Pediatric Trauma
7.1 Introduction
This chapter begins with a presentation of the unique considerations in pediatric trauma, followed by a systematic, proximal-to-distal presentation of the principles and algorithms for the management of pediatric orthopaedic trauma. Common diaphyseal fractures are not covered if there are no unique pediatric features. References are provided at the end of each section for further information.
7.2 Basic Principles
7.2.1 Differences in Anatomy
Periosteum:
Thicker and stronger in children.
Often intact on the compressed side of fractures; use as hinge in reduction.
Elastic bones:
Torus/buckle fractures: Bulging of the cortex after axial loading force.
Greenstick fractures: Incomplete fracture on one side of diaphysis.
Bowing fracture: Bending of bone without visible fracture or cortical injury.
7.2.2 Physeal Fractures Classification
There are several classification systems, but the most commonly used is still that of Salter and Harris. The systems’ goals are to (1) facilitate communication, (2) predict the risk of growth disturbance, and (3) determine treatment.
The classifications provide information on:
Physeal alignment.
Articular alignment.
Stability and risk of displacement.
Physeal damage can occur from:
Step off at the level of the physis, with bar formation.
Damage to and death of physeal cells.
Ischemia of the physis if severe soft-tissue damage occurs.
The classifications are usually predictive of the risk of growth disturbance. Salter I and II fractures are typically at low risk of growth disturbance because the growth plate is not traversed by the fracture. However, there are some notable exceptions because damage may occur to the physis but not be visible on plain films. This is most common in the distal femur and the distal tibia, where there is a high risk of growth disturbance even in the “benign” fracture types such as Salter I and II. This may be due to complex physeal anatomy as well as compressive forces involved. By contrast, there is a low risk of growth plate damage in Salter I and II fractures of the distal radius and ulna and the proximal humerus.
Salter–Harris classification: The most widely used (▶ Fig. 7.1). Note that type V fractures are rarely, if ever, seen.
Peterson classification: Recognizes a broader spectrum of injuries.
Fig. 7.1 Salter–Harris classification of physeal injuries.
7.2.3 Management of the Polytrauma Patient
Definition: The polytrauma patient is a patient with more than one organ system injured or more than one component injured within one organ system.
Laboratory studies: Complete blood cell count, type and cross, urinalysis, blood urea nitrogen, creatinine, amylase, electrolytes.
Indications for radiographic studies:
Cervical, thoracic, lumbar spine:
Tender.
Unconscious or heavily sedated.
Neurologically abnormal.
Pelvis:
Tender.
Unconscious.
Hematuria present.
Skull:
Head trauma and loss of consciousness for longer than 5 minutes, hematoma.
Skull depression.
Focal neurologic signs.
Cerebrospinal fluid from nose or middle ear.
Blood in middle ear.
Computed tomography (CT) of the head:
Glasgow Coma Scale score less than 8.
Focal neurologic signs.
CT of the abdomen.
Shock.
Severe head injury.
Abnormal abdominal examination.
7.2.4 Evaluation of Patient
Primary survey: To detect most urgent priorities (“ABCDE”).
A—Airway.
B—Breathing (ventilation).
C—Circulation (hemorrhage).
D—Disability (neurologic status).
E—Exposure (temperature).
Secondary survey:
Complete physical examination.
History of event.
Medical history.
Laboratory and radiographic results.
Reevaluation and stabilization.
Normal vital signs for children (▶ Table 7.1).
Glasgow Coma Scale (▶ Table 7.2).
Table 7.1 Normal vital signs by age
Age
Pulse (beats/min)
Respirations (per min)
Blood pressure (mm Hg, systolic/diastolic)
1–6 mo
130 ± 45
30–40
80/46
6–12 mo
114 ± 40
24–30
95/65
1–2 y
110 ± 40
20–30
99/65
2–6 y
105 ± 35
20–25
100/60
6–12 y
95 ± 30
16–20
110/60
12 y
80 ± 25
12–16
120/60
Response | Score |
Eye opening | |
| 1 |
| 2 |
| 3 |
| 4 |
Verbal | |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
Motor | |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 6 |
Total | Up to 15 points |
7.2.5 Adjuncts in Management
Intracranial pressure measurement indications:
Glasgow Coma Scale less than 5, or less than 8 if shock is present.
CT scan showing mass or shift.
Progressive neurologic deterioration.
Parenteral nutrition: indicated in polytrauma patient if enteral feeding not expected within 24 hours.
Repeat physical examination: Should be performed at 24 and 48 hours because of the incidence of missed injuries (bone scan is an alternative).
Indications for deep venous thrombosis prophylaxis in polytrauma:
Oral contraceptive use.
Vascular injury.
Sickle cell anemia.
Prolonged immobility in older adolescents.
7.3 Pediatric Shoulder Injuries
7.3.1 Principles
The proximal humeral physis is one of the most active in the skeleton, contributing 80% of the length of the humerus: therefore, it has tremendous remodeling potential.
Ossification:
Begins at 6 months in proximal humeral epiphysis, and growth ceases at 15 years in girls and 18 years in boys.
Ossific center for greater tuberosity appears at age 1; medial clavicle physis closes at around 23 years.
7.3.2 Birth Fractures
Risk factors:
Difficult delivery.
Large size.
Breech presentation.
Presentation:
“Pseudoparalysis”—limb moves little.
Rule out sepsis, brachial plexus injury.
Diagnosis: Plain radiographs or ultrasound.
Treatment: Gently immobilize the arm to the chest using an Ace wrap.
7.3.3 Proximal Humeral Fractures
Background:
Age-based patterns: Preadolescent usually has fracture of metaphyseal region; adolescent, physeal fracture; Salter I or II.
Mechanism: Axial load or abduction; external rotation.
Muscle insertions with respect to physis: Internal and external rotators all on proximal fragment; deltoid and pectoralis, distal fragment displaces anteriorly and medially.
Criteria for acceptable alignment:
Child younger than 12 years: Virtually any alignment is acceptable.
Child older than 12 years: Shortening or overlap less than 3 cm.
Angulation less than 45 degrees.
Classification of displacement (pediatric):
Neer and Horowitz:
I: Less than 5 mm translation.
II: 5 mm to 33%.
III: 33 to 66%.
IV: Greater than 66% (most are grade IV).
Translation itself is not a problem. Note: Appearance on emergency department film is not the same as the appearance later. Angulation usually improves.
Treatment methods:
Sling.
Traction.
Shoulder spica.
Abduction brace.
Internal fixation.
General recommendations:
If alignment is acceptable, swing or hang cast.
Reduce and pin if < 2 years of growth remaining and >45 degrees malalignment.
Additionally, consider open reduction and internal fixation (ORIF) if:
Severe head injury with spasticity.
Polytrauma: To facilitate management.
Vascular injury.
Tenting skin: Risk of breakdown.
Fracture through unicameral bone cyst (UBC):
Common cause of proximal humerus fracture in child.
Differential diagnosis:
Eosinophilic granuloma.
Aneurysmal bone cyst (ABC).
Fibrous dysplasia.
Fibrous cortical defect.
Treatment of UBC:
Sling to heal fracture: 4 to 6 weeks.
Cyst regresses about 20% of time.
Assess and discuss the risk of refracture with family: depends mainly on cortical thickness.
Inject with methylprednisolone or bone graft if (a) persistently thin cortex; (b) high desired activity level; (c) family prefers active treatment.
May need several injections.
7.3.4 Sternoclavicular Injuries
7.3.4.1 Background
Medial clavicle is last epiphysis to appear and to close (< 23 years old), providing 80% of clavicle growth.
Medial fracture: Usually Salter–Harris I or II physeal separation; epiphysis hard to visualize.
Diaphyseal fracture: More common, middle one-third of clavicle.
Mechanism: Fall on outstretched arm or other lateral force on shoulder girdle.
7.3.4.2 Treatment
Medial fracture:
CT often necessary to identify.
Anterior or superior displacement: usually no reduction attempted.
Posterior displacement: reduce if significant dysphagia or pulmonary issues.
Diaphyseal fracture:
Reduction generally not attempted in children or adolescents.
Treat only if significant displacement or evidence of:
Venous congestion.
Decreased pulse.
Difficulty breathing, swallowing.
Sensation of choking.
Operative treatment, if indicated:
Closed reduction: May use towel clips.
Internal fixation: use sutures if unstable.
Reassure family that a bump will occur and gradually shrink at the site of remodeling.
Bibliography
1. Bae DS, Kocher MS, Waters PM, Micheli LM, Griffey M, Dichtel L. Chronic recurrent anterior sternoclavicular joint instability: results of surgical management. J Pediatr Orthop 2006;26(1):71–74
2. Baxter MP, Willey JJ. Fractures of the proximal humeral epiphysis. Their influence on humeral growth. J Bone Joint Surg Br 1986;68(4):570-573
3. Skaggs DL, Frick S. Management of fractures. In: Morrissy RT, Weinstein SL, Flynn JM, eds. Lovelland Winter’s Pediatric Orthopaedics. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 20014:1694–1773
7.4 Pediatric Elbow Injuries
7.4.1 Supracondylar Humerus Fracture
Background and classification:
Direction of displacement:
95% are due to hyperextension; periosteal hinge will be posterior.
5% are due to flexion; periosteal hinge will be anterior.
Degree of displacement (Gartland classification):
Type I: Undisplaced.
Type II: Hinged/greenstick fracture:
IIa: Not rotated.
IIb: Rotated.
Type III: Completely displaced with intact periosteal hinge.
Type IV: Multidirectionally unstable without periosteal hinge.
7.4.2 Principle
Type III fractures have an appreciable incidence of nerve and artery damage with little intrinsic stability. Pretreatment neurovascular exam is essential, which includes the following:
Median nerve: Check active palmar flexion.
Anterior interosseous nerve: Distal interphalangeal (DIP) flexion of index finger and thumb.
Posterior interosseous nerve: Dorsiflexion of the metacarpophalangeal joints.
Ulnar nerve: Flexion of the fifth finger distal interphalangeal joint or crossing of the index and second fingers (▶ Fig. 7.2).
Fig. 7.2 Documentation of the status of all nerves and circulation before treatment of supracondylar humerus fractures. This involves (a) checking active palmar flexion (median nerve); (b) flexion of distal interphalangeal joints of the index finger and thumb-anterior interosseous nerve; (c) dorsiflexion of the metacarpophalangeal joints—posterior interosseous nerve; (d) flexion of the fifth finger distal interphalangeal joint; or (e) crossing of index and second fingers—ulnar nerve.
7.4.3 Treatment
Type II: Check varus valgus and consider reduction if the Baumann angle is greater than 5 to 10 degrees off normal.
Type III: Percutaneous pin fixation best (▶ Fig. 7.3): One medial and lateral or two lateral pins. Both pins should start distal to the fracture site with longitudinal traction and slight flexion. The lateral pin should engage a portion of the capitellum, and the medial pin should be slightly medial and anterior on the epicondyle to avoid the ulnar nerve (▶ Fig. 7.4). Make a small incision to clear a tract. If two lateral pins are used, one should cross the lateral third of the fracture, and one should cross the central third of the fracture (▶ Fig. 7.5).
If anatomic closed reduction is not possible, perform open reduction. Check alignment of the fracture using the Baumann angle (▶ Fig. 7.6a); normal is 72 ± 4 degrees. Also check the anterior humeral line (▶ Fig. 7.6b), which should intersect the anterior one-third to one-half of the capitellum.
Aftercare: May begin protected range of motion at around 3 weeks with temporary splint removal. Remove pins at 6 weeks.
Fig. 7.3 One technique of closed reduction and percutaneous pinning. Longitudinal traction is applied in slight flexion to correct angulation and yet allow visualization. Fluoroscopy receiver serves as platform.
Fig. 7.4 Desired pin placement for medial and lateral pin technique.
Fig. 7.5 Lateral pin fixation for type III supracondylar humerus fractures.
Fig. 7.6 (a) Baumann angle (normal, 72 degrees). (b) The anterior humeral line should intersect anterior or middle third of capitellum.
7.4.4 Nerve Injury
Frequency: Radial > anterior interosseous > ulnar > median.
Treatment: If deficit is present before reduction, then it is probably a neuropraxia resulting from the injury; proceed with closed reduction. If no return by 5 months after injury, then obtain electromyelogram; explore and perform neurolysis if no recovery.
7.4.5 Arterial Insufficiency
Reduce fracture; do not hyperflex:
If perfusion returns, pin fracture.
If perfusion does not return, perform an open exploration through an anterior Henry approach.
If artery is entrapped, release and watch.
If in spasm, use lidocaine.
If an intimal tear occurs, repair.
If transected, vein graft.
Measure compartment pressures after reperfusion and perform fasciotomy if needed.
7.4.6 Lateral Condyle Fracture
Background:
Mechanism: fall onto outstretched hand.
Collateral vascular supply to the capitellum and lateral trochlea mostly enters posteriorly.
Fracture may occur with varus or valgus force.
Distinguish this injury from a transphyseal separation by lack of swelling and tenderness medially and by alignment of the humerus with the forearm (▶ Fig. 7.7); ultrasound may help.
Internal oblique radiograph shows the fracture best.
Principles and significance:
Lateral condyle fracture is one of the few pediatric fractures in which nonunion and avascular necrosis are not rare.
Cast is rarely able to maintain reduction of a displaced lateral condyle.
Jakob classification:
Type I: <2 mm displacement, undisplaced.
Type II: >2 mm displacement, hinged.
Type III: >2 mm displacement, translated.
Treatment:
Type I: Splint in 90 to 100 degrees of flexion; pronation: recheck at 5 and 10 days (ORIF if further displacement).
Type II or III, or if follow-up is unreliable: Attempt closed reduction (optional):
Avoid posterior dissection; visualize reduction anteriorly.
Internal fixation: Two divergent pins preferred.
May cross physis if needed.
May use screw; remove later.
Usually remove pins and splint at 6 to 8 weeks.
Fiberglass allows best visualization of fracture.
Late presentation (displaced and ununited longer than 6 weeks):
Approach anteriorly with graft and rigid fixation if in good position (early). Operate only for lateral instability symptoms if after 3 weeks. Avoid excessive dissection.
Valgus osteotomy if significant deformity exists.
Ulnar nerve anterior transposition if deformity is increasing.
Fig. 7.7 Differentiation of lateral condyle from distal humeral physeal fracture. In the latter, displacement of the entire forearm follows the metaphyseal fragment. In minimally displaced fractures, physical examination, ultrasound, arthrogram, or MRI may be helpful. The top illustration shows normal alignment of ulna and humerus. (Lower left) Alignment maintained in lateral condyle fracture. (Lower right) Alignment is lost in distal humeral Salter II physeal fractures.
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