Managing Pediatric Orthopedic Trauma Emergencies When is it not

1
Managing Pediatric Orthopedic Trauma
EmergenciesWhen is it not Just a broken bone

• Stephen A. Mendelson M.D.
• Director of Orthopedic Trauma
• Childrens 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
Orthopedic TraumaSimple to Complex

• Broken Finger

• Pelvic Facture

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
Dislocations

• Shoulder
• Elbow
• Hip
• Knee
• Ankle

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

• gt50 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!