Pediatric Polytrauma Management Robert M

ORIGINAL ARTICLE

Pediatric Polytrauma Management Robert M. Kay, MD and David L. Skaggs, MD

Abstract: Appropriate care of pediatric polytrauma patients requires GENERAL APPROACH TO the knowledge and expertise of a variety of subspecialists. Though POLYTRAUMA PATIENTS most of pediatric polytrauma patients survive, long-term sequelae The philosophy behind trauma centers resulted from the are common. The most common causes of long-term functional de- wartime experience showing that injured soldiers who were ficits after pediatric polytrauma involve injuries to the central ner- rapidly mobilized and transported for acute, emergency care vous and musculoskeletal systems. Orthopaedic care of polytrauma fared better than did those treated locally by less sophisticated patients is important to facilitate early mobilization and care of these teams and facilities. There is some evidence that care at children, as well as to minimize late impairment. pediatric trauma centers may result in lower mortality than at community hospitals,6 though the high costs of such centers Key Words: pediatric, polytrauma, orthopaedics and geographic realities have limited the number of such (J Pediatr Orthop 2006;26:268Y277) centers. Partly due to the limited number of pediatric trauma centers, adult trauma centers are often used to care for children who sustain polytrauma. Initial stabilization of the child is carried out by emer- rauma remains the leading cause of death in children over gency medical technicians in the field and is comparable to T1 year of age. This is true throughout the world, even in that for adults. The child is rapidly stabilized, fractures are societies with the most advanced medical systems, including often splinted, and the child is brought as quickly as possible state-of-the-art pediatric trauma centers. to a trauma facility. Immediate establishment of an airway Common sites of injury in polytrauma patients include may mean the difference between life and death in the case of the head, chest, abdomen, and genitourinary and musculoskele- severe injury. tal systems. Recent series report death in 3% to 27% of children Cervical spine stabilization is performed at the scene if after polytrauma, with death most frequently correlating with the child is unconscious or has neck pain. Due to the large the severity of the traumatic brain injury.1Y5 In the survivors, head size of young children, a special board with an occipital some injuries to the various organ systems may not be detected cut-out is used for children under 6 years. Use of an adult for days to weeks after injury. Obviously, traumatic brain backboard will result in neck flexion and put the child at injuries make the assessment of many trauma victims quite increased risk of iatrogenic neurologic injury.7 challenging. Many young children have difficulty sufficiently communicating with medical personnel, especially in the PATIENT EVALUATION AND TREATMENT frightening emergency situation. Upon arrival to the hospital, the ABCs of trauma care Though rarely life-threatening, orthopaedic injuries ac- (Airway, Breathing, Circulation) are performed by the emer- count for a high proportion of injuries in polytrauma patients gency physicians and/or trauma staff. Primary and second- and may result in significant long-term impairment. The con- ary surveys are performed and appropriate subspecialists cept of early fracture fixation has carried over from adult to consulted. pediatric trauma victims, though there is less supporting evi- Many trauma scoring systems have been used to assess dence for such a mandate in children. children after polytrauma. It does not appear that specialized Though the management of pediatric trauma victims has pediatric trauma scores are necessary. The Injury Severity Score similarities to the management of adult trauma victims, studies is reproducible and is useful in pediatric trauma patients.8 suggest that the care of such populations isVand should Acidosis, hypothermia, and coagulopathyVthe Btriad beVsomewhat different. Fortunately, children generally have of death[Vmay occur in trauma patients due to hypovolemia far greater potential for recovery than do adults, in regard to and the systemic response to trauma.9 Blood pressure and both musculoskeletal and other system injuries. organ perfusion must be maintained, because death may occur if hypovolemia is not quickly reversed. Because most pediatric polytrauma results from blunt trauma, bleeding From University of Southern California Keck School of Medicine, Children’s most commonly is internal (due to visceral injuries and/or Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA. fractures), and the amount of ongoing bleeding may be Study conducted at Children’s Hospital Los Angeles, Los Angeles, CA. underestimated. Monitoring of vital signs and the use of a None of the authors received financial support for this study. Reprints: David L. Skaggs, MD, 4650 Sunset Blvd., MS # 69, Los Angeles, urinary catheter are helpful in this assessment. Care needs CA 90027 (e-mail: [email protected]). to be exercised when hydrating children with head injuries Copyright * 2006 by Lippincott Williams & Wilkins to avoid overhydration and cerebral edema.

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Initial fluid resuscitation is with crystalloid solution. If long-term disability in children after polytrauma.3,4 However, venous access is difficult to obtain, intraosseous infusion with children can make remarkable progress after significant head large-bore catheters is effective. This is most often performed injuries, and children must be assumed capable of full re- in the proximal tibial apophysis, at least one fingerbreadth covery, thus necessitating the appropriate management of below the tibial tuberosity to make certain the physis is fractures to avoid the sequelae of malunion. avoided. A bone marrow needle with a stylet is used to pre- Acute management of children with head injuries often vent a bone plug from blocking inflow. This has been shown to includes elevation of the head of the bed, hyperventilation of be effective clinically10 and also to be safe for the bone and the intubated patient, and fluid restriction. In addition, frac- physis in a rabbit model.11 ture stabilization (temporary, as with a splint, as well as ulti- A thorough orthopaedic evaluation includes assessment mate fracture fixation) is necessary to minimize potentially of the spine, pelvis, and extremities. In the unconscious, intu- deleterious rises in intracranial pressure after brain injury.17 bated patient, the only signs may be swelling, ecchymosis, Letts et al reported residual neurologic impairment in and/or crepitus with manipulation of the injured extremity. 13% of 149 pediatric trauma patients at an average of 1 year Screening pelvis and spine x-rays are obtained routinely and of follow-up.1 At a mean of 4.2 years of follow-up, Schalamon extremity films are ordered as indicated. Fractured extremities et al reported a 10% rate of late neurologic sequelae, which are splinted to facilitate transport throughout the facility for was due to the severity of the initial head trauma.3 The same additional workup and to minimize pain while moving and authors noted that of 11 children with late deficits after transporting the injured child. Minimizing such discomfort not polytrauma, the deficits followed severe head trauma in only is humane but is also important in the setting of head injury 8 children (73%).3 to avoid increasing intracranial pressure and worsening the cerebral insult. Abdominal Injuries The physician and family need to understand that late 1 18 Abdominal injuries are reported in 8% to 27% of diagnosis of injuries in polytrauma patients is common. Letts pediatric polytrauma patients. Because children are generally et al reported that injuries were initially missed in 9% of 149 otherwise healthy, with good physiologic reserve, they may pediatric trauma patients.1 Such diagnoses are often not made initially remain stable clinically despite significant injuries. for weeks after injury and can include additional fractures (fre- Abdominal visceral injuries may often not be appreciated quently of the upper extremities, but also including those of until CT scans are obtained in polytrauma patients. the pelvis and spine) as well as visceral injuries. The patient’s Abdominal wall ecchymosis often indicates serious vis- and family’s help can be enlisted in the ongoing search for 19,20 ceral or spine injury but is often absent in many children such injuries by informing them of the high incidence of late with such injuries. Forty-eight percent of children (22/46) with diagnosis and asking them to communicate any previously such ecchymosis in one series required abdominal exploration, undetected sources of pain in the days and weeks after injury. and 23% of children (14/61) with such ecchymosis in another series were noted to have spine fractures.20 MECHANISM OF INJURY CT scan is generally the study of choice to assess for The two most common cause of polytrauma in children intra-abdominal pathology. In addition to being better than remain falls from height and motor vehicle accidents. Public ultrasound for assessing intra-abdominal pathology, CT scan awareness of these problems and legislation has made limited also allows the team to look for concomitant pelvic and/or inroads in these areas. spine fractures, which may be missed on plain films.21,22 Falls from height remain a common problem, despite Hepatic and splenic injuries are well visualized on CT changes in building codes to minimize the risk of young chil- scans, both initially and throughout the hospital stay when dren pushing out windows and falling. Falls from trees and necessary. Nonoperative treatment of splenic and hepatic in- balconies and down stairs are also common. Education juries (with serial hematocrits, serial clinical examinations, regarding the danger of infants and toddlers walking by stairs and serial radiographic examinations) has become increas- and the need to Bbaby proof[ play areas for children remains ingly popular, though the impact of nonoperative treatment suboptimal. Associated injuries after falls from heights include on length of hospital stay and cost is unclear.23,24 12 12 head injuries in 39% and orthopaedic injuries in 34%, with Abdominal vascular injuries are quite rare in children. 12,13 mortality in 2%. Motor vehicle accidents involving However, because approximately half of such injuries in chil- children result in more than 250,000 injuries and more than dren are fatal, this diagnosis should be considered by the 14 1,700 deaths in the United States annually. Despite legislation trauma team if a child has significant ongoing needs for regarding the use of appropriate child car seats, many families volume support after resuscitation.25 continue to transport children without the use of such devices, while others install and use the seats improperly.15,16 Thoracic Injuries Thoracic injury accounts for 5% to 12% of admissions NONORTHOPAEDIC INJURIES 26 AND CONDITIONS to pediatric trauma centers, and thoracic trauma has been reported in 8%1 to 62%3 of cases of pediatric polytrauma. Head Injuries Isolated thoracic trauma has been reported to have a 5% mor- Closed head injuries have been reported in 17% of tality; that figure increases to 25% when there are concomi- children with polytrauma1 and are the most common cause of tant head or abdominal injuries.26

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Rib fractures in isolation are generally of little con- FAT EMBOLISM AND ACUTE RESPIRATORY sequence, though they are often indicators (especially in DISTRESS SYNDROME the setting of multiple rib fractures) of more severe chest Most commonly, fat embolism and acute respiratory injuries, including lung contusion or laceration, hemotho- distress syndrome (ARDS) are seen in patients with multiple rax, pneumothorax, mediastinal injury, and cardiac and/or system injuries and/or multiple fractures, though the inci- great vessel injury. Multiple rib fractures are also asso- dence of each is lower in children than in adults.31,32 Typical ciated with severe trauma to other parts of the body, in- 26 signs and symptoms include axillary petechiae and hypoxemia, cluding the brain, spine, abdomen, pelvis, and extremities. and plain chest radiographs may show pulmonary infiltrates In the absence of an unambiguous history of trauma, child within hours of the initial injury.33 Hypoxemia likely occurs abuse should be considered in patients with rib and/or much more commonly than is clinically evident because many skull fractures. of the children appear stable and are not subject to continuous Pulmonary contusions remain the most common form cardiopulmonary monitoring. A change in sensorium and the of pediatric thoracic trauma. These are usually diagnosed on onset of disorientation are often telltale signs of hypoxemia, screening chest x-rays in approximately 90% of children, and arterial blood gas measurements and a chest x-ray should with half of such radiographs showing rib fractures or other be obtained to assess for ongoing care needs. findings such as hemothorax and/or pneumothorax.26 CT scan may aid in the detection of previously undiagnosed pulmonary contusions. ORTHOPAEDIC INJURIES A pneumothorax may be either Bsimple[ or a Btension[ Fractures 26 type. Simple pneumothoraces may be seen in an asymp- Extremity fractures have been reported in up to 76% of tomatic patient and may first be noted on CT scan. Either type children after polytrauma.3 Fractures, though rarely a cause of of pneumothorax may be life-threatening and should be man- mortality, are often an important component of the initial in- aged with prompt chest tube placement. juries and long-term morbidity after pediatric polytrauma.1,3 Hemothorax may occur after blunt or penetrating trau- A thorough knowledge of associated injuries is important ma. Drainage is required and generally can be accomplished to maximize patient care. For instance, calcaneal fractures are with the use of a chest tube. Approximately 5% of children associated with other fractures in up to one third of children, with hemothorax will require surgical drainage, though the with spine fractures occurring in 5%.34,35 Jawadi et al reported 26 indications for such surgery remain controversial. that 58% of children with femur fractures after motor vehicle Injuries to the heart and great vessels are usually the accidents had additional injuries, most commonly involving the 26 result of high-energy trauma. Because of the mechanism of head (14%), chest (6%), abdomen (5%), and genitourinary injury, associated injuries and death are common. Paraplegia system (4%).36 The head and neck have also been reported to be 26 is common with aortic injuries. the most common site of injuries in pediatric pedestrian versus Airway injuries are rare, but they are lethal in up to one motor vehicle accidents, accounting for 35% of all injuries in 26 third of children with such injuries. These injuries generally such children.37 It has been suggested that up to 20% of children occur from either penetrating or blunt trauma and are most with cervical spine injuries have injuries at multiple levels.38 often located at the level of the lower trachea or upper bron- When a long bone fracture is noted, adjacent physes should be chus. The result may be a tension pneumothorax, mediastinal carefully inspected on radiographs for a physeal injury. In cases air, subcutaneous emphysema, or persistent air leak from a of high-force injury such as a motor vehicle accident, chest tube. Emergent treatment is necessary for this life- inspection of adjacent physes with live fluoroscopy under threatening injury. anesthesia may be warranted (Fig. 1). Due to the high-energy mechanisms often associated with polytrauma, the incidence of open fractures is much Genitourinary Injuries greater in polytrauma patients. Open fractures account for Genitourinary injuries are most commonly seen in approximately 10% of extremity fractures in polytrauma pa- conjunction with anterior pelvic injuries and have been re- tients.1,3 As in adults, the Gustilo and Anderson classification 27 28 ported in 9% to 24% of children with pelvic fractures. scheme is used for grading such fractures in children.33,39 These injuries are more common in males than in females, Neurovascular examination is an important part of the 29,30 and they frequently occur at the level of the bulbourethra. initial orthopaedic evaluation. Neurologic examination may Injuries to other portions of the urethra may also occur, be quite difficult in a young child due to associated injuries 29 as may injuries to the prostate and bladder. Extreme and the frightening emergency situation and is obviously care is warranted when placing a urinary catheter in the limited in intubated and/or obtunded patients. Distal perfu- setting of an anterior pelvic fracture. Preoperative imaging sion must be assessed. The results of the neurovascular studies are often of limited value in patients requiring sur- examination are noted, including noting whether portions of gical reconstruction. the examination cannot be reliably performed. Renal injuries may also occur with blunt trauma. Schalamon et al noted a 9% incidence of renal injuries in General Treatment of Orthopaedic Injuries pediatric polytrauma patients.3 In three of the six children The orthopaedic injuries must be viewed in the context of with renal injuries, there were associated injuries of the liver the overall status of the multiply injured child. Most ortho- or spleen. paedic injuries do not require emergent care, though obvious

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tients who may have sustained closed head injuries and often remain in the same position for prolonged periods of time. The optimal timing of fracture ﬁxation in pediatric polytrauma patients has not been deﬁned. There is generally a consensus that early fracture stabilization facilitates patient mobilization and may decrease the rate of complications, though the data are less compelling in children than in adults.41,42 This may be due to the decreased rate of ARDS in children. It seems prudent to perform operative stabilization of these fractures in the setting of multitrauma within 24 to 72 hours when the child is stable enough to undergo surgery.

Imaging Studies Radiographs Plain radiographs remain of central importance in the assessment of the polytrauma patient. Although plain radiographs are the mainstay in the evaluation of most injuries to the appendicular skeleton, other imaging modalities are used more commonly in the evaluation of the axial skeleton and in special circumstances. In a child with a head injury or neck pain or tenderness, a screening lateral cervical spine x-ray should be obtained. Though the lateral radiograph is sensitive for most injuries, up to 25% of lateral radiographs fail to clearly show pathology, so additional images may be necessary.43 Prevertebral soft tissue swelling on a lateral radiograph is usually considered a sign of cervical spine pathology in an adult, but in the young child it is often a result of crying (Fig. 2). In cases of suspected injury, AP and lateral cervical spine radiographs are obtained, with an open-mouth odontoid view often added in children 9 years and older.44,45 CT scans may provide additional valuable information regarding potential osseous FIGURE 1. Retropharangeal swelling in a young child is a physiologic reaction to crying and not necessarily indicative of spinal injuries, and magnetic resonance imaging (MRI) of the cer- pathology. (Used with permission from Skaggs DL, Flynn JM. vical spine is often a useful adjunct to assess for bony and soft Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia: Lippincott Williams & Wilkins 2006.) exceptions include open fractures, compartment syndromes, and those with associated vascular injuries. Patients with vertebral fractures and pelvic fractures are generally the most critical patients, as they have a mean of five other concomitant injuries and mortality rates of 0.8% and 0.6%, respectively.40 As noted above, children often recover remarkably well from what may initially seem to be devastating injuries to the central nervous system and other organ systems. Con- sequently, orthopaedic care must be undertaken to optimize fracture alignment and potential function with the expec- tation of complete recovery of the injured child. Clinicians should remember that for unknown reasons, fractures in children with traumatic brain injuries heal rapidly and form abundant callus. Surgical fixation of fractures is much more commonly performed in polytrauma patients than in children with iso- FIGURE 2. When placing an external fixator on the pelvis of a lated injuries. Operative treatment often facilitates patient multitrauma patient, allow adequate space for abdominal care and early mobilization, allows serial examinations (in- swelling and access. (Used with permission from Skaggs DL, cluding those of the nervous, cardiovascular, and other organ Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. systems), and minimizes the risk of cast complications in pa- Philadelphia: Lippincott Williams & Wilkins 2006.)

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Kay and Skaggs J Pediatr Orthop & Volume 26, Number 2, March/April 2006 tissue injuries, especially in obtunded patients; both CT and trauma evaluation. Once the child is stabilized, definitive care MRI are discussed below. may be undertaken. Loder reported that early operative fixation If a child is awake, alert, and cooperative, a lateral of fractures (within 2 to 3 days of injury) in 78 polytraumatized flexion cervical spine x-ray may be taken in the presence of children led to shorter stays in both the intensive care unit and the orthopaedist to look for instability. In children under age the hospital, and decreased time on a ventilator.41 Fewer com- 12, up to 4 to 5 mm at the atlantoYdens interval may be plications were reported in the early operative group as well. considered normal. Up to 3 mm of motion of C2 on C3 may More recently, Loder et al reported a trend toward increased be physiologic as well. In skeletally mature patients, the complications of immobilization (including pulmonary com- motion of C1 on C2 should be less than 3 mm, and there plications) for fractures treated more than 3 days after injury in should not be motion of C2 on C3. polytraumatized children, though the difference was not statis- Due to the lower sensitivity of clinical examination for tically significant.42 potential fractures of the thoracic and lumbar spine, screening x-rays of these areas should be routinely performed in in- Pelvic Fractures tubated and/or obtunded patients. Most pelvic fractures are stable, though in one recent study 30% of 189 pelvic ring fractures were reported to be CT unstable.58 Most pelvic fractures can be managed nonopera- CT scans are routinely used in the assessment of poly- tively, but unstable pelvic fractures and acetabular fractures trauma patients to look for head, abdominal, and/or thoracic may require operative stabilization. Occasionally, an external injuries. fixator is indicated to close down a pubic symphysis diastasis In patients undergoing CT scans for other reasons, im- to decrease pelvic volume and decrease bleeding in a poly- ages through the spine and/or pelvis have been reported to be trauma patient or to stabilize the child’s pelvis to facilitate more sensitive for detecting injuries than are plain films and patient transport and care. may decrease the need to repeat plain films.44,46Y48 Pelvic fractures are an obvious, though often not an In one recent study, only 54% of pelvic fractures iden- isolated, source of bleeding. Retro- or intraperitoneal sources tified with screening CT scans were identified on plain radio- of bleeding (either from visceral or blood vessel injury) are graphs.47 Though CT scans are good at assessing bony injury, common in these children as well.59 they do not show soft tissue injuries that may occur in the Life-threatening hemorrhage from a pelvic fracture is spine without associated bony injuries. extremely rare, and other sources of bleeding must be sought if there is significant, ongoing bleeding after initial resuscita- Radionuclide Scans tion.60,61 Even with pelvic fractures, life-threatening hemor- Bone scans play little if any role in polytrauma rhage is rare. patients. One possible exception is the child with multiple Probably the most important aspect of pelvic fractures injuries who is the victim of abuse. In such cases, a bone scan is that they are often associated with very high-energy injuries may be performed in conjunction with a skeletal survey to and significant injuries to the remainder of the skeleton and look for new or old fractures.49Y51 other organ systems. Such children often require prolonged ICU stays and have higher mortality rates. MRI Spinal cord injury without radiographic abnormality Open Fractures (SCIWORA) is an entity unique to children. Thought to occur Open fractures account for approximately 10% of ex- secondary to a stretch or distraction injury in conjunction with tremity fractures in children with multiple injuries.3,62 Twenty- the increased elasticity of the young spine, SCIWORA results five percent to 50% of polytraumatized children with open in neurologic deficits in the absence of bony injury.52Y55 MRI fractures have additional skeletal or other system injuries. scans are helpful in showing the levels and extent of the spinal After the resuscitation of the child (including the ABCs), cord injury or nerve root compression and may also show an a moistened saline or povidoneYiodine (Betadine) dressing apophyseal fracture with cord compression.44,46 is applied to the open fracture and the limb is aligned and MRI has also been reported to be a useful screening tool splinted to enhance patient comfort, to protect the soft tissue for cervical spine injuries in intubated pediatric polytrauma envelope, and to facilitate patient transport. Tetanus prophy- patients.56,57 The routine use of MRI to clear the cervical laxis should be given if the patient’s status is unknown or if spines of such patients has been reported to decrease time in a more than 5 years have elapsed since the most recent booster. cervical collar, decrease hospital stay, and decrease hospital Intravenous antibiotics are essential in the treatment costs.56,57 of children with open fractures and must be started as soon as possible. For type I fractures and some type II fractures, we routinely use a first-generation cephalosporin (cefazolin ORTHOPAEDIC MANAGEMENT OF 100 mg/kg/d divided q8h, maximum daily dose 6 g). We THE POLYTRAUMA PATIENT use a combination of a cephalosporin and aminoglycoside (gentamicin 5Y7.5 mg/kg/d divided q8h) for more se- Timing vere type II fractures and for type III fractures. Penicillin Initial emergency care consists of splinting the injured (150,000 units/kg/d divided q6h, maximum daily dose extremities to enhance patient comfort and facilitate a thorough 24 million units) is used in addition to the cephalosporin

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Pediatr Orthop & Volume 26, Number 2, March/April 2006 Pediatric Polytrauma Management and aminoglycoside for farm injuries or grossly contaminated The traumatic wound may be left open to drain or may fractures. Antibiotics are routinely given intravenously for 48 be closed over a drain. If a wound has been extended for to 72 hours. We give antibiotics for an additional 48 to 72 access to the fracture and soft tissues, then this surgically hours around subsequent surgeries including (a) repeat created portion of the wound may be closed primarily with irrigation and d2bridement, (b) delayed wound closure, (c) interrupted nylon sutures. Drains are generally removed 48 to open reduction and internal fixation of fractures, and (d) 72 hours after surgery unless a repeat irrigation and d2bride- secondary bone reconstruction procedures. ment is planned. Once the patient can be brought to the operating room, For grade I injuries a single operative irrigation and d2- thorough irrigation and d2bridement of the wounds is per- bridement is sufficient. For grade III and some grade II injuries, formed. Both bone ends of the open fracture are thoroughly repeat irrigation and d2bridement is performed 2 to 3 days after cleaned. Traditionally, timing of open fracture repair has been initial treatment and repeated every 2 to 3 days until tissue within the first 6 to 8 hours of injury, though more recent viability appears excellent and the wound is pristine. studies have shown that the rate of infection does not appear In cases of extensive soft tissue loss, early soft tissue to be higher if surgery must be delayed, as long as intravenous coverage appears beneficial. Local and free muscle flaps are antibiotics are started promptly upon patient presentation.63,64 sometimes needed to cover exposed bone ends. Vacuum- Skaggs et al found no difference in infection rates for those assisted closure with the VAC device (Kinetic Concepts, Inc, open fractures operated on within 6 hours of injury versus San Antonio, TX) sometimes obviates the need for local or those operated on 6 to 24 hours after injury.63,64 free flaps and has played an increasing role in children with Normal saline solution is routinely used to clean the open fractures and soft tissue defects (Fig. 3).68Y70 wounds. Antibiotics and/or soap may be added to the irriga- Fracture stabilization in children with open fractures tion solution. A pulsed lavage system may be used to irrigate is most commonly operative using internal, external, or per- the open fracture with sterile normal saline, though the high cutaneous fixation. Operative fixation of these open fractures pressure may damage the osteophytes. A recent study in mice increases patient comfort, protects the soft tissue enve- reported that a 1% soap solution is effective in removing lope from ongoing injury, enhances wound access, facili- bacteria from contaminated bone while proving less delete- tates mobilization of the injured child, and allows early soft rious to the osteophytes than other solutions.65 tissue coverage. Cultures are not routinely performed because there is Open diaphyseal forearm fractures are commonly fixed poor correlation of bacterial growth on routine cultures in with flexible intramedullary implants in the radius and/or open fractures with ultimate wound infections.66,67 Cultures ulna. Loss of reduction in open forearm fractures is mini- should be obtained at the time of reoperation only in patients mized when intramedullary fixation is used.71 Displaced dis- with clinical evidence of infection. Valenziano et al reported tal forearm fractures are commonly treated with percutaneous comparable rates of infection regardless of whether a routine fixation of the radius; such fixation of the ulna is often super- wound culture taken at the time of presentation to the trauma fluous after pinning of the radius. center was positive, with wound infection noted in 7% (2/28) Intramedullary fixation has replaced external fixation as of those with positive cultures and 6% (5/89) with negative the treatment of choice for most open pediatric tibia and femur cultures.67 In addition, these routine cultures were positive in fractures. Though both external fixators and intramedullary rod only 29% of cases (2/7) in which infection resulted. fixation allow access to the wounds for dressing changes and Lee reported poor correlation of both pre- and post- ongoing d2bridement (if necessary), there are several benefits d2bridement cultures with ultimate wound infection.66 Lee to internal fixation in such cases: (a) wound access is often reported that pre-d2bridement cultures were positive in 53% better, especially with extensive wounds, (b) daily pin care is of cases (119/225), though the overall infection rate was 14% not necessary, (c) the scars are more cosmetic, and (d) intra- (31/225). In fact, only 20% open fractures with positive pre- medullary implants are load-sharing. d2bridement cultures (24/119) ultimately became infected. Despite its inherent limitations, external fixation is still Though positive post-d2bridement cultures were better pre- indicated in length-unstable fractures, including those with dictors of infection, wound infections occurred in only 28% significant bone loss, and for some juxta-articular fractures. of cases (9/32) with positive post-d2bridement cultures.66 In For most of such length-unstable fractures, a uniplanar or the same series, post-d2bridement cultures were negative in biplanar configuration suffices. In cases with extensive bone 53% of cases that resulted in infection. loss, ring fixators may be used for bone transport. Thorough d2bridement is achieved when contaminated, Due to their better circulation and overall good health, dead, and ischemic tissues have been removed; the bone ends children generally heal their bony and soft tissue injuries are clean and have bleeding edges; and only viable tissue lines better than do adults. Many fractures, including those with the wound bed. Because young children have better healing IIIC injuries, that might be treated with primary amputation in potential than adults, soft tissue of questionable viability often adults are preserved in children. The Mangled Extremity improves with time and may be left at the time of initial Severity Score correlates much more poorly in children than d2bridement if a second irrigation and d2bridement is planned. in adults with the risk of amputation.72 When amputation is Although small bone fragments devoid of soft tissue attach- necessary, every attempt is made to preserve limb length and ments are discarded, larger fragments are often replaced in the intact physes in children: a stump that appears Btoo short[ in a wound and often heal due to the child’s better soft tissue growing child may grow to a good length by the time of envelope and healing potential. physeal closure.

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FIGURE 3. Child on back of bicycle struck by car sustained ipsilateral proximal femoral and tibial shaft fracture. A and B, Proximal tibial physeal fracture on initial radiographs were not appreciated. C, After external fixation of the tibial diaphyseal fracture, a Salter- Harris type I fracture of the proximal tibial physeal is evident. D, Closed reduction and Kirschner wire fixation were used to treat the proximal tibial physeal fracture. E, Compartment syndrome occurred, which is associated with proximal physeal fractures of the tibia. In this case, the contribution of concomitant injuries to the compartment syndrome is difficult to discern. (Used with permission from Skaggs DL, Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia: Lippincott Williams & Wilkins 2006.)

Bone reconstruction is much less commonly needed in complications of immobilization.42 The closed treatment of the child than in the adult. Because overgrowth of 1 to 2 cm displaced fractures in children with head injuries puts the can be expected in the severely traumatized extremity, the child at risk for unrecognized pressure sores in casts. Serial orthopaedist can consider using an external fixator (or some- abdominal examinations are not possible if a spica cast has times intramedullary rods) to provide a stable construct with been applied in a child with polytrauma. the bone held 1 to 2 cm short to decrease the defect size. This Loder reported that operative fixation of fractures in will increase the likelihood of healing while decreasing the multiply injured children within 2 to 3 days of injury led frequency and intensity of reconstructive surgery and main- to fewer complications, shorter stays in both the ICU and taining acceptable limb length. the hospital, and decreased time on a ventilator.41 More recently, Loder et al reported a trend toward increased complications of immobilization (including pulmonary compli- Closed Fractures cations) in polytraumatized children with fractures treated Operative stabilization of fractures is common in poly- more than 3 days after injury.42 The pulmonary benefits of trauma patients, with many of the potential benefits being operative stabilization of fractures in polytrauma patients non-orthopaedic in nature. Operative treatment facilitates have not been as well documented in children as they have patient care and mobilization and appears to decrease the in adults. In general, the indications for operative stabilization of

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Pediatr Orthop & Volume 26, Number 2, March/April 2006 Pediatric Polytrauma Management closed fractures in pediatric patients are relative rather than External Fixation absolute. External fixation is most commonly used for fixation of long bone fractures associated with one or more of the fol- Options for Operative Fixation lowing: open fractures with significant soft tissue injury, head injury, and Bfloating knee[ injuries (fractures of the ipsilateral Intramedullary Rod Fixation 79Y88 Intramedullary fixation of long bone fractures of both femur and tibia). Due to the advances in intramedullary the upper and lower extremities is becoming increasingly fixation, external fixation is now much less commonly used popular. Flexible titanium rods with diameters of 2 to 4 mm than historically. External fixation of the pelvis is useful for are routinely used to fix unstable diaphyseal forearm fractures fracture stabilization as well as decreasing potential space for through adolescence71,73Y75 and femur fractures in children bleeding (Fig. 4). between 5 years and skeletal maturity. A closed tibia fracture Advocates of external fixation cite the ability to rapidly is commonly fixed with such devices if the fracture is mar- externally fix long bone fractures and the ability to manage soft kedly unstable (especially in adolescents), a component of a tissue wounds with the fixator in place. One area in which we Bfloating knee[ injury, or associated with polytrauma. Intra- find the external fixator to play a significant role is in degloving medullary fixation of the humerus is rarely needed, though injuries to the foot and ankle. In such instances, a fixator can be indications may include polytrauma or a Bfloating[ injury of used to span the ankle, maintaining the foot in a plantigrade the shoulder or elbow. position to prevent progressive equinus and provide immobi- Most forearm fractures treated with intramedullary fixa- lization to allow soft tissue healing (which often includes a tion can be reduced closed, followed by passage of the rods skin graft) (see Fig. 4 to 3). Hybrid external fixators, though using fluoroscopic guidance, though 23% (10/43) of closed commonly used to treat periarticular fractures in adults, play a forearm fractures treated with intramedullary rod fixation re- smaller role in children with open growth plates. quired open reduction in one recent study.75 Displaced distal The prime disadvantages of external fixation include forearm fractures in polytrauma patients often are well treated refracture and unsightly scarring. Refracture occurs at a rate with closed reduction and percutaneous pinning, thus afford- of approximately 10% after removal of external fixators in pediatric femur fracture patients, though rates have been ing sufficient stability for use of a short-arm cast in these 81,89,90 polytrauma patients. reported to range from 1% to 22%. Whether dynami- zation of external fixators prior to removal decreases the rate Flexible intramedullary rods are the most commonly 91 used fixation for both open and closed pediatric femoral shaft of refracture is controversial. Less serious disadvantages of fractures. In general, antegrade intramedullary rods are best external fixation include frequent pin tract infections (though avoided prior to closure of the proximal femoral physis, except in extraordinary circumstances, due to the risk of avascular necrosis of the femoral head. Results of greater trochanteric entry nails are encouraging but too early for general recommendation. Flexible intramedullary rod fixation is also becoming more popular in the treatment of diaphyseal tibial fractures and obviates the need for a long-leg cast in such patients. The rods are inserted antegrade, one each from medial and lateral, with care taken to avoid the tibial tubercle. A splint may be applied to allow access to the wounds associated with open and/or degloving injuries.

Compression Plates Compression plating does have some advocates, particu- larly for operative treatment of long bone fractures such as the femur in polytrauma patients.76,77 However, other alter- natives, such as flexible intramedullary nails, are much more commonly used, even for these relatively narrow complications. Disadvantages of plating include the fact that such FIGURE 4. A pedestrian child was hit by a car and dragged, plates are not load-sharing devices and that they traditionally causing a distal tibia and fibular fracture, in addition to severe have required a much larger exposure (and soft tissue dissec- soft tissue loss exposing bone and joint. An external fixator tion) for plate insertion. Newer, Bpercutaneous[ plating tech- across the ankle helps maintain stability of the tibia fracture, niques78 hold the potential advantage of a decreased soft prevents ankle equinus, and immobilizes the area of soft tissue tissue dissection at the initial surgery compared with standard injury to maximize chances of a future skin graft being successful. In this child a wound VAC was used to prepare the plating (but not compared with intramedullary nails). There is area of exposed bone and joints prior to skin grafting. (Used concern that removal of such implants requires more ex- with permission from Skaggs DL, Flynn JM. Staying Out of tensive surgery than does removal of flexible rods and also Trouble in Pediatric Orthopaedics. Philadelphia: Lippincott leaves multiple stress risers. Williams & Wilkins 2006.)

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Kay and Skaggs J Pediatr Orthop & Volume 26, Number 2, March/April 2006 serious infections are rare) and the fact that some patients and spine. The standard backboard may be hazardous. J Bone Joint Surg Y families have difficulty complying with pin care. [Am]. 1989;71:15 22. 8. Wesson DE, Spence LJ, Williams JI, et al. Injury scoring systems in children. Can J Surg. 1987;30:398Y400. PATIENT OUTCOMES 9. Wetzel RC, Burns RC. Multiple trauma in children: critical care overview. Crit Care Med. 2002;30:S468YS477. Though most pediatric polytrauma patients survive, 10. Guy J, Haley K, Zuspan SJ. Use of intraosseous infusion in the pediatric many are left with significant sequelae. The most common trauma patient. J Pediatr Surg. 1993;28:158Y161. long-term impairments involve the central nervous and mus- 11. Bielski RJ, Bassett GS, Fideler B, et al. Intraosseous infusions: effects on culoskeletal systems. In one series of 74 pediatric polytrauma the immature physisVan experimental model in rabbits. J Pediatr patients, 80% (59/74) survived, though 22% were Bdisabled[ Orthop. 1993;13:511Y515. 4 12. Lallier M, Bouchard S, St-Vil D, et al. Falls from heights among at 1 year after the injury, primarily due to severe brain injury. children: a retrospective review. J Pediatr Surg. 1999;34:1060Y1063. In the same series, 12% had physical impairments 9 years 13. Wang MY, Kim KA, Griffith PM, et al. Injuries from falls in the after the injury. The quality of life was deemed comparable to pediatric population: an analysis of 729 cases. J Pediatr Surg. 2001;36: that of a healthy population. In another series of 70 pediatric 1528Y1534. 14. U.S. Department of Transportation NHTSA. Traffic safety facts 2002. polytrauma patients, all patients survived, but 19% of patients 2004; DOT HS 809 620:1Y202. 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