Chapter 5: Management of the Multiply Injured Child

Susan A. Scherl, Robert M. Kay

Chapter Outline

Role of the Pediatric Trauma Center

Key Concepts

  •  
    The American College of Surgeons has established specific criteria for pediatric trauma centers, which include the same principles of rapid transport and rapid treatment by an in-house surgical team as in adult trauma centers.
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    Rapid assessment and treatment during the “golden hour” decreases mortality.
  •  
    There is increasing evidence that pediatric trauma centers do provide improved outcomes for severely injured children, but there are relatively few such centers, and many children will be stabilized or treated definitively at adult trauma centers.
After the rapid transport of wounded soldiers to a specialized treatment center proved effective in improving survival in the military setting, trauma centers, using the same principles of rapid transport and immediate care, have been established throughout the United States. These trauma centers are supported by the states on the premise that the first hour (the “golden hour”)42 after injury is the most critical in influencing the rates of survival from the injuries. Rapid helicopter or ambulance transport to an onsite team of trauma surgeons in the trauma center has led to an improvement in the rates of acute survival after multiple injuries have occurred. 
The first trauma centers focused on adult patients because more adults than children are severely injured. However, pediatric trauma centers have been established at numerous medical centers across the United States with the idea that the care of pediatric polytrauma patients differs from the care given to adults and that special treatment centers are important for optimal results.69,72,89 The American College of Surgeons has established specific criteria for pediatric trauma centers, which include the same principles of rapid transport and rapid treatment by an in-house surgical team as in adult trauma centers. A pediatric general surgeon is in the hospital at all times and heads the pediatric trauma team. This surgeon evaluates the child first, and the other surgical specialists are immediately available. General radiographic services and computed tomography (CT) capability must be available at all times for patient evaluation, and an operating room must be immediately available. 
There is increasing evidence that survival rates and outcomes for severely injured and younger children are improved at a pediatric trauma center compared to a community hospital.3,47,50,120,133,179,185 However, the costs associated with such a center (particularly the costs of on-call personnel) have limited the number of existing pediatric trauma centers. Therefore, pediatric trauma patients are often stabilized at other hospitals before transfer to a pediatric trauma center, or treated definitively at an adult trauma center. One European cohort study comparing 2,961 pediatric polytrauma patients to 21,435 adults, found that the “golden hour” for pediatric patients often elapses in the field, or is consumed during transfer between hospitals.216 
Larson et al.100 reported that there did not appear to be better outcomes for pediatric trauma patients flown directly to a pediatric trauma center than for those stabilized at nontrauma centers before transfer to the same pediatric trauma center. Other centers have documented the need for improved transfer coordination.159,182 
Knudson et al.97 studied the results of pediatric multiple injury care in an adult level 1 trauma center and concluded that the results were comparable to national standards for pediatric trauma care. Sanchez et al.162 reported that adolescent trauma patients admitted to an adult surgical intensive care unit (SICU) had similar outcomes to comparable patients admitted to a pediatric intensive care unit (PICU) in a single institution. However, those admitted to the SICU were more likely to be intubated and to have a Swan–Ganz catheter placed and had longer ICU stays and longer hospital stays.162 The use of a general trauma center for pediatric trauma care may be an acceptable alternative if it is not feasible to fund a separate pediatric trauma center. 

Initial Resuscitation and Evaluation

Key Concepts

  •  
    Regardless of the mechanism causing the multiple injuries, the initial medical management focuses on the life-threatening, nonorthopedic injuries to stabilize the child's condition.122
  •  
    Initial resuscitation follows the Advanced Trauma Life Support (ATLS) or Pediatric Advanced Life Support (PALS) protocols.
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    The primary survey comprises the “ABCs”: Airway, Breathing, Circulation, Disability (neurologic), and Exposure and screening radiographs (cervical spine, chest, and pelvis).
  •  
    Hypovolemia is the most common cause of shock in pediatric trauma patients so early and adequate fluid resuscitation is critical.165

Initial Evaluation

The initial steps in resuscitation of a child are essentially the same as those used for an adult.6,43,122 The primary survey begins with assessment of the “ABCs,” Airway, Breathing, Circulation, Disability (neurologic), and Exposure, followed by screening radiographs (cervical spine, chest, and pelvis). In severe injuries, the establishment of an adequate airway immediately at the accident site often means the difference between life and death. The cervical spine needs to be stabilized for transport if the child is unconscious, there is facial trauma, or if neck pain is present (Fig. 5-1). A special transport board with a cutout for the occipital area is recommended for children younger than 6 years of age because the size of the head at this age is larger in relation to the rest of the body. Because of this larger head size, if a young child is placed on a normal transport board, the cervical spine is flexed, a position that is best avoided if a neck injury is suspected.77 
Figure 5-1
Temporary cervical spine stabilization is imperative in any child with multitrauma, especially those who are unconscious or complain of neck pain.
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Fluid Replacement

Once an adequate airway is established, the amount of hemorrhage from the injury, either internally or externally, is assessed. This blood loss is replaced initially with intravenous (IV) crystalloid solution. In younger children, rapid IV access may be difficult. In this situation, the use of intraosseous fluid infusion via a large bore needle into the tibial metaphysis can usually be placed within 1 to 2 minutes and has been found safe and effective for IV fluids and drug delivery during resuscitation. Bielski et al.,16 in a rabbit tibia model, likewise demonstrated no adverse effects on the histology of bone or the adjacent physis with intraosseous injection of various resuscitation drugs and fluids. 
Because death is common if hypovolemic shock is not rapidly reversed, the child's blood pressure must be maintained at an adequate level for organ perfusion. Most multiply injured children have sustained blunt trauma rather than penetrating injuries, and most of the blood loss from visceral injury or from pelvic and femoral fractures is internal and may be easily underestimated at first. The “triad of death,” consisting of acidosis, hypothermia, and coagulopathy, has been described in trauma patients as a result of hypovolemia and the systemic response to trauma.212 Peterson et al.142 reported that an initial base deficit of eight portends an increased mortality risk. 
Despite the need to stabilize the child's blood pressure, caution needs to be exercised in children with head injuries so that overhydration is avoided because cerebral edema is better treated with relative fluid restriction. Excessive fluid replacement also may lead to further internal fluid shifts, which often produce a drop in the arterial oxygenation from interstitial pulmonary edema, especially when there has been direct trauma to the thorax and lungs. In some instances, to accurately assess the appropriate amount of fluid replacement, a central venous catheter is inserted during initial resuscitation. A urinary catheter is essential during the resuscitation to monitor urine output as a means of gauging adequate organ perfusion. 

Evaluation and Assessment

Key Concepts

  •  
    Trauma rating systems have two functions: To aid in triage, and to predict outcomes.
  •  
    There are many rating systems, each with strengths and weaknesses.
  •  
    Of the commonly used systems, both the Injury Severity Score (ISS) and Glasgow Coma Score have predictive value for prognosis.
  •  
    The secondary survey is a systematic examination of the patient from head to toe.
  •  
    It includes a complete history, physical examination, focused radiographs, and adjunctive imaging studies such as CT and MRI scans.

Trauma Rating Systems

After initial resuscitation has stabilized the injured child's condition, it is essential to perform a quick but thorough check for other injuries. At this point in the evaluation, a trauma rating is often performed. The purpose of the trauma rating is twofold: To aid in triage, and to predict outcomes. Several trauma rating systems have been validated for the pediatric population,5,21,34,54,147,149,167,168,178,193 but the most commonly utilized are the Glasgow Coma Scale (GCS), the Injury Severity Score (ISS), and the Pediatric Trauma Score (PTS). Each of the scoring systems has strengths and weaknesses. The ISS is a valid, reproducible rating system that can be widely applied in the pediatric polytrauma setting (Table 5-1).211 It is an ordinal, not a linear scale (i.e., a score of 40 is not twice as bad as a score of 20). It has been found to be a valid predictor of mortality, length of hospital stay, and cost of care.24 Another injury rating system for children that has been shown to be valid and reproducible is the PTS (Table 5-2).211 It has good predictive value for injury severity, mortality, and the need for transport to a pediatric trauma center; however, it is a poor predictor of internal injury in children with abdominal blunt trauma.160 The injury rating system chosen varies among trauma centers, but whether the ISS or PTS is used, each allows an objective means to assess mortality risk at the time of initial treatment, as well as allowing some degree of prediction of future disability.138,186,218 
 
Table 5-1
Injury Severity Score
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Table 5-1
Injury Severity Score
Abbreviated Injury Scale (AIS)
The AIS classifies injuries as moderate, severe, serious, critical, and fatal for each of the five major body systems. The criteria for each system into the various categories are listed in a series of charts for each level of severity. Each level of severity is given a numerical code (1–5). The criteria for severe level (Code 4) is listed below.
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General
Severe lacerations and/or avulsions with dangerous hemorrhage; 30–50% surface second- or third-degree burns.
Head and Neck
Cerebral injury with or without skull fracture, with unconsciousness >15 min, with definite abnormal neurologic signs; posttraumatic amnesia 3–12 h; compound skull fracture.
Chest
Open chest wounds; flail chest; pneumomediastinum; myocardial contusion without circulatory embarrassment; pericardial injuries.
Abdomen
Minor laceration of intra-abdominal contents (ruptured spleen, kidney, and injuries to tail of pancreas); intraperitoneal bladder rupture; avulsion of the genitals.
Thoracic and/or lumbar spine fractures with paraplegia.
Extremities
Multiple closed long-bone fractures; amputation of limbs.
Injury Severity Score (ISS)
The injury severity score (ISS) is a combination of values obtained from the AIS. The ISS is the sum of the squares of the highest AIS grade in each of the three most severely injured areas. For example, a person with a laceration of the aorta (AIS = 5), multiple closed long-bone fractures (AIS = 4), and retroperitoneal hemorrhage (AIS = 3) would have an injury severity score of 50 (25 + 16 + 9). The highest possible score for a person with trauma to a single area is 25. The use of the ISS has dramatically increased the correlation between the severity and mortality. The range of severity is from 0–75.
 

Adapted from Committee on Medical Aspects of Automotive Safety. Rating the severity of tissue damage. I. The abbreviated scale. JAMA. 1971; 215(2):277–280; Baker SP, O'Neill B, Haddon W Jr, et al. The Injury Severity Score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974; 4:187–196.

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Table 5-2
Pediatric Trauma Score
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Table 5-2
Pediatric Trauma Score
Category
Component +2 +1 −1
Size ≥20 kg 10–20 kg <10 kg
Airway Normal Maintainable Unmaintainable
Systolic Blood Pressure ≥90 mm Hg 90–50 mm Hg <50 mm Hg
Central Nervous System Awake Obtunded/LOC Coma/decerebrate
Open Wound None Minor Major/penetrating
Skeletal None Closed fracture Open/multiple fractures
 

This scoring system includes six common determinants of the clinical condition in the injured child. Each of the six determinants is assigned a grade: +2, minimal or no injury; +1, minor or potentially major injury; −1, major, or immediate life-threatening injury. The scoring system is arranged in a manner standard with advanced trauma life support protocol, and thereby provides a quick assessment scheme. The ranges are from −6 for a severely traumatized child to +12 for a least traumatized child. This system has been confirmed in its reliability as a predictor of injury severity.

 

Adapted from Tepas JJ 3rd, Mollitt DL, Talbert JL, et al. The Pediatric Trauma Score as a predictor of injury severity in the injured child. J Pediatr Surg. 1987; 22(1):14–18, with permission.

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Head injury is most often evaluated and rated by the GCS, which evaluates eye opening (1 to 4 points), motor function (1 to 6 points), and verbal function (1 to 5 points) on a total scale of 3 to 15 points (Table 5-3).192 There are some limitations in the use of the GCS in children who are preverbal or who are in the early verbal stages of development, but in other children this rating system has been a useful guide for predicting early mortality and later disability. A relative head injury severity scale (RHISS) has been validated44 and is available in trauma registries, thus is useful for comparative studies of large populations. As a rough guide in verbal children, a GCS score of less than 8 points indicates a significantly worse chance of survival for these children than for those with a GCS of more than 8. The GCS should be noted on arrival in the trauma center and again 1 hour after the child arrives at the hospital. Serial changes in the GCS correlate with improvement or worsening of the neurologic injury. Repeated GCS assessments over the initial 72 hours after injury may be of prognostic significance. In addition to the level of oxygenation present at the initial presentation to the hospital, the 72-hour GCS motor response score has been noted to be very predictive of later permanent disability as a sequel to the head injury.70,125,219 
 
Table 5-3
Glasgow Coma Scale
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Table 5-3
Glasgow Coma Scale
Response Action Score
Best motor response Obeys M6
Localizes 5
Withdraws 4
Abnormal flexion 3
Extensor response 2
Nil 1
Verbal response Oriented V5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
Nil 1
Eye opening Spontaneous E4
To speech 3
To pain 2
Nil 1
 

This scale is used to measure the level of consciousness using the eye opening, best verbal, and best motor responses. The range of scores is from 3 for the most severe to 15 for the least severe. This is a measure of level and progression of changes in consciousness.

 

Adapted from Jennett B, Teasdale G, Galbraith S, et al. Severe head injuries in three countries. J Neurol Neurosurg Psychiatry. 1977; 40(3):291–298, with permission.

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Physical Assessment

The secondary survey starts with a full history and physical examination. In a child with multiple injuries, a careful abdominal examination is essential to allow early detection of injuries to the liver, spleen, pancreas, or kidneys. Ecchymosis on the abdominal wall must be noted, because this is often a sign of significant visceral or spinal injury.29,175 In one series, 48% (22/46) of children with such ecchymosis required abdominal exploration,29 whereas in another series 23% (14/61) of children were noted to have spine fractures.175 
Swelling, deformity, or crepitus in any extremity is noted, and appropriate imaging studies are arranged to evaluate potential extremity injuries more fully. If extremity deformity is present, it is important to determine whether the fracture is open or closed. Sites of external bleeding are examined, and pressure dressings are applied if necessary to prevent further blood loss. A pelvic fracture combined with one or more other skeletal injuries has been suggested to be a marker for the presence of head and abdominal injuries.206 Major arterial injuries associated with fractures of the extremity are usually diagnosed early by the lack of a peripheral pulse. However, abdominal venous injuries caused by blunt trauma are less common and are less commonly diagnosed before exploratory laparotomy. About half of abdominal venous injuries have been reported to be fatal, so the trauma surgeon needs to consider this diagnosis in children who continue to require substantial blood volume support after the initial resuscitation has been completed.59 
Initial splinting of suspected extremity fractures is routinely done in the field. However, once the injured child is in the hospital, the orthopedist should personally inspect the extremities to determine the urgency with which definitive treatment is needed. Most important are whether a vascular injury has occurred, whether the fracture is open or closed. The back and spine should be carefully examined. If there is noopen fracture and if the peripheral vascular function is normal, there is less urgency in treating the fracture and splinting will suffice until the other organ system injuries are stabilized. 
Splinting decreases the child's pain while the child is resuscitated and stabilized and minimizes additional trauma to the soft tissue envelope surrounding the fracture. Splinting also facilitates transport of the child within the hospital while the trauma workup, including appropriate imaging studies, is completed. If the child is to be transferred to a trauma center, splints are invaluable for patient comfort and safety during transfer. 
Any evident neurologic deficit is noted to document the extremity function before any treatment. It is important to remember that a detailed neurologic examination may not be possible because these are often young and scared children who are in pain and may have a central nervous system injury. The inability to obtain a reliable examination should also be documented. 
Head injuries and extreme pain in certain locations can result in some injuries being missed initially. In a series of 149 pediatric polytrauma patients, 13 injuries were diagnosed an average of 15 days following the initial accident, including five fractures (one involving the spine), four abdominal injuries, two aneurysms, one head injury, and one facial fracture.85,109 Given this 9% incidence of delayed diagnosis, it is imperative that polytrauma patients be reexamined once they are more comfortable to reassess for potential sites of injury. In some cases, despite careful inpatient reevaluations, some pediatric injuries escape detection until later follow-up visits. In addition, children with head injuries need to be reassessed once they awaken enough to cooperate with reexamination. Families and patients need to be informed of the frequency of delayed diagnosis of some injuries in polytrauma patients so that they can partner with the medical team in recognizing such injuries (often evident as previously undetected sites of pain or dysfunction). 

Imaging Studies

Radiographs

Imaging studies should be obtained as quickly as possible after the initial resuscitation and physical examination. Any extremity suspected of having a significant injury should be examined on radiograph. Primary screening radiographs classically consist of a cross-table lateral cervical spine, anteroposterior chest, and anteroposterior pelvis.53,150 In some centers, a lateral cervical spine radiograph is obtained only if the child has a head injury or if neck pain is noted on physical examination. Some centers evaluate the cervical spine with a CT scan in children with polytrauma who have neck pain, a traumatic brain injury (TBI), or who have been drinking alcohol.161 Further workup with cervical spine magnetic resonance imaging (MRI) is necessary before cervical spine clearance in those who have persistent neck pain or tenderness despite normal plain films and CT, and should be considered in patients who remain obtunded (see “Magnetic Resonance Imaging”). 
If a cervical spine injury is present, the lateral radiograph of this area will detect it in 80% of cases.105 If there is suspicion of a cervical spine injury on the neutral lateral view, a lateral flexion radiograph of the cervical spine taken in an awake patient will help detect any cervical instability. The cervical spine of a young child is much more flexible than the cervical spine in an adult. Under the age of 12 years, the movement of C1 on C2 during flexion of the neck can normally be up to 5 mm, whereas in adults, this distance should be less than 3 mm. Likewise in this young age group, the distance between C2 and C3 is up to 3 mm. No forward movement of C2 on C3 should be present in a skeletally mature individual when the neck is flexed. This so-called pseudosubluxation of C2 on C3 in a child should not be diagnosed as instability that requires treatment because this is a normal finding in young children.33 Because it is difficult to detect a fracture of the thoracic or lumbar spine clinically, radiographs of this area, primarily a lateral view, should be carefully evaluated, particularly in a comatose child. 

Computed Tomography

CT is essential in evaluating a child with multiple injuries. If a head injury is present, CT of the head will detect skull fractures and intracranial bleeding. With abdominal swelling, pain, or bruising, CT of the abdomen with IV contrast provides excellent visualization of the liver and spleen and allows quantification of the amount of hemorrhage present. Because most hepatic and splenic lacerations are treated nonoperatively,29,79,155 the CT scan and serial hematocrit levels are used to determine whether surgical treatment of these visceral lacerations is needed. 
CT of the pelvis is more sensitive for pelvic fractures than is a screening pelvic radiograph (Fig. 5-2). In one study, a screening pelvic radiograph demonstrated only 54% of pelvic fractures identified on CT scan.66 CT also is useful for thoroughly evaluating fracture configuration and determining appropriate treatment options, both surgical and nonsurgical. If abdominal CT is being done to evaluate visceral injury, it is simple to request that the abdominal CT be extended distally to include the pelvis. CT of a fractured vertebra will provide the information needed to classify the fracture as stable or unstable and determine whether operative treatment is needed. 
Figure 5-2
CT is an excellent addition to radiographs for evaluation of pelvic fractures.
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Intravenous Pyelography

There is a strong correlation of urologic injury with anterior pelvic fractures, as well as with liver and spleen injury. Although CT and ultrasonography are used to evaluate renal injuries, the IV pyelogram still has a role in helping to diagnose bladder and urethral injuries.136 Regardless of the methods of imaging, the anatomy of the urethral disruption often cannot be accurately demonstrated preoperatively.4 

Radionuclide Scans

Bone scans have a limited role in the acute evaluation of a child with multiple injuries. In conjunction with a skeletal survey, a technetium-99m bone scan is sometimes used in children with suspected child abuse to detect previously undetected new or old fractures.75,94,123 
Heinrich et al.75 reported that bone scans in 48 children with multiple injuries often demonstrated an unsuspected injury. Nineteen previously unrecognized fractures were identified by obtaining radiographs of the areas with increased isotope uptake. In addition, there were 66 false-positive areas of increased uptake in the 48 patients. Of their 48 patients, six had a change in their orthopedic care as a result of this bone scan, although this treatment was usually simple cast immobilization of a nondisplaced fracture. In some instances, the bone scan can be useful to differentiate a normal variation in skeletal ossification (normal uptake) from a fracture (increased uptake), particularly in an extremity or a spinal area where pain is present. Areas of increased uptake require further imaging studies to determine if orthopedic treatment is required. 

Magnetic Resonance Imaging

MRI is used primarily for the detection of injury to the brain or the spine and spinal cord. In young children, the bony spine is more elastic than the spinal cord. As a result, a spinal cord injury can occur without an obvious spinal fracture in children with multiple injuries, particularly in automobile accidents.9,22,57 In the spinal cord injury without radiographic abnormality (SCIWORA) syndrome, MRI is valuable in demonstrating the site and extent of spinal cord injury and in defining the level of injury to the disks or vertebral apophysis. A fracture through the vertebral apophysis is similar to a fracture through the physis of a long bone and may not be obvious on planar radiographs. MRI in obtunded and intubated pediatric trauma patients has been reported to lead to a quicker cervical spine clearance with a resulting decrease in hospital stay and cost.61 
MRI is also useful in evaluating knee injuries,118 particularly when a hemarthrosis is present. If blood is present on knee arthrocentesis, MRI can assist in diagnosing an injury to the cruciate ligaments or menisci. In addition, a chondral fracture that cannot be seen on routine radiographs may be demonstrated by MRI. 

Ultrasonography

Ultrasound evaluation has been shown to be an accurate means of detecting hemopericardium and intraperitoneal fluid following injury. Some trauma centers have replaced peritoneal lavage and laparoscopy with serial ultrasound evaluations to monitor liver, spleen, pancreas, and kidney injury in children with multiple injuries.27,79,155 The protocol most typically used is called “Focused Assessment with Sonography for Trauma” (FAST). FAST consists of a rapid ultrasound examination of four areas: The right upper abdominal quadrant, the left upper abdominal quadrant, the subxiphoid area, and the pelvis. The role of FAST in the evaluation of pediatric trauma patients is still being established.39,55,80,81,184 As a result, CT is more often used for assessment and monitoring of visceral injury in children sustaining multiple injuries. Comparisons of CT and ultrasonography have demonstrated the superiority of CT for diagnosing visceral injury in children with polytrauma,39,131,152,187 but there is evidence that hemodynamically unstable children with a positive FAST should be taken for laparotomy rather than for CT scanning.113 

Nonorthopedic Conditions in the Multiply Injured Child

Key Concepts

  •  
    Head injury severity is the principle determinant of morbidity and mortality in a multiply injured child.
  •  
    Children often make substantial recovery from even severe head trauma.
  •  
    Management of orthopedic injuries in children with head trauma should be based on the presumption of full recovery from the head injury.
  •  
    Spasticity and contracture are common sequelae of brain injury, and should be addressed early.
  •  
    There is an association between pediatric pelvic fractures and both intra-abdominal and genitourinary injuries.
  •  
    Motion at the site of a long-bone fracture results in increased intracranial pressure (ICP). To control ICP, it is imperative that long-bone fractures are immobilized until definitive fracture care can be provided.

Head Injury

Prognosis for Recovery

Head injuries occur in children with multiple injuries even more often than orthopedic injuries. In a review of 494 pediatric polytrauma patients, Letts et al.109 reported closed head injuries in 17% and skull fractures in 12%, whereas Schalamon et al.166 reported injuries to the head and neck region in 87% of pediatric polytrauma patients. It has been clearly demonstrated that a child recovers more quickly and more fully from a significant head injury than does an adult.40,112,214 Even children who are in a coma for hours to days often recover full motor function. Mild cognitive or learning deficits may persist, so educational testing needs to be considered for children who have had head injury and coma. Two factors that have been linked to poorer functional recovery and more severe permanent neurologic deficits are a low oxygen saturation level at the time of presentation to the hospital and a low GCS score 72 hours after the head injury. In fact, the severity of TBI is the single most important determinant of long-term outcome in polytraumatized children.87 Because children with head injuries are often transported long distances, evacuation of a cerebral hematoma within 4 hours is not always possible.190 
Despite the fact that excellent motor recovery is expected in most children after a head injury, children are often left with significant residual cognitive deficits. Many children who sustain TBIs are unaware of their residual cognitive limitations and tend to overestimate their mental capacities.71 Children who have had a TBI also often have behavioral problems, the presence of which may be predictive of behavioral problems in uninjured siblings as well.188 Greenspan and MacKenzie65 reported that 55% of children in their series had one or more health problems at 1-year follow-up, many of which were relatively minor. Headaches were present in 32% and extremity complaints in 13% of patients. The presence of a lower extremity injury with a head injury led to a higher risk of residual problems. 
Because of the more optimistic outlook for children with head injuries than for adults with similar injuries, timely orthopedic care should be provided, and the orthopedist should base the orthopedic care on the assumption of full neurologic recovery. Waiting for a child to recover from a coma is not appropriate, and comatose children tolerate general anesthesia well. Unless the musculoskeletal injuries are treated with the assumption that full neurologic recovery will take place, long-bone fractures may heal in angled or shortened positions. In the absence of optimal orthopedic care, once neurologic recovery occurs, the primary functional deficit will be from ill-managed orthopedic injuries rather than from the neurologic injury. 

Intracranial Pressure

After a head injury, ICP is commonly monitored to prevent excessive pressure, which may lead to further permanent disability or death. Normally, ICP does not exceed 15 mm Hg, and all attempts should be made to keep the pressure under 30 mm Hg after a head injury. This is accomplished by elevating the head of the bed to 30 degrees, lowering the PCO2, and restricting IV fluid administration. Ventilator assistance is used to lower the PCO2, which helps lessen cerebral edema. Fluid restriction also is recommended if peripheral perfusion can be maintained despite the polytrauma. Elevation of serum norepinephrine has been shown to correlate well with the severity of head injury in patients with injury of multiple organ systems.215 
Motion at the site of a long-bone fracture results in increased ICP. To control ICP, it is imperative that long-bone fractures are immobilized until definitive fracture care can be provided. Initial immobilization is usually accomplished by splinting or casting of the fractures, or by use of traction for femoral shaft fractures. Fracture stabilization with internal or external fixation facilitates dressing changes for the treatment of adjacent soft tissue injury as well as allowing inhospital transport for imaging studies and other necessary treatments.196,197 

Secondary Orthopedic Effects of Head Injuries

A head injury can have later impact on the management of musculoskeletal injuries, even after the acute phase has passed. Persistent spasticity, the development of contractures, heterotopic bone formation in soft tissue, and changes in fracture healing rates are all sequelae of a head injury in children. 
Spasticity
Spasticity may develop within a few days of head injury. The early effect of this spasticity is to cause shortening at the sites of long-bone fractures if traction or splint or cast immobilization is being used. If fracture displacement or shortening occurs in a circumferential cast, the bone ends may cause pressure points between the bone and the cast, leading to skin breakdown at the fracture site, with a higher risk for deep infection. Even with skeletal traction for femoral fractures, fracture shortening and displacement will occur as the spasticity overcomes the traction forces. Once spasticity develops and long-bone fractures displace, internal or external fixation is needed to maintain satisfactory reduction. This operative stabilization should be done as soon as the spasticity becomes a problem for fracture reduction because fracture healing is accelerated by a head injury.195,197 
Contractures
The persistence of spasticity in the extremities often leads to subsequent contractures of the joints spanned by the spastic muscles. Contractures can develop quickly, and early preventative stretching or splinting should begin while the child is in the intensive care unit. Nonselective mass action muscle activity associated with brain injury can be used to help prevent these early contractures. If the child lies in bed with the hips and knees extended, there will usually be strong plantarflexion of the feet at the ankles. If the hip and knee are flexed, it will be much easier to dorsiflex the foot at the ankle, so part-time positioning in this way will prevent early equinus contractures from developing. Stretching and splinting can often be effective in preventing contractures, and casting may be needed if contractures develop. If these measures are not successful and are interfering with rehabilitation, these contractures may need to be released surgically. 
Heterotopic Bone Formation
Heterotopic bone may form in the soft tissues of the extremity as early as a few weeks after a head injury with persistent coma.96 Although any joint can be affected, the most common sites are the hip and the elbow. There is some evidence that heterotopic bone formation can be stimulated by surgical incisions. In head-injured teenagers who undergo antegrade reamed femoral intramedullary nailing of femoral fractures, heterotopic bone that later restricts hip motion can form at the nail insertion site.92 A sudden increase of alkaline phosphatase a few weeks after the onset of coma, even with fractures coexisting, may mean that heterotopic bone is starting to form and a more careful examination of the extremities is indicated.127 Technetium-99 bone scans show increased isotope uptake in the soft tissue where heterotopic bone forms, and this imaging study should be considered if new swelling is noted in the extremity of a comatose child. Other diagnoses that must be considered in a comatose child with new swelling of the extremity are a new long-bone fracture and deep venous thrombosis.181 
Observation and excision are the two primary approaches taken in managing heterotopic bone formation in an injured child. If the child remains comatose, usually little treatment is administered. There are no conclusive data to support medical treatment because diagnosis of heterotopic bone formation is typically made after the inflammatory stage of heterotopic bone formation. In theory, it might be useful to try to block some of the heterotopic bone formation by the use of salicylates or nonsteroidal anti-inflammatory medication if the diagnosis were established very early. If the child has recovered from the head injury and has heterotopic bone that does not interfere with rehabilitation, no intervention is required. If there is significant restriction of joint motion from the heterotopic bone, this bone should be excised to facilitate rehabilitation. The timing of the heterotopic bone excision is controversial, but resection should be considered whenever heterotopic bone significantly interferes with rehabilitation, rather than waiting for 12 to 18 months until the bone is more mature. After surgical excision, early postoperative prophylaxis with local low-dose radiation therapy or medications (salicylates or nonsteroidal anti-inflammatory drugs) decreases the risk of recurrence. Mital et al.127 reported success in preventing recurrence of heterotopic bone after excision by use of salicylates at a dosage of 40 mg/kg/day in divided doses for 6 weeks postoperatively. 
Fracture Healing Rates
Long-bone fractures heal more quickly in children and adults who have associated head injuries.222 It has been demonstrated that polytrauma patients in a coma have a much higher serum calcitonin level than do conscious patients with similar long-bone fractures, but how or whether this finding influences fracture healing is still unclear.48 

Peripheral Nerve Injuries

Although TBI most often accounts for persistent neurologic deficits in a child with multiple injuries, peripheral nerve injury should be considered as well during the rehabilitation process. In one clinical review of brain-injured children, 7% had evidence of an associated peripheral nerve injury documented by electrodiagnostic testing.144 For closed injuries, the peripheral nerve injury is typically associated with an adjacent fracture or with a stretching injury of the extremity. In most cases, observation is indicated because these injuries often recover spontaneously. However, if the nerve injury is at the level of an open fracture, then exploration of the nerve is indicated at the time of the initial surgery. In children being observed following a nerve injury, if function does not return within 2 to 3 months, then electrodiagnostic testing should be undertaken. It is important to recognize these injuries because surgical peripheral nerve repair with nerve grafts offers an excellent chance of nerve function recovery in young patients. 

Abdominal Injuries

Studies have reported abdominal injuries in 8%109 to 27%51 of pediatric polytrauma patients. Abdominal swelling, tenderness, or bruising are all signs of injury. CT evaluation has largely replaced peritoneal lavage or laparoscopy as the initial method of evaluation of abdominal injury.191 Abdominal injury is common if a child in a motor vehicle accident (MVA) has been wearing a lap seat belt, regardless of whether a contusion is evident.29,201 Bond et al.20 noted that the presence of multiple pelvic fractures strongly correlated (80%) with the presence of abdominal or genitourinary injury, whereas the child's age or mechanism of injury had no correlation with abdominal injury rates. Although hepatic and splenic injuries are much more common, 22% of pediatric cases of pancreatitis result from trauma.15 
The usual practice is to treat hepatic and splenic lacerations nonoperatively, by monitoring the hematocrit, by repeating the abdominal examination frequently, and by serial CT scans or ultrasound examinations.31,36,37,38,108,191,203 Once the child's overall condition has stabilized, and the child is stable to undergo general anesthesia, the presence of nonoperative abdominal injuries should not delay fracture care. 

Genitourinary Injuries

Genitourinary system injuries are rare in the pediatric polytrauma population, with Letts et al.109 reporting an incidence of 1% in these patients. However, genitourinary injuries have been reported in 9%172 to 24%198 of children with pelvic fractures. Most injuries to the bladder and urethra are associated with fractures of the anterior pelvic ring (Fig. 5-3).12 Such injuries are more common in males and usually occur at the bulbourethra, but the bladder, prostate, and other portions of the urethra can also be injured.12,136 Although less common following pelvic fracture in girls, such injuries are often associated with severe injuries, including those to the vagina and rectum, with long-term concerns regarding continence, stricture formation, and childbearing.146,158 If the iliac wings are displaced or the pelvic ring shape is changed, it may be necessary to reduce these fractures to reconstitute the birth canal in female patients. There are increased rates of cesarean section in young women who have had a pelvic fracture.41 Adolescent females with displaced pelvic fractures should be informed of this potential problem with vaginal delivery. If the injury is severe, kidney injury may also occur, but most urologic injuries that occur with pelvic fractures are distal to the ureters.1 
Figure 5-3
Most injuries to the bladder and urethra are associated with anterior pelvic ring fractures and should be suspected with these injuries.
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Fat Embolism and Pulmonary Embolism

Although fat embolism and acute respiratory distress syndrome are relatively common in adults with multiple long-bone fractures, they are rare in young children.115,154 When fat embolism occurs, the signs and symptoms are the same as in adults: Axillary petechiae, hypoxemia, and radiograph changes of pulmonary infiltrates appearing within several hours of the fractures. It is likely that hypoxemia develops in some children after multiple fractures, but the full clinical picture of fat embolism seldom develops. If a child with multiple fractures without a head injury develops a change in sensorium and orientation, hypoxemia is most likely the cause, and arterial blood gases are essential to determine the next step in management. The other primary cause of mental status change after fracture is overmedication with narcotics. 
If fat embolism is diagnosed by low levels of arterial oxygenation, the treatment is the same as in adults, generally with endotracheal intubation, positive pressure ventilation, and hydration with IV fluid. The effect of early fracture stabilization, IV alcohol, or high-dose corticosteroids on fat embolism syndrome has not been studied well in children with multiple injuries. 
Deep venous thrombosis and pulmonary thromboembolism also are rare, but are increasingly reported in children.10,11,46,114,200 The risk of deep venous thrombosis and pulmonary embolism is increased in children older than 9, those with an ISS greater than or equal to 25, and/or a GCS lower than or equal to 8, and those with central venous catheters34,155 The role of prophylaxis for pediatric deep venous thrombosis and pulmonary thromboembolism is unclear.23,156,163,200 

Nutritional Requirements

Pediatric polytrauma patients have high caloric demands. If an injured child requires ventilator support for several days, caloric intake through a feeding tube or a central IV catheter is necessary to avoid catabolism, improve healing, and help prevent complications. The baseline caloric needs of a child can be determined based on the weight and age of the child. Children on mechanical ventilation in a PICU have been shown to require 150% of the basal energy or caloric requirements for age and weight.194 The daily nitrogen requirement for a child in the acute injury phase is 250 mg/kg. 

Orthopedic Management of the Multiply Injured Child

Key Concepts

  •  
    Most fractures in multiply injured children can be splinted initially, and undergo definitive treatment urgently, not emergently.
  •  
    Pelvic fractures in children can typically be treated nonoperatively, but may require fixation if the child is hemodynamically unstable.
  •  
    Tetanus toxoid and antibiotics should be provided for all open fractures, though routine culture is unnecessary.
  •  
    The timely administration of IV antibiotics and appropriate irrigation and debridement are the most important steps in the treatment of open fractures.
  •  
    There are many options for stabilization of open fractures. In each case stabilization should be planned to allow easy access for further treatment of the soft tissue injury.
  •  
    Children will often heal open fractures that would necessitate amputation in an adult.
  •  
    If amputation is necessary, preserve as much stump length as possible.

Timing

Because fractures are rarely life-threatening, splinting generally suffices as the initial orthopedic care while the child's overall condition is stabilized. Loder116 reported that, in 78 children with multiple injuries, early operative stabilization of fractures within the first 2 or 3 days after injury led to a shorter hospital stay, a shorter stay in the intensive care unit, and a shorter time on ventilator assistance. In addition, there were fewer complications in those who had surgical treatment of the fractures less than 72 hours after injury. In a more recent study, Loder et al.117 reported a trend toward a higher rate of complications of immobilization (including pulmonary complications) in fractures treated late (after 72 hours), but the difference did not reach statistical significance. In this more recent study, age greater than 7 years and Modified Injury Severity Score (MISS) ≥140 were predictive of an increased rate of complications of immobilization. A mixed series of adults and children demonstrated comparable results for early (within 24 hours) and late (after 24 hours) fixation of fractures in the setting of blunt trauma and severe head injuries.207 

Pelvic Fractures

Pelvic fractures are common in children and adolescents with multiple injuries and have been reported in up to 7% of children referred to level 1 regional trauma centers.180,209 Survival is related to ISS and type of hospital.209 In two series, 60% to 87% of pelvic fractures involved a pedestrian struck by a motor vehicle.172,183 Other common mechanisms include being a passenger in an MVA or falling from a height.172,183 Although many of these pelvic injuries are stable, unstable patterns have been reported in up to 30% of cases.18 
Injuries to the axial skeleton have been reported to be associated with the most intense hospital care and higher mortality rates than other injury combinations.26 In their series of 166 consecutive pelvic fractures, Silber et al.172 reported associated substantial head trauma in 39%, chest trauma in 20%, visceral/abdominal injuries in 19%, and a mortality rate of 3.6% (Fig. 5-4). In this same series,172 12% (20/166) had acetabular fractures, whereas in another series, 62% of children (8/13) with pelvic fractures had other orthopedic injuries.183 
Figure 5-4
Bilateral superior and inferior pubic rami fractures.
 
Genitourinary and abdominal injuries must be ruled out with severe pelvic fractures.
Genitourinary and abdominal injuries must be ruled out with severe pelvic fractures.
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Figure 5-4
Bilateral superior and inferior pubic rami fractures.
Genitourinary and abdominal injuries must be ruled out with severe pelvic fractures.
Genitourinary and abdominal injuries must be ruled out with severe pelvic fractures.
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Control of bleeding, either from the retroperitoneum near the fracture or from the peritoneum from injured viscera, may present an immediate threat.86 However, death of children with pelvic fractures appears to be caused more often by an associated head injury rather than an injury to the adjacent viscera or vessels.130 
Anterior pelvic ring fractures are the primary cause of urethral injury,1,12,146,158 although urethral injuries are reported to occur less frequently in children than in adults.172 Bilateral anterior and posterior pelvic fractures are most likely to cause severe bleeding,124 but death from blood loss in children is uncommon.49,130 Injury to the sciatic nerve or the lumbosacral nerve roots may result from hemipelvis displacement through a vertical shear fracture. Nonorthopedic injuries associated with pelvic fractures led to long-term morbidity or mortality in 31% (11/36) of patients in one review of pediatric pelvic fractures.62 Most pelvic fractures in children are treated nonoperatively. However, in a child or preadolescent, an external fixator can be used to close a marked pubic diastasis or to control bleeding by stabilizing the pelvis for transport and other injury care. The external fixator will not reduce a displaced vertical shear fracture, but the stability provided is helpful to control the hemorrhage while the child's condition is stabilized.151,189 Another option for acute pelvic stabilization in the emergency department is a simple pelvic binder.87 Though reported to be safe for children, the C-clamp is not typically utilized for the pediatric population.82 Operative treatment can result in healing by 10 weeks with a low complication rate.90 

Open Fractures

Background

Most serious open fractures in children result from high-velocity blunt injury involving vehicles. Penetrating injuries are much less common in children than in adults; however, many low-energy blunt injuries can cause puncture wounds in the skin adjacent to fractures, especially displaced radial, ulnar, and tibial fractures. In children with multiple injuries, approximately 10% of the fractures are open.26,166 When open fractures are present, 25% to 50% of patients have additional injuries involving the head, chest, abdomen, and other extremities.166 

Wound Classification

The classification used to describe the soft tissues adjacent to an open fracture is based on the system described by Gustilo and Anderson67 and Gustilo et al.68 Primary factors that are considered and ranked in this classification system are the size of the wound, the degree of soft tissue damage and wound contamination, and the presence or absence of an associated vascular injury (Table 5-4). 
 
Table 5-4
Classification of Open Fractures
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Table 5-4
Classification of Open Fractures
Type I An open fracture with a wound <1 cm long and clean
Type II An open fracture with a laceration >1 cm long without extensive soft tissue damage, flaps, or avulsions
Type III Massive soft tissue damage, compromised vascularity, severe wound contamination marked fracture instability
Type IIIA Adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound
Type IIIB Extensive soft tissue injury loss with periosteal stripping and bone exposure; usually associated with massive contamination
Type IIIC Open fracture associated with arterial injury requiring repair
 

Adapted from Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma. 1984; 24(8):742–746; Gustilo RB, Anderson JT. Prevention of infection in the treatment of 1025 open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am. 1976; 58(4):453–458.

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Type I. Type I fractures usually result from a spike of bone puncturing the skin (from the inside to the outside). The wound is less than 1 cm in size, and there is minimal local soft tissue damage or contamination. 
Type II. A type II wound is generally larger than 1 cm and is typically associated with a transverse or oblique fracture with minimal comminution. There is adjacent soft tissue injury, including skin flaps or skin avulsion, and a moderate crushing component of adjacent soft tissue usually is present. Skin grafts or flaps should not be needed for coverage. 
Type III and Subgroups. The most severe open fractures are classified as type III, with associated subgroups A, B, or C; the letters indicate increasing severity of injury. These fractures typically result from high-velocity trauma and are associated with extensive soft tissue injury, a large open wound, and significant wound contamination. In a type IIIA fracture, there is soft tissue coverage over the bone, which is often a segmental fracture. In a type IIIB fracture, bone is exposed at the fracture site, with treatment typically requiring skin or muscle flap coverage of the bone. Type IIIC fractures are defined as those with an injury to a major artery in that segment of the extremity, regardless of wound size or the other soft tissue disruption. Although these injuries are commonly associated with extensive soft tissue loss and contamination, a type IIIC injury may, in fact, be associated with even a small wound in some cases. Also, key distinguishing factors between type II and type III fractures are the amount of periosteal stripping of the bone, and the severity of the damage to the surrounding soft tissues, as opposed to the size of the skin laceration per se (Fig. 5-5). Some of the factors which determine the correct classification of the open fracture may not be known until the time of surgery; as such, the grade the orthopedic surgeon assigns to the open fracture may change at the time of surgery. 
Figure 5-5
 
A: Grade IIIC open tibia fracture in a 9-year-old boy hit by a bus. B: Appearance of the wound after several debridements. C, D: AP and lateral radiographs showing external fixation of the fracture. Note the vascular clips distally, where an autologous vein graft from the popliteal trifurcation was anastomosed to the posterior tibial artery.
A: Grade IIIC open tibia fracture in a 9-year-old boy hit by a bus. B: Appearance of the wound after several debridements. C, D: AP and lateral radiographs showing external fixation of the fracture. Note the vascular clips distally, where an autologous vein graft from the popliteal trifurcation was anastomosed to the posterior tibial artery.
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Figure 5-5
A: Grade IIIC open tibia fracture in a 9-year-old boy hit by a bus. B: Appearance of the wound after several debridements. C, D: AP and lateral radiographs showing external fixation of the fracture. Note the vascular clips distally, where an autologous vein graft from the popliteal trifurcation was anastomosed to the posterior tibial artery.
A: Grade IIIC open tibia fracture in a 9-year-old boy hit by a bus. B: Appearance of the wound after several debridements. C, D: AP and lateral radiographs showing external fixation of the fracture. Note the vascular clips distally, where an autologous vein graft from the popliteal trifurcation was anastomosed to the posterior tibial artery.
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This classification is widely used and has been shown to correlate in adults with sequelae of the injury, including the potential for infection, delayed union, nonunion, amputation, and residual impairment. However, studies have shown that the Gustilo classification has only moderate interobserver reliability.25,83,134 The Orthopaedic Trauma Association137 has proposed a new classification system that evaluates five parameters: Skin injury, muscle injury, arterial injury, contamination, and bone loss. It has not yet been fully validated. The final functional results of type III fractures in children appear to be superior to results after similar fractures in adults, likely because of their better peripheral vascular supply and the regenerative potential of pediatric periosteum. 

Author's Preferred Method

Three Stages

The treatment of open fractures in children is similar to that for open fractures in adults. The primary goals are to prevent infection of the wound and fracture site, although allowing soft tissue healing, fracture union, and eventual return of optimal function. Initial emergency care includes the ABCs of resuscitation, application of a sterile povidone-iodine dressing, and preliminary alignment and splinting of the fracture. If profuse bleeding is present, a compression dressing is applied to limit blood loss. In the emergency department, masks and gloves should be worn as each wound is thoroughly inspected. Tetanus prophylaxis is updated as needed, and the initial dose of IV antibiotics is given. The dose of tetanus toxoid is 0.5 mL intramuscularly to be given if the patient's immunization status is unknown, or if it is more than 5 years since the last dose. The second stage of management is the primary surgical treatment, including initial and (if necessary) repeat débridement of the tissues in the area of the open fracture until the entire wound appears viable. The fracture is reduced and stabilized at this time. If the bone ends are not covered with viable soft tissue, muscle or skin flap coverage is considered. Vacuum-assisted closure (VAC) therapy (Kinetic Concepts, Inc., San Antonio, TX) may be a useful adjunct to facilitate coverage and obviate the need for flaps in some patients.76,129,210 VAC has been shown to shorten the time of healing of wounds associated with open fractures.107 The third and final stage of this management is bony reconstruction as needed if bone loss has occurred and followed by rehabilitation of the child. 

Cultures

Previous studies have demonstrated poor correlation of growth on routine cultures with wound infections.104,205 Lee104 reported that neither pre- nor postdébridement cultures accurately predicted the risk of infection in open fractures. He noted that only 20% of wounds (24/119) with positive predébridement cultures and only 28% (9/32) with positive postdébridement cultures became infected.104 Although postdébridement cultures were more predictive of infection, these cultures identified the causative organism in only 42% (8/19) of infected wounds. Valenziano et al.204 found that cultures at the time of presentation to the trauma center also were of no value, with only 2 of 28 patients (7%) with positive cultures becoming infected, in comparison to 5 of 89 patients (6%) with negative initial cultures. Initial cultures were positive in only two of seven cases that became infected. Open fractures do not need to be routinely cultured. Cultures should be obtained only at the time of reoperation in patients with clinical evidence of infection. 

Antibiotic Therapy

Antibiotic therapy decreases the risk of infection in children with open fractures. Wilkins and Patzakis213 reported a 13.9% infection rate in 79 patients who received no antibiotics after open fractures, and a 5.5% rate in 815 patients with similar injuries who had antibiotic prophylaxis. Bacterial contamination has been noted in 70% of open fractures in children, with both Gram-positive and Gram-negative organisms noted, depending on the degree of wound contamination and adjacent soft tissue injury. We limit antibiotic administration generally to 48 hours after each surgical treatment of the open fracture.103 
For all type I and some type II fractures, we use a first generation cephalosporin (cefazolin 100 mg/kg/day divided q8h, maximal daily dose 6 g).103 For more severe type II fractures and for type III fractures, we use a combination of a cephalosporin and aminoglycoside (gentamicin 5 to 7.5 mg/kg/day divided q8h).103 
For farm injuries or grossly contaminated fractures, penicillin (150,000 units/kg/day divided q6h, maximal daily dose 24 million units) is added to the cephalosporin and aminoglycoside. All antibiotics are given intravenously for 24 to 72 hours. Although there is a trend toward a shorter duration (24 hours) of antibiotic prophylaxis, there is currently a lack of evidence-based medicine to support specific regimens of duration of antibiotic prophylaxis in children. Oral antibiotics are occasionally used if significant soft tissue erythema at the open fracture site remains after the IV antibiotics have been completed. Gentamicin levels should be checked after four or five doses (and doses adjusted as necessary) during therapy to minimize the risk of ototoxicity. 
An additional 48-hour course is given around subsequent surgeries, such as those for repeat irrigation and débridement, delayed wound closure, open reduction and internal fixation of fractures, and secondary bone reconstruction procedures. 
It should be noted, however, that the guidelines above were developed prior to the widespread prevalence of community-acquired methicillin-resistant Staphylococcus Aureus (MRSA). If the patient is at risk for MRSA, consideration should be given to adding clindamycin or vancomycin to the regimen. Moreover, evidence-based guidelines published in 2006 found that the available data support the conclusion that a short course of a first generation cephalosporin, combined with appropriate orthopedic management, does decrease risk of subsequent infection in open fractures. However, the data were inadequate to either support or refute additional practices such as adding an aminoglycoside for Gustilo type II fractures, or increasing the duration of antibiotic administration.73 

Débridement and Irrigation

After antibiotics are given, débridement and irrigation of the open fracture in the operating room is the next critical step in the primary management of open fractures in children. Some authors have reported that significantly higher infection rates occurred if débridement and irrigation were done more than 6 hours after open fractures in children.98 A multicenter report, however, demonstrated an overall infection rate of 1% to 2% after open long-bone fractures, with no difference in infection rates between groups of patients treated with irrigation and débridement within 6 hours of injury and those treated between 6 and 24 hours following injury.176 Another study of pediatric type I open fractures reported a 2.5% infection rate with nonoperative treatment.85 One likely reason for the low rates of infection in these two series is the early administration of IV antibiotics in both groups. Although up to a 24-hour delay does not appear to have adverse consequences regarding infection rates, it may be necessary to perform an earlier irrigation and débridement to minimize compromise of the soft tissue envelope. The débridement needs to be performed carefully and systematically to remove all foreign and nonviable materials from the wound. The order of débridement typically is (a) excision of the necrotic tissue from the wound edges, (b) extension of the wound to adequately explore the fracture ends, (c) débridement of the wound edges to bleeding tissue, (d) resection of necrotic skin, fat, muscle, and contaminated fascia, (e) fasciotomies as needed, and (f) thorough irrigation of the fracture ends and wound. 
Because secondary infection in ischemic muscle can be a major problem in wound management and healing, in adults, all ischemic muscle is widely débrided back to muscle that bleeds at the cut edge and contracts when pinched with the forceps. In children, who generally heal better and have fewer comorbidities than adults, it is often possible to do a less aggressive debridement at the initial surgery, and wait until questionable tissue declares itself at a second look to determine the definitive necessary extent of debridement. 
When débriding and irrigating an open diaphyseal fracture, we typically bring the proximal and distal bone ends into the wound to allow visual inspection and thorough irrigation and débridement. This often necessitates extension of the open wound, which is preferable to leaving the fracture site contaminated. We carefully remove devitalized bone fragments and contaminated cortical bone with curettes or a small rongeur. If there is a possible nonviable bone fragment, judgment is needed as to whether this bone fragment should be removed or left in place. Small fracture fragments without soft tissue attachments are removed, whereas very large ones may be retained if they are not significantly contaminated. Reconstruction of a large segmental bone loss has a better outcome in children than in adults because children have a better potential for bone regeneration and a better vascular supply to their extremities. Nearby major neurovascular structures in the area of the fracture are identified and protected. Débridement is complete when all contaminated, dead, and ischemic tissues have been excised; the bones' ends are clean with bleeding edges; and only viable tissue lines the wound bed. 
Although a high-pressure lavage system can be used for irrigation, there have been reports of complications, including acute compartment syndrome, using these devices.102,173 Therefore, gravity lavage using wide-bore cystoscopy tubing is a reasonable alternative. Several recent studies, including the multicenter, randomized, blinded Fluid Lavage of Open Wound (FLOW) study have found that low-pressure lavage is safer and more effective than high-pressure lavage.139,143 These studies also examined lavage solutions. Although there were the same number of reoperations in patients treated with saline versus soap (13 in each group), the total number of post-op infections, both operative and nonoperative, and both deep and superficial, was higher in the soap group. The difference approached, but did not reach, statistical significance (p = .019). We routinely use 3 to 9 L of normal saline (with or without soap as per surgeon preference) for the lower extremities and 2 to 6 L in the upper extremities because of the smaller compartment size. Note that high-powered lavage is >70 psi. Many “powered” lavage systems are low pressure, (around 12 psi) so one must consult the manufacturer's data for the details of the particular system in use. 
After the débridement and irrigation are complete, local soft tissue is used to cover the neurovascular structures, tendons, and bone ends. If local soft tissue coverage is inadequate, consideration should be given to local muscle flaps or other coverage methods, including VAC. The area of the wound that has been incised to extend the wound for fracture inspection can be primarily closed. The traumatic wound should either be left open to drain or may be closed over one or more drains. Wounds that are left open can be dressed with a moistened povidone-iodine or saline dressing, but are probably better treated with a VAC. Types II and III fractures are routinely reoperated on every 48 to 72 hours for repeat irrigation and débridement until the wounds appear clean and the tissue viable. This cycle is repeated until the wound can be sutured closed or a split-thickness skin graft or local flap is used to cover it. If flap coverage is necessary, this is optimally accomplished within 1 week of injury. 

Fracture Stabilization

Fracture stabilization in children with open fractures decreases pain, protects the soft tissue envelope from further injury, decreases the spread of bacteria, allows stability important for early soft tissue coverage, decreases cerebral pressure, and improves the fracture union rate. 
Principles for stabilization of open fractures in children include allowing access to the soft tissue wound and the extremity for débridement and dressing changes, allowing weight bearing when appropriate, and preserving full motion of the adjacent joints to allow full functional recovery. 
The concept of “damage-control” orthopedics, in which an external fixator is used to temporarily stabilize a long-bone fracture until the patient is systemically stable enough to undergo definitive fracture fixation, is well studied and accepted in the adult literature.140,164,189,202 There is essentially no pediatric literature on “damage-control” orthopedics, except for one case series of three patients with femur fractures, initially treated with an external fixator, and subsequently revised to submuscular plating.128 External fixators can be put on quickly and safely in the ICU or at bedside without fluoroscopy for pelvic, femur, tibia, and other fractures for initial stabilization, with the understanding that definitive alignment can be achieved later. 
Although casts or splints can be used to stabilize isolated type I fractures and occasionally type II fractures with relatively small wounds and minimal soft tissue involvement, difficulties with soft tissue management and loss of alignment as swelling subsides are common with such closed treatment. Most of these injuries involve the radius or ulna in the upper extremity or the tibia in the lower extremity. Splint or cast immobilization is generally not satisfactory for the more unstable type II and most type III injuries. 
For diaphyseal forearm fractures, a flexible intramedullary implant in the radius and/or ulna commonly provides enough stability of the fracture to allow dressing changes through the cast or splint. For intramedullary fixation, we prefer 2- to 4-mm diameter flexible titanium implants for stabilizing open fractures in the forearm when reduction of either the radial or ulnar fracture is unstable. Since the ulnar canal is straight, the implant chosen is often at least 80% of the narrowest canal diameter, whereas the implant for the radius is generally 50% to 60% of the narrowest canal diameter. The ulnar implant is inserted antegrade, and the radial implant is inserted retrograde just proximal to the distal radial physis. One or both bones can be stabilized, and the implants can be removed easily after fracture healing. 
For distal forearm fractures, percutaneous pinning of the radius (and, occasionally, the ulna) is generally appropriate and provides sufficient stability. A short-arm cast usually is sufficient to maintain appropriate alignment following such fixation. The pins are removed in the office at 3 to 4 weeks, but the cast is used for a total of 6 weeks. 
We also use flexible intramedullary nails for most open fractures of the femoral shaft. For type III fractures, especially if there is a large or contaminated soft tissue wound present, external fixation may be indicated. Trochanteric-entry antegrade nails are gaining popularity and may be considered in children ≥10 years old or those who weigh ≥50 kg (110 lb). 
For most open tibial and femoral fractures in children, flexible intramedullary rod fixation has replaced external fixation as our treatment of choice. Both intramedullary rodding and external fixation allow access to the wound for débridement and dressing changes as well as any soft tissue reconstruction needed.132 Wound access, however, may be limited with external fixators, especially when there are extensive soft tissue wounds. Intramedullary rods generally are better tolerated by patients and families, do not require daily care, leave more cosmetic scars, and are load-sharing devices. With intramedullary rodding, the child is allowed to weight bear as tolerated following transverse or short oblique fractures, but weight bearing is protected for 4 to 6 weeks following comminuted or spiral fractures. 
External fixation is preferable for fractures with segmental bone loss, and ring fixators may even be used in such instances for bone transport. External fixation allows weight bearing relatively soon after the injury. We find that a uniplanar frame is best for most fractures and is relatively easy to apply. For some segmental fractures in the metaphysis and diaphysis, as well as soft tissue injuries, a multiplanar or ring fixator may be a better choice. 
We use open reduction and internal fixation for open intra-articular fractures. When feasible, fixation should be parallel to (and avoid) the physis. Cannulated screws often are used in such instances. Screws or threaded pins should not cross the physis. If fixation across the physis is necessary, smooth pins are used; they should be removed 3 to 4 weeks after injury to minimize the risk of growth disturbance. 
For fractures that involve both the metaphysis and diaphysis, open reduction and internal fixation can be combined with external fixation. For diaphyseal fractures in skeletally immature children, we prefer flexible intramedullary nails to compression plates for internal fixation of type I, type II, and some type III fractures. The superiority of intramedullary or external fixation for type IIIB fractures has not been firmly established. For treatment of a floating joint, usually the knee or elbow, we almost always stabilize both fractures operatively.19,111 

Wound Management

Serial irrigation and débridement are done every 2 to 3 days until the wounds are clean and all remaining tissue appears viable. Fracture fixation at the time of initial surgery (as described previously) facilitates wound management. We prefer to provide soft tissue coverage of the open fracture and adjacent soft tissue defect by 5 to 10 days after the injury to limit the risk of later infection. Most type I wounds heal with local dressing changes. For some type II and type IIIA fractures, we use delayed wound closure or a split-thickness skin graft over underlying muscle cover. 
Large soft tissue loss is most often a problem with types IIIB and IIIC fractures. In the proximal tibia, plastic surgeons may be needed to provide a gastrocnemius rotational flap, followed by secondary coverage of the muscle with a skin graft. In the middle-third of the leg, a soleus flap is used with skin graft coverage, and a vascularized free muscle transfer is necessary if local coverage is inadequate. Free flaps may be required for coverage of the distal third of the tibia, especially in adolescents,153 although there is a 60% postoperative complication rate. VAC sometimes can reduce the need for free tissue transfers. The VAC can convert wounds that need free tissue to ones that need split-thickness skin graft or can heal completely.32,129 
The flaps and grafts used for reconstructing severe injuries are either muscle flaps or composite grafts. For a massive loss of soft tissue and bone, composite grafts of muscle and bone often are necessary. The younger the child, the better the likelihood that autogenous graft will fill in a bone defect if there is a well-vascularized bed from the muscle flap. Free flaps, especially from the latissimus dorsi, are useful in the midtibial and distal tibial regions to decrease infection rates and improve union rates. Vascularized fibular grafts rarely are used acutely to reconstruct bone defects, but may be useful after soft tissue healing. 
For the rare case of significant bone defect in a child, we rely on the healing capacity of young periosteum and bone and the vascular supply of a child's extremity (Fig. 5-6). An external fixator is used to hold the bone shortened about 1 to 2 cm to decrease the size of the bone loss. In a growing child, 1 to 2 cm of overgrowth can be expected in the subsequent 2 years after these severe injuries, so the final leg length will be satisfactory. Autogenous bone graft can be used early, but if there is surviving periosteum at this site, spontaneous bone formation often is surprisingly robust and may preclude the need for bone grafting. In teenagers with bone loss, once the soft tissue has healed, bone transport using either a uniplanar lengthening device or a circular thin wire external fixator is our preferred method of reconstruction, although use of an allograft or vascularized fibular graft may be considered. 
Figure 5-6
 
A: AP radiograph of a 6-year-old boy with bilateral open fractures, fixed with external fixators. Note the bone loss on the left, with only a thin piece of cortical bone remaining. However, his periosteum was preserved. B: Result at 1 year, with healing and hypertrophy of the cortical bone, without bone grafting.
A: AP radiograph of a 6-year-old boy with bilateral open fractures, fixed with external fixators. Note the bone loss on the left, with only a thin piece of cortical bone remaining. However, his periosteum was preserved. B: Result at 1 year, with healing and hypertrophy of the cortical bone, without bone grafting.
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Figure 5-6
A: AP radiograph of a 6-year-old boy with bilateral open fractures, fixed with external fixators. Note the bone loss on the left, with only a thin piece of cortical bone remaining. However, his periosteum was preserved. B: Result at 1 year, with healing and hypertrophy of the cortical bone, without bone grafting.
A: AP radiograph of a 6-year-old boy with bilateral open fractures, fixed with external fixators. Note the bone loss on the left, with only a thin piece of cortical bone remaining. However, his periosteum was preserved. B: Result at 1 year, with healing and hypertrophy of the cortical bone, without bone grafting.
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Amputation

In children, attempts should generally be made to preserve all extremities, even with type IIIC open fractures that are usually treated with primary amputation in adults. Wounds and fractures that do not heal in adults often heal satisfactorily in children and preservation of limb length and physes are important in young children. Although the Mangled Extremity Severity Score (MESS) correlates well with the need for amputation in adults, the correlation is less in children.58 In one series,58 the MESS predicted limb amputation or salvage correctly in 86% (31/36) of children, with 93% accuracy in salvaged limbs but only 63% in amputated limbs. 
If amputation is absolutely necessary, as much length as possible should be preserved. For example, if the proximal tibial physis is preserved in a child with a below-knee amputation at age 7 years, 3 to 4 in more growth of the tibial stump can be expected by skeletal maturity. Thus, even a very short tibial stump in a skeletally immature child may grow to an appropriate length by skeletal maturity. As a result, even a short below-knee amputation at the time of injury would likely be superior to a knee disarticulation in final function. 
Although amputations to treat congenital limb deficits usually are done through the joint to limit bone spike formation (overgrowth) at the end of the stump, we prefer to maintain maximal possible length if amputation becomes necessary as a result of a severe injury. 

Management of Other Fractures

When a child with an open fracture is brought to the operating room for irrigation and débridement of the open fracture, the orthopedist may use this opportunity to treat the other fractures as well, whether operative treatment or closed reduction and casting are needed. In the setting of pediatric polytrauma, most long-bone fractures are treated surgically, to facilitate patient care and rehabilitation. 

Stabilization of Fractures

Key Concepts

  •  
    Fracture stabilization aids in the overall care of the multiply injured child.
  •  
    There are many different operative techniques and implants available and useful to the pediatric orthopedic surgeon.
  •  
    Although about 22% of children who sustain polytrauma have some residual disability, optimal treatment of their orthopedic injuries in a timely fashion decreased their burden of musculoskeletal disability.
  •  
    The best predictor of long-term disability was the Glasgow Outcome Scale 6 weeks after injury and later.205

Beneficial Effects

Fracture stabilization also provides a number of nonorthopedic benefits to a child with multiple injuries. Among the potential benefits are ease of patient mobilization, ease of nursing care, decreased risks of pressure sores, and better access to the wounds. Pulmonary contusions at the time of injury often lead to increasing respiratory problems in the first few days after injury.145 If the lungs have been severely contused, protein leaks into the alveolar spaces, making ventilation more difficult. This may be exacerbated by the systemic inflammatory response syndrome, which is commonly seen following severe trauma.154,212 Surfactant dysfunction follows and is most abnormal in patients with the most severe respiratory failure.108 As the time from the injury increases, pulmonary function deteriorates and general anesthesia becomes more risky. Orthopedic surgical treatment before such pulmonary deterioration limits the anesthetic risks in these patients. In patients with severe pulmonary contusions and multiple fractures, the use of extracorporeal life support may be the only treatment available to allow patient survival.170 
In adults with multiple injuries, early operative stabilization of fractures decreases pulmonary and other medical complications associated with prolonged bed rest that is a part of nonoperative fracture treatment.14 Most adult trauma centers follow the treatment protocol of early fracture stabilization, even though Poole et al.148 reported that, despite early fracture stabilization simplifying patient care, pulmonary complications in patients with marked chest trauma were not prevented and the course of the head injury was not affected. In children, medical complications are less common, so the recommendations that mandate early fracture stabilization are somewhat more difficult to support in young patients. Nonetheless, bruises on the chest or rib fractures should alert the orthopedist to potential pulmonary contusions as a part of the injury complex.141 Initial chest radiographs may not clearly demonstrate the degree of pulmonary parenchymal injury, and arterial blood gas determinations are more useful in estimating the anesthetic risk of these patients during operative care of the fractures. 

Timing

As noted, splinting is needed at the time of the initial resuscitation. In a child with multiple closed fractures, definitive treatment should proceed expeditiously once the child's condition has been stabilized. Loder116 reported that operative stabilization of fractures within the first 2 or 3 days after injury led to fewer complications, shorter hospital and intensive care unit stays, and a shorter time on ventilator assistance in children with multiple injuries. A more recent study by Loder et al.117 reported a trend toward a higher rate of complications in fractures treated after 72 hours. Although there appear to be other factors besides the timing of surgery that affect the eventual outcomes of polytrauma patients, the timing of surgery is a variable that can be controlled by the surgeon, and it seems prudent to complete fracture stabilization within 2 to 3 days of injury when possible. 

Operative Fixation

The type of operative stabilization used in multiply injured children commonly depends on the training, experience, and personal preference of the orthopedist. The most common methods used are intramedullary rod fixation, external fixation, compression plating, and locking plating; Kirschner wires or Steinmann pins may be used in conjunction with casts. 

Intramedullary Rod Fixation

There has been an increase in the use of 2- to 4-mm diameter flexible titanium intramedullary rods for stabilization of long-bone fractures of the upper and lower extremities in children. Intramedullary rodding is most commonly used for unstable closed fractures of the radius and ulna in patients through adolescence and for femoral shaft fractures in patients between the ages of 5 and skeletal maturity.197,208 A trochanteric-entry antegrade nail is often a viable option in children of 10 years old or older or in those with comminuted or length-unstable femoral fractures. The tibia also can be fixed with intramedullary rods in children with an open fracture, polytrauma, a “floating knee” injury (concurrent femur fracture), or a high-energy, unstable injury (especially during adolescence). A diaphyseal fracture of the humerus can be treated with intramedullary fixation in the presence of a “floating” shoulder or elbow.157 
Common indications for intramedullary fixation of forearm fractures include unstable diaphyseal fractures (especially in adolescents) and open fractures.64,101,106,119 Forearm fractures can generally be treated with closed reduction, with the intramedullary implant passed across the fracture site under fluoroscopy for stabilization.101 In one study,106 23% (10/43) of closed forearm fractures treated with intramedullary rod fixation required open reduction. The ulnar implant is placed in antegrade fashion and can be inserted through the lateral proximal metaphyseal area or the tip of the olecranon. The radial implant is inserted retrograde and is contoured to conform to the normal radial bow before insertion. The insertion point is proximal to the distal radial physis and the rod can be inserted from the radial aspect of the distal radius or dorsally (slightly ulnar to Lister tubercle). Stability of both fractures may be achieved by instrumenting only the radius or the ulna in younger children, but both bones are more commonly fixed in adolescents. Intramedullary fixation of open forearm fractures appears to decrease the rate of loss of reduction.64,119 In one series,106 reduction was maintained in all 27 patients treated with rodding of both bones or of only the radius, compared with loss of reduction in 32% (7/22) of patients in whom only the ulna was rodded. The high rate of failure may be because of the small diameter pins (1.6 or 2 mm) used to fix the ulna in this series.106 A cast is used for further immobilization. 
The implants are easily removed from the wrist area and the elbow region 6 to 12 months after insertion. Despite the utility of flexible intramedullary implants for stabilizing forearm fractures in children, the radius and ulna in young patients have significant remodeling capacity and not all fractures require anatomic reduction. A closed reduction and cast immobilization may suffice. Displaced distal forearm fractures in polytrauma patients are often well treated with closed reduction and percutaneous pinning; thus affording sufficient stability for use of a short-arm cast in these polytrauma patients. 
In a series of 20 pediatric patients treated with intramedullary rodding of forearm fractures, 50% of patients had complications including loss of reduction, infection, hardware migration, nerve injury, and delayed union, although 95% (19/20) of patients had excellent or good results at follow-up.45 In another series,220 compartment syndromes occurred in 6 of 80 (7.5%) patients with forearm fractures treated with intramedullary fixation; risk factors in this study were reported to be increased operative time and increased intraoperative use of fluoroscopy. 
If flexible intramedullary nails are used in the femur, the most common technique is retrograde insertion from the medial and lateral metaphyseal region of the distal femur, 2 to 3 cm proximal to the physis. Two rods are used to cross the fracture site and obtain purchase in the proximal femur, usually with one at the base of the femoral neck and the other at the base of the greater trochanter. Rod diameter is generally 40% of the intramedullary diameter of the femoral isthmus, up to a maximum rod size of 4 to 4.5 mm (depending on manufacturer). A cast is not necessary postoperatively, although a fracture brace can be used to help control rotation at the fracture site and provide some patient comfort during early walking, especially for proximal third fractures or those with significant comminution. The implants usually are removed within 1 year of the fracture.74,84 One study showed that intramedullary nailing of the femur had more complications in comminuted fractures and children weighing over 100 lb,60 whereas another noted higher complication rates in children of 10 years old or older at the time of surgery.78 
The use of reamed antegrade intramedullary rods to treat femoral shaft fractures in the pediatric population should be reserved for those with a closed proximal femoral physis. In younger children, rod insertion at the piriformis fossa may interfere with the vascular supply to the femoral epiphysis leading to avascular necrosis (AVN), may cause growth arrest of the greater trochanter (i.e., apophysis with resultant coxa valga), or may interfere with the appositional bone growth at the base of the femoral neck, thereby thinning this region and potentially predisposing the child to a femoral neck fracture.13,30,110,126,135 Some authors have advocated rigid intramedullary rodding using an entrance point at the tip of the greater trochanter.88,119 Nails designed to be inserted through the lateral aspect of the greater trochanter, not the tip, have also shown good results.63,91 A recent meta-analysis of rigid nailing in the pediatric population found an AVN rate of 2% for the piriformis entry site, 1.4% for the trochanteric tip, and no cases of AVN when the lateral trochanteric entry site was used.121 AVN of the femoral head can be a catastrophic iatrogenic injury best avoided. 
Flexible intramedullary rod fixation is becoming increasingly common for diaphyseal tibial fractures. The most common indications currently are open fractures, “floating knee” injuries, and unstable diaphyseal fractures in adolescents. The rods are inserted in antegrade fashion, with medial and lateral entrance points distal to the physis and avoiding the tibial tubercle. As with femoral fractures, rod diameter is 40% of the narrowest intramedullary diameter, with a maximum rod size of 4 to 4.5 mm (depending on implant manufacturer). A short-leg walking cast or fracture boot often is used for comfort for the first 4 to 6 weeks postoperatively, although a splint may be used initially to allow access to wounds associated with an open fracture or degloving injury. 

Compression Plates

Some authors have advocated the use of compression plates to stabilize long-bone fractures, especially in the femoral shaft, in children with multiple injuries.28,99 Kregor et al.99 reported an average overgrowth of the femur of 9 mm, and all fractures healed in a near anatomic position. Caird et al.28 noted that 3% of patients (2/60) had a limb length discrepancy of greater than 2.5 cm following femoral plating, including a 5-cm discrepancy in one child. The disadvantages of compression plating include the need for more extensive operative exposure at the site of the fracture, the fact that they are not load-sharing devices, and the usual need to remove the plate through a relatively long incision once healing is complete. Minimally invasive percutaneous submuscular plating techniques have eliminated some of the problems associated with traditional plating (Fig. 5-7).89,174 Refracture may occur through the screw holes left after plate removal if physical activity is resumed too quickly.89 Stiffness of adjacent joints is rarely a problem in children unless there has been an associated severe soft tissue injury. The number of cortices the screws cross on each side of the fracture may be fewer in children than in adults, because a cast or splint is routinely used in young patients. Kanlic et al.89 reported an 8% incidence of leg length discrepancy after submuscular bridge plating. 
Figure 5-7
Stabilization of femoral shaft fractures in children with multitrauma can be obtained with several methods.
 
Minimally invasive percutaneous submuscular plating techniques can occasionally be used.
 
(Courtesy of Steven T. Morgan, MD, Denver, CO.)
Minimally invasive percutaneous submuscular plating techniques can occasionally be used.
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Figure 5-7
Stabilization of femoral shaft fractures in children with multitrauma can be obtained with several methods.
Minimally invasive percutaneous submuscular plating techniques can occasionally be used.
(Courtesy of Steven T. Morgan, MD, Denver, CO.)
Minimally invasive percutaneous submuscular plating techniques can occasionally be used.
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Although some authors have recommended open reduction and compression plate fixation of displaced radial and ulnar fractures,217 we prefer flexible intramedullary nails in children, as noted earlier. The use of compression plates in the forearm requires a larger operative incision with a resultant scar, a second extensive procedure for plate removal, and a significant risk of refracture following hardware removal. We do not believe that the healing capability of the young child requires the rigid fixation of compression plating to obtain fracture union. 

External Fixation

Traditional indications for external fixation in a child with multiple injuries are open fractures with significant soft tissue injury, fractures in children with a head injury and coma, and “floating knee” fractures of the femur and tibia.7,8,17,19,95,111,157,169,196,221 With advances in intramedullary rod techniques, external fixation is now less common. A unilateral fixator generally is sufficient to hold the fracture reduced in this age group. 
If external fixation is used, the caliber of the pin should be less than 30% of the diameter of the bone into which it is to be inserted to minimize the risk of fracture through a pin site. The distal and proximal pins must be inserted at a level to avoid the physis, and we recommend leaving at least 1 to 2 cm between the pin and physis, partly to avoid any adverse effect on the physis should a pin track infection occur. The proximal tibial physis is more distal anteriorly below the tibial tubercle, and this area must be avoided or a recurvatum deformity of the proximal tibia and knee will result. The external fixator is usually left in place until fracture healing is complete, but it can be removed once the reason for placement has resolved (such as waking from coma or healing of a skin wound).56,214 If the fixator is removed early, a walking cast is applied. Transverse open fractures reduced out to length take longer to heal than do oblique fractures reduced with slight overlap. Refracture is a well-described risk following fixator removal. However, refracture rates have been variable, with a 21% rate noted in a series in which a rigid transfixion type of fixator was used195 and a 1.4% rate in a series with more flexible unilateral frames.17 One report indicated that if three of the four cortices at the fracture site appear to be healing on anteroposterior and lateral radiographs of the fracture, the refracture rate after frame removal should be low.177 
Laboratory studies have suggested that dynamization of external fixators may stimulate early fracture healing.35,100 We prefer to dynamize the fixator early to stimulate callus formation, although the effect of dynamization on refracture rates is unclear.52,93 

Outcomes of Treatment of the Multiply Injured Child

In one review of 74 children with multiple injuries, 59 (80%) survived, but after 1 year, 22% were disabled, mainly from a brain injury.205 At 9 years after the injuries, 12% had significant physical disability, whereas 42% had cognitive impairment. In this group, however, the SF-36 or functional outcome survey did not differ from the control population. The best predictor of long-term disability was the Glasgow Outcome Scale 6 weeks after injury and later.205 Letts et al.109 reported that 71.6% of multiply injured children made a full recovery, with a mean of 28 weeks until full recovery. Of the 53 residual deficits in 48 patients, the common deficits were neurologic (38%), psychosocial (34%), and musculoskeletal (24%).109 Outcomes of children with pelvic fractures were near normal at 6 months.171 
Whether operative or nonoperative fracture treatment is chosen for a child with multiple injuries, it is important that an orthopedist be involved in the care of the child from the start. Although recognizing the need to care for the other organ system injuries the child has sustained, it is important to advocate for the expeditious and appropriate treatment of the fractures that are present. Failure to do so will leave the multiply injured child with musculoskeletal disability once healing of the other injuries occurs. 
After multiple injuries, the most common long-term problems relate to either sequelae of the head injury or of the orthopedic injuries. 

Acknowledgments

The authors gratefully acknowledge Vernon T. Tolo, MD and Frances Farley, MD, for their past contributions to this chapter. 

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