substantial recovery from even severe head trauma.

• Management of orthopedic injuries in children with head trauma should be based on the presumption of full recovery from the head injury.

• Spasticity and contracture are common sequelae of brain injury, and should be addressed early.

• There is an association between pediatric pelvic fractures and both intra-abdominal and genitourinary injuries.

• Motion at the site of a long-bone fracture results in increased intracranial pressure (ICP). To control ICP, it is imperative that long-bone fractures are immobilized until definitive fracture care can be provided.

Head Injury

Prognosis for Recovery

Head injuries occur in children with multiple injuries even more often than orthopedic injuries. In a review of 494 pediatric polytrauma patients, Letts et al.¹⁰⁹ reported closed head injuries in 17% and skull fractures in 12%, whereas Schalamon et al.¹⁶⁶ reported injuries to the head and neck region in 87% of pediatric polytrauma patients. It has been clearly demonstrated that a child recovers more quickly and more fully from a significant head injury than does an adult.^40,112,214 Even children who are in a coma for hours to days often recover full motor function. Mild cognitive or learning deficits may persist, so educational testing needs to be considered for children who have had head injury and coma. Two factors that have been linked to poorer functional recovery and more severe permanent neurologic deficits are a low oxygen saturation level at the time of presentation to the hospital and a low GCS score 72 hours after the head injury. In fact, the severity of TBI is the single most important determinant of long-term outcome in polytraumatized children.⁸⁷ Because children with head injuries are often transported long distances, evacuation of a cerebral hematoma within 4 hours is not always possible.¹⁹⁰

Despite the fact that excellent motor recovery is expected in most children after a head injury, children are often left with significant residual cognitive deficits. Many children who sustain TBIs are unaware of their residual cognitive limitations and tend to overestimate their mental capacities.⁷¹ Children who have had a TBI also often have behavioral problems, the presence of which may be predictive of behavioral problems in uninjured siblings as well.¹⁸⁸ Greenspan and MacKenzie⁶⁵ reported that 55% of children in their series had one or more health problems at 1-year follow-up, many of which were relatively minor. Headaches were present in 32% and extremity complaints in 13% of patients. The presence of a lower extremity injury with a head injury led to a higher risk of residual problems.

Because of the more optimistic outlook for children with head injuries than for adults with similar injuries, timely orthopedic care should be provided, and the orthopedist should base the orthopedic care on the assumption of full neurologic recovery. Waiting for a child to recover from a coma is not appropriate, and comatose children tolerate general anesthesia well. Unless the musculoskeletal injuries are treated with the assumption that full neurologic recovery will take place, long-bone fractures may heal in angled or shortened positions. In the absence of optimal orthopedic care, once neurologic recovery occurs, the primary functional deficit will be from ill-managed orthopedic injuries rather than from the neurologic injury.

Intracranial Pressure

After a head injury, ICP is commonly monitored to prevent excessive pressure, which may lead to further permanent disability or death. Normally, ICP does not exceed 15 mm Hg, and all attempts should be made to keep the pressure under 30 mm Hg after a head injury. This is accomplished by elevating the head of the bed to 30 degrees, lowering the PCO2, and restricting IV fluid administration. Ventilator assistance is used to lower the PCO2, which helps lessen cerebral edema. Fluid restriction also is recommended if peripheral perfusion can be maintained despite the polytrauma. Elevation of serum norepinephrine has been shown to correlate well with the severity of head injury in patients with injury of multiple organ systems.²¹⁵

Motion at the site of a long-bone fracture results in increased ICP. To control ICP, it is imperative that long-bone fractures are immobilized until definitive fracture care can be provided. Initial immobilization is usually accomplished by splinting or casting of the fractures, or by use of traction for femoral shaft fractures. Fracture stabilization with internal or external fixation facilitates dressing changes for the treatment of adjacent soft tissue injury as well as allowing inhospital transport for imaging studies and other necessary treatments.^196,197

Secondary Orthopedic Effects of Head Injuries

A head injury can have later impact on the management of musculoskeletal injuries, even after the acute phase has passed. Persistent spasticity, the development of contractures, heterotopic bone formation in soft tissue, and changes in fracture healing rates are all sequelae of a head injury in children.

Spasticity. Spasticity may develop within a few days of head injury. The early effect of this spasticity is to cause shortening at the sites of long-bone fractures if traction or splint or cast immobilization is being used. If fracture displacement or shortening occurs in a circumferential cast, the bone ends may cause pressure points between the bone and the cast, leading to skin breakdown at the fracture site, with a higher risk for deep infection. Even with skeletal traction for femoral fractures, fracture shortening and displacement will occur as the spasticity overcomes the traction forces. Once spasticity develops and long-bone fractures displace, internal or external fixation is needed to maintain satisfactory reduction. This operative stabilization should be done as soon as the spasticity becomes a problem for fracture reduction because fracture healing is accelerated by a head injury.^195,197

Contractures. The persistence of spasticity in the extremities often leads to subsequent contractures of the joints spanned by the spastic muscles. Contractures can develop quickly, and early preventative stretching or splinting should begin while the child is in the intensive care unit. Nonselective mass action muscle activity associated with brain injury can be used to help prevent these early contractures. If the child lies in bed with the hips and knees extended, there will usually be strong plantarflexion of the feet at the ankles. If the hip and knee are flexed, it will be much easier to dorsiflex the foot at the ankle, so part-time positioning in this way will prevent early equinus contractures from developing. Stretching and splinting can often be effective in preventing contractures, and casting may be needed if contractures develop. If these measures are not successful and are interfering with rehabilitation, these contractures may need to be released surgically.

Heterotopic Bone Formation. Heterotopic bone may form in the soft tissues of the extremity as early as a few weeks after a head injury with persistent coma.⁹⁶ Although any joint can be affected, the most common sites are the hip and the elbow. There is some evidence that heterotopic bone formation can be stimulated by surgical incisions. In head-injured teenagers who undergo antegrade reamed femoral intramedullary nailing of femoral fractures, heterotopic bone that later restricts hip motion can form at the nail insertion site.⁹² A sudden increase of alkaline phosphatase a few weeks after the onset of coma, even with fractures coexisting, may mean that heterotopic bone is starting to form and a more careful examination of the extremities is indicated.¹²⁷ Technetium-99 bone scans show increased isotope uptake in the soft tissue where heterotopic bone forms, and this imaging study should be considered if new swelling is noted in the extremity of a comatose child. Other diagnoses that must be considered in a comatose child with new swelling of the extremity are a new long-bone fracture and deep venous thrombosis.¹⁸¹

Observation and excision are the two primary approaches taken in managing heterotopic bone formation in an injured child. If the child remains comatose, usually little treatment is administered. There are no conclusive data to support medical treatment because diagnosis of heterotopic bone formation is typically made after the inflammatory stage of heterotopic bone formation. In theory, it might be useful to try to block some of the heterotopic bone formation by the use of salicylates or nonsteroidal anti-inflammatory medication if the diagnosis were established very early. If the child has recovered from the head injury and has heterotopic bone that does not interfere with rehabilitation, no intervention is required. If there is significant restriction of joint motion from the heterotopic bone, this bone should be excised to facilitate rehabilitation. The timing of the heterotopic bone excision is controversial, but resection should be considered whenever heterotopic bone significantly interferes with rehabilitation, rather than waiting for 12 to 18 months until the bone is more mature. After surgical excision, early postoperative prophylaxis with local low-dose radiation therapy or medications (salicylates or nonsteroidal anti-inflammatory drugs) decreases the risk of recurrence. Mital et al.¹²⁷ reported success in preventing recurrence of heterotopic bone after excision by use of salicylates at a dosage of 40 mg/kg/day in divided doses for 6 weeks postoperatively.

Fracture Healing Rates. Long-bone fractures heal more quickly in children and adults who have associated head injuries.²²² It has been demonstrated that polytrauma patients in a coma have a much higher serum calcitonin level than do conscious patients with similar long-bone fractures, but how or whether this finding influences fracture healing is still unclear.⁴⁸

Peripheral Nerve Injuries

Although TBI most often accounts for persistent neurologic deficits in a child with multiple injuries, peripheral nerve injury should be considered as well during the rehabilitation process. In one clinical review of brain-injured children, 7% had evidence of an associated peripheral nerve injury documented by electrodiagnostic testing.¹⁴⁴ For closed injuries, the peripheral nerve injury is typically associated with an adjacent fracture or with a stretching injury of the extremity. In most cases, observation is indicated because these injuries often recover spontaneously. However, if the nerve injury is at the level of an open fracture, then exploration of the nerve is indicated at the time of the initial surgery. In children being observed following a nerve injury, if function does not return within 2 to 3 months, then electrodiagnostic testing should be undertaken. It is important to recognize these injuries because surgical peripheral nerve repair with nerve grafts offers an excellent chance of nerve function recovery in young patients.

Abdominal Injuries

Studies have reported abdominal injuries in 8%¹⁰⁹ to 27%⁵¹ of pediatric polytrauma patients. Abdominal swelling, tenderness, or bruising are all signs of injury. CT evaluation has largely replaced peritoneal lavage or laparoscopy as the initial method of evaluation of abdominal injury.¹⁹¹ Abdominal injury is common if a child in a motor vehicle accident (MVA) has been wearing a lap seat belt, regardless of whether a contusion is evident.^29,201 Bond et al.²⁰ noted that the presence of multiple pelvic fractures strongly correlated (80%) with the presence of abdominal or genitourinary injury, whereas the child’s age or mechanism of injury had no correlation with abdominal injury rates. Although hepatic and splenic injuries are much more common, 22% of pediatric cases of pancreatitis result from trauma.¹⁵

The usual practice is to treat hepatic and splenic lacerations nonoperatively, by monitoring the hematocrit, by repeating the abdominal examination frequently, and by serial CT scans or ultrasound examinations.^{31,36,37,38,108,191,203} Once the child’s overall condition has stabilized, and the child is stable to undergo general anesthesia, the presence of nonoperative abdominal injuries should not delay fracture care.

Genitourinary Injuries

Genitourinary system injuries are rare in the pediatric polytrauma population, with Letts et al.¹⁰⁹ reporting an incidence of 1% in these patients. However, genitourinary injuries have been reported in 9%¹⁷² to 24%¹⁹⁸ of children with pelvic fractures. Most injuries to the bladder and urethra are associated with fractures of the anterior pelvic ring (Fig. 5-3).¹² Such injuries are more common in males and usually occur at the bulbourethra, but the bladder, prostate, and other portions of the urethra can also be injured.^12,136 Although less common following pelvic fracture in girls, such injuries are often associated with severe injuries, including those to the vagina and rectum, with long-term concerns regarding continence, stricture formation, and childbearing.^146,158 If the iliac wings are displaced or the pelvic ring shape is changed, it may be necessary to reduce these fractures to reconstitute the birth canal in female patients. There are increased rates of cesarean section in young women who have had a pelvic fracture.⁴¹ Adolescent females with displaced pelvic fractures should be informed of this potential problem with vaginal delivery. If the injury is severe, kidney injury may also occur, but most urologic injuries that occur with pelvic fractures are distal to the ureters.¹

Fat Embolism and Pulmonary Embolism

Although fat embolism and acute respiratory distress syndrome are relatively common in adults with multiple long-bone fractures, they are rare in young children.^115,154 When fat embolism occurs, the signs and symptoms are the same as in adults: Axillary petechiae, hypoxemia, and radiograph changes of pulmonary infiltrates appearing within several hours of the fractures. It is likely that hypoxemia develops in some children after multiple fractures, but the full clinical picture of fat embolism seldom develops. If a child with multiple fractures without a head injury develops a change in sensorium and orientation, hypoxemia is most likely the cause, and arterial blood gases are essential to determine the next step in management. The other primary cause of mental status change after fracture is overmedication with narcotics.

If fat embolism is diagnosed by low levels of arterial oxygenation, the treatment is the same as in adults, generally with endotracheal intubation, positive pressure ventilation, and hydration with IV fluid. The effect of early fracture stabilization, IV alcohol, or high-dose corticosteroids on fat embolism syndrome has not been studied well in children with multiple injuries.

Deep venous thrombosis and pulmonary thromboembolism also are rare, but are increasingly reported in children.^{10,11,46,114,200} The risk of deep venous thrombosis and pulmonary embolism is increased in children older than 9, those with an ISS greater than or equal to 25, and/or a GCS lower than or equal to 8, and those with central venous catheters^34,155 The role of prophylaxis for pediatric deep venous thrombosis and pulmonary thromboembolism is unclear.^{23,156,163,200}

Nutritional Requirements

Pediatric polytrauma patients have high caloric demands. If an injured child requires ventilator support for several days, caloric intake through a feeding tube or a central IV catheter is necessary to avoid catabolism, improve healing, and help prevent complications. The baseline caloric needs of a child can be determined based on the weight and age of the child. Children on mechanical ventilation in a PICU have been shown to require 150% of the basal energy or caloric requirements for age and weight.¹⁹⁴ The daily nitrogen requirement for a child in the acute injury phase is 250 mg/kg.

ORTHOPEDIC MANAGEMENT OF THE MULTIPLY INJURED CHILD

Key Concepts

• Most fractures in multiply injured children can be splinted initially, and undergo definitive treatment urgently, not emergently.

• Pelvic fractures in children can typically be treated nonoperatively, but may require fixation if the child is hemodynamically unstable.

• Tetanus toxoid and antibiotics should be provided for all open fractures, though routine culture is unnecessary.

• The timely administration of IV antibiotics and appropriate irrigation and debridement are the most important steps in the treatment of open fractures.

• There are many options for stabilization of open fractures. In each case stabilization should be planned to allow easy access for further treatment of the soft tissue injury.

• Children will often heal open fractures that would necessitate amputation in an adult.

• If amputation is necessary, preserve as much stump length as possible.

Timing

Because fractures are rarely life-threatening, splinting generally suffices as the initial orthopedic care while the child’s overall condition is stabilized. Loder¹¹⁶ reported that, in 78 children with multiple injuries, early operative stabilization of fractures within the first 2 or 3 days after injury led to a shorter hospital stay, a shorter stay in the intensive care unit, and a shorter time on ventilator assistance. In addition, there were fewer complications in those who had surgical treatment of the fractures less than 72 hours after injury. In a more recent study, Loder et al.¹¹⁷ reported a trend toward a higher rate of complications of immobilization (including pulmonary complications) in fractures treated late (after 72 hours), but the difference did not reach statistical significance. In this more recent study, age greater than 7 years and Modified Injury Severity Score (MISS) ≥140 were predictive of an increased rate of complications of immobilization. A mixed series of adults and children demonstrated comparable results for early (within 24 hours) and late (after 24 hours) fixation of fractures in the setting of blunt trauma and severe head injuries.²⁰⁷

Pelvic Fractures

Pelvic fractures are common in children and adolescents with multiple injuries and have been reported in up to 7% of children referred to level 1 regional trauma centers.^180,209 Survival is related to ISS and type of hospital.²⁰⁹ In two series, 60% to 87% of pelvic fractures involved a pedestrian struck by a motor vehicle.^172,183 Other common mechanisms include being a passenger in an MVA or falling from a height.^172,183 Although many of these pelvic injuries are stable, unstable patterns have been reported in up to 30% of cases.¹⁸

Injuries to the axial skeleton have been reported to be associated with the most intense hospital care and higher mortality rates than other injury combinations.²⁶ In their series of 166 consecutive pelvic fractures, Silber et al.¹⁷² reported associated substantial head trauma in 39%, chest trauma in 20%, visceral/abdominal injuries in 19%, and a mortality rate of 3.6% (Fig. 5-4). In this same series,¹⁷² 12% (20/166) had acetabular fractures, whereas in another series, 62% of children (8/13) with pelvic fractures had other orthopedic injuries.¹⁸³

Control of bleeding, either from the retroperitoneum near the fracture or from the peritoneum from injured viscera, may present an immediate threat.⁸⁶ However, death of children with pelvic fractures appears to be caused more often by an associated head injury rather than an injury to the adjacent viscera or vessels.¹³⁰

Anterior pelvic ring fractures are the primary cause of urethral injury,^1,12,146,158 although urethral injuries are reported to occur less frequently in children than in adults.¹⁷² Bilateral anterior and posterior pelvic fractures are most likely to cause severe bleeding,¹²⁴ but death from blood loss in children is uncommon.^49,130 Injury to the sciatic nerve or the lumbosacral nerve roots may result from hemipelvis displacement through a vertical shear fracture. Nonorthopedic injuries associated with pelvic fractures led to long-term morbidity or mortality in 31% (11/36) of patients in one review of pediatric pelvic fractures.⁶² Most pelvic fractures in children are treated nonoperatively. However, in a child or preadolescent, an external fixator can be used to close a marked pubic diastasis or to control bleeding by stabilizing the pelvis for transport and other injury care. The external fixator will not reduce a displaced vertical shear fracture, but the stability provided is helpful to control the hemorrhage while the child’s condition is stabilized.^151,189 Another option for acute pelvic stabilization in the emergency department is a simple pelvic binder.⁸⁷ Though reported to be safe for children, the C-clamp is not typically utilized for the pediatric population.⁸² Operative treatment can result in healing by 10 weeks with a low complication rate.⁹⁰

Open Fractures

Background

Most serious open fractures in children result from high-velocity blunt injury involving vehicles. Penetrating injuries are much less common in children than in adults; however, many low-energy blunt injuries can cause puncture wounds in the skin adjacent to fractures, especially displaced radial, ulnar, and tibial fractures. In children with multiple injuries, approximately 10% of the fractures are open.^26,166 When open fractures are present, 25% to 50% of patients have additional injuries involving the head, chest, abdomen, and other extremities.¹⁶⁶

Wound Classification

The classification used to describe the soft tissues adjacent to an open fracture is based on the system described by Gustilo and Anderson⁶⁷ and Gustilo et al.⁶⁸ Primary factors that are considered and ranked in this classification system are the size of the wound, the degree of soft tissue damage and wound contamination, and the presence or absence of an associated vascular injury (Table 5-4).

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