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Managing Pediatric Orthopedic Trauma Emergencies When is it not “Just a broken bone”. Stephen A. Mendelson M.D. Director of Orthopedic Trauma Children’s Hospital Of Pittsburgh of UPMC. Pediatric Orthopedic Trauma. Pediatric Orthopedic Trauma. Pediatric Orthopedic Trauma.

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Managing Pediatric Orthopedic Trauma Emergencies When is it not “Just a broken bone”


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    1. Managing Pediatric Orthopedic Trauma EmergenciesWhen is it not “Just a broken bone” Stephen A. Mendelson M.D. Director of Orthopedic Trauma Children’s Hospital Of Pittsburgh of UPMC

    2. Pediatric Orthopedic Trauma

    3. Pediatric Orthopedic Trauma

    4. Pediatric Orthopedic Trauma

    5. Pediatric Orthopedic Trauma

    6. Pediatric Orthopedic Truama

    7. Pediatric Orthopedic TraumaNonaccidental Injury

    8. Pediatric Orthopedic Trauma • 20-30% Trauma patients have orthopedic injury. • 55% of Nonaccidental patients have musculoskeletal injury • As many as 1/3 ER visits related to accidents or injuries

    9. Broken Finger Pelvic Facture Orthopedic TraumaSimple to Complex

    10. Factors Predicting Injury Severity and Outcomes • Injury Mechanism • High Impact • MVA • Fall from Height • Motorcycle and ATV • Low Impact • Ground Level Fall • Sports Accident

    11. Factors Predicting Injury Severity and Outcomes • Concurrent Injuries • Head Injury • Visceral Injuries • Burns • Soft Tissue

    12. Factors Predicting Injury Severity and Outcomes • Associated Injuries • Vascular • Neurologic

    13. Factors Predicting Injury Severity and Outcomes Comorbidities Systemic Musculoskeletal

    14. Orthopedic EmergenciesThe Big Seven! • Open Fracture • Compartment syndrome • Vascular Compromise • Deteriorating Neurologic Exam • Acute Dislocation Major Joint • Femoral Neck fracture • Open or Septic Joints

    15. Open Fractures • Any fracture where the bone is exposed to the environment through a soft tissue defect. Graded I,II, III based on severity of soft tissue wound. • Require urgent cleansing and surgical debridement to prevent infection, and promote healing

    16. Open fracture

    17. Compartment syndrome • Soft tissue injury and subsequent swelling that exceeds the capacity of the fascial space or muscle compartment causing increasing pressure in the muscle compartment. Ultimately cutting off circulation and damaging the muscles and nerves

    18. Compartment Syndrome Symptoms and Signs • Pain • Out of proportion to injury • Pain with passive muscle stretch • Paresthesia • Pallor • Cool, mottled, loss of capillary refill • Pulselessness • Paralysis

    19. Compartment SyndromeDiagnosis and Treatment • Physical exam • Most reliable in awake patient • Compartment pressure measurements • FASCIOTOMY!!!

    20. Fasciotomy

    21. Fractures with associated vascular Compromise • Immediate vascular insufficiency • Reduce (align) fracture • If vascular perfusion not restored explore, repair or consult • Initial pulse lost aster reduction • Vessel caught in fracture site. Explore, repair or consult

    22. Vascular Injuries

    23. Deteriorating Neurologic Exam • Static Neurologic Deficit • Can observe or explore at time of fracture treatment • Deteriorating Neurologic Deficit • Nerve compressed, stretched or entrapped • Reduce fracture and explore nerve before permanent damage

    24. Common Nerve Injuries

    25. Femoral Neck Fractures • Blood supply to femoral head very tenuous • Prolonged loss of blood to femoral head causes permanent damage … Avascular Necrosis (AVN) • Emergent reduction and stabilization reduces risk of AVN

    26. Pediatric Femoral Neck Fractures

    27. Avascular Necrosis

    28. Shoulder Elbow Hip Knee Ankle Dislocations

    29. Open Joint

    30. Common orthopedic injuries that are not as urgent as the look (Or The surgeon may say they are to get into the OR quicker)

    31. Badly Displaced fractures

    32. Growth Plate Fracture Salter Harris Classification

    33. Salter Harris 1

    34. Salter Harris 2

    35. Salter Harris 3

    36. Salter Harris 4

    37. Intraarticular fractures

    38. Static Neurologic deficit • Nerve Palsey • Complete Spinal Cord Injury

    39. Other Orthopedic considerations

    40. Child Abuse • >50% long bone fractures in nonambulatory children. • 20% Recurrence Rate. • 1-5% Mortality.

    41. Child abuse fracture Patterns

    42. Polytrauma • ARDS • Shock • Fat Emboli

    43. Multidisciplinary Approach • Paramedics and Transport • Emergency Room • Trauma Service • Intensives Care Unit • Neurosurgery • Orthopedics

    44. Damage Control OrthopedicsProvisional Stabilization During Resuscitation period

    45. Summery • Orthopedic trauma can very from simple sprains strains and minor fractures to major multisystem polytrauma. • Recognition of orthopedic emergencies and urgencies can help triage and manage the care of all patients in a trauma center setting. • Orthopedic injuries are common, recognizing the common pitfalls is critical to avoiding serious complications. • A team approach is best!!!!!!!!

    46. Thank You!