European Journa l o f T rauma and Emergency Surgery Focus on Pediatric Polytrauma

Pediatr ic Polytrauma ManagementHeike Jakob, Thomas Lustenberger, Dor ien Schneidmi i l ler , Anna L. Sander, Fel ix Walcher,Ingo Marzi '

AbstractCar ing fo r ped ia t r i c t rauma pat ien ts requ i res anunderstanding of the dist inct anatomy and patho-physiology of the pediatr ic populat ion compared toadu l t t rauma pat ien ts . In i t ia l eva lua t ion , manage-ment, and resuscitat ion are performed as a mult idis-c ip l inary approach inc lud ing ped ia t r i c phys ic ians ,trauma surgeons, and pediatr ic intensive care physi-cians. Head injury severi ty is the pr inciple determinaniof outcome and mortal i ty in polytraumatized chi ldren.Abdominal in jur ies rarely require surgery in contrast toadults, but need to be detected. Spine and pelvicinjur ies as wel l as injur ies of the extremit ies requireage-adapted surgical procedures. However, the degreeof recovery in polytraumatized chi ldren is oftenremarkable, even after apparent ly devastat inginjur ies. Maximal care should, therefore, be renderedunder the assumption that a complete recovery wi l l bemade.

Key WordsPediatr ic polytrauma ' Injury pattern 'Trauma

room management 'Cr i t i ca l care

Eur J Trauma Emerg Surg zoro;36:325-38

DOI 10.1007/s00068-010-1125-3

IntroductionPediatric trauma is the number one cause of death inchildren, exceeding all other causes of death combined

[1, 2]; trauma is also the leading cause of permanentdisabil ity in this population [1, 3]. Motor vehicle cra-shes (38%), pedestrian-related trauma (28%), andbicycle-related injuries (26%) account for a high pro-portion of pediatric trauma deaths [4, 5]. Other areasof concern include falls, drowning, and burns [6].

Although the principles of trauma care are identi-cal for children and adults. the differences in carerequired for the optimal treatment of the injuredpediatric patient necessitate special knowledge andattention to the unique anatomy and physiology of thegrowing child or adolescent [7]. The body of a child isvery elastic, and internal injuries without significantexternal signs can occur. Children are at special risk forsevere injuries due to their close proximity of vitalorgans, their unfavorable head-to-body ratio, and theirIower weight and height. Clinicians must be aware ofthe characteristics that require specialized strategiesfor the assessment and management of injuries inpolytraumatized children [8].

Init ial Assessment and ResuscitationThe Advanced Trauma Life Support (ATLS)-basedprimary survey with simultaneous resuscitation ad-dresses l ife-threatening injuries that compromise oxy-genation and circulation [9]. Upon arrival at the hospital,the child's airway, breathing, and circulation are evalu-ated. Use of the Broselow Pediatric Emergency Tapehas become standard for determining height, weight, theappropriate size for resuscitative equipment, and correctdrug doses and drip concentrations in a child [10, 11].

Airway control is the first priority for any traumapatient, but a child's airway is anatomically distinctfrom an adult 's. A child's neck is shorter, the epiglottisis large and floppy, and the vocal cords are locatedhigher and more anterior. For a child, intubation iseasier with a straight laryngoscope blade, and theendotracheal tube size can be estimated using thechild's f ifth digit. The subglottic trachea is the nar-rowest portion of the pediatric airway and provides aphysiological cuff; thus, uncuffed endotracheal tubes inchildren less than 8 vears of ase should be used in

'Department of f rauma, Hand and Reconstruct ive Surgery, JohannWolfgang Coethe Univers i ty Medical School , Frankfur t /Main,Cerma ny.

Rece i ved : June 14 ,2o1o ; accep ted : June r5 ,2o ro ;Publ ished Onl ine: July 29, 2o1o

325Eur . l T rauma Emerg Surg 2o1o ' No. 4 Unean & VocrL

Jakob H, e t a l . Ped ia t r i c Po ly t rauma Management

ordcr to avoid subglottic edema and injury. The tubeposition should always be checked with a chest X-ray,since a high incidence of right mainstem intubation isfound in emcrgencv intubations [12]. Surgical crico-thyroidotomy should be avoided in children youngerthan 6 years of age due to the high association withsecondary subglottic stenosis.

Assessment of the patient's breathing followsestablishment of the airway. Infants and small childrenare primarily diaphragmatic breathers; consequently,any compromise of diaphragmatic excursion signifi-cantly l imits the child's abil ity to ventilate. Severe gastricdilation due to the swallowing of air may cause respira-tory diff iculties or complicate the abdominal examina-tion. Gastric decompression with a naso- or orogastrictube should be employed in appropriate casqs.

Children are known to have an amazing cardio-vascular reserve; therefore, init ial normal vital signsshould not impart any sense of security with regard tothe status of the child's circulating volume. Obvioussigns of shock, such as hypotension or a decrease inurinary output, may not occur unti l more than 30% ofthe b lood volume has been lost [13] .

As in adults. a focused assessment sonography intrauma (FAST) is performed during the primary pediatric scoring systemscvaluation of the injured child [14]. A recent review Many trauma scoring systems have been used to assessdemonstrated the sensitivity of FAST examination to children following polytrauma. The Injury Severitybc 30-8U% and the specificity to be 42-100% in Score (ISS), an anatomical scoring .ytG- that pro-

Table r. Computed tomography (CT) diagnostic during the init ial assessment.

TechnicaI considerations Specifi c diagnostic considerations

pediatric trauma patients Il-5]. In children in particular,a lack of free intraperitoneal f luid does not excludesignificant organ injuries. The majority of children withhemoperitoneum do not necessarily require operativeintervention [16, l]1.

Computed tomography (CT) scanning of the head,chest, abdomen, spine, and pelvis is the preferredtechnique for imaging hemodynamically stable injuredchildren or for imaging hemodynamically stable. intu-bated patients with suspicious injury mechanisms (Ta_ble 1) [18]. However - in particular in the awakepatient * a thorough physical examination and evalu-ation of the trauma mechanism may permit theavoidance of a complete CT diagnostic. reducing theradiation burden. Nevertheless, despite the seven timesincreased radiation exposure in polytrauma CT scanscompared to conventional X-rays, long-term adverseeffects have not been proven yet. In particular in theseverely injured patient, the shorter diagnostic work-up time and valuable information on intracorporalinjuries may beneflcially influence outcome t19](Figures 1 and2).

CT brain and cerv icaL spine

CT chest and thoracic spine

CT abdomen , [ umba r sp ine

and peLvis

Age-based CT sl ice th ickness

Sequent iaI tech nique

i .v. contrast i f c l in icaL suspic ion of vascuLar in juryCoronary reconstruct ion of skut l and facia[ bones

Age-based i .v . contrast dosage

Age-based CT sl ice th ickness

MuLt ip[anar reconstruct ion of the spine

Weight-based i .v . contrast dosage

Adequate delay t imes (ear ly phase for ar ter ia[ in jur ies,portaI venous phase as standard, late phase for k idney in jur ies)

Brain and skuLlr Int racrania l henrorrhageo Edemao Vascular in juryo Fracture

Cervical spine. Fracture, assessntent o1'stabi l i tve Luxat ion

Parenchyma[ in jur ies

Co ntusions

Pneum o-/hem othorax

Posi t ion of thoracostomy tubePericardia[ fluid

VascuLar in jury

Fracture, assessment of stabilityLuxat lon

Sol id organ in jur ies

Free fluid

Retroper i toneal in jur ies and retroper i toneal bLeedingHol tow viscus in jur ies

Fracture, assessment of stabi l i ty

326 E u r J T r a u m a E m e r g S u r g 2 o t o . N o . 4

Jakob H, et al . Pediatr ic Polytrauma Management

Figure r . Standardized in i t ia l

assessment and resusci tat ionof the polytraumat ized pediat-

r ic pat ient (adapted f rom Franke t a l . [ 62 ] and He lm e t a l . [ 63 ] ) .

Table z. The pediatr ic Glasgow Coma Scale (CCS) [S8, Sg] .

Eye opening VerbaI response

Frpd]\ l;i*lI I areaJ lc i rc t

- I Disal

[8'*;-ll Lj-p.

I operationI

l c t rar l ie l - . - * lse

,f' operationI

@ - * E

Primary SurveyAirwayBreathingCirculationDisabilityExposure

Intubation/Correction of tubus sizeReanimationChest TubeHemorrhage 'control/

ResuscitationC-spine im mobilizatiorrFAST

Stabilization ofvi tal funct ions

Secondary Survey

X-ray chest / pelvis, CTBlood samples, urinary catheterization

X-ray extremities, angiography,operative procedures

Motor response

6

5

4

3

2

1

Spo nta neous

To voice

To pain

None

Age-appropr iate words, sociaL smiLe, f ixes and fo l lows

Cries, but consoLabte

PersistentLy initab[eR o c i l a < q : n i i : f p d

None

Norma[, spontaneous, obeys commands

Local izes pain

Withdraws f rom pain

FLexion posture to pain

Extension posture to pain

None

vides an overall score for patients with multiple inju-ries, is reproducible and useful in pediatric traumapatients 120-221. An ISS of 16 or more is usually takento indicate a polytrauma.

The Pediatric Trauma Score (PTS) is a physiolog-ical score emphasizing the child's weight and airway.Several studies have confirmed that the PTS is a validtool for predicting the mortality of a traumatically in-jured child [23-25]. Mortality is estimated at 9% with aPTS > 8 and at 100% with a PTS ( 0.

The Glasgow Coma Scale (GCS) score is a uni-versal tool for the rapid assessment of an injuredchild's consciousness level. A modified verbal andmotor version has been developed to aid in the eval-uation of the consciousness level of infants and vounschildren (Table 2).

Head InjuriesHead injuries have been reported in l1"h of childrenwith polytrauma [26]. representing the most commoncause of long-term disability l2l, 28]. Compared to

adults, the pediatric population is more susceptible totraumatic brain injury (TBI) because the more pliable,thinner. immature skull provides less protection to theintracranial contents. Weak cervical musculature and aproportionally increased head mass also bias thepediatric population toward TBI. ln addition, myeli-nation occurs between 6 and24 months of age, makingthe brain very soft and prone to disruption prior to thecompletion of this process.

lnjuries to the brain are classified as primary orsecondary. Primary injuries are infl icted immediatelyby trauma. while secondary injuries result from hypoxia,hypotension, hypercarbia, anemia, hyperglycemia.infections, seizures, or increased intracranial pressure(ICP) in addition to the primary injury. Following TBl,the incidence of increased ICP is far higher in childrenthan in adults (80 vs. 50%) [29], constituting a signifi-cant source of secondary brain injury (Figure 3). Ele-vated ICP may be caused by hematoma, increasedcerebral blood volume. or increased brain volume. andmay cause a reduction in cerebral perfusion pressure(CPP). Target CPP levels are 60*tl0 mmHg in older

Eur J T rauma Emerg Su rg 2o ro No . 4 ?27

Jakob H, et al . Pediatr ic Polytrauma Management

Figure z. Acute managementof l i fe-threatening injuries andhemodynamica l l y uns tab lepediatr ic patients.

Severe traumatic braininjury

Chest trauma with hemo-/tension-pneumothorax

Abdominal trauma withpresence of free intra-abdominal fluid

Pelvic trauma

Extremity trauma withactive bleeding

Hemorrhagic shock

Operation, Decompression

Thoracostorny tubeOperation

Damage Control Laparotomy,,Packing"

Pelvic binder, sheet wrapFixateur externe

Ongoing bleeding:EmbolizationPelvic tamponade

Compression bandageVascular clampOperation..life befbre Iimb"

Volume substitution therapyTransfusionCoagulation factor replacemenlWarm blanket

children and at least 50 mmHg in children less than8 years of age. The ICP should ideally be maintainedbelow 20 mmHg. Table 3 depicts age-appropriate CPPthresholds.

Children often sustain severe TBI. which is animportant prognostic factor. In the intubated pediatricpatient, a CT scan of the head is essential to allow earlyoperative intervention.

Acute management of children with head injuriesincludes elevation of the head of the bed. the rareuse of hyperventilation of the intubated patient,f luid restriction, and the administration of barbitu-rates. ICP monitoring is recommended in infants and

Goals:

. Regaining sufllcient cardiovascular function

. Reversal of coagulopathy

. Normalization of body core temperature

. Early decision regarding the therapeutic approach (,,treat first what killsfirst")

. Minimizing blood loss

Table 3. Age-appropriate CPP thresholds in severe traumatic braininjury (according to Fri tz et al. [6o] and Jcjhr et al. [6r]). (Cpp: cerebralperfusion pressure).

Age group (years) CPP threshold (mmHg)

0-11-6o - 1 J

> 1 3

6060-657070-80

children with a GCS score of 8 or less, particularly inchildren with closed cranial sutures. Optimally,intracranial hematomas - subdural as well as epidural

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Jakob H, et al . Pediatr ic Polytrauma Management

Figures 3a to 3c. A 3 years and 3 months old gir l was air l i f ted to our hospital after a fal l from the fourth f loor of a bui lding. Admission

computed tomography (CT) scan of the head demonstrates traumatic brain injury with severe brain edema obl i terat ing the ventr icles (a).

Intracranial pressure ( lCP) monitoring was init iated on admission day (b). Due to increasing brain edema and subsequent uncontrol lable

intracranial hypertension, bi lateral decompressive craniectomy was performed on day z after trauma (c).

Figure 4. Current treatmentprocedures for pediatr ic braininj u r ies.

Minor injury w/o ongoingbleeding or signs ofincreasing cerebral edema

Intracranial hematomaswith increasing ICP

Cerebral edema /uncontrollable intracranialhypertension

T-:------.----t+ l u D e r a t t v e l _ - _ )

Intensive careHyperventilationFluid restrictionBarbituratesICP monitoring

Evacuation

Decompressivecraniectomy

hematomas - resulting in intracranial hypertension

should be evacuated within the first 3 h following

injury, as long-term results significantly worsen

thereafter [30]. A decompressive craniectomy should

be considered in children with cerebral edema and

medically uncontrolled intracranial hypertension [31].Nutrit ional support and treatment of postinjury

seizures are further important aspects of the care of the

brain-injured child.After init ial hemodynamic stabil ization, a TBI

requiring operative intervention takes priority. As in

adults. the severe TBI in children is the most common

cause of death and is an important determinant pre-

dicting outcome (Figure 4).

Indications for operative interventions in pediatric

traumatic brain injuries (TBIs):

. lncreased ICP due to space-occupying intracranial

hemorrhages requires immediate operative intervention.

. Aggressive ICP monitoring in cases of severe TBIand GCS < 8 allows the early detection of diffusebrain swelling with the consecutive risk of brainischemia and brain infarction.

Chest InjuriesChest injuries account for 5 to 72"/" of admissions topediatric trauma centers [32] and thoracic trauma hasbeen reported in 8 to 62"/" of pediatric polytraumacases [26, 27]. While a 57o mortality rate for isolatedchest trauma has been reported, this figure increases to25"/" in the presence of concomitant head or abdominalinjuries [32]. Thoracic injuries are important variablespredicting outcome and play a cornerstone role in themanagement of pediatric trauma [33].

Children exhibit distinct patterns of chest injuriescompared to adults [3a]. The pediatric thorax has agreater cartilage content and incomplete rib ossification,

Eur J Trauma Emerg Surg 2o1o No. 4 ?29

Jakob H, et al . Pediatr ic Polytrauma Management

Figures 5a and 5b. Severeb i l a t e ra l l ung con tus i ons andpneumo tho rax (a ) i n a r 6 - yea rold g i r l fo l lowing a motorveh i c l e acc i den t . Abdom ina l CTscan addi t ional ly shows f reein t r ape r i t onea l f l u i d and asp len i c l ace ra t i on (b ) , wh i chwas successful ly t reated non-operat ively.

making fractures of the ribs and sternum less common.Severe parenchymal thoracic injuries may be present withminimal or no signs of external trauma and with a normaladmission chest X-ray. Finally, the mobil ity of the heart,and mediastinum may result in heart dislocation, tran-section, or angulation of the great vessels, and trachealcompression and angulation. Injuries to the heart andgreat vessels, while rare. are highly morbid and requirerapid diagnosis and treatment. The diagnosis is suggestedby the observation of a widened mediastinum on plainfi lm. but mostly may be recognized in contrast mediaenhanccd CT.

Isolated rib fractures are generally of I itt le concern.although they often indicate morc severe chest injuries.including lung and cardiac contusion or laceration,hemo- and pneumothorax, or mediastinal injury (Fig-ure -5). Multiple rib fractures are associated with severetrauma to other body areas.

Pulmonary contusions remain the most commonform of pediatric thoracic trauma; the diagnosis ismade by chest X-rays in approximately 90% of cases,with half of the cases demonstrating rib fractures,hemothorax, and/or pneumothorax on radiographs

[32]. Pulmonary contusions may lead to atelectasis,consolidation. and progressive inflammation. possiblyresulting in pneumonia, venti lation-perfusion mis-match, and respiratory insufficiency. The risk ofdeveloping pneumonia in cases of severe pulmonarycontusions is 20-30"/, ' , supporting the use of earlyantibiotic trcatment. In contrast to adults. a kinctictherapy is, in general. not necessary.

Pneumo- and/or hemothorax are managed by promptchest tube placement. Approximately 5"h of childrenwith a hemothorax will require surgical drainage due toongoing bleeding from the thoracostomy tube; however,the indications for surgery remain controversial.

Tracheobronchial injury Bronchoscopicexamination

Figure 5. Current treatment procedures for pediatric chest trauma.

Tracheobronchial injuries are usually located in thelower trachea or upper bronchus. Multiple 1indingsmay include pneumothorax, hemothorax, pneumome-diastinum, subcutaneous emphysema, or persistent airleak from a chest tube. If the injury involves less thanone-fourth of the bronchus diameter. nonoperativetherapy with frequent bronchoscopic examination maybe su i l ab le (F igu re 6 ) .

Indications for operative intervention in pediatric chesttrauma:

o Persisting hemodynamics compromising thoracos-tomy tube output.

. Cardiac tamponade.o Massive air leak frorn the thoracostomy tube.o Penetrating object with injury of lung parenchyma.

Abdominal InjuriesAbdominal injuries are reported in 8 to 27"/" of pedi-atric polytrauma patients 126,351. Because children aregenerally healthy, with good physiological reserves,they may init ially remain clinically stable, despite sig-nificant injuries. Tachycardia is the earliest (and oftenthe only) sign of hemorrhagic shock with imminenthemodynamic decompensation.

I

Pneumo-/Hemothorax

Ongoing bleeding

Chest Tube

Surgery

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Jakob H, e t a l . Ped ia t r i c Po ly t rauma Management

Anatomical differences in children make themmore vulncrable to maior abdominal injuries fromminor forces. Compared with the adult patient. thechild's intra-abdominal organs are proportionally largcrand in closer proximity to each other. The child's smalland pliable rib cage and the undeveloped abdominalmusculature provide little protection for major organs. l.

In the hemodynamically unstable patient, imme-diate operative intervention is indicated followingcompletion of the primary or secondary surveys,respectively. In less crit ically i l l patients, further diag-nostic evaluation for intra-abdominal injuries is gen-

erally performed by CT scan.Liver and spleen inj uries are commonly seen in

polytraumatized children. The vast majority of theseinjuries can be managed non-operatively with successrates of up to 95% [36-38]. Selective, non-opcrativemanagement requires hemodynamic stabil ity and ab-scnce of peritoneal signs. Those patients should bemonitored closely with serial clinical examinations andserial hematocrits for evidence of ongoing bleeding.Failure of non-operative treatment usually occurswithin the first few hours o[ admission. Although themajority of children do not require surgery for splenicor hepatic injuries, children presenting hemodynamicinstabil ity belong in the operating room for hemor-rhage control. Organ-preserving techniques are pre-ferred in adequately resuscitated patients that do notdemonstrate ongoing hemorrhagic shock. Splenorrha-phy and partial splenectomy are techniques to controlbleeding while preserving splenic parenchyma. Sple-nectomy may be required in the crit ically i l l child or inthe case of a completely shattered spleen. Hepator-rhaphy, perihepatic packing. or suture l igation ofbleeding vessels are preferred over extensive hepaticresections.

The operative management of l iver injurics isbased on the "damage control" concept. Patients with

a major hepatic laceration. surgically uncontrollablebleeding, coagulopathy, or hypothermier require peri-hepatic packing [36]. Definit ive operative treatment ofinjured l iver vessels or bile ducts is performed afterachieving hemodynamic stabil ization and reversal ofcoagulopathy.

Following primary l ife-saving operativc intcrvcn-tions of abdominal injuries. the diagnostic evaluationshould be completed.

Hollow viscus injuries are frequently encounteredin rest ra ined chi ldren involved in a motor vehic leaccident. This injury mechanism is often indicated byabdominal wal l ecchymosis ( "seatbel t s ign") , wi th asudden increase in the in t ra luminal pressure resul t ingin "b lowout" or per forat ion of the in test ine. CTscanning is diagnostic in only 60% of bowel perfora-tion cases and may reveal free fluid without evidenceof sol id organ in jur ies [39] . Close observat ion andser ia l physical examinat ion should guide ambiguousfindings, and fluid around the duodenum and pan-creas may be a predictive sign. Once diagnosed. thesurgical treatment of perforations involving greaterthan 50% of the circumference usually requires seg-mental resect ion wi th pr imary anastomosis, whcrcasperforations of less than 50% of the circumferencecan be repaired primarily. Only in cases of severeabdominal contamination or rectal injuries is a two-stage procedure wi th temporary creat ion of a colos-tomv indicated. l

Fancreatici-i juries arc rarc, comprising less than5% of a l l pediat r ic abdominal in jur ies, and whosediagnoses are frequently delayed. The diagnosis ofpancreatic injury is suggested by an elevated amylaselevel and the clinical sign of significant epigastricpa in . On l y i n ex tens i ve panc rea t i c i n j u r i es \ asearly partial resection associated with improved out-comes as compared to conservat ive management [40](F igure 7) .

Figure 7. Current treatmentprocedures for pediatr icabdomina l t rauma.

Liver / splenicinjury

Hollow viscusinj ury

He rrxrdynamical lyunstablc

Hemodynarnical lystable

lmmediate operativeintervention

lmmediate opelat ion

e.g. abdorninal packing

Non-operativeSerial cl inical examinations.blood values

./\

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Jakob H, et al . Pediatr ic Polytrauma Management

Figute 8. Current treatmentprocedures for pediatr ic pelvict ra u ma.

Stable fiacture

Unstable fiacture

Ongoing bleeding

Intraperitoneal bladderinjury

Pelvic TraumaThe immature pelvis has greater elasticity in thesacroil iac joint and the symphysis, making fracturesdependent on higher energy forces. Pediatric pelvicfractures consequently accompany multiple injuries

141, 421. Clinical signs of pelvic fractures includesuperficial hematomas above the inguinal l igament orthe scrotum (Destot's sign), a decrease in the distancebetween the greater trochanter and the pubic spine ascompared to the contralateral side (Roux's sign) inlateral compression fractures, and a large hematoma ora palpable fracture l ine discovered on rectal examina-tion (Earle's sign).

Most pelvic fractures are stable and can be man-aged non-operatively, except overriding bus or caraccidents. Unlike pelvic fractures in adults, pediatricpelvic fractures are generally not hemodynamicallysigniflcant [43]. In most cases, pediatric avulsionfractures and type A fractures are treated conserva-tively, aiming at pain relief and early mobilizationGeneral indications for surgery include unstable type Cfractures and rotationally unstable type B fractures.Abdominal and retroperitoneal concomitant injuriesinfluence the therapeutic approach in those cases [44].Operative management includes anterior external f ix-ation, which can be a definit ive approach in children,and open reduction and internal f ixation with a plateosteosynthesis. The C-clamp for emergent externalposterior f ixation has no role in the acute managementof pelvic fractures in children. as bounding the patient'sknees and ankles loosely together to aid in reduction issufl icient [45]. Displacement of large fragments of morethan 1 cm. a diastasis of the symphysis pubis of morethan 2 cm, and open pelvic ring fractures representfurther indications for operative intervention. Closedfractures of the anterior pelvic ring with a dislocation ofless than -5 mm and a diastasis of the symphysis pubisof less than 1 cm can be treated non-operatively.

-------* F;*,tJlExternal flxationPlate osteosynthesis

Extraperitoneal packingExternal fixation

ReconstructionOsteosynthesis

Acetabular fractures in children are infrequent andevidence-based studies regarding the treatment ofpediatric acetabular fractures are rare. Iniurv of thegrowth p late might resul t in growth arre i r and sub-sequent subluxation of the femoral head. Conse-quently, an adequate diagnostic evaluation is necessaryto determine the management strategy on an individ-ual basis.

Treatment of pediatric acetabular fractures:

o In acetabular fractures, anatomical reduction isnecessary to achieve good long-term results. Thepreferred approach is screw osteosynthesis [aa].

o To avoid the risk of growth disturbances, earlyremoval of the implant should be performed [41].

Head, chest, and visceral trauma are often combinedwith pediatric pelvic fractures [a6]. The urogenitalsystem, especially the perineum, vagina, rectum, andbladder, should receive specific evaluation during theinitial physical examination, as those injuries are oftenmissed and can lead to potentially serious conse-quences. Bladder injuries may require urgent repair inthe case of intraperitoneal rupture, or delayed repairversus observation for extraperitoneal injury (Fig-ure 8).

Spinal TraumaSpine fractures are rare in children, representing onlyl*2'/" of all pediatric fractures [a7]. This low incidenceis due not only to the plasticity of the pediatric spine,but also to the usually severe (if not fatal) associatedinjuries. The disproportionately large head size andrelatively weak neck muscles, the horizontal orienta-tion of the upper cervical facet joints, and ligamentouslaxity place the upper cervical spine (C0-C2) at

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Jakob H, et al . Pediatr ic Polytrauma Management

Figure 9. Current treatmentprocedures for pediatr ic spinalt rauma.

Stable fracture

Unstable fiactureNeurologic defici ts

high risk for injury in children younger than 12 years of

age.lncomplete ossification and physiological hyper-

mobil ity of the pediatric cervical spine contribute to

imaging findings that can be confused with pathological

conditions. Increased anterior displacement of C2 on

C3 (pseudosubluxation) may be mistaken for a cervical

spine injury; this condition may be found in patients up

to 16 years old. Pseudosubluxation of C3 on C4 occurs

less frequently, while an increased distance between

the dens and the anterior arch of C1 occurs in

approximately 20"/" of young children. Normal wedg-

ing of an intervertebral space or the C3 body and

normal translucencies of the dens may also be mis-

taken as spinal trauma and fractures, respectively [48].Atlanto-occipital dislocation is a rare and often

fatal iniury [49]. These patients are usually polytrauma

victims with severe head injuries who present with a

range of clinical neurological issues, from cranial nerve

dysfunction to varying degrees of quadriplegia and

complete loss of neurological function below the brain

stem [-50]. Early reduction and deflnit ive immobiliza-

tion using a halo cast alone or with supplemental

internal f ixation and posterior fusion should be per-

formed [51, 52].Odontoid fractures are a common pediatric cervi-

cal spine injury; however. neurological deficits are rare

[53]. These fractures usually displace anteriorly, with

the dens posteriorly angulated. Displaced odontoid

fractures in children reduce easily following mild

extension and posterior translation. Healing is rapid

and immobilization with a halo cast can be completed

in 6-10 weeks.Traumatic l igamentous instabil ity usually occurs in

the upper cervical spine (C2lC3) in younger children.

Treatment consists of closed reduction and halo

immobilization for approximately 8 weeks. However,

in rare cases, posterior cervical fusion with subsequent

Minerva jackets or halo immobilization is necessary.C3-C1 fractures are more common in older chil-

dren and adolescents than in younger children [54].The typical injury patterns include compression

fractures of the vertebral body, which can be treated

with Philadelphia immobilization. Persistent instabil-

-------* F;;;-lLaminectomyInternal fixation

i ty, neurological deficits, or increasing cyphosis repre-sent indications for posterior cervical fusion.

The majority of thoracolumbar spine fractures inchildren and younger adolescents are minor. stable,and without neurological deficit [-53]. Older adolescentssustain injuries similar to those seen in adults, andshould be managed accordingly. Compression frac-tures, mostly occurring in the thoracic spine, are seenin 90"/" of the cases. Treatment usually consists of bedrest with gradual resumption of activit ies. Surgicaldecompression by l igamentotaxis with reduction ofretropulsed fragments, posterior distraction, andinstrumentation are recommended for neurologicallycompromised patients. End plate damage may result inan increase in deformity, especially during the rapidadolescent growth spurt.

Type B and C spine injuries are rare in childrenbelow the age of 12 years. However, up to 50% ofcases are associated with severe chest, abdominal, orretroperitoneal injuries. Operative intervention is rec-ommended. but the treatment of concomitant intra-thoracic or intra-abdominal injuries takes priority.

Neurologic deficits due to a narrowing of the spinalcanal are - as in adults - treated by dorsal decom-pression by laminectomy, distraction, and stabil izationby internal f ixation. The goal of the operative man-agement of spinal injuries is a stable osteosynthesis,allowing early mobilization, facilitating care of thepatient, and avoiding secondary spinal cord damage(Figure 9).

Extremity TraumaExtremity fractures have been reported in up to 76%of children following polytrauma, implying thatorthopedic injuries must be viewed in the context ofthe overall status of the multiply injured child [6. 27].

Definit ive care of extremity injuries in the pediatricpolytrauma is usually undertaken within the first 24 hof injury (Figure 10). ln cases of clinical suspicion ofvascular injuries, color flow Doppler imaging and/orangiography are the investigations of choice. Openfractures. fractures with associated vascular injuries,compartment syndromes, and amputation injuries re-

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Jakob H, et al . Pediatr ic Polytrauma Management

Figures roa to rof. A t6-year-old boy was admit ted to thet rauma room a f t e r a j ump f r omthe second f loor of a bui ld ing.Shock room CT revealed severet rauma t i c b ra i n i n j u r y w i t hsuba rachno id hemor rhage , i n -t r apa renchyma l hema tomas ,and sku l l f r ac tu re , as we l asseve re ches t t r auma w i t h l ungcon tus i ons on t he r i gh t s i de .Admission X-rays demonstratea f racture of the r ight femoralneck (a) , and a r ight d ista l ra-d i us f r ac tu re ( b ) . Du r i ng t hein i t i a l p rocedu re , i n t r ac ran ia lp ressu re ( lCP) mon i t o r i ng wasinstal led, a thoracostomy tubewas inserted, the femoral neckfracture was stabi l ized by screwosteosynthesis (c, d) , and as tab i l i za t i on o f t he d i s t a l r ad iusfracture using K-wires wasperformed (e, f).

qulre emergency care. Stable osteosynthesis of thefracture is performed by. f irstly, repair of the extremityartcry, veins secondly, and, f inally. t issue coverage isperformed.

Fractures of the epi- and metaphysis are mostlytreated by K-wire osteosynthesis. Some cases requireadditional or alternative application of an externalfixator. Depending on the fracture pattern and char-acteristics, as well as the age of the child, open reduc-tion and internal fixation using screw and/or plateosteosynthesis may be an option. Diaphyseal fracturesare predominantly fixed using flexible intramedullaryrods, such as elastic stable intramedullary nailing. Plateosteosynthesis of diaphyseal fractures during adolescenceshould, at most, be considered as a temporary stabil iza-tion using minimally invasive techniques [5-5]. However,early definitive osteosynthesis of extremity fracturesshould be a goal of pediatric patient management.

Compartmental hypertension is a potentially dev-astating complication of extremity injury. which is

treated by decompression of the affl icted compart-ments by the incision of their fascia. The stabil izationof fractures is subsequently performed as describedabove. Vacuum-assisted closure devices or artif icialskin are used to temporarily cover tissue defects orfasciotomy sites.

Open fractures and open ioint injuries are pri-marily washed out, debrided, and subsequently stabi-l ized. In cases of severe, open articular fractures, a two-stage management mav be necessary.

Early fracture stabil ization reduces the systemiceffects of fractures, including a systemic inflammatoryresponse syndrome, sepsis, multiple organ failure, andacute respiratory distress syndrome, even the latter, areless important in children. E,arlv stabil ization also re-duces pain, the risk of secondary neurovascular dam-age, and promotes mobil ization of the patient. lngeneral, initial definitive surgical care should beundertaken in fractures of the humerus, forearm shaftfractures, and fractures of femur and tibia. Non-dis-

334 E u r J T r a u m a E m e r g S u r g 2 o 1 o N o . 4

Jakob H, e t a l . Ped ia t r i c Po ly t rauma Management

Figure tt . Currentprocedures forextremity trauma.

treatmentped iatr ic

placed distal forcarm fractures can be addressed bycasting.

Polytrauma patients have a severely deranged ini-mune response, characterized by an early excessiveactivation of innate immunity (hyperinflammation),followed by a delayed immunosuppression and en-hanced susceptibil i ty to infection, sepsis, and multipleorgan failure [56]. Due to the hyperinflammation ob-served on day 2 to 5, surgical interventions during thisintermediate phase should ideally be avoided.

Children often recover remarkably well from whatinit ially appear to be devastating injuries to the centralnervous system or other organ systems. Consequently.optimal orthopedic care must be undertaken with theassumption that the injured child wil l completely re-cover (F igure 11) .

The complications after trauma are given inTable 4.

Pediatric Crit ical CareOnce the patient leaves the emergency department orthe operating room, the pediatric intensive care unit(PICU) provides an optimal environment in whichpatient outcome can be improved through the recog-nition of acute changes in clinical status followed byimmediate treatment. Pediatric trauma victims benefitfrom care under a multidisciplinary team, including apediatric crit ical care physician, the trauma surgeon,PICU nurses, respiratory therapists, and further pedi-atric subspecialists. Recent data suggest that the careof injured children in a dedicated PICU improvessurvival [57].

In the severely head-injured pediatric traumapatient, optimizing the CPP is of utmost importance,either by decreasing the ICP or augmenting the meanarterial pressure (MAP). ICP management may

DebridementExternal f ixat ion

OsteosynthesisExternal t ixat ion

ReductionOsteosyntesis

--------* [or-t,t'"

-l

include sedation, osmotic therapy (including mannitoland hypertonic saline solutions), and pentobarbitalcoma for refractory cases. Adequate CPP may also bemaintained through MAP support, using norepineph-rine if the central venous pressure is adequately high,or epinephrine in case of insufficient myocardial con-traction. The use of a PiCCO system allows the mon-itoring of intravascular volume and catecholaminetherapy.

To avoid secondary lung damage (pneumothoraxor acute respiratory distress syndrome), venti lation isbased on pressure control, which provides peak inspi-ratory pressure throughout inspiration. Init ially,relaxation may be required to reach the therapeutictarget of arterial pOz > 100 mmHg. ln brain-injuredpatients. the positive end-expiratory pressure shouldbe minimized to allow sufficient drainage from thecervical venous system; however. the pressure shouldnot fall below 3 cm H2O. Again. PiCCO monitoringmay be a valuable tool in patient management.

Conclus ionCar ing fo r ped ia t r i c t r auma pa t i cn t s requ i res anunderstanding of the distinct anatomy and patho-physiology of the pediatric population compared toadul t t rauma pat ients. In i t ia l evaluat ion, manage-ment, and resuscitation require a muhidisciplinaryapproach including trauma surgeons, anesthesiolo-gists. and pediatric intensive care physicians. Headinjury severity is the principle determinant of out-come and mortality in polytraumatized children.Nevertheless, the degree of recovery in polytrauma-tized children is often remarkable, even after appar-ently devastating injuries. Maximal care should.therefore, be rendered under the assumption that acomolete recoverv wil l be madc.

Open fiacture

Closed diaphysealfiacture

Joint fracture

Compartment syndrome

Eur I T rauma Emerg Su rg 2o ro No . 4 335

Jakob H, et al . Pediatr ic Polytrauma Management

Table 4. Complications after trauma in the pediatr ic patient.

Traumatic brain injury

Chest t rauma

AbdominaL t r auma

SpinaI t rauma

Pelv ic t rauma

Extremity t rauma

Dif fuse brain edema

Coagu[opathy

Thromboembo[ ic events

ApaLt ic syndrome

Posttraumatic epiLepsy

Posto perative[y:

o Increase of ICPo Bleeding

Increased r isk of comp[ icat ions wi th GCS < 8

Pneumon ia

Acute respiratory d ist ress syndrome (ARDS)A h c r o < < o m n r r o m r

Post in jury organ fa iLure due to abdominaL malperfusion dur ing hemorrhagic shockSecondary hemodynamic instabiL i ty in cases of non-operat ively t reated Liver and splenic in jur iesPer i toni t is dr te to hol low v iscus in jur ies or protracted intest inal wa[[ necrosisDelayed so[id organ rupture

Postoperativety:o Re-bleeding. Infectionsiwound dchiscence (abdominal wall)o Abscess. Adhesions. post t raumat ic i leus. Abdominal wnl l hernia

Late comp[ ' icat ions:

Main[y due to missed in jur ies, most ly of the intest ine, fo l lowing blunt abdominal t rauma

Growth disturbance/deformity in cases of injured growth ptate

Progressive deformity in case of pers ist ing instabiL i ty and neurological symptomsPosttraumatic paraLysis

Fusion of spinal segments fo lLowing damage of end plates

PostoperativeLy:r Progression of r.reurological delicitso Rc-bleeding. Implant d is locat ion

Ear ly compLicat ions:. Blood loss due to intr:l-abdominal or retroperitoneal injuries (fracture. presacral venous plexus)o Pcritonitis following drsruption of the pelvic floor, rectal injurieso Urinzrry incontinence

l - + ^ ^ ^ - - l : ^ - + : ^ - - .L O L t L U i l r p L t L d L t U i l > .

o Grorvth disturbance (fusion of pubic symphysis or iliosacral gap)o Acetabular dysplasia wi th h ip luxat ion

PostoperativeLy:o Re-blcedingo Neurovascular in ju ly. Implant d is locat ion

Compartment syndrome

Infecti on

Soft tissue defect

ImpLant fa i ture

Premature growth plate closure, growth arrest

N on -u n i on

Leg length discrepancy

Nerve in jury, motor ic dysfunct ion

336 E u r J T r a u m a F m e r g S u r g 2 o t o . N o . 4

Jakob H, et al . Pediatr ic Polytrauma Management

Conflict of interest statementThe authors declare that there is no actual or potential conflict of

intercst in relation to this article.

2.

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Address for €orrespondenceProf. Dr. Ingo MarziDepartment of Trauma, Handand Reconstruct ive SurgeryJohann Wol fgang Coethe Univers i ty Medical SchoolTheodor-Stern-kai 76o59o Frankfur t /MainCermanyPhone (+49169) 63ot-6t4, Fax -6439e-mai l : ma rz i@trau ma.uni - f ran kfur t .de

338 E u r I T r a u m a E m e r g S u r g 2 o t o . N o . 4