Paediatric Major Trauma Research Articles

Management of Subtrochanteric Fractures in Skeletally Immature Adolescents

There have been no studies that have specifically looked at the management of subtrochanteric femoral fractures in skeletally immature adolescents. It was the purpose of this study to investigate the treatment of this injury in this unique patient population. A retrospective review of all subtrochanteric femoral fractures treated at a major pediatric trauma center since 1990 was performed. There were 13 adolescents with an average age of 13 years and 6 months. The average length of follow-up was 2 years and 3 months. Eight of the 10 operatively treated patients had a satisfactory result, whereas the outcome was unsatisfactory in all three patients treated nonoperatively. Complications included three limb-length discrepancies, one case of avascular necrosis of the femoral head, one transient peroneal nerve palsy, and one case of asymptomatic heterotopic ossification. At the time of most recent follow up, all had returned to preinjury level of function. Operative treatment provided more satisfactory results than nonoperative methods.

Commentary to: The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients

The paper by Smith et al. adds to the growing evidence that intraosseous (IO) lines are a useful tool in the management of the severely traumatised child. Much of the evidence for the use of IO lines has come from the resuscitation of children in cardiac arrest from medical causes, and the addition of this large UK series for trauma patients enhances our knowledge and experience of the technique.

The usefulness of a modified adult protocol for the clearance of paediatric cervical spine injury in the emergency department.

To determine if the use of a modified adult protocol that uses cervical spine imaging on presentation for the assessment of cervical spine injury in children improves clinical outcome. This is a case series study on all consecutive trauma patients presenting from April to July 2000 inclusive to the ED of a major paediatric trauma hospital. Children presenting to the ED with potential cervical spine injury (CSI) were identified using standard selection criteria. Patient demographics, mechanism of injury, method and time of presentation, associated injuries, radiological investigation and clinical outcome were recorded. The major outcome measures for this study were: time to clearance of the cervical spine, length of stay in the ED and admission to an in-hospital bed. Data were analysed for compliance to the protocol, this being the standard assessment pathway of cervical spine clearance used by our trauma service. The trauma registry identified 1721 trauma presentations during the 4-month study period; 208 presentations representing 200 children with potential CSI were entered into the study. Males represented 72.5% of the study population, having a mean age of 8.32 years, although 29% were less than 5 years of age. The majority of presentations (69%) occurred outside of normal working hours. In 17.8% of cases the cervical spine was cleared based on clinical assessment alone, half less than 5 years of age. Compliance to the protocol occurred in 78% of presentations. However, when examined by age group, children 5 years of age or above were 1.5 times more likely to comply with the protocol as compared with younger children. Adequate plain imaging was not obtained in 18% of presentations, this group almost exclusively less than 5 years of age. There were no missed injuries and no short or long-term neurological sequelae reported during this study. There were no differences in time to clearance, length of stay and admission rate between compliant and non-compliant groups. Modified adult protocols for cervical spine clearance offer guidance in managing the majority of children suffering blunt trauma. However, we recommend caution in rigidly applying such protocols, especially to children of young age.

Complications of rigid intramedullary rodding of femoral shaft fractures in children.

Intramedullary rodding of femoral shaft fractures has been frequently performed in adults, but until recently rarely in children. It was the purpose of this study to investigate the experience with this treatment method at a pediatric trauma center. From 1987 to 1998, 54 children were treated for traumatic femoral fractures with intramedullary rods at a major pediatric trauma center. The average age was 15 years 3 months, ranging between 11 years 4 months and 17 years 11 months. The average follow-up was 5 years 3 months, ranging from 20 months to 10 years 1 month. All of the fractures occurred secondary to trauma and the most common anatomic fracture site was the femoral midshaft. Complications encountered included 8 instances of minor limb length discrepancy, 11 instances of discomfort because of rod prominence, 1 case of avascular necrosis of the femoral head, 2 instances of heterotopic ossification over the rod tip, 1 broken rod, and 3 cases that demonstrated decreased external rotation of the affected limb. One child developed osteomyelitis after intramedullary rodding for a fracture previously treated with external fixation. There were no cases of surgically induced nonunion or malunion and only one delayed union secondary to infection. Results of this series demonstrate intramedullary rodding to be an effective treatment modality for femoral fractures in skeletally mature children. In children with open femoral physes, rigid rodding should be avoided because of the small but serious occurrence of avascular necrosis of the femoral head. Intramedullary rodding is not recommended in children initially treated with external fixation because of the increased risk of infection.

Partial Sleeve Fractures of the Tibia in Children: An Unusual Fracture Pattern

Sleeve avulsion fractures of the patella are a well-recognized fracture pattern in children. Less appreciated is a similar fracture pattern involving the anterior metaphyseal area of the tibia. These metaphyseal sleeve fractures represent a fracture pattern characterized by the avulsion of a large area of periosteal attachment of the patellar tendon associated with small subchondral fragments of bone, encountered in skeletally immature children secondary to contraction of the quadriceps associated with forced knee flexion. Although an avulsion fracture of the tibial tubercle is the usual result of this type of trauma, partial sleeve avulsion fractures of the tibial apophysis and adjacent metaphysis occasionally occur and have not been adequately described. It was the authors' purpose to describe their experience with this fracture pattern. Since 1998, three boys have presented to a major pediatric trauma center with a partial sleeve fracture of the tibia. The average age was 13 years 6 months (range 10 years 3 months to 15 years 3 months). Follow-up ranged from 1 year 5 months to 2 years 3 months, with an average of 1 year 9 months. All three boys were treated with open reduction and internal fixation with small cancellous screws and postoperative plaster immobilization. At the time of most recent follow-up, each child showed full range of knee motion and had returned to all sports activities.

Current trends in the management of major paediatric trauma.

See Commentary, page 405.

Titanium Elastic Nails for Pediatric Femur Fractures: A Multicenter Study of Early Results with Analysis of Complications

Titanium elastic nailing is used instead of traction and casting in many European centers, but limited availability has prevented widespread use in North America. Before a planned general release in America, titanium elastic nails (TENs) were trialed at several major pediatric trauma centers. This multicenter study is a critical analysis of early results and complications of the initial experience. Overall, TENs allowed rapid mobilization with few complications. The results were excellent or satisfactory in 57 of the 58 cases. No child lost rotational alignment in the postoperative period. Irritation of the soft tissue near the knee by the nail tip occurred in four patients, leading to a deeper infection in two cases. As indications, implantation technique, and aftercare are refined, TENs may prove to be the ideal implant to stabilize many pediatric femur fractures, avoiding the prolonged immobilization and complications of traction and spica casting.

Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications.

Titanium elastic nailing is used instead of traction and casting in many European centers, but limited availability has prevented widespread use in North America. Before a planned general release in America, titanium elastic nails (TENs) were trialed at several major pediatric trauma centers. This multicenter study is a critical analysis of early results and complications of the initial experience. Overall, TENs allowed rapid mobilization with few complications. The results were excellent or satisfactory in 57 of the 58 cases. No child lost rotational alignment in the postoperative period. Irritation of the soft tissue near the knee by the nail tip occurred in four patients, leading to a deeper infection in two cases. As indications, implantation technique, and aftercare are refined, TENs may prove to be the ideal implant to stabilize many pediatric femur fractures, avoiding the prolonged immobilization and complications of traction and spica casting.

Major pediatric hand trauma associated with fireworks.

To characterize the injury pattern and economic impact of major pediatric hand trauma secondary to fireworks. Retrospective. Pediatric Level I trauma center. N/A MAIN OUTCOME MEASUREMENTS: Fractures, amputations, soft tissue defects, length of hospitalization, number and type of procedures performed were obtained from charts, radiographs, and operative reports. Hospital charges were obtained from the billing office. Records of patients with a diagnosis of fireworks-related injuries admitted over a period of ten years were reviewed. Twenty-two patients were identified to have sustained twenty-two hand injuries. The group consisted of nineteen boys and three girls, with an average age of 9.3 years (range, 4 to 17 years). There were thirty-one fractures, nineteen amputations, and one dislocation. The nineteen amputations occurred in nine hands. Local skin graft or flap coverage was required in six hands acutely, and delayed soft tissue procedures were performed on four hands. Four hands had digital neurovascular injuries; two required microsurgical repairs at the time of injury, and two were irreparable. Resource use included: average hospital stay of 4.3 days (range, 0 to 20), average number of trips to the operating room, 1.2 (range, 0 to 3), and average hospital charges of $11,582 (range, $1,035 to $39,489). This study illustrates the severity of pediatric hand injuries associated with fireworks and the significant burden placed on medical resources in treating these injuries. Efforts toward public education and legislative reforms may help to prevent these unnecessary injuries.

Prehospital Triage in the Injured Pediatric Patient

Identifying major trauma patients in the prehospital setting is essential in determining management, destination, and best utilization of emergency department resources. Few methods of trauma triage have been accepted unanimously. This study prospectively evaluates the efficacy of comprehensive field triage using 12 criteria (simplified version of the American College of Surgeon's guidelines) in 1,285 pediatric trauma patients. Major trauma was defined as occurring in those who died in the emergency room, had major surgery (penetrating injury involving surgery of the head, neck, chest, abdomen, or groin), or were admitted directly to the intensive care unit. The correlation between trauma triage criteria, hospital disposition, and triage accuracy were determined prospectively and compared in the pediatric patients (36 months) with an adult cohort of patients (12 months). A total of 1,285 pediatric trauma patients were evaluated and compared with 1,326 adult trauma patients. The most accurate trauma triage criterion for major injury was a blood pressure < or = 90 mmHg (systolic) with an accuracy of 86%. This was followed by burn greater than 15% total body surface area (79%), Glasgow Coma Scale score < or = 12 (78%), respiratory rate less than 10/min or greater than 29/min (73%), and paralysis (50%). Less accurate criteria included a fall from greater than 20 feet (33%); penetrating injury to head, neck, chest, abdomen, or groin (29%); ejection from vehicle (24%); pedestrian struck at greater than 20 mph (16%); paramedic judgement (12%); rollover (3%); and extrication (0%). The Glasgow Coma Scale score was a more accurate indicator of major injury in children than adults, and paramedic judgement was less accurate in children when compared with adults. Of the 379 major pediatric trauma victims, the Revised Trauma Score and Pediatric Trauma Score missed 36% and 45% of these major trauma victims, respectively. The overtriage rate for children was 71% with a sensitivity of 100% (no missed major trauma patients). Physiological variables, anatomic site, and mechanism of injury provide a sensitive and safe system of triage. Continued education of prehospital personnel regarding pediatric trauma and stratification of the current triage tools are necessary to minimize overtriage in an era of shrinking resources.

Injuries caused by water tubing.

Water tubing (the pulling of an inner tube behind a power boat) is growing in popularity and unfortunately is becoming an increasing source of pediatric trauma. This is related to the lack of control of either the driver or the rider in directing the inner tube away from objects in the water or along the shore. Because of the severe trauma from this increasingly popular sport, we thought it appropriate to review our experience at a major pediatric trauma center to draw attention to this increasing cause of injury in children and to develop guidelines to reduce such injuries. A retrospective review of children admitted over a 10-year period revealed eight children who required admission to hospital for injuries sustained in water tubing. Five patients sustained fractures, one a splenic contusion, and two atlantoaxial rotatory subluxation. A set of safety guidelines for water tubing has been developed in an attempt to minimize the dangers to children who wish to pursue this sport.

Fractures of the Capitellum in Adolescents

Fractures of the capitellum are rare in children. The treatment of these injuries has been controversial. At a major pediatric trauma center, seven capitellar fractures were seen in children between 1988 and 1994. The average age of the children was 14.7 years (range, 11-17). Six of these fractures were type I injuries, with large anterosuperior fragments that required operative reduction and internal fixation in five cases. Internal fixation methods used were K wires in three patients, Herbert screws in one patient, and cannulated screws in one patient. The remaining type I fracture was treated with a closed reduction. The seventh fracture was a type II fracture, treated nonoperatively. Five children did well with their respective treatments, but one required reoperation to remove an exostosis block to flexion. Accurate open reduction and internal fixation for the displaced capitellar fracture in children is an effective treatment to restore normal elbow function.

Use of resuscitation skills by paramedics caring for critically injured children in oregon

Objectives. 1) To perform a statewide analysis of the frequency of major pediatric trauma cases and the use of resuscitation skills by paramedics (EMT-Ps). 2) To determine whether EMT-Ps use resuscitation skills less frequently for injured children than for older patients.Methods. Study Design: Retrospective, database analysis of major trauma cases. Setting and Population: 1995 statewide trauma registry data for patients with EMT-P scene care.Observations. The database included patient demographics, field vital signs, field procedures [e.g., intravenous (IV) line placement, chest compressions, needle thoracostomy, endotracheal intubation], field medication, and vital signs at ED presentation. Data Analysis: Patients aged ≤ 12 years (“pediatric”) were compared with those aged >12 years (“older”). Analyses of patients with tachycardia, hypotension, and obtundation were performed using χ2 analysis (α = 0.05).Results. Of 3,502 trauma patients managed by an EMT-P, only 297 (8%) were aged ≤ 12 years. Fewer pediatric patients (18%) than adults (27%) had an injury severity scale score ≤ 16, p < 0.005. The frequency of most resuscitation skills and the administration of medications were not statistically different between patient groups. However, IVs were four times more likely to be placed in adults (76%) than in pediatric patients (42%), p < 0.001. Subanalyses indicated fewer pediatric patients with tachycardia (p = 0.02) or hypotension (p = 0.02) received an IV, compared with adults who had similar physiologic parameters. Obtunded patients were equally likely to receive endotracheal intubation, although the procedure was rarely used (20%).Conclusions. EMT-Ps infrequently manage seriously injured children. IVs are less frequently placed in pediatric trauma patients, even in the setting of physiologic abnormalities. The contributions of these field procedures to patient outcomes should be evaluated further.

Evaluating the effectiveness of a pediatric trauma educational program in Central America.

To evaluate the effectiveness of a pediatric trauma course taught in a developing country. A pediatric trauma course was designed with didactic presentations and reinforced with small group case discussions. Subjects included a general trauma overview, head trauma, airway/chest trauma, cervical spine trauma, abdominal trauma, shock, burns, and orthopedic injuries. Evaluation consisted of a pre- and post-course test and questionnaire assessing the participants' knowledge and level of comfort in managing trauma. Nine months after the course, the participants were evaluated with the same post-course test. Also a questionnaire was given to physician and nurse co-workers from the participating institutions, who themselves had not participated in the course, to assess the perceptual and attitudinal impact of the pediatric trauma course. Guatemala City, Guatemala. Forty-three physicians from Central America. Initial and nine-month post-test scores showed uniform improvement (P value < 0.05) when compared to pretest results using the Wilcoxon signed-ranks test. Analysis of the pre- and post-course questionnaires indicated that all participants felt more comfortable (scale 1 to 5) after the course managing pediatric trauma patients. All participants "strongly agreed" the course provided information that would improve their management of the pediatric trauma victim. Nine months after the course, 100% of their medical co-workers perceived physicians who participated in the pediatric trauma course to have better resuscitative skills, and 92% perceived these physicians to have a higher level of confidence. This course, when presented to physicians in a developing country, appears to be effective in improving their knowledge base regarding pediatric trauma and increasing their comfort level in managing major pediatric trauma.

Radiographic Assessment of Renal Trauma

We sought to evaluate the continuing validity of our criteria for radiographic imaging of renal injuries, that is penetrating flank or abdominal trauma, blunt trauma with gross hematuria or microscopic hematuria and shock, deceleration or major associated abdominal injury and pediatric renal trauma. We reviewed the records of 2,254 patients who presented to our institution with suspected renal trauma between 1977 and 1992. Of the 1,588 blunt trauma patients with microscopic hematuria and no shock 3 had significant injury but these cases were discovered during imaging or exploratory laparotomy for associated injuries. Followup in 515 of 1,004 patients (51%) who did not undergo initial imaging revealed no significant complications. Adults with blunt renal trauma, microscopic hematuria and no shock or major associated intra-abdominal injuries can safely be spared radiographic imaging.

Radiographic Assessment of Renal Trauma: Our 15-year Experience

Purpose We sought to evaluate the continuing validity of our criteria for radiographic imaging of renal injuries, that is penetrating flank or abdominal trauma, blunt trauma with gross hematuria or microscopic hematuria and shock, deceleration or major associated abdominal injury and pediatric renal trauma. Materials and Methods We reviewed the records of 2,254 patients who presented to our institution with suspected renal trauma between 1977 and 1992. Results Of the 1,588 blunt trauma patients with microscopic hematuria and no shock 3 had significant injury but these cases were discovered during imaging or exploratory laparotomy for associated injuries. Followup in 515 of 1,004 patients (51 percent) who did not undergo initial imaging revealed no significant complications. Conclusions Adults with blunt renal trauma, microscopic hematuria and no shock or major associated intra-abdominal injuries can safely be spared radiographic imaging.

Nonoperative management of blunt pediatric major renal trauma

Although algorithms exist for the management of renal trauma in adults, guidelines have not been established in children. Of 1,175 patients entered into our Trauma Registry between 1987 and 1991, 61 (5.2%) presented with gross or microscopic hematuria. Eight of the 58 patients (13.8%) who had blunt abdominal trauma had major renal injuries. Gross hematuria (n = 10) was a significant predictor of major renal injury (n = 5) (p < 0.001). All 3 patients with microscopic hematuria and a major renal injury also had evidence of multisystem trauma. Admission blood pressure, hemoglobin, and trauma score were not predictors of major renal trauma. All cases were managed nonoperatively except for 1 patient who required a partial nephrectomy for continued hemorrhage. These data suggest that hematuria of any degree should be evaluated in the pediatric population, since major injuries can occur with even microscopic hematuria or in the absence of shock. Nonoperative management in this series resulted in no morbidity or delayed complications and suggests that surgical exploration be reserved for ongoing bleeding.

Chapter 17 Anesthetic Considerations for Major Pediatric Trauma

Chapter 17 Anesthetic Considerations for Major Pediatric Trauma