Trauma
Trauma Systems
Marcella D. Bono
Background/Definition
A trauma system is a defined group of health care providers and entities from prehospital through rehabilitation within a specific geographic location designed to optimize the care of injured patients.
State level.
Policies and guidelines are in place for trauma center designation.
Field triage guidelines for emergency medical system providers.
Trauma center levels of care with identified resources.
The American College of Surgeons (ACS) Committee on Trauma verifies trauma centers and provides guidelines for trauma care.
ACS guidelines are often more stringent than state requirements.
Trauma centers within trauma systems submit data to the state through the trauma registry.
In addition to establishing guidelines for the care of injured patients, trauma system members work together to develop and provide injury prevention resources for the community.
Injury prevention in children often focuses on motor vehicle safety such as the appropriate use of car seats and seat belts, pedestrian safety, home safety, burn prevention, and firearm safety.
Trauma Survey
Marcella D. Bono
Background
Unintentional injuries are the number one killer of children 1 to 19 years of age.
Definition
Trauma survey: a systematic approach to the assessment of an injured patient used to quickly identify and evaluate injuries.
Types.
Primary survey.
Airway and cervical spine protection.
Assess patency.
Protect cervical spine.
Breathing and ventilation.
Inspect for chest wall excursion.
Auscultate breath sounds.
Identify flail chest, closed or open pneumothorax.
Circulation.
Level of consciousness.
Skin color.
Pulse.
Hemorrhage control.
Disability.
Level of consciousness.
Pupil size.
Spinal cord injury (SCI) level if applicable.
Glasgow Coma Scale.
Exposure.
Completely undress patient.
Secondary survey.
Vital signs.
History.
AMPLE.
Allergies.
Medications.
Past illness/pregnancy.
Last meal, last menstrual period.
Events/Environment related to injury.
Head to toe physical examination.
Abdominal Trauma
Kristen Hittle
Abdominal Trauma: Liver Laceration, Pancreas Laceration, and Splenic Laceration
Background
Abdominal trauma is the primary cause of morbidity and mortality.
The spleen is the most commonly injured organ; however, the liver is also at high risk due to its large size and anatomical location.
Pancreatic injuries are challenging to diagnose with initial imaging, and symptoms often present hours after the original trauma.
Definition
Injury to a solid organ(s) in the abdomen that are graded on an injury scale that delineates severity.
Etiology/Types
Blunt injury: motor vehicle collisions, falls, bicycle accidents, all-terrain vehicle accidents, sports injuries, nonaccidental trauma.
Penetrating injury: firearms, stabbings, impalement.
Clinical Presentation
Abdominal pain, distension, tenderness, guarding, ecchymosis (e.g., “seat belt sign” or handlebar marking), abrasions, referred pain (Kehr sign), signs of a penetrating wound, hypotension, and tachycardia.
Diagnostic Evaluation
Abdominal computed tomography (CT) with and without contrast.
Abdominal ultrasound (focused assessment with sonography for trauma).
Diagnostic peritoneal lavage.
Magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography for pancreatic injuries.
Management
Based on grade of injury and hemodynamic status.
Nonoperative.
Liver and Spleen: bed rest, serial abdominal examinations, hemodynamic monitoring, nothing by mouth (NPO), maintenance IV fluids, frequent hemoglobin and hematocrit monitoring, transfusions as indicated.
Pancreas: bed rest, serial abdominal examinations, hemodynamic monitoring, NPO, Salem sump placement for gastric decompression, parenteral nutrition, elemental enteral nutrition, octreotide infusion.
Operative.
Liver: hepatic artery embolization, exploratory laparotomy.
Spleen: repair, partial splenectomy, total splenectomy.
Pancreas: endoscopic stent placement, laparotomy with pancreatectomy, Whipple procedure (pancreaticoduodenectomy).
Pediatric Burns
Elizabeth Leachman
Background
Leading cause of injury-related death in children of all ages.
Flame, scald, contact, cold, and radiation burns are the most common types of burns in childhood.
Scald burns are the most common cause of burns in infants, toddlers, and preschoolers.
Contact burns are most common in toddlers.
Curiosity and naivety lead to most burn injuries in school-age and teenage children.
Burns are dynamic injuries and often evolve into deeper injuries over time.
Most burns have a combination of depths. The center of the burn usually demonstrates a higher degree of burn than the periphery.
The depth of the burn is directly related to the etiology of the burn and the amount of time the skin is in contact with the source.
Special characteristics of children.
Thinner skin and the less resistance to heat.
Slower reflexes.
Greater body surface area and percentage of water in relation to weight.
Lower tolerance of hypothermia.
Accentuated metabolism which can lead to metabolic acidosis.
Definition
Damage to varying layers of the skin caused by heat, cold, electricity, chemicals, or friction.
Etiology
Scald burn: caused when skin comes in contact with hot fluid such as coffee, tea, or soup.
Contact burn: caused when skin touches a hot object such as a stove, iron, grill, or muffler.
Mechanical burn: friction with a surface such as a treadmill, rope, or pavement.
Flame burn: contact with fire.
Electrical burn: occurs when electrical current travels from the contact site into the body. In children, these burns most often occur when the child inserts a metal object, such as a hair pin, into a household electrical socket. There is usually an entrance and exit wound.
Chemical burn: occurs when skin comes in contact with strong acids (e.g., drain and toilet cleaners) or strong alkalis (e.g., fertilizers, detergents, oven cleaners).
Inhalation burn: Hot gases or smoke results in burns in the oropharynx.
Pathophysiology
The skin is the largest organ in the body offering protection from infection, fluid loss, and heat loss. The epidermis prevents infection and fluid loss. The dermis prevents heat loss and consists of hair follicles, sweat glands, nerve fibers, and connective tissue.
Burns cause an increase in capillary permeability, which leads to loss of fluid and proteins, including immune globulins, increasing the risk of infection and dehydration.
Loss of the protective skin barrier in children increases the risk of hypothermia and metabolic acidosis.
Clinical Presentation
Superficial burn: involves the outer layer epidermis which results in pain and erythema. The tissue remains intact and the burn usually heals without scarring in 4 to 5 days.
Superficial partial-thickness burn: involves the epidermis and superficial layer of the dermis, causing blistering, erythema, blanching, and pain. Typically heals in 7 to 10 days. Scarring is minimal.
Deep partial-thickness burn: involves the epidermis and more than 50% of the dermis, which causes destruction of nerve endings and is erythematous, moist, nonblanching, and less painful. Typically heals in 2 to 3 weeks and causes scarring.
Full-thickness burn: involves the entire epidermis and dermis which appears white, waxy, nonblanching, and is insensate due to the complete destruction of nerve fibers. Typically takes over a month to heal with significant scarring.
Evaluation
Initial evaluation: airway, breathing, and circulation, followed by disability and evaluation of the burn (depth and total body surface area [TBSA]).
During evaluation, address thermoregulation with heat lamps or warmed fluids. A sheet or blanket will also limit burn exposure to the environment and decrease pain.
TBSA in children is calculated using the Lund and Browder chart or palmar surface. The child’s palm, including fingers, is approximately 0.8% to 1% of the TBSA.
Management
Superficial burns: thin layer of moisturizer every 6 to 8 hours.
Superficial partial-thickness burns: Xeroform, Mepilex AG.
Xeroform: petrolatum gauze infused with 3% bismuth tribromophenate.
Mepilex AG: silver-impregnated antimicrobial dressing, lasts 5 to 7 days.
Deep partial-thickness burns: Mepitel and Acticoat.
Acticoat: silver-impregnated rayon/polyester/polyethylene mesh. Active release of antimicrobial silver ions into burn wound when moistened; lasts 3 to 7 days. Antimicrobial activity up to 96 hours.
Full-thickness burns: silver sulfadiazine, skin grafting.
Silver sulfadiazine 1% cream: absorbed into epidermis and dermis. Bactericidal against gram-positive and gram-negative organisms, fungi, and some viruses.
Tetanus: booster injection if >5 years since the last tetanus vaccine.
<7 years: DTaP.
>7 years: Tdap or Td if child has already received one Tdap. Latest recommendations can be found on the CDC website at: http://www.cdc.gov/vaccines/
If contraindication to pertussis vaccine: Td.
Not previously immunized: Tetanus IG plus appropriate tetanus vaccine.
Partial-thickness burns <10% of TBSA and full-thickness burns <2% TBSA can usually be managed in the outpatient setting.
Partial-thickness burns 10% to 20% and full-thickness burns >5% should be admitted to the hospital.
Burns >10% TBSA require intravenous crystalloid fluid resuscitation.
Patients with burns greater than 15% should be resuscitated using the Parkland formula.
Parkland formula: 4 mL × TBSA (% burned) × Body weight (kg).
Administer half of the volume in the first 8 hours.
Administer second half of the formula in the remaining 16 hours.
Titrate fluid resuscitation to achieve urine output of 1 mL/kg/hour.
Maintenance fluid (normal saline, lactated Ringer) added for children <5 years of age. Normal saline or lactated Ringer plus 5% dextrose added for children <20 kg.
Consulting services: physical therapy for mobility, occupational therapy for splint fabrication, nutrition, case management, social work, child life, plastic surgery.
PEARLS
Prevention of burns is the most important concept for children, which includes information about water heater temperatures, keeping hot and caustic substances, and household objects like electrical cords away from young children.
Installing smoke detectors and teaching children to “Stop, drop, and roll” when clothing is burning and what to do in a suspected fire situation are other important teaching points.
Drowning/Submersion Injuries
Alexandra K. Yockey
Background
Approximately 3,500 fatal unintentional drownings annually; approximately 10 deaths per day. The number of unreported or nonfatal submersions may be several hundred times higher.
Children at the greatest risk of submersion injuries are <5 years of age; another peak in incidence is between 16 and 24 years of age; males predominate in all age groups, and minority children are at higher risk than whites.
Factors impacting submersion injury: alcohol or drug consumption, lack of supervision, lack of protective barriers, trauma, and lack of ability to swim.
Only a few inches of water are required for a child to drown, making bathtubs and other small reservoirs of water (e.g., toilets or buckets) just as deadly as large bodies of water.
Definition
A process resulting in primary respiratory injury from submersion/immersion in a liquid medium.
Terms such as near-drowning, secondary drowning, and wet versus dry drowning should not be used as they can be ambiguous or confusing.
Pathophysiology
Drowning is typically preceded by panic, breath holding, and struggling to stay above the surface. Involuntary laryngospasm occurs as water comes into contact with the airway after submersion, causing a conscious person to cough and inhale more water. Aspiration of water and vomitus causes further laryngospasm, leading to hypoxemia and loss of consciousness. Hypoxemia stimulates a shift in the acid-base balance, resulting in arrhythmias, myocardial and cardiac arrest due to metabolic or respiratory acidosis.
Water entering the airway triggers an inflammatory cascade, causing pulmonary vasoconstriction and pulmonary edema. Surfactant is denatured and the lungs become noncompliant and difficult to ventilate with increased atelectasis. Intrapulmonary shunting with ventilation/perfusion mismatching can occur in this setting.
Cerebral ischemia results from inadequate blood flow to the brain, and if deprived of oxygen for an extended amount of time, the brain tissue begins to die, causing cerebral infarcts. The injured brain then begins to swell, resulting in cerebral edema and increased intracranial pressure (ICP), further injuring the nervous system.
Submersion injuries do not directly cause cardiovascular injury; it is the resultant hypoxia and pulmonary injury that affect the myocardium.
Hypothermia and electrolyte disturbances result in arrhythmias. The cardiovascular system is able to recover from hypoxia if oxygenation and acid-base balance are restored.
Clinical Presentation
Varies based on length of submersion, temperature, and degree of hypoxia, along with possible causes of drowning (e.g., seizure, trauma, or arrhythmia).
Children may present to the emergency department (ED) asymptomatic. A thorough evaluation is still required as even mild hypoxia can increase permeability of pulmonary capillaries, with alveolar fluid leak and surfactant damage.
Respiratory dysfunction may take hours to manifest, making it crucial for children to be observed for a prolonged time frame after submersion incident. Pulse oximetry should be monitored; if abnormal or in the presence of respiratory distress, arterial blood gas (ABG) values and chest radiograph should be obtained.
Symptomatic patients present anywhere on a continuum of symptoms: anxiety, vomiting, cough, wheezing, hypothermia, altered mental status, metabolic acidosis, respiratory failure, and finally respiratory/cardiac arrest.
Evaluation
ABCs (airway, breathing, and circulation) algorithm for pediatric advanced life support. ABG values are helpful in evaluating the degree of hypoxemia in children who have been submerged; should be obtained on all symptomatic children and those with a prolonged event who are asymptomatic.
Vital signs: heart rate, respiratory rate, blood pressure, temperature, and pulse oximetry on every submersion victim.
Chest radiograph: evaluation for atelectasis, pulmonary edema, and aspiration.
Further imaging and testing will depend on the degree of deterioration and other coinciding injuries related to the incident.
Management Occurs in Three Phases
Prehospital: Rescue victim from the source of submersion. Immediate resuscitation by witnesses is proven to increase survival rates. Unlike standard basic life support, which is very compression driven, opening and maintaining the airway is priority.
Routine cervical spine immobilization is not indicated unless there is obvious trauma.
The basic life support algorithm should be initiated if the child is not breathing and/or pulseless. Supplemental oxygen should be administered to all submersion victims. All submersion victims should be taken to the hospital for evaluation regardless of severity of injury.
ED: First priority is establishing an airway. Indications for intubation include unconscious child, peripheral arterial carbon dioxide (Paco2) levels >50 mmHg, inability to maintain peripheral arterial oxygen (Pao2) >90% with supplemental oxygen. Positive end-expiratory pressure should be used to prevent atelectasis and overcome intrapulmonary shunting.
Noninvasive ventilation with either continuous positive airway pressure or bilevel positive airway pressure may be indicated in alert patients with ongoing respiratory symptoms despite supplemental oxygen.
Chest radiograph is indicated on all submersion victims.
Gastric decompression via orogastric or nasogastric tubes should be placed to minimize aspiration risk in patients with altered level of consciousness.
Hypothermia can be both protective and harmful. Remove all wet clothing and cover patient. Evaluate for hypothermia, hypoglycemia, and electrolyte abnormalities; common in submersion injuries.
Inpatient: focus of hospitalization is supportive; primary goal is preventing secondary cerebral injury. The initial cerebral ischemic injury occurs during the time a victim is submerged. Secondary cerebral injury occurs later from prolonged hypoxemia, cerebral edema, acidosis, hypovolemia, seizures, and electrolyte imbalances.
Respiratory treatments and interventions should be tailored by clinical condition and ABG values once in a controlled environment.
Hypercapnia should be avoided; increased cerebral hypertension further compounds cerebral edema.
Aspiration pneumonitis can further complicate pulmonary status; antibiotic therapy for aspiration is controversial.
Normalize blood pressure; vasoactive agents may be required. Hypotension decreases blood flow to the brain, further compromising oxygenation, potentially resulting in poor neurologic outcomes. poor neurologic outcomes.
Hypervolemia can exacerbate pulmonary edema and should be avoided. The use of diuretics and fluid restriction may be indicated in some cases.
Hypermetabolic states (e.g., seizure and fever) should be treated aggressively to avoid secondary brain insults/injury.
Electroencephalography (EEG) should be used to detect subclinical seizures, especially in patients requiring neuromuscular blocking agents.
PEARL
The best treatment and management for submersion injuries is prevention. Community awareness of risks, CPR training, and education of first responders will help save lives.
Pneumothorax Resulting from Trauma
Anne Vasiliadis
Background
Air leak syndromes include any pathology in which air enters a normally closed space within the thorax.
Definition
A pneumothorax is an abnormal collection of air between the visceral and parietal pleura in the thoracic cage. In the case of trauma, pneumothorax can be a result of blunt, crushing, or penetrating injury directly to the chest.
A tension pneumothorax can occur as a result of lung laceration or injury to a major airway and can cause sudden or acute symptoms.
Incidence
Chest trauma is infrequent in children; responsible for 4% to 8% of all pediatric traumas. Blunt injuries are responsible for 85% of chest injuries.
May occur as a result of increased intrathoracic pressure (e.g., mechanical ventilation).
Pathophysiology
Acute increase in transpulmonary pressure; causes alveolar overdistention and rupture.
Clinical Presentation
History of blunt trauma, fall, or other trauma event.
Review of symptoms: typically pleuritic chest pain (e.g., sharp and worse with inspiration), dyspnea, or may be asymptomatic. The chest pain usually resolves or changes to a dull pain within 1 to 3 days despite the persistence of the pneumothorax.
Physical Examination
Ipsilateral hyperresonance to percussion.
Ipsilateral decreased air entry.
Ipsilateral decreased vocal fremitus.
Clinical Findings
Hypoxia.
Tachycardia.
Increased peak inspiratory pressures or decreased expired tidal volumes (if on mechanical ventilation).
Tension pneumothorax: tracheal deviation, asphyxia, and decreased cardiac output leading to hypotension, tachycardia, and hypoxemia. A medical emergency requiring immediate intervention.
Diagnostic Evaluation
Radiography: Diagnosis is typically confirmed with a posterioanterior chest radiograph. A lateral decubitus radiograph may be needed if suspicion is high with normal posterioanterior radiograph. CT is not necessary to diagnose pneumothorax, but may help identify underlying blebs/bullae or very small pneumothoraces not detected by radiography (Figure 12.1).
Estimation of size: Clinical history is not a reliable indicator of size. There are multiple equations for calculating size of pneumothorax in adults, but these methods are not accurate in the pediatric population.
Laboratory findings: ABG analysis may reveal decreased Pao2.
Management
Treatment is dictated by the type and size of pneumothorax and clinical condition of the patient.
Observation: Clinically stable patients may only require observation with pulse oximetry and cardiorespiratory monitoring. During observation, patient should receive 100% oxygen delivered via face mask to wash out nitrogen from pleural space.
Needle aspiration: Air is aspirated via a temporary needle inserted at the second intercostal space, midclavicular line.
Thoracostomy tube: Catheter is placed in the pleural space at fourth, fifth, or sixth intercostal space at the midaxillary line and connected to water seal or suction.
 FIGURE 12.1 • Pneumothorax Chest Radiograph. Large left pneumothorax in otherwise healthy 16-year-old boy. |
PEARLS
Not all pneumothoraces require intervention.
Conservative and noninvasive treatment options should be considered first in the clinically stable patient.
Tension pneumothorax is diagnosed by clinical findings and is considered a medical emergency.
Pulmonary Contusions
Catherine Walsh
Definition
Injury to lung parenchyma with edema and hemorrhage without associated pulmonary laceration.
Background
Most common traumatic chest injury in children.
Early diagnosis and intervention may improve outcomes.
Fewer short- and long-term complications in pediatric populations than in adults.
Etiology
Pulmonary contusions are the most common pediatric thoracic trauma injury.
Children are more likely to have pulmonary contusions without other chest wall injury (e.g., rib fractures) due to high chest wall compliance.
Child thorax offers less protection to lung tissue than adult.
Flail chest and scapular fractures are rare in children, but are almost always associated with pulmonary contusions.
Most commonly seen in children struck by vehicles.
Associated with blunt chest wall trauma.
Suspect in patients who have sustained falls, rapid deceleration, or blast injuries. Due to severe mechanism of injury (MOI), patients frequently sustain damage to other body systems.
Pathophysiology
Lung tissue injury due to hemorrhage, edema, and alveolar collapse. Results in poor gas exchange, increased pulmonary vascular resistance, and inflammatory reaction.
Deceleration at different rates results in shearing of alveolar tissue and hemorrhage.
Alveolar membrane is disrupted, resulting in increased cell membrane permeability and fluid extravasation.
Parenchymal damage is caused by overexpansion of intrapulmonary air.
Pathophysiologic changes peak 24 to 48 hours after injury and typically resolve within 7 days.
Subsequent respiratory impairment may be due to local inflammatory response from sequestered blood, systemic response from associated injuries, and possible nosocomial pneumonia.
Posttraumatic empyema is rare, but has potentially severe sequelae.
Clinical Presentation
Initial presentation may be subtle. Symptoms may include tachypnea, hypoxemia, hypercarbia, hemoptysis, and respiratory distress.
May be associated sign of chest wall injury.
ABG may be normal or demonstrate hypoxemia.
Delayed presentation may occur as symptoms peak 24 to 48 hours after injury.
Diagnostic Evaluation
Goal of primary evaluation is to identify potential life-threatening conditions.
High suspicion determined by mechanism and type of injury.
Radiographic findings of consolidation: Chest radiography and CT are the primary forms of testing. Bedside ultrasound can be used for unstable patients.
Chest radiography:
Irregular opacification in area of chest wall injury/impact.
Chest radiograph changes may not be noted until 4 to 6 hours after injury, and changes may not appropriately reflect extent of injury.
Enlargement of contusion in the first 24 hours after injury is likely indicative of increased morbidity.
May underestimate severity of ventilation/perfusion mismatch.
May be difficult to separate degree of contusion from other conditions including aspiration, pneumonia, and fluid overload (Figure 12.2).
CT.
Highly sensitive, but may detect mild and asymptomatic contusions.
More accurate in differentiating other causes of consolidation. Subpleural sparing is seen in pulmonary contusions but unlikely with atelectasis or pneumonia.
Better able to calculate extent of injury and predict need for respiratory support.
Management
PRIMARY management is supportive. Most children with pulmonary contusions require no intervention.
Address life-threatening injuries and ensure oxygenation, ventilation, cardiovascular support.
Close monitoring; injury evolves over first 24 to 48 hours after injury.
FIGURE 12.2 • Pulmonary Contusion Chest Radiograph. This 3-year-old child was struck by a car. The radiograph shows the pulmonary contusion, looking much like pneumonia. Note the malpositioned nasogastric tube and the resultant distended abdomen.
Supplemental oxygen for hypoxia.
Pulmonary toilet, fluid management, and pain control are essential.
Fluids:
Judicious fluid administration. Avoid underresuscitation, which may result in hypovolemia and hypoxemia; overresuscitation may result in pulmonary edema.
No benefit of prophylactic antibiotics or corticosteroids.
Intubation:
Most commonly used for patients with extra-thoracic injuries.
For patients requiring respiratory support, the goal is to maximize oxygenation and minimize secondary lung injury.
Use of positive pressure improves alveolar recruitment.
Single lung ventilation for unilateral injuries may improve oxygenation and ventilation/perfusion mismatch.
Pain may contribute to hypoventilation, atelectasis, and respiratory deterioration.
Patients with boney chest wall injury may benefit from regional analgesia.
Positioning.
Frequently change patient position.
Prone position and injured lung in dependent position may improve perfusion.
Complications include pneumonia and acute respiratory distress syndrome.
Risk for pneumonia due to blood in alveolar space and decreased pulmonary toilet. Appropriate antibiotic coverage for patients with fever with worsening respiratory function.
Long-term consequences rarely seen in children.
PEARLS
Pulmonary contusions are frequently seen with injury to other organ systems.
Primary goal is to identify other life-threatening injuries. Management is primarily supportive.
Injury may evolve over 24 to 48 hours.
Severe pulmonary hemorrhage may be associated with diffuse hemorrhage, related liver damage, massive hilar contusions.
Limb Trauma: Fractures and Sprains
Cathy Haut
Background
Unintentional or accidental limb injuries occur as a result of sports injuries, motor vehicle accidents (MVAs), and falls.
More than 3.5 million children <14 years of age are injured each year playing sports or involved in recreational activities.
When evaluating limb trauma, it is important to note the MOI, which represents the effect that energy has on human tissue, thus the expected severity of the injury.
Fractures are extremely common injuries sustained by children as a result of trauma, with lifetime risk of sustaining a fracture, 42% to 60% of boys and 27% to 40% of girls sustaining fractures during childhood.
Fractures
Background/Definition
A fracture is a break or disruption in the continuity of bone. Fractures in children can involve the epiphysis or metaphysis; disrupting the epiphyseal plate may interfere with bone growth.
Most fractures in children are a result of low-velocity trauma. Fractures in children <2 years of age: highly suspicious for child maltreatment.
Etiology/Types
Epiphyseal injuries occur most frequently with distal radius and ulnar fractures, excluding phalangeal fractures. The MOI is usually a fall on an arm or hand; ages 11 to 15 years are the most common group affected with injury to the radius and ulna.
Forearm and wrists are the most common fracture sites in children >5 years of age, and categories include fracture dislocations, midshaft, and distal fractures.
Clavicle fractures occur frequently in children resulting from a fall landing on the shoulder.
Humerus fractures include the supracondylar site and can be associated with an acute vascular injury. Injury to the shaft of the humerus results from twisting mechanism. Distal humeral fractures occur more often in the lateral epicondyle.
Young children and adolescents sustain femur fractures which are often associated with a MVA involving high-energy force.
Tibial fractures are diaphyseal in school-age children and nondisplaced often from MVAs and sports injuries.
Ankle fractures, often the result of direct trauma, are more likely to involve the tibia and fibula than the talus.
Foot fractures involve the metatarsals and phalanges and are usually not displaced.
Pelvic fractures, uncommon in children, are usually the result of a crush-type injury or high-energy force. Abdominal hemorrhage and damage to other soft tissue in the abdominal area should be suspected with pelvic fracture.
Hip fractures can result in avascular necrosis of the femoral head, damage to the physis with growth arrest, malunion, and nonunion. Hip fractures are uncommon except for pelvic avulsion fractures occurring in adolescent boys.
Spinal fractures, rare in children, most often involve the cervical spine, from significant direct trauma in MVA, fall, or pedestrian-struck MVA.
Classification of Fractures
Either open or closed.
Open: Wound communicates with fracture.
Result of high-energy trauma or penetrating wound.
Closed: Skin is intact.
Explanation of Classification or Type of Fractures
Plastic deformation: a bending of the bone which causes a small fracture that does not cross the bone. Most common in the ulna.
Buckle (torus) fractures: fracture on the tension side of the bone near the softer metaphyseal bone; crosses the bone and buckles the harder bone on the opposite side, causing a bulge.
Greenstick fracture: Bone is bent with an initial fracture which does not go through bone.
Complete fracture: involves total width of bone.
Spiral: occurs from a rotational or twisting force.
Oblique: viewed diagonally across the diaphysis.
Transverse is usually diaphyseal.
Epiphyseal: through the physis or growth plate.
Pathophysiology
Limb injury results in a break in the continuity of the bone, followed by a staged healing process which involves coagulation of blood between bone fragments, formation of bone matrix, and mineralization of the matrix.
Clinical Presentation
History of injury or trauma.
Inability to stand, walk, or use injured part, with substantial pain or point tenderness.
Visible or palpable limb deformity and ecchymosis, crepitus, or grating.
Spontaneous onset of pain (usually seen with pathologic fractures).
Local swelling and marked tenderness, possible movement between bone fragments, muscle spasm.
Diagnostic Evaluation
Radiographs of suspected limb fractures should include the joint above and below the injury.
Comparison views of the opposite extremity are often obtained to help distinguish the fracture line from the growth plate.
In some situations, oblique radiographs are warranted in order to identify a fracture that is difficult to detect.
Further radiologic studies may be indicated in certain instances to evaluate a fracture: ultrasound, tomography, CT, magnetic resonance imaging (MRI), bone scan, fluoroscopy.
Vascular assessment may include the use of Doppler studies, compartment pressure monitoring, and/or angiography.
Management
Dependent on the type of fracture, location, and the age of the child.
Treatment may consist of immobilization by cast, splint, or brace, closed reduction followed by a period of immobilization in a cast or splint, or open reduction with or without internal fixation, and usually followed by a period of immobilization in a cast or splint. Closed reduction and percutaneous pinning followed by a period of immobilization. Closed or open reduction and application of an external fixator.
Traction (i.e., skin, skeletal) followed by a period of immobilization.
Immobilization for most fractures ≤12 weeks.
Simple fractures that are closed and nondisplaced can heal enough to be free from immobilization within 3 weeks.
Potential Complications from Fractures or Treatment of Fractures
Infection, avascular necrosis, vascular injuries, delayed union, nonunion, malunion, epiphyseal arrest, nerve and visceral injuries, tendon and joint injuries, fat embolism, compartment syndrome (see Musculoskeletal section), osteoarthritis, reflex sympathetic dystrophy.
Sprains
Definition
Injury to a ligament resulting from excessive stretching force.
Etiology
Typical causes are falls or sports-related injury, mostly in basketball, running, and soccer, grades I to III. Ankle sprains constitute approximately 25% of all sports-related injuries; 75% of sprains involve the ankle.
Grade I: minimal discomfort, minimal or no loss of function.
Grade II: ligaments are partially torn with tenderness, swelling, and ecchymosis with mild-to-moderate loss of function.
Grade III: completely torn ligament with unstable joint, significant tenderness, swelling, and ecchymosis with loss of function.
Pathophysiology
An injury to the articular ligament, which is a connective tissue connecting the bone to another bone.
Clinical Presentation
History of feeling a tear or hearing a pop with activity, swelling, and pain, typically in the wrist or ankle.
Pain and swelling in shoulder, knee, or elbow can also indicate sprain, but these areas are much less common.
Diagnostic Studies
Imaging is not usually indicated for a sprain.
Ottawa ankle rules provide guidelines for deciding about radiography: Radiographies are ordered only if there is point tenderness on the lateral or medial malleolus and the distal 6 cm of the posterior edge of the tibia or fibula or if inability to bear weight or take four unassisted steps in the examination room.
Management
Provide relief of discomfort with ice, rest, and nonsteroidal anti-inflammatory drugs or acetaminophen, maintain joint stability with Ace wrap or splint, and minimize swelling.
RICE: rest, ice, compression, elevation.
Complete healing should occur between 4 and 6 weeks.
PEARL
Prevention of fractures and sprains is the most important management through the use of supervision of young children, protective gear, well-fitting shoes, and warming up/stretching prior to exercise.
Ophthalmic and Facial Trauma
Cathy Haut
Background
Young children are more susceptible to facial trauma due to their greater cranial mass to body ratio.
MOI is important to assist in determining the severity of injuries.
Definition
Physical trauma to the face involving soft tissue injuries, fractures to the nose or orbits, and eye injuries.
Types
Eye and orbital injuries.
Midface, nose, and jaw injuries.
Malocclusion of the jaw with mandibular fracture.
Pathophysiology
Facial trauma may be blunt or penetrating and occurs within three functional divisions of the face: upper third, midface, and lower third. Trauma can affect muscle movement, cranial nerve innervation, and function.
Clinical Presentation
History of injury: fall, sports-related, or MVA.
Pain, bleeding, bruising.
Diagnostic Studies
Orbital assessment includes evaluation of visual acuity, pupillary size and response, visual fields, diplopia, and extraocular muscle function.
Subconjunctival hemorrhage or hyphema requires urgent ophthalmologic consultation.
Compare preinjury photo with current status.
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