Pediatric Polytrauma

Key Points:

  • Trauma is the leading cause of death in the United States for children between the ages of 1 and 14.
  • Critical differences in the physiologic effects of multi-system injury exist between children and adults.
  • The orthopedist’s role in managing hemodynamic instability, vascular insult, and neurologic damage is essential. 
  • Unlike patients who present with isolated injuries, operative indications and postoperative immobilization differ in the multiply injured pediatric patient.
  • Early fracture stabilization is important in managing children with polytrauma and open fractures to protect soft tissues, reduce pain and facilitate rehabilitation.

Description:

Trauma is the leading cause of death in the United States for children between the ages of 1 and 14 and costs our society more than 81 billion dollars per year. (Danseco, 2000) With nearly 63% of pediatric polytrauma patients presenting with extremity fractures, the role of the orthopaedic surgeon in managing these patients is critical. (Loder, 1987) Although rarely a cause of mortality, orthopaedic injuries in these patients can cause long-term morbidity. (Demetrediase, 2003)

Epidemiology:

Clinical Findings:

Etiology:

Treatment:

Complications:

Initial Assessment:

The care of the pediatric polytrauma patients begins with the principles of Pediatric Advanced Life Support (PALS) and Advanced Trauma Life Supports (ATLS).  The primary aim of the initial resuscitation is to prevent acidosis, hypothermia, and coagulopathy.   Perfusion maintenance via large bore intravenous access is critical with intra-osseous infusion utilized as needed (in the proximal tibia below the tibial tuberosity to prevent physeal damage). (Guy, 1993) From a physiologic standpoint, children do not develop hypotension until nearly 25% of their blood volume is lost.  The heart rate, therefore, should be carefully monitored. 

Cervical spine stabilization with the appropriate head board that has a cervical cut-out is essential, along with splinting of affected extremities. (Herzenberg, 1989) Care must be taken to assess for orthopaedic injuries during tertiary exams as injuries can often be missed.  The importance of this initial emergency room assessment and stabilization of pediatric patients is paramount.  Courville et al. examined 224,628 pediatric patients who were admitted to the hospital, and found that the risk of in-hospital mortality was most related to their initial presentation in the emergency room including the Glasgow Coma Scale score at presentation and systolic blood pressure. (Courville, 2009)  
Furthermore, the need for these patients to present to pediatric-specific trauma centers has been well documented.  Oyentunji et al. reviewed the National Trauma Data Bank with 53,702 children, and found that the odds of mortality were 20% less at pediatric trauma centers compared to adult trauma centers for pediatric patients. (Oyetunji, 2011) An understanding of the differences between adult and pediatric physiologic responses to trauma, particularly for the orthopaedic surgeon attempting to manage their injuries is essential.

Systemic Response to Trauma:

Organ system injury in adult trauma patients leads to a cascade of inflammatory activation (i.e. TNF-alpha, IL-1,2,4,6,10) resulting in endothelial permeability, interstitial edema, intravascular occlusion, micro-vascular ischemia, and eventual organ failure. (Rankin, 2004) Studies examining cytokine levels in the pediatric trauma patient unfortunately do not exist.  What is known is that the rate and overall pattern of multi-organ system failure is actually quite different in the pediatric population due to different physiologies.  Calkins et al. examined 534 children with Injury Severity Scores (ISS) greater than 15, and found that the rate of multi-organ failure in those who survived greater than 24 hours was only 3%. (Calkins 2002)  This is in contrast to the adult population which has a rate of multi-organ failure ranging from 19% to 40%.(Sauaia, 1998)

Furthermore, if multi-organ system failure does occur, the timing in a pediatric trauma patient is much different.  Failure in children occurs earlier during resuscitation and affects all organs almost simultaneously, whereas adult organ failure occurs sequentially starting with the lungs and begins 48 hours after injury.  In addition, the rate of acute lung injury has been found to be almost six times lower in children compared to adults who experience trauma. (Wilkinson, 1986)  

The pediatric physiologic response is characterized by a dampened systemic inflammatory response with a robust inflammatory response at the tissue level, allowing for tissue repair at the local level with less systemic damage as a by-product. Since appropriate pre-operative pulmonary status is maintained more often in children in the acute phase of trauma, as long as adequate resuscitation is achieved, pediatric patients can potentially undergo fixation during the early period of multi-system insult due to a lower risk of sequential and prolonged organ failure.

Conversely, adult polytrauma physiology has shifted from early definitive care of orthopaedic injuries to an approach where fractures are not stabilized until completion of proper resuscitation 48 – 72 hours after the initial injury.  This “damage control” orthopedics approach has been shown to lower rates of multiple organ failure, severe systemic inflammatory response, and acute respiratory distress syndrome. (Pape, 2002) Though the orthopedic trauma community recognizes the importance of timing of fracture fixation in the adult polytrauma patient, few studies have focused on the effect of fracture stabilization in the pediatric population. 

A retrospective review of 387 pediatric patients found that pulmonary complications were not influenced by the timing of femur fracture stabilization, but rather by the presence of severe head or spinal cord injury. (Hedequist, 1999) Another retrospective review of pediatric patients with closed head injury and femur fractures found that early treatment of the femur fractures  reduced the length of intensive care unit hospitalization by 4 days and the length of total hospital stay by 8 days. (Mendelson, 2001) Even with these retrospective studies and our understanding of pediatric polytrauma physiology, prospective trials are needed in the pediatric population to help inform decision-making regarding the timing of fracture stabilization and definitive fixation.

Non-Musculoskeletal System Injury:

Due to a more pliable, plastic bony skeleton, pediatric patients are less likely to suffer severe bony injuries (i.e. pelvic ring injuries) with a higher energy injury mechanism, but will rather have that energy transferred to other organ systems.  Demetriades et al. examined pelvic fractures from all trauma admissions at their institution over an eight-year period, and although adult and pediatric patients with pelvic fractures had the same percentage of solid organ injury (11.5%), death related to bleeding was only present (2.9%) in adults. (Demetriades, 2003)  Silber et al. examined 166 pediatric pelvic fractures and found that the morbidity from pelvic fractures in skeletally immature patients could more often be attributed to associated injuries rather than the pelvic fracture itself.(Silber 2001)  As a result of this structural difference during skeletal immaturity, the pelvic ring and thoracic cage is less able to “shield” the organs from trauma, and internal organ injury can occur in the pelvis and thorax without fractures in the supporting “ring.”

Furthermore, traumatic injury of the pediatric patient occurs over a smaller surface area and there is a greater likelihood of multiple organs being injured simultaneously due to their close proximity.  Injuries to the neurologic (closed head injury), abdominal (abdominal wall ecchymoses indicating splenic / intestinal injuries), genitourinary (bladder, urethral, renal damage from anterior pelvic ring injuries), and thoracic regions (rib fractures, hemothorax, pneumothorax), are commonplace, and may have the greatest impact on morbidity/mortality in these patients. (Bliss 2002)

It is important to note that multiple studies have demonstrated that neurologic injuries are the biggest factor causing continued morbidity and mortality in pediatric polytrauma patients.  Up to 22% of pediatric polytrauma patients have a severe brain injury with 44% of patients with a neurologic injury having cognitive impairments at ten year follow-up. (Schalamon, 2003)

Management of Non-Musculoskeletal Injury:

Hemodynamic Instability
In the pediatric polytrauma patient, the orthopaedist can play a critical role in managing the overall physiology of the patient, particularly as it relates to hemodynamic instability from the pelvic ring injury. Pelvic fracture patterns differ between skeletally immature and mature patients.  Immature patients with an open triradiate cartilage and Risser stage 0 have a higher proportion of iliac wing and pubic rami fractures, whereas skeletally mature patients have a higher proportion of “adult-type” acetabular fractures and sacroiliac diastasis. (Hauschild, 2008) Demetriades et al. found that while pediatric patients were less likely to suffer a pelvic injury after blunt trauma, the incidence of severe pelvic fractures was similar in both adult and pediatric populations. (Demetriades, 2003)  Only 1% of pediatric trauma patients require angiographic intervention after pelvic trauma. (Puapong, 2006) Although life-threatening hemorrhage from pelvic trauma is rare, more severe Tile type-C pelvic fractures in children may have higher transfusion and angiographic requirements.  Pelvic ring injury should be a marker of injury to other organ systems, and other sources of bleeding should be investigated. 

Adult trauma principles of pelvic fracture management still apply to pediatric patients.  Early stabilization with pelvic binders and external fixation may help decrease pelvic volume and blood loss.  Pelvic asymmetry and acetabular incongruence remodels poorly even in skeletally immature patients, supporting the use of minimally-invasive and open approaches for anatomic reduction of pelvic and acetabular fractures. (Smith, 2005)         
 
Vascular Injury
With compromised vascular perfusion to the extremities in the setting of a fracture and/or dislocation, a multidisciplinary team of pediatric trauma, vascular, and orthopaedic surgeons allows for optimal management of a threatened limb in the pediatric polytrauma patient.  Though vasospasm may occur more commonly in a pediatric patient, a thorough investigation of a limb-threatening vascular injury with physical examination, Doppler examination, and even angiography is paramount. Orthopaedic surgeons should efficiently perform temporary reduction and stabilization of fractures alongside definitive vascular reconstruction to allow for optimal recovery as in the adult population.
 
Neurologic Injury
While brain and spinal cord injury are the leading causes of long-term disability in pediatric polytrauma, children may experience a higher rate of neurologic recovery than adults.  Since most pediatric polytrauma patients survive their injury, orthopaedic injuries should be aggressively managed to allow the highest level of function and independence.  Coordination with a neurosurgery team is essential to determine the appropriate timing of fixation during the acute phase of a traumatic brain injury, particularly as it relates to intra-cranial pressure.

The obtunded pediatric patient presents a unique challenge in the diagnosis of compartment syndrome; earlier use of objective compartment measurements in high-risk injuries is recommended.  Even in the alert patient, the classic signs of compartment syndrome in the adult population have been shown to be unreliable in children.  Bae et al. examined 36 cases of compartment syndrome in children and found that increasing analgesia requirement was a more sensitive indicator for compartment syndrome in children than criteria used in adults. (Bae, 2001) 

This was further supported by the work of Flynn et al. (Flynn, 2011) Unfortunately, with an obtunded patient, increasing analgesia requirements cannot be utilized, and physical findings of “tight” compartments can be subjective.  As a result, a low threshold should therefore exist for objective compartment measurements in patients who are victims of high-energy injury mechanisms, particularly since high-energy injuries account for the majority of reports for compartment syndrome in children.  Every effort should be made to aggressively treat compartment syndrome, since excellent recovery from compartment syndrome can be expected if urgent fasciotomy is performed even up to 48 hours from injury.

General Principles of Orthopedic Stabilization:

The indications for definitive surgical fixation, as well as the timing for fixation, have evolved over the past few decades in the pediatric population.   Early osteosynthesis in the first 72 hours after injury has been shown by Loder et al. to shorten hospital stay, intensive care unit stay, and length of time of ventilator support in pediatric polytrauma patients. (Loder, 1987) Patients who required prolonged immobilization had an increased rate of complications related to immobilization.  Therefore, surgical indications and fixation techniques should be tailored to promote mobility and prevent prolonged periods of casting and/or bedrest.

 Loder has recommended using the Modified Abbreviated Injury Severity Scale (MISS) in children with polytrauma to predict morbidity and mortality and to aid in the appropriate timing of fracture fixation.  The MISS categorizes the severity of injury on a 5-point scale in five anatomic locations (neural, face and neck, chest, abdomen and musculoskeletal). (Loder, 1987) The MISS score is calculated by adding the sum of the squares of the three most severely injured body areas.  A score of 25 points or greater is associated with an increased risk of impairment and a score of 40 points or more is usually predictive of death. (Mayer, 1984) To minimize the complications of immobilization, Loder recommends  osteosynthesis within 2 or 3 days of injury for any child with a neurologic injury of MISS score 3 or 4, and/or having concomitant chest or abdominal injury of MISS score 3 or greater. (Loder, 1987) Little objective data exists for the treatment of the child with severe head injury (a neurologic MISS score of 5 or GCS less than 5) even after 3 days of intensive care and pulmonary support.  In general, as severe head injuries have a better prognosis in children than in adults; definitive fracture fixation should be performed with the assumption that the child will achieve full locomotor recovery.
Pediatric polytrauma patients have a decreased risk of sequential multi-organ system failure in the first 48 hours after injury, so after adequate resuscitation, early definitive orthopaedic stabilization is encouraged to improve outcomes by avoiding the complications of prolonged immobilization.

Treatment of Open Fractures:

The incidence of open fractures in the pediatric polytrauma patient has been reported to be about 10%. (Buckley, 1994) The management and prognosis of these injuries is very different from the adult population, primarily because of a thicker and more active periosteum which provides greater fracture stability and leads to more rapid and reliable fracture-healing in children.  As these patients near skeletal maturity, surgical debridement and fixation should be performed using adult fracture treatment algorithms.

The modified Gustilo-Anderson system is commonly used to classify open fractures in the pediatric population. (Gustilo, 1984) The infection rates after an open fracture in children, however, have been reported to be substantially lower than in adults with similar fractures.  In 2005, a multicenter retrospective study reported an overall 3% infection rate in a series of 554 open fractures (2% for type I, 2% for type II, and 8% for type III). (Skaggs, 2005) Prompt administration of appropriate antibiotics within three hours of the injury is the most important factor in minimizing the morbidity of these injuries.  Cefazolin (100 mg/kg/d) is the primary antibiotic choice in the treatment of most open fractures, while clindamycin (15-40 mg/kg/d) can be used in patients with allergies to cephalosporins or penicillin.  In patients with severe soft tissue injury (grade II or III open fractures), gentamicin (5-7.5 mg/kd/d) can be used in conjunction with cefazolin, while penicillin can be added if there is need for anaerobic coverage for gross contamination or farm injuries.   Additionally, the patient’s tetanus status should be confirmed and updated.  Children with an unknown vaccination history or who have not had a booster within 5 years should receive a dose of tetanus toxoid.

In 1989, Patzakis and Wilkins found that early administration of antibiotics against gram-positive and gram-negative organisms significantly reduced the rate of deep soft tissue and bone infections. (Patzakis, 1989) They also showed that the time from injury to debridement, type of wound closure, and the duration of antibiotic treatment (3 versus 5-10 days) had no effect on the infection rate.  Other authors have also questioned the need for urgent surgical debridement in pediatric patients with open fractures.  A multicenter retrospective study reported no significant difference in infection rates due to a delay in irrigation and debridement (3% treated within 6 hours of the injury compared to 2%  treated more than 7 hours after the injury). (Doak, 2009) Although this study was underpowered, the current consensus seems to be that as long as intravenous antibiotics are started urgently (within 3 hours) and the patient does not have neurovascular compromise, irrigation and debridement can be performed within the first twenty-four hours of the injury or once the patient has been medically stabilized.
           
Non-operative management of Gustilo-Anderson type I open fractures, although uncommon, has been evaluated in the pediatric population.  Various authors have reported a less than 5% infection rate after lavage and closed reduction of type I open fractures in the emergency department. (Doak, 2009; Iobst, 2005; Yang, 2003)  This treatment methodology can be considered if the patient receives intravenous antibiotics and is observed in the hospital for 48 hours after the injury, especially in a polytrauma patient that is too unstable for a trip to the operating room.  Two other studies have supported closed treatment of open fractures in children even after a formal irrigation and debridement in the operating room.  Greenbaum et al. reported that internal fixation of 37 open forearm fractures did not decrease the need for re-manipulation or angular deformity compared to cast treatment (n=25). (Greenbaum, 2001) Lim et al. reported a higher infection rate and higher delayed union rate in the internal fixation group (n=16), compared to only one re-manipulation required in the cast group (n=15).(Lim 2007)  All these studies however had relative small sample sizes, and nonoperative management of pediatric open fractures remains controversial and is not recommend in the majority of cases.

Fracture stabilization is important in managing children with polytrauma and open fractures to protect soft tissues, reduce pain and facilitate rehabilitation.  Definitive fixation should be performed in the medically stable pediatric polytrauma patient, while temporary stabilization with an external fixator may be used if the patient has extensive soft-tissue injuries or neurovascular injury that will require repair or reconstruction.  The use of rigid intramedullary nails for open tibia and femur fractures is common practice in adults, but little orthopaedic data exists as to the efficacy and safety of immediate flexible nailing of these injuries in children.

Soft tissue injuries are managed differently in the pediatric population compared with adults.  Serial debridements should be performed to remove gross contamination and foreign bodies, however, tissue of questionable viability can be preserved, as children have a better healing potential.  Additionally, bone fragments stripped of soft tissue and periosteum may also be retained as they often get incorporated into the healing callus.  Early closure of Type-I or II traumatic wounds can be performed over a drain if appropriate debridement has been performed.  Type III wounds with severe soft tissue injury can be initially treated with a vacuum-assisted device to expedite the index procedure and maintain a clean wound bed between serial debridements.  Definitive local or free-flap coverage is often required for these injuries.

References:

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Top Contributors:

Vidyadhar Upasani, MD