Orthopedics and traumatology

Burn

• A is a type of to flesh or skin caused by heat (thermal burn), electricity, chemicals, friction or radiation. • The characteristics of a burn depend upon its depth. Superficial cause pain lasting two or three days. Full-thickness burns may be entirely insensitive to light touch or puncture. • While superficial burns are typically red in color, severe burns may be pink, white or black. • Burns around the mouth or singed hair inside the nose may indicate that burns to the airways have occurred. More worrisome signs include: shortness of breath, hoarseness, and stridor or wheezing. • Itchiness is common during the healing process, occurring in up to 90% of adults and nearly all children.

• The most causes of burns are hot liquids and fire

Electrical injuries

• Electrical injuries primarily result in burns, they may also cause fractures or dislocations secondary to blunt force trauma or muscle contractions. In high voltage injuries, most damage may occur internally and thus the extent of the injury cannot be judged by examination of the skin alone. Contact with either AC (alternating current) or DC (direct current) may produce cardiac arrhythmias or .

Electrical burns TBSA – total body surface area

● trunk 18%+18%

● legs 18%+18% RULE OF ● hands 9%+9% NINES ● head 9%

● scrotum 1%

As for infants - head 18%, legs 14% each

American Burn Assosciation classification

Circumferential burns of the limbs or chest may need urgent surgical release of the skin, known as an escharotomy to prevent problems with distal circulation, or ventilation. Fasciotomies may be required for electrical burns. Escharotomy

Fasciotomies

Management

1. begins with the assessment and stabilization of the person's airway, breathing and circulation. ( ABC) 2. care- early cooling, extensive irrigation, dressing applications (with silver sulfadiazine is not recommended as it potentially prolongs healing time), dressing containing silver, Management

3. Intravenous infusions – Ringer's solutions, crystalloid or colloid fluids. At first basic needs, after that… The Parkland formula - determine the volume of intravenous fluids required over the first 24 hours. The formula is based on the affected individual's TBSA and weight. Half of the fluid is administered over the first 8 hours, and the remainder over the following 16 hours. The time is calculated from when the burn occurred, and not from the time that fluid resuscitation began.

4ml x %TBSA x kg

4. Pain management 5. Tetanus shot

Later management

- intravenous antibiotics for extensive burns (55% Staph aur., Pseud aer. 20%, streptococcus sp 17%, Acinetobacter 10%. Candida 3%) - negative-pressure wound therapy.

- - hyperbaric oxygenation

• requiring surgical closure with skin grafts or flaps should be dealt with as early as possible.

Is a life-threatening medical condition of low blood perfusion to tissues resulting in cellular injury and inadequate tissue function If shock progresses anaerobic metabolism will begin to occur with an increased blood lactic acid. Types: hypovolemic, cardiac, septic, distributive Types of shock

1. Hypovolemic shock is the most common type of shock and is caused by insufficient circulating volume. Its primary cause is hemorrhage (internal and/or external), or loss of fluid from the circulation. Vomiting and diarrhea are the most common cause in children. With other causes including burns, environmental exposure and excess urine loss due to diabetic ketoacidosis and diabetes insipidus. Types of shock

2. is caused by the failure of the heart to pump effectively- due to damage to the heart muscle, most often from a large myocardial infarction. Besides- dysrhythmias, cardiomyopathy/myocarditis, congestive heart failure (CHF), contusio cordis, or cardiac valve problems. 3. Obstructive shock is due to obstruction of blood flow outside of the heart.: - • - constrictive pericarditis • - tension • - pulmonary • - aortic stenosis 4. is due to impaired utilization of oxygen and thus production of energy by the cell: - - anaphylactic shock,

The prognosis of shock depends on the underlying cause and the nature and extent of concurrent problems. Hypovolemic and anaphylactic shock are readily treatable and respond well to medical therapy. Septic shock however, is a grave condition with a mortality rate between 30% and 50%. The prognosis of cardiogenic shock is even worse. Management

1. ABC, securing the airway via intubation if necessary to decrease the work of breathing and for guarding against respiratory arrest. 2. Oxygen supplementation 3. Keep the person warm and decrease anxiety as these can increase oxygen consumption. 4. Pain management 5. Aggressive intravenous fluids - colloids or crystalloids, -if the person remains in shock after initial resuscitation packed red blood cells should be administered to keep the hemoglobin greater than 10g/dl 6. Vasopressors

The goal of treatment is to achieve a urine output of greater than 0.5 ml/kg/h, a central venous pressure of 8-12 mmHg and a mean arterial pressure of 45-95 mmHg. In trauma the goal is to stop the bleeding which in many cases requires surgical interventions. Birth trauma

Birth trauma (BT) refers to damage of the tissues and organs of a newly delivered child, often as a result of physical pressure or trauma during childbirth. There are often clear distinctions to be made between brain damage caused by birth trauma and that induced by intrauterine asphyxia.

Most common birth trauma - subcutaneous hemorrhages, - subgaleal hemorrhage - management consists of vigilant observation over days to detect progression.The subgaleal space is capable of holding up to 50% of a newborn baby's blood and can therefore result in acute shock and death. Transfusion and phototherapy may be necessary. Investigation for may be indicated. - subdural hemorrhage, - subarachnoid hemorrhage, - epidural hemorrhage, intraventricular hemorrhage - small subperiosteal hemorrhages,

Birth trauma - Hemorrhages along the displacements of cranial bones, - Brachial plexus palsy ( Klumpke's, Erb's) - facial nerve palsy- Bell's syndrome - Phrenic nerve palsy - Bone fractures- clavicule, humerus, femur, - visceral injuries- liver, spleen or suprarenal glands( >> Right side), kidneys - accidental injuries during delivery f.x. skin cuts - oxygen deprivation or anoxia, before or during birth can cause serious health problems to a newborn. This type of birth of trauma can occur if the placenta separates prematurely or if the umbilical cord becomes entangled around the baby’s neck and reduces oxygen flow to the brain. This category of birth injury destroys brain cells within a matter of minutes and causes seizures, coma, and, if a baby is not placed in life support in time, death. - intrauterine hipoksia may cause further epilepsy, ADHD, eating disorders and cerebral palsy.

Birth trauma causes

- cephalopelvic disproportion, - the quick and rapid delivery, - delayed and prolonged delivery, - the abnormal birth position, - asynclitic birth (asinklitismus), - obstetric turn, - acceleration and stimulation of the birth, - breech presentation, - forceps and vacuum extraction Hip joint dysplasia

Hip dysplasia, developmental dysplasia of the hip (DDH or congenital dysplasia of the hip (CDH ) is a congenital or developmental deformation or misalignment of the hip joint. - it means unstable or dislocatable hips and poorly developed acetabula Causes: - multifactorial inheritance - possible indicated by genetic factors- A locus has been described on chromosome 13 - possible hormone influence - is more frequent in females than in males - the baby’s womb position can increase pressure on the hips joints, stretching the ligaments. Babies in the breech position are more likely to have hip instability than babies in a normal womb position. - the bones of an infant’s hip joint are much softer than an adult hip joint. It is easier for an infant’s hip to become misaligned (subluxate) or dislocate than an adult hip. This is because an infant hip socket is mostly soft, pliable, cartilage. Whereas an adult’s hip socket is hard bone. - infant positioning during the first year of life - a hip-safe method should be used. Use of overly restrictive baby seats, carriers and other methods of transporting babies John F.Crowe classification

Diagnosis

As a standard newborn exams that include a hip joint exam screening for early detection of hip dysplasia can be confirmed by ultrasound and X-ray. Physical examination: - asymmetrical gluteal folds and an apparent limb-length inequality can further indicate unilateral hip dysplasia - apparent limb-length inequality Treatment

- pavlik harness - frejka pillow - Otto Bock harness - traction - surgical procedures - closed reduction, open reduction, or osteotomy, arthroplasty in babies and young children Children’s posture

Posture can be defined as the relationship of the parts of the body to the line of the center of gravity. The posture is a gauge of mechanical efficiency of the neuromusculoskeletal system in the erect position - In the uterus the fetus is almost invariably in a position of flexion, with the convex curve of the spine lying against the curve of the uterine wall. The head, arms, and legs of the fetus are flexed on the torso. The rate of development of muscle strength varies in the different parts of the body. - When the infant is in a horizontal position, the hip flexors, the anterior muscles of the neck, and the abdominal muscles are stretched and used minimally, whereas the extensors of the neck, back, and thigh are relaxed and are the first to increase their motor power. - When the child is able to support his head and begins to sit up, the weight of the head, combined with the persistent In flexion of knee, flexor surface or posterior surfaces of leg and thigh come close."flexion attitude of the hips and the associated of the pelvis on the spine, produces a long convex curve of the entire spine. - When the child begins to stand and walk, the extensor muscles of the back, neck, and hips are well developed and the spine is usually straight. Our posture should follow a vertical line through our ear, shoulder, hip, knee and just in front of our ankle The line of the center of gravity of the body passes from the mastoid process to the cervicodorsal junction, crossing the bodies of the vertebrae at the dorsolumbar junction, and falling just anterior to the sacro-iliac articulation and slightly posterior to the hip joint; it passes through the anterior knee joint and terminates at the front of the talus in the ankle.

The posture of each person has characteristics that are uniquely his. Various factors affecting posture are: ● Bone Contours ● Ligaments ● Fascial and Musculotendinous Tautness ● Muscle Strength ● Pelvic Inclination - The pelvis is the base upon which the vertebral column rests.

Posture can be classified into four grades: A- Excellent or almost perfect posture B- Good, but not ideal posture C- Poor, but not the worst possible posture D- Bad and very possibly symptom-producing posture Postural defects

There are three common postural defects: 1. Kyphosis is an exaggerated curve of the thoracic region which causes the shoulders to be rounded, the neck to be shortened and the chin to poke forward. The muscles in the upper back are weakened, and the pectoralis major muscle tightens.

2. Lordosis is the exaggerated curve in the lumbar region, and causes the pelvis to tilt forward. The abdominals and hip extensors are weakened and the trunk extensors and hip flexors tighten. 3. Scoliosis is lateral curvature of the spine. Muscles on the outside of the curve become weak, and muscles on the inside of the curve become tight.

Treatment

Poor posture in children should be observed, and corrective measures taken to increase the strength of the back so that it will be less susceptible in adult life to fatigue, back strain, and injury. Children rarely complain of backache from poor posture. Treatment consists of passive and active exercises. The aim is to gradually build up aerobic resistance in the postural musculature, i.e. the shoulder, back, abdominals and hip extensors.

This in turn would maintain or realign a correct posture. The effects of this are: · An improvement in neuromuscular control, postural reflexes and muscle tone · Reduction in the energy requirements needed to maintain correct alignment · Reduction in wear and tear on the joints Exercises to increase the motor strength of the key muscles affecting posture are also helpful. The most important is the pelvic tilt. The patient is instructed to decrease the pelvic inclination by use of the abdominal and gluteus maximus muscles. Postural exercises should be carried out until the individual is able to maintain the correct posture naturally. The patient should continue the exercises until they become part of his normal stance and gait.

Fractures in children

Can occur due to accidents, child abuse or due to some pathologies. e.x. motor vehicle accidents and falls from a height account for major mechanisms of accidental trauma causing fractures in children. Some fractures are known to occur more in specific age groups.  fractures of the femur are most common in children ages 0 to 3 years of age  fractures of supracondylar area in humerus are more common in second decade and peak is around 7 years of age.  nonaccidental trauma [Child abuse] is the leading cause of fractures during the first year of life  physeal fractures are more common near skeletal maturity.  distal forearm, proximal humerus peak around 14 years of age.  Clavicle, Femur, foot bones, forearm bones have peak incidence of fractures around 5 years and 15 years whereas ankle, carpal metacarpal rise linear with age. Diaphyseal fractures showed irregular pattern. In children, upper limb is injured much more commonly than the lower limb. Radius is most common fracture in uppper limb followed by elbow. - Physeal injuries constitute 15-25% of pediatric injuries. - Open fractures constitute about 3-5% of the injuries - Multiple fractures in children are uncommon. Fractures in children

Incidence − the boys 3 times more than the girls − each year ap.2% of all the children sustain a fracture. − about 20% of children out of all children with injury, would have a fracture. − fractures show a linear increase with age, peaking at 12 years and then decrease until age of 16 years - left upper extremity demonstrates a slight but significant predominance in most of the reports - fractures are more common during the summer (older children) - still increasing amount of abusing children

Diagnosis

• Radiographs After the physical examination, xrays are done. Any limb with a significant injury should be examined on x-ray. In presence of or suspected neck injury, a lateral cervical spine x-ray is obtained. • Computed Tomography Computed tomography is essential in a child with multiple injuries. • Ultrasound Ultrasound reporting is dependent on operator and in comparison CT is superior for diagnosing visceral injury in children. • Magnetic Resonance Imaging Primary use of the Magnetic resonance imaging is for the detection of injury to the brain or the spine and the spinal cord. In SCIWORA syndrome, MRI demonstrates the site and extent of and in defining the level of injury to the disks or vertebral apophysis. MRI also is very useful in evaluating knee injuries that cannot be visualized on routine x-rays. SCIWORA syndrome

● Stands for spinal cord injury without radiographic abnormality. ● The most common are injuries in the cervical [most common] or thoracic spine, ● the absence of identifiable bony or ligamentous injury on radiographs or computed tomography ● Flexion and extension injuries are the most common mechanism, but lateral bending, distraction, rotation, axial loading, or a combination may also be involved. ● These injuries accounts for about 60% of severe cervical injuries in children < 8 years of age ● should be suspected in patients subjected to who report early or transient symptoms of neurologic deficit or who have a neural deficit on clinical examination. ● Following injuries have been noted in cases of SCIWORA − Transverse atlantal ligament injury − Fracture through the cartilaginous end plates (which are not visualized by x-rays), may be among the causes of this injury − Unrecognized interspinous ligamentous injury − Adult with acute traumatic prolapse − Hyperextension injury in cervical spondylosis

Treatment

● Life threatening injuries are priority. ● Splinting of the fractures will generally suffice as the initial management. ● After the child is stabilized, the management of orthopedic injuries is done depending on the type of injury. ● Classically, fractures in children were treated with non operative treatment. ● With evolution of orthopedics and improvement in surgical techniques, availability of C-arm image intensifier more and more fractures see increased operative management. ● One of the major advances in orthopedics is surgical techniques that allow to fix the fractures with percutaneous methods. Children tolerate all types of casts well for short periods of time, which allows a minimally stabilized fracture to be immobilized with a cast until there is sufficient internal callous. ● Actual treatment of the fracture depends on site of fracture, age and body habitus of the child, expectation of the parents and concomitant injuries. Greenstick fractures

● typically occurs in children. ● are incomplete fractures of long bones and are commonly mid-diaphyseal. Forearm bones [radius, ulna] and leg bones are commonly affected. ● The fractures typically affect the forearm and lower leg. ● occurs when the force applied to a bone results in bending of the bone and breaks the bone on convex aspect of the bend but does not extend the break to concave surface. The bones of children are soft and are covered with thick fibrous periosteum of immature bone. ● The situation is similar to bending a soft green branch of tree [stick]. If you hold a green branch or stick and bend it, it would bend only till some time. If further force is applied, the stick would break on the convex surface. ● does occur in similar manner when a bending force acts on the bone, one of the cortex bends whereas other breaks. ● would cause pain at the injured area. The area may be swollen and either red or bruised and there could be a visible deformity. Older child may guard the area. ● Anteroposterior and xrays of the affected part are standard imaging for a greenstick fracture. Monteggia fracture dislocation

- Fracture of the proximal third of the ulna with dislocation of the head of the radius

Mechanisms: Fall on an outstretched hand with the forearm in excessive pronation (hyper-pronation injury).

- Direct blow on back of upper forearm would be a very uncommon cause. In this context, isolated • ulnar shaft fractures are most commonly seen in defence against blunt trauma (e.g.nightstick injury). • Such an isolated ulnar shaft fracture is not a Monteggia fracture. It is called a 'nightstick fracture'.

● May be managed conservatively in children with closed reduction (resetting and casting), • but due to high risk of displacement causing malunion, open reduction internal fixation • is typically performed

● Complications can include non-union, malunion, nerve palsy and damage, muscle damage, • arthritis, tendonitis, infection, stiffness and loss of range of motion, , • deformity, and chronic pain Galeazzi fracture

● Fracture of the radius with dislocation of the distal radioulnar joint. ● It classically involves an isolated fracture of the junction of the distal third and middle third of the radius with associated subluxation or dislocation of the distal radioulnar joint; ● the injury disrupts the forearm axis joint ● Pain and soft-tissue swelling are present at the distal-third radius fracture site and at the wrist joint. ● Is confirmed on radiographic evaluation. ● May be associated with compartment syndrome. ● Anterior interosseous nerve (AIN) palsy- can cause paralysis of the flexor pollicis longus and flexor digitorum profundus muscles to the index finger, resulting in loss of the pinch mechanism between the thumb and index finger. ● Sometimes are associated with wrist drop due to injury to radial nerve, extensor tendons or muscles. ● Best treated with open reduction of the radius and the distal radio-ulnar joint. ● Typically treated with closed reduction in childhood Pediatric Trauma Score

● A Coma Score of 13 or higher correlates with a mild brain injury,

● 9 to 12 is a moderate injury and 8 or less a severe brain injury.

● Any combined score of less than eight represents a significant risk of mortality. Pediatric trauma score is a score used in pediatric injuries to gauge vulnerability of the injured child to traumatic injury. The score uses following parameters ∙ Weight of the child ∙ Airway status ∙ Systolic BP ∙ Consciousness Level ∙ Type of fractures ∙ Type of Wound Final score is the sum total of all the scores. The minimal score is -6 and the maximum score is +12. Pediatric trauma score has been found to be a valid and reliable tool in predicting mortality of an injured child. ∙ If pediatric trauma score is >8, mortality is about 9% ∙ If pediatric trauma score is <0, mortality is 100% Thank you for the attention!