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The Multiply Injured Child: Musculoskeletal Aspects

The multiply injured child: Musculoskeletal aspects
Objectives
  1. Discuss priorities for imaging musculoskeletal injuries in the multiply injured child
  2. Discuss the indications for operative fixation of fractures in the multiply injured patient, and whether indications are altered from those for a patient with a single fracture
  3. Discuss the different methods of fixation available, and your indications for cast or splint, external fixation, intramedullary nailing, and plate fixation
  4. Describe the incidence of open fractures in the multiply injured child, and their management

Discussion points
  1. What are the differences in indications for rigid fixation of fractures in the child and adult?
  2. Are there any absolute indications for immediate fracture fixation in the multiply injured child?
  3. Is there a "golden period" for debriding open fractures? Can debridement safely be postponed under any circumstances?

Discussion
Multiply injured children are optimally managed at a pediatric trauma center or adult level 1 trauma center, where added expertise is available. In general, the neck should be considered as injured in an unconscious child until proven otherwise. In conscious and cooperative patients (Glasgow Coma Scale 14-15), clinical assessment of neck stability was found to be reliable without radiography. The common pseudosubluxation of C2-3 was found in 21% of multiply injured children and should be considered a normal variant. In children under 6, a special transport board should be used because the young child's head is proportionally larger in relation to the trunk, so standard boards will flex the neck. Fractures are not life threatening, so their assessment is secondary to measures necessary to manage head or visceral trauma. If the child is unconscious, the neck should be splinted during imaging studies of other systems, as should any obviously displaced fractures. With the ability of the child to undergo spinal cord injury without radiographic abnormality, MR scanning of the spine has been suggested for comatose children. Technetium scanning has been reported to be beneficial in discovering additional fractures in the multiply injured child. A pelvic fracture accompanied by another skeletal injury indicates serious injury. Femoral fractures account for almost 25% of fractures in the multiply injured child. Loder reported that operative stabilization of fractures less than 72 hours after injury resulted in a shorter hospital stay, a shorter intensive care stay, and less ventilatory assistance. Hedequist, however, found early stabilization of femoral fractures had no effect on the pulmonary complication rate. Recent suggests that mandatory debridement less than 8 hours after injury is not always necessary, and that outcome did not suffer from longer delays when other injuries delayed debridement. External fixation has been advocated either as a temporizing measure when fractures must be quickly stabilized, or for definitive management. Increased complications have also been reported with external fixation, especially in regard to delayed union or refracture.

The particular type of fixation for a given fracture is, for the most part, arguable. External fixation allows access to open wounds, but can be cumbersome and suffer pin tract problems. Union can be delayed if the fracture is distracted. Plate fixation allows primary closure, is reliable for fixation, but can predispose to leg length discrepancy in the femur, requires additional dissection, and has a small but definite risk of complication. In a small series of patients aged 8-12, excellent results were reported. Casting or splinting require repeated careful assessment in non-responsive patients to avoid pressure complications or compartment syndrome. Rigid intramedullary nailing must avoid growth plates, and especially, the piriformis fossa of the femur, to avoid the possibility of avascular necrosis of the proximal femur. Flexible intramedullary nailing is safe, but does not impart rigid fixation. K wires have been used as lower cost flexible intramedullary rods (Qidwai). A study suggesting that multiply injured children without head injury may not receive the rehabilitation necessary to achieve optimum functional recovery (Aitken).

References
  1. Aitken ME, Jaffe KM, DiScala C, Rivara FP. Functional outcome in children with multiple trauma without significant head injury. Archives of Physical Medicine & Rehabilitation 1999; 80( 8): 889-95.
  2. Armstrong PF. Initial management of the multiply injured child. Instruct Course Lect 1992; 41: 347-50.
  3. Bennek J. The use of upper limb external fixation in paediatric trauma. Injury 2000; 31( Suppl 1): 21-6.
  4. Curran C, Dietrich AM, Bowman MJ, Ginn-Pease ME, King DR, Kosnik E. Pediatric cervical-spine immobilization: achieving neutral position? Journal of Trauma-Injury Infection & Critical Care 1995; 39( 4): 729-32.
  5. Ferguson J, Beattie TF. Occult spinal cord injury in traumatized children. Injury 1993; 24( 2): 83-4.
  6. Fyodorov I, Sturm PF, Robertson WW, Jr. Compression-plate fixation of femoral shaft fractures in children aged 8 to 12 years. Journal of Pediatric Orthopedics 1999; 19( 5): 578-81.
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  8. Hedequist D, Starr AJ, Wilson P, Walker J. Early versus delayed stabilization of pediatric femur fractures: analysis of 387 patients. Journal of Orthopaedic Trauma 1999; 13( 7): 490-3.
  9. Heinrich SD, Gallagher D, Harris M, Nadell JM. Undiagnosed fractures in severly injured children and young adults. identification with technetium scanning. J Bone Joint Surg (Am) 1994; 76( 561-72).
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  11. Hutchins CM, Sponseller PD, Sturm P, Mosquero R. Open femur fractures in children: treatment, complications, and results. Journal of Pediatric Orthopedics 2000; 20( 2): 183-8.
  12. Kregor PJ, Song KM, Routt ML, Jr., Sangeorzan BJ, Liddell RM, hansen ST, Jr. Plate fixation of femoral shaft fractures in multiply injured children. J Bone Joint Surg( Am) 1993; 75: 1774-80.
  13. Loder RT. Pediatric polytrauma: Orthopaedic care and hospital course. J orthop Trauma 1987; 1: 48-54.
  14. Qidwai SA, Khattak ZK. Treatment of femoral shaft fractures in children by intramedullary Kirschner wires. Journal of Trauma-Injury Infection & Critical Care 2000; 48( 2): 256-9.
  15. Shaw M, Burnett H, Wilson A, Chan O. Pseudosubluxation of C2 on C3 in polytraumatized children--prevalence and significance. Clinical Radiology 1999; 54( 6): 377-80.
  16. Skaggs DL, Kautz SM, Kay RM, Tolo VT. Effect of delay of surgical treatment on rate of infection in open fractures in children. Journal of Pediatric Orthopedics 2000; 20( 1): 19-22.
  17. Tolo VT. External fixation in multiply injured children. Ortho Clin North Am 1990; 21: 393-400.
  18. Vasquez WD, Garcia VF. Pediatric pelvic fractures combined with an additional skeletal injury is an indicator of significant injury. Surg Gynecol Obstet 1993; 177: 468-72.

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