Courtesy: Nirav Pandya, Associate Prof, UCSF, California, USA

Epidemiology

Trauma

• Accounts for approximately 60 percent of pediatric deaths.
• One in four children experiences trauma.
• About 76 percent of polytrauma patients have associated orthopedic injuries.
• High velocity injuries and adult type trauma patterns are becoming more common.

Most Important Injury

Neurologic injury

• Traumatic brain injury is the main determinant of outcome.
• Approximately 30 percent develop residual neurological deficits.
• Close collaboration with neurosurgery is essential.

Children Are Not Small Adults

Physiological differences

• Hypotension is a late sign of shock and usually occurs only after more than 25 percent blood loss.
• Tachycardia is a more reliable early indicator of hypovolemia.
• The head is proportionally larger and the neck is shorter, requiring an occipital cutout during cervical immobilization.
• The flexible cervical spine increases the risk of spinal cord injury without radiographic abnormality (SCIWORA).
• Avoid proximal tibial traction pins because of the risk of physeal arrest and genu recurvatum.
• Distal femoral traction pins are preferred.

Pediatric Versus Adult Polytrauma

Children

• Organ failure occurs early.
• Multiple organ systems are affected simultaneously.
• Lower systemic inflammatory response.
• Better local healing potential.
• Lung injury is less common.
• Mortality is more often due to solid organ injury.

Adults

• Organ failure usually develops after 48 to 72 hours.
• Organ failure occurs sequentially.
• Greater systemic inflammatory response.
• Poorer healing potential.
• Lung injury is more common.
• Mortality is often related to pelvic hemorrhage.

Timing of Fracture Fixation

Early fixation is preferred in children.

Benefits

• Earlier mobilization.
• Reduced intensive care stay.
• Reduced ventilator requirement.
• Fewer complications related to prolonged immobilization.
• Improved overall outcomes.

Orthopedic Management

Treatment principles

• More aggressive fixation is often appropriate.
• Surgical fixation may be indicated even for fractures usually treated conservatively.

Examples

• Bilateral femoral fractures.
• Combined limb injuries.
• Upper limb injuries that delay mobilization.

Open Fractures

Key principle

• Early administration of antibiotics is more important than the exact timing of surgical debridement.

Management

• Administer antibiotics immediately in the emergency department.
• Always evaluate for associated abdominal, genitourinary, and brain injuries after high energy trauma.

Soft Tissue Management

Treatment options

• Vacuum assisted closure (VAC).
• Split thickness skin graft.
• Rotational flap.
• Free flap reconstruction with better success in children older than 2 years.

Pediatric Pelvic Fractures

General features

• Rare, accounting for approximately 1 to 2 percent of pediatric fractures.
• Commonly associated with other major injuries.
• Cause less hemorrhage than adult pelvic fractures.

Mortality

• Usually related to associated solid organ injury rather than pelvic bleeding.

Classification

Open triradiate cartilage

• Iliac wing fractures occur more commonly.
• Pelvic ring disruption is less frequent.

Closed triradiate cartilage

• Adult type pelvic ring injuries.
• Greater pelvic instability.

Indications for Surgery

Operate when displacement exceeds 2 cm.

Reasons

• Poor remodeling potential, especially at the posterior sacroiliac region.
• Prevents limb length discrepancy.
• Reduces chronic pain.
• Minimizes neurological complications.

Pediatric Acetabular Fractures

Features

• Most are managed nonoperatively.
• Always assess for triradiate cartilage injury.

Complications

• Growth arrest.
• Acetabular dysplasia.
• Late hip subluxation.
• Greater risk in children younger than 10 years.

Indications for surgery

• Displacement greater than 2 mm.
• Joint incongruity.
• Hip instability or fracture dislocation.

Follow Up

Importance

• Long term follow up is essential, even after apparently minor injuries.

Late complications

• Hip pain.
• Acetabular dysplasia.

Exam Pearls

• Tachycardia is a more reliable early sign of shock than hypotension.
• Early fracture fixation is preferred in pediatric polytrauma.
• Early antibiotics are more important than the timing of debridement in open fractures.
• Neurological injury is the most important prognostic factor.
• Pelvic fractures rarely cause death in children.
• Triradiate cartilage injury may result in acetabular dysplasia.
• Pelvic fractures with more than 2 cm displacement generally require surgical fixation.