managing pediatric orthopedic trauma emergencies when is it not “just a broken bone”

Managing Pediatric Orthopedic Managing Pediatric Orthopedic Trauma EmergenciesTrauma Emergencies

When is it not “Just a broken When is it not “Just a broken bone”bone”

Stephen A. Mendelson M.D.Stephen A. Mendelson M.D.Director of Orthopedic TraumaDirector of Orthopedic Trauma

Children’s Hospital Of Pittsburgh of Children’s Hospital Of Pittsburgh of UPMCUPMC

Pediatric Orthopedic TraumaPediatric Orthopedic Trauma

Pediatric Orthopedic TraumaPediatric Orthopedic Trauma

Pediatric Orthopedic TraumaPediatric Orthopedic Trauma

Pediatric Orthopedic TraumaPediatric Orthopedic Trauma

Pediatric Orthopedic TruamaPediatric Orthopedic Truama

Pediatric Orthopedic TraumaPediatric Orthopedic TraumaNonaccidental InjuryNonaccidental Injury

Pediatric Orthopedic TraumaPediatric Orthopedic Trauma

20-30% Trauma patients have orthopedic 20-30% Trauma patients have orthopedic injury.injury.55% of Nonaccidental patients have 55% of Nonaccidental patients have musculoskeletal injurymusculoskeletal injuryAs many as 1/3 ER visits related to As many as 1/3 ER visits related to accidents or injuriesaccidents or injuries

Orthopedic TraumaOrthopedic TraumaSimple to ComplexSimple to Complex

Broken FingerBroken Finger Pelvic FacturePelvic Facture

Factors Predicting Injury Severity Factors Predicting Injury Severity and Outcomesand Outcomes

Injury MechanismInjury Mechanism– High ImpactHigh Impact

MVAMVAFall from HeightFall from HeightMotorcycle and ATVMotorcycle and ATV

– Low ImpactLow ImpactGround Level FallGround Level FallSports AccidentSports Accident

Factors Predicting Injury Severity Factors Predicting Injury Severity and Outcomesand Outcomes

Concurrent InjuriesConcurrent Injuries– Head InjuryHead Injury– Visceral InjuriesVisceral Injuries– BurnsBurns– Soft Tissue Soft Tissue

Factors Predicting Injury Severity Factors Predicting Injury Severity and Outcomesand Outcomes

Associated InjuriesAssociated Injuries– VascularVascular– NeurologicNeurologic

Factors Predicting Injury Severity Factors Predicting Injury Severity and Outcomesand Outcomes

ComorbiditiesComorbiditiesSystemicSystemicMusculoskeletalMusculoskeletal

Orthopedic EmergenciesOrthopedic EmergenciesThe Big Seven!The Big Seven!

Open FractureOpen FractureCompartment syndrome Compartment syndrome Vascular CompromiseVascular CompromiseDeteriorating Neurologic ExamDeteriorating Neurologic ExamAcute Dislocation Major JointAcute Dislocation Major JointFemoral Neck fractureFemoral Neck fractureOpen or Septic JointsOpen or Septic Joints

Open FracturesOpen Fractures

Any fracture where the bone is exposed to Any fracture where the bone is exposed to the environment through a soft tissue the environment through a soft tissue defect. Graded I,II, III based on severity of defect. Graded I,II, III based on severity of soft tissue wound.soft tissue wound.Require urgent cleansing and surgical Require urgent cleansing and surgical debridement to prevent infection, and debridement to prevent infection, and promote healingpromote healing

Open fractureOpen fracture

Compartment syndrome Compartment syndrome Soft tissue injury and Soft tissue injury and subsequent swelling that subsequent swelling that exceeds the capacity of exceeds the capacity of the fascial space or the fascial space or muscle compartment muscle compartment causing increasing causing increasing pressure in the muscle pressure in the muscle compartment. Ultimately compartment. Ultimately cutting off circulation and cutting off circulation and damaging the muscles damaging the muscles and nervesand nerves

Compartment Syndrome Compartment Syndrome Symptoms and Signs Symptoms and Signs

PainPain– Out of proportion to injuryOut of proportion to injury– Pain with passive muscle stretchPain with passive muscle stretch

Paresthesia Paresthesia PallorPallor– Cool, mottled, loss of capillary refillCool, mottled, loss of capillary refill

PulselessnessPulselessnessParalysisParalysis

Compartment SyndromeCompartment SyndromeDiagnosis and TreatmentDiagnosis and Treatment

Physical examPhysical exam– Most reliable in awake patientMost reliable in awake patient

Compartment pressure measurementsCompartment pressure measurements

FASCIOTOMY!!!FASCIOTOMY!!!

FasciotomyFasciotomy

Fractures with associated Fractures with associated vascular Compromisevascular Compromise

Immediate vascular insufficiencyImmediate vascular insufficiency– Reduce (align) fracture Reduce (align) fracture – If vascular perfusion not restored explore, If vascular perfusion not restored explore,

repair or consultrepair or consult

Initial pulse lost aster reductionInitial pulse lost aster reduction– Vessel caught in fracture site. Explore, repair Vessel caught in fracture site. Explore, repair

or consultor consult

Vascular InjuriesVascular Injuries

Deteriorating Neurologic ExamDeteriorating Neurologic Exam

Static Neurologic DeficitStatic Neurologic Deficit– Can observe or explore at time of fracture Can observe or explore at time of fracture

treatmenttreatment

Deteriorating Neurologic DeficitDeteriorating Neurologic Deficit– Nerve compressed, stretched or entrappedNerve compressed, stretched or entrapped– Reduce fracture and explore nerve before Reduce fracture and explore nerve before

permanent damagepermanent damage

Common Nerve InjuriesCommon Nerve Injuries

Femoral Neck FracturesFemoral Neck Fractures

Blood supply to femoral head very tenuous Blood supply to femoral head very tenuous Prolonged loss of blood to femoral head Prolonged loss of blood to femoral head causes permanent damage … Avascular causes permanent damage … Avascular Necrosis (AVN)Necrosis (AVN)Emergent reduction and stabilization Emergent reduction and stabilization reduces risk of AVNreduces risk of AVN

Pediatric Femoral Neck FracturesPediatric Femoral Neck Fractures

Avascular NecrosisAvascular Necrosis

DislocationsDislocations

ShoulderShoulderElbowElbowHipHipKneeKneeAnkleAnkle

Open JointOpen Joint

Common orthopedic injuries Common orthopedic injuries that are not as urgent as the that are not as urgent as the

looklook

(Or The surgeon may say they (Or The surgeon may say they are to get into the OR quicker)are to get into the OR quicker)

Badly Displaced fracturesBadly Displaced fractures

Growth Plate FractureGrowth Plate FractureSalter Harris Salter Harris ClassificationClassification

Salter Harris 1Salter Harris 1

Salter Harris 2Salter Harris 2

Salter Harris 3Salter Harris 3

Salter Harris 4Salter Harris 4

Intraarticular fracturesIntraarticular fractures

Static Neurologic deficitStatic Neurologic deficit

Nerve PalseyNerve PalseyComplete Spinal Cord Complete Spinal Cord InjuryInjury

Other Orthopedic considerationsOther Orthopedic considerations

Child AbuseChild Abuse

>50% long bone fractures in nonambulatory children.20% Recurrence Rate.1-5% Mortality.

Child abuse fracture PatternsChild abuse fracture Patterns

PolytraumaPolytrauma

ARDSARDSShock Shock Fat EmboliFat Emboli

Multidisciplinary ApproachMultidisciplinary ApproachParamedics and TransportParamedics and TransportEmergency RoomEmergency RoomTrauma ServiceTrauma ServiceIntensives Care UnitIntensives Care UnitNeurosurgeryNeurosurgeryOrthopedicsOrthopedics

Damage Control OrthopedicsDamage Control OrthopedicsProvisional Stabilization During Provisional Stabilization During

Resuscitation periodResuscitation period

SummerySummeryOrthopedic trauma can very from simple sprains Orthopedic trauma can very from simple sprains strains and minor fractures to major multisystem strains and minor fractures to major multisystem polytrauma.polytrauma. Recognition of orthopedic emergencies and Recognition of orthopedic emergencies and urgencies can help triage and manage the care urgencies can help triage and manage the care of all patients in a trauma center setting. of all patients in a trauma center setting. Orthopedic injuries are common, recognizing the Orthopedic injuries are common, recognizing the common pitfalls is critical to avoiding serious common pitfalls is critical to avoiding serious complications.complications. A team approach is best!!!!!!!!A team approach is best!!!!!!!!

Thank You!Thank You!