Epidemiology and mechanism of injury in pregnancy

Dealing with trauma in pregnant patient is of a significant concern due to the difficulty of optimizing health outcomes for both mother and the fetus. Women are inherently more cautious during pregnancy by limiting physical activates and avoiding risky activities that may impose a risk on the fetus. This makes the incidence of trauma in pregnancy relatively low in pregnant patients compared to non-pregnant patients. Pregnant women undergo vagarious checks and follow up throughout pregnancy, which minimizes any obstetrics complications. However, trauma is one of the leading non-obstetrics causes of death during pregnancy, due to its unpredictable nature and complex management. Studies have shown that 6–8% of pregnant women had complicated pregnancy due to experiencing some form of physical trauma during pregnancy, with motor vehicle accident (MVAs) accounting for approximately 70% of these cases. ^,

Understanding the nature of injuries is paramount for effective management. In pregnancy, this is influenced by the mechanism of injury, maternal physiological changes, and gestational stage of the pregnancy. For instances, trauma experienced in the second and third trimesters lead to poorer outcomes. The continuous enlargement of the uterus during these stages of gestation, pushes on and displaces the internal organs. This alters the centre of gravity and increases the risks of high-impact injuries and falls. Pelvic and extremities fractures, and abdominal injuries are the most common outcomes of trauma in pregnancy, all of which can significantly impact the maternal and fetal health.

Blunt trauma, particularly MVAs, is a significant concern due to the extreme force exerted on the body. The sudden deacceleration, high impact and blunt trauma have been shown to lead to severe complications such as uterine rupture, placental abruption and sudden fetal death. Placental abruption, happening in 3.5% of cases, results in major maternal haemorrhage, compromising the blood flow to the fetus leading to pre-term labour, or fetal demise in severe cases. Penetrating trauma has also been seen in pregnancy, although less common, they tend to have a catastrophic outcome specially if they affect vital organs. Implementing effective strategies to manage trauma in pregnant patients require an understanding of the epidemiology and the mechanism of injuries, this is to ensure optimal care is delivered taking into account the maternal and fetal well-being.

Physiological considerations in pregnant trauma patients

The physiological changes that occur during pregnancy mask the typical signs of trauma, making it difficult to assess the severity of the case. These changes are profoundly significant in the cardiovascular system marked by increase in cardiac output and blood volume and decrease in systemic vascular resistance. These adaptations alter the haemodynamics causing trauma to present differently in pregnant patients compared to non-pregnant patients. According to the ACS, signs of shock develop after 30% of the circulating blood is depleted in a pregnant patient, causing critical interventions to be significantly delayed.

The growing uterus also compresses the inferior vena cava resulting in reduced venous return. This results in a decrease in blood pressure, and pooling of the blood in the lower extremities. This phenomenon is known as the supine hypotensive syndrome and can be exacerbated if a pregnant patient is placed supine during the initial assessment, particularly in the second and third trimesters. If not counteracted, this can compromise blood flow to the fetus. Therefore, it is recommended to place pregnant patients in a left lateral tilt position to increase blood flow by relieving the compression on the inferior vena cava.

Additionally, pregnant patients are at an increased risk of hypoxia following trauma. The growing uterus reduces the capacity of the lung, resulting in reduced oxygen intake. This is particularly concerning as the fetal oxygen saturation depends entirely on the maternal oxygen saturation. As a result, prolonged maternal hypoxia can lead to fetal distress or demise.

Trauma assessment and resuscitation in pregnancy

Assessment and resuscitation of a pregnant woman following trauma should follow the guidelines of Advanced Trauma Life Support (ATLS), with specific measures adjusted for pregnancy. Fetal survival depends entirely on the maternal survival, and therefore, the main focus should be on stabilizing the mother. Stabilization should accommodate for the physiological changes in pregnancy and follow the ABCs (Airway, Breathing, Circulation) approach.

Oedema of the mucous membrane is common in pregnancy, so attention should be paid to secure the airway in primary survey. This is to ensure early oxygenation and reduced risk of maternal hypoxia. The assessment of maternal breathing should consider the reduced lung capacity in pregnancy, which could lead to reduced oxygen intake and reserve.

As mentioned in the above section, signs of shock could be delayed following trauma due to increased blood volume in pregnancy. During circulation assessment, it is recommended to have a low threshold for hypotension in a pregnant patient, and to start aggressive fluid resuscitation to ensure an adequate maternal blood pressure and perfusion. The improper use of vasopressor in resuscitation could compromise uterine blood flow, so they should be used with caution with the recommendation of a senior member of staff.

Fetal assessment and monitoring

After the initial assessment and full stabilization of the mother is achieved, assessment of the fetus should start immediately. The fetus is highly sensitive to maternal hypoxia, and thus rapid assessment of its condition can provide an insight to the extent of maternal injuries. Continuous cardiotocography is recommended to monitor fetal heart rate, particularly in pregnancy beyond 24 weeks’ gestation. The aim of the cardiotocography is to detect any signs of fetal bradycardia, which can be used as an indirect measure for maternal hypovolaemia or uterine injuries.

Focused assessment with sonography for trauma (FAST) is a useful tool that can be used to assess cases of severe trauma in pregnant women. FAST allows for the rapid assessment for free fluid in the abdomen, which can be the result of internal bleeding, uterine rupture or placental abruption. However, the low sensitivity of this modality in detecting some obstetric emergencies must be acknowledged. It has been shown that FAST could result in a delay in the detection of smaller placental abruption and yield false-negative results. For that reason, it is recommended to have a low threshold of suspicion for placental abruption, and to deliver the fetus promptly, especially if there are any signs of distress.

Special considerations for orthopaedic injuries in pregnancy

Trauma resulting in orthopaedic injuries during pregnancy present with unique challenges, especially if it leads to pelvic fractures. The pelvic ring and lower extremities are particularly vulnerable in high-impact and blunt trauma, putting the maternal and fetal health at a significant risk due to the proximity of the uterus to the bony pelvis. If pelvic fracture is suspected, a rapid assessment for haemorrhage should be the focus of attention, and controlling it is vital to prevent fetal and maternal death.

Once haemorrhages have been controlled, or ruled out, conservative measures can be taken by employing a pelvic binder. Pelvic binders work by stabilizing a fractured pelvis, and preventing further displacements of the bony pelvis, but caution must be taken when applying them to not exacerbate any uterine injuries. If surgical innervation is necessary, then the focus of attention should be on stabilizing the mother, with continuous monitoring of the fetal viability throughout the procedure.

With fractures, or injuries, affecting the lower extremities, the approach with pregnant patients is similar to that of non-pregnant patients. The only difference is positioning of pregnant patients should be accounted for when dealing with long bone fractures, to avoid the compression of the inferior vena cava. The use of ionizing radiation for imaging should be used only when absolutely necessary or should be avoided particularly in the first trimester. When used, using shields and optimizing the dose of radiation is recommended.

Long-term outcomes and prognosis

The extent of injury and the timing of intervention following trauma in pregnancy determine the long-term outcomes. The introduction and advancement of trauma protocols in pregnancy have improved maternal mortality in recent years, but fetal mortality rate has not improved. Placental abruption and uterine rupture remain the leading cause of fetal death, with fetal demise occurring in 1–5% of these case.

Studies have shown that orthopaedic injuries and severe abdominal trauma have been linked to low birth weight, pre-term labour, premature rapture of the membrane and increased rates of caesarean sections. A multidisciplinary approach helps to optimize the care for the mother and the fetus following trauma, but more work should be put in minimizing the post-trauma long-term complications.

Epidemiology and mechanisms of injury in childhood

It has been shown that sport-related injuries, MVAs and falls are the most common causes of trauma in children, raising the rates of disability and death in those patients significantly. Age of the patient is usually associated with the mechanism of injury, with falls being the leading cause of trauma in children, and MVAs are seen more in adolescence.

Children have a larger head-to-body ratio, making it more difficult to maintain their balance at a young age. This anatomical difference in paediatric patients increases the likelihood of falls, making them more vulnerable to sustain traumas particularly to the head and extremities. Due to the high degree of bone remoulding and development, children tend to have more flexibility compared to adults. This protects them from injuries after low-impact trauma, but internal injuries may still occur severely. All these factors make trauma management in children uniquely challenging, and therefore special considerations accounted for.

Physiological differences in paediatric trauma

As seen in pregnant patients, paediatric patients respond physiologically different from adult in response to trauma. The main physiological difference is the elevated metabolic rate found in children compared to adults, which leads to faster depletion of energy storages, especially during trauma, making them susceptible to developing hypothermia even in mild environmental conditions. ^, Additionally, children’s cardiovascular system can maintain normal blood pressure, even with a significant blood loss following trauma. This could have a masking effect making it difficult to recognize and treat a haemorrhagic shock. ^,

Maintaining the airway of a child is challenging due to the anatomical differences compared to adult patients. On average, children have narrower airway and a larger tongue, making intubation more difficult to achieve and increasing the likelihood of obstructions. ^, Due to these physiological and anatomical differences, children should receive specialized care following trauma, as outlined by the ACS ATLS guidelines.

Common types of paediatric trauma

The mechanism of injury determines the severity of trauma experienced by children. Age is also a contributing factor, as the type and level of activities leading to trauma differ in different age groups.

Head injuries are the most concerning following trauma experienced by children. Children have a high head-to-body ratio, making them susceptible to falls and more devastating outcomes particularly after MVAs. Depending on the degree of impact to the head, these can lead to a non-reversible traumatic brain injury, resulting in long-term complications, such as impaired development, cognitive decline and behavioural changes. For these reasons, head injuries are the commonest cause of morbidity and mortality in children following trauma.

Thoracic and abdominal trauma: children have a higher degree of bone flexibility compared to adults. This can protect them from fractures following a low-energy impact. For instance, thoracic trauma may not result in obvious rib fracture, or external injuries, but it can have severe effects on the internal organs without obvious signs. Due to the flexibility of the rib cage, trauma sustained to the chest can lead to pneumothorax or pulmonary contusions without any fractures to the ribs. Similarly, blunt trauma to the abdomen can result in severe injuries to vital organs like spleen and liver. This is concerning as it is difficult to detect injuries to these organs without advanced imagining, possibly delaying prompt medical innervation.

Orthopaedic trauma: from the beginning of childhood to adolescence, bones undergo gradual remoulding and growth. This gives children and adolescents quick healing properties following fractures compared to adults. Bone growth continues from the growth plates that remain open until early adulthood. Fractures that affect the growth plates are particularly concerning, as they can result in limb deformities or length discrepancies, and in severe case complete growth arrest. Long bones are among the commonest sites of fractures in children, especially factures affecting the forearm, femur and clavicle. All of which require surgical intervention to avoid long-term functional impairments.

Paediatric trauma management

A multidisciplinary approached is required for an effective management of paediatric trauma. The team is usually composed of orthopaedics and trauma surgeons, emergency medicine and paediatric intensive care doctors. Initial assessment and resuscitation protocols are similar to the one used for adults, with special adjustment made to account for the unique physiological and anatomical differences seen in paediatric patients. The aim is to rapidly recognize any life-threatening injuries, maintain airway and early resuscitation.

Injuries leading to fractures or polytrauma present with unique challenges requiring coordinated approach from the orthopaedic team. Studies have shown that paediatric trauma handled by a tertiary centre, equipped with paediatric-specific equipment and trained staff, have significantly improved outcomes compared to centres with limited resources. Therefore, all hospital staff should be well trained on paediatric-specific ATLS protocols, and annual audits should be conducted to highlight any weaknesses in the system, all of which aim to reduce paediatric mortality rate following trauma.

Long-term outcomes and rehabilitation

Traumatic brain injury and spinal cord injuries have been associated with profound long-term consequences in paediatric patients. These types of injuries are the most challenging to manage and associated with lengthy recovery time. In severe cases, full recovery may not be possible, leaving the child with permanent disability. Consequently, rehabilitation plays a curial role in shortening the recovery process and achieving an optimal long-term outcome. A comprehensive rehabilitation plan involves occupational and physical therapies, and psychological support aimed at children that sustained disabling injuries. The support delivered by the rehabilitation team, along with regular follow-ups with orthopaedic surgeons, are vital to minimizing functional disability and improving quality of life in children after trauma.

Minimally invasive techniques in trauma management

Minimally invasive techniques have gradually been incorporated in the care for both children and pregnant patients. Now trauma guidelines recommend using laparoscopic procedures in pregnancy for their advantages in reducing risk of infection, haemorrhages, and ultimately maternal and fetal mortality rates. The use of flexible intramedullary nailing (FIN) for fractures in paediatric patients is becoming increasingly common. FIN has been shown to minimize complications associated with open surgeries and yields improved outcomes following rehabilitation, which reduces the length of recovery.

Advancements in diagnostic imaging

Innovations in imaging modalities have revolutionized trauma diagnostics in pregnant and paediatric patients. New modalities and techniques were developed with the aim of delivering a low dose of radiation to these populations. Fast MRI, portable ultrasounds and low-dose CT scans have been used as the first choices diagnostic imaging modalities, due to their high safety profiles. NICE guidelines promote safe diagnostic practice by emphasizing the importance of reducing exposure to ionizing radiation, where possible. ^, For instance, the use of MRI in paediatric trauma patients is becoming vital to their diagnostic workups as it provides clear scans of polytrauma injuries without radiation risks. ^,

Digital health and telemedicine

Since the coronavirus disease (COVID-19) pandemic, access to healthcare has been different, with digital health and telemedicine becoming increasingly used in different healthcare institutions. This has revolutionized the access to post-trauma follow-ups and rehabilitation services, making it easier for patients to access care. Digital health is becoming an integral part of post-trauma protocols in the NHS, allowing for remote monitoring and assessment of post-surgical recovery, this is in accordance with the current NICE guidelines for post-acute and chronic care settings.

Innovations in mobile phone applications made it possible to track progress in rehabilitation and evaluate pain levels over a long period of time. Overall, digital health and telemedicine reformed the recovery pathways for both children and pregnant patients after trauma.

Training in major trauma for pregnant and paediatric patients

The unique nature of pregnant and paediatric patients requires orthopaedic training programs to provide their trainees with comprehensive knowledge and skill set to effectively manage them. Clear competencies and outcomes for trainees are set in the UK by regulating bodies, such as the Royal College of Surgeons and General Medical Council (GMC), to ensure that all graduates are well equipped with the skills needed to manage high-risk trauma in these populations. This is aligned with the guidelines sat by NICE, and in keeping with international best practices.

For pregnant patients, trainees must understand the dual-patient nature of this group of patients. Knowledge of maternal and fetal physiology is necessary to tailor resuscitation techniques, including awareness of fetal monitoring protocols and maternal left lateral tilt. An awareness of obstetric emergencies, such as uterine rupture and placental abruption, is essential. Meanwhile, in paediatric patients, the focus emphasis should be more on the anatomical features, with comprehensive understanding of growth plate fractures, age-related outcomes to trauma, and fluid resuscitation to avoid overload.

Simulation-based learning and hands-on experience

Orthopaedic training programmes now include simulation-based learning. This provides trainees with the opportunity to practise their skills in a low-risk environment before handling real-life cases. For pregnant patients, trainees receive training on high fidelity simulations, including sessions on resuscitation techniques, haemorrhage control and safe rapid sequence induction.

For paediatrics, trainees practise complex polytrauma scenarios in simulation. This includes training on managing limb-length discrepancies and growth plate injuries. The training also provides trainees with the skills needed to resuscitate children, with more emphasis on maintaining their airways. Trainees must be aware of the anatomical differences in children, and how they influence surgical outcomes. ^, These simulation-based scenarios allow trainees to refine their skills and practise decision-making under pressure, away from the fast pace nature of trauma bays.

Beyond simulations, learning by doing is an integral part of orthopaedic education. Trainees are placed in major trauma centres across the UK, specialized in paediatric and maternal care. This direct exposure provides a valuable hands-on experience, further strengthening their skills under direct supervision. ^,

Ethical and medico-legal considerations

Caring of pregnant and paediatric patients come with sophisticated medico-legal and ethical dilemmas, requiring orthopaedics trainees to receive adequate training in handling these matters. One of the hot topics in pregnant women is consent following trauma. Obtaining an informed consent becomes challenging if the patient is unconscious or incapacitated, especially when a surgical innervation is needed and may affect both the mother and the fetus. Although the main goal is to stabilize the mother, it is essential to balance the autonomy of the mother with the fetal health by following legal protocols to avoid litigations. ^,

In paediatric trauma, the process of obtaining a consent may be slightly easier, as consent may be obtained from a parent or a guardian. However, the challenge is to recognize non-accidental traumas and cases of neglect, requiring the trainee to navigate the legal framework around child protection guidelines. Therefore, awareness of the safeguarding guidelines and mandatory reporting protocols is essential in case of suspected child abuse. When child abuse is suspected, an inter-professional collaboration is required, involving law enforcement, social services and healthcare provider. This adds more complexity to the clinical environment, requiring adequate communication and documentation.

Most legal cases in paediatric trauma arise from complications and delayed management or diagnosis. Complications such as growth plate injuries can lead to long-term complications if not recognized and managed appropriately. To avoid potential legal challenges, clear communications with the parents discussing the possible complications and future expectations is essential. Trainees must adopt a thorough approach to documentations to include all clinical findings, interventions, and the outcomes of the conversation held with parents. ^,

Overall, the care provided by orthopaedic surgeons and trainees involves familiarity with the mix of legal, ethical and clinical knowledge. Orthopaedic training programmes in the UK provide their trainees with structured simulation-based learning to prepare them with skills needed to work safely and independently. Additionally, engaging in hands-on experiences refines their expertise and builds their confidence in managing challenging clinical and ethical dilemmas.