Overview of Pediatric trauma

1. Overview of Pediatric trauma Presenter: DrGituri Philip Moderator: Dr E. Gakuya

2. An 8-year-old boy presents to the emergency department with a Salter-Harris type IV fracture of the distal femur from a football tackle. The fracture has 3mm of displacement and 15 degrees of angulation in the sagittal plane. Because of his young age you know he has excellent potential to remodel. The BEST treatment option would include: • Long-leg cast • Percutaneous pinning in situ • Open reduction and internal fixation with distal femoral locking plate • Open reduction and internal fixation of the metaphysealcomponent but not the epiphyseal component to avoid potential growth arrest • Open reduction and internal fixation of both components with plates and or screw fixation

3. outline • Epidemiology of Pediatric Fractures • Uniqueness of Children's bones • Child abuse/Neglect/ Non-accidental trauma (NAT) • Multiply injured Child • Principles of Management • Specific cases/Precautions

4. Introduction • over 40% of boys and 25% of girls sustain a fracture by 16 years of age1 • properties of the immature skeleton- these injuries have different characteristics, complications, and management than similar adult injuries • data from five large epidemiologic studies :distal forearm # most common (nearly 25% of 12,946 fractures), then clavicle # (over 8% of all children's fractures) • Mann et al. [5] reported of 2,650 long bone fractures in children, 30% involved the physis.

5. Properties of the immature skeleton • Plastic Deformation- most common in the forearm, particularly the ulna • Stress–strain curves for mature and immature bone. The increased strain of immature bone before failure represents plastic deformation.

7. Buckle (Torus) Fractures- most commonly occur at transition between metaphyseal woven bone and the lamellar bone of the diaphyseal cortex

8. 3. Greenstick Fractures - immature bone is more flexible and has a thicker periosteum than mature adult bone Reduction: “unlock” the impacted fragments on the tension side by initially exaggerating the deformity and then applying traction and a reducing force stable after reduction but have an increased likelihood of refracture immobilize these fractures for a full 6 weeks

10. 4. Remodeling/Overgrowth -fractures heal more rapidly than those in adults, but once healed, they remodel residual deformity Factors affecting remodellong potential: • amount of growth remaining (the patient's skeletal age) • the plane of the deformity in relation to adjacent joints • the deformity's proximity to the physis and • the growth potential of the particular physis

12. 5. Potential for accelerated growth of an injured limb -most frequently seen in diaphyseal femoral fractures.(spontaneously correctting shortening of up to 2 cm) Theories ascribe this to hyperemia

14. 6. PhysealInjuries • 15% to 30% of all fractures in children • peak in adolescents • growth deformity is rare, occurring in only 1% to 10% of all physeal injuries.

15. Most injuries occur just above area of provisional calcification within the hypertrophic zone. Germinal layer frequently remains intact and attached to the epiphysis Physeal anatomy

16. CLASSIFICATION OF PHYSEAL INJURIES

18. Goal in treating physeal fractures • to achieve and maintain an acceptable reduction without subjecting the germinal layer of the physis to any further damage. • determining the limits of an acceptable reduction • Because of the intra-articular component, displaced type III and IV injuries must be reduced regardless of the time that has elapsed since the injury • reduction can be maintained with a cast, pins, internal fixation, or some combination of these three

19. COMPLICATIONS OF PHYSEAL INJURIES • malunion, • infection, • neurovascular problems, • Osteonecrosis • Growth Disturbance

20. Care of the Multiply Injured Child • Blunt trauma -leading cause of death in children older than 1 year of age • Children possess a number of anatomic and physiologic characteristics that make their injuries and their injury response different from adults'

21. Open Fractures • Incidence and mechanism of open fractures differ between children and adults • their management is similar, requiring an aggressive, thorough, and systematic approach • most common open fractures in children involve the hand and upper extremity • Open fractures of the lower extremities, esp tibia, are the result of higher-energy trauma, esp automobile–pedestrian or automobile–bicycle accidents

22. Gustilo and Anderson classification system • Type I • Wound <1 cm long • Moderately clean puncture wound • Usually “inside-out” injury • Little soft tissue damage, no crushing • Little comminution • Type II • Wound >1 cm long • No extensive tissue damage • Slight or moderate crush injury • Moderate comminution or contamination • Type III • Extensive soft tissue damage to muscles, skin, and neurovascular structures and a high degree of contamination • Three subtypes: • Adequate soft tissue coverage (includes high-energy segmental, comminuted fractures, regardless of normal size) • Local or free flap required for coverage • Arterial injury requiring repair

23. Open Fracture Management • Thorough assessment for life-threatening injuries • Immediate intravenous antibiotics, continue for 48 hours: • Grade I—first-generation cephalosporin • Grades II and III—first-generation cephalosporin + aminoglycoside • “Barnyard” injuries—add anaerobic coverage (penicillin or metronidazole) • Tetanus prophylaxis • Thorough operative debridement • Adequate fracture stabilization • Second operative debridement in 48-72 hours if indicated • Early definitive soft tissue coverage • Early bone grafting if indicated

24. Child Abuse/Nonaccidental trauma/Battered child syndrome • 1% to 1.5% of all children are abused each year • children are more likely to be abused by caregivers who are young, poor, and of minority status • Younger children are also more likely to die from abuse • After skin lesions, fractures are the second most common physical presentation • bone that fractures under tension with torsion • Femoral shaft, hands and feet fractures in nonambulatory infants

25. Fractures in unusual locations

26. Specific Fractures • Cervical spine injuries in children (1% of pediatric fractures and 2% of all spinal injuries ) • younger than 8 years age - upper cervical spine, • older children and adolescents - either the upper or lower C- spine • Pelvic fractures comprise less than 0.2% of all pediatric fractures • two most common classification systems used :Young and Burgess and Tile and Pennal

27. Torode and Zieg Classification of pelvic fractures in children

28. Hip Fractures: blood supply of the proximal femur comes from two major branches of the profunda femoris artery—the medial and lateral circumflex arteries • classified into four types based on the anatomic location of the fracture as described by Delbet • Type I: Transepiphyseal • Type II: Transcervical • Type III: Cervicotrochanteric • Type IV: Pertrochanteric or intertrochanteric

29. fractures about the Elbow • 5% to 10% of all fractures in children • distinguishing fractures from the six normal secondary ossification centers • (CRITOE)

31. Spinal Cord Injury Without Radiographic Abnormality(SCIWORA) • overwhelmingly found in children (15% to 35% of SCIs in children) • most, if not all, will have abnormal findings on MRI • spinal column is more elastic than the spinal cord • more common in children under 8 years of age than in older children • predisposing factors • cervical spine hypermobility, • ligamentous laxity, and • an immature vascular supply to the spinal cord

32. Pathologic fractures • May results from • Local causes: primary bone tumors, metastases , osteomyelitis, pronounced bowing of the bone (e.g. in crus varumcongenitum , which can then develop into congenital tibialpseudarthrosis) • Generalized causes: Osteogenesisimperfecta , Stuve-Wiedemannsyndrome , rickets , juvenile osteoporosis , storage disorders such as Gaucher disease .

33. Birth Injuries • Clavicle- commonest site, followed by the humerus and femur • Risk factors: Shoulder dystocia, high birth weight and gestational age • Proximal and distal humerus, distal femur: Epiphyseal separations due to birth trauma at best, suspected on an x-ray since the humeral head and distal end of the humerus and femur cartilaginous • confirmed sonographically

35. Treatment of fracturesin children • Closed treatment • majority of fractures treated by closed reduction and casting or traction • well-molded cast. • Open treatment • Open fractures. • Polytrauma. • Patients with head injuries. • Femoral fractures in adolescents. • Femoral neck fractures. • Certain types of forearm fractures. • Certain types of physeal injuries. • Fractures associated with burns.

36. Types of Fixation • Treatment of periarticular and articular fractures -3.5 mm cortex screws, 4.0 mm cancellous bone screws (exceptionally 6.5mm), and cannulated screws • epiphyseal and metaphyseal fragments- K-wire fixation • Transphyseal wires should be non-threaded • External fixation devices for patients with open fractures, polytrauma, and fractures associated with burns(great care exercised not to damage the growth plate)

37. Standard closed intramedullary nailing used in femoral shaft fractures in adolescents, in younger children the use of elastic titanium nails (TEN)

38. THE END