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!