Managing Pediatric Orthopedic
Trauma Emergencies
When is it not “Just a broken
bone”
Stephen A. Mendelson M.D.
Director of Orthopedic Trauma
Children’s Hospital Of Pittsburgh of
UPMC
Pediatric Orthopedic Trauma
Pediatric Orthopedic Trauma
Pediatric Orthopedic Trauma
Pediatric Orthopedic Trauma
Pediatric Orthopedic Truama
Pediatric Orthopedic Trauma
Nonaccidental Injury
Pediatric Orthopedic Trauma
20-30% Trauma patients have orthopedic
injury.
55% of Nonaccidental patients have
musculoskeletal injury
As many as 1/3 ER visits related to
accidents or injuries
Orthopedic Trauma
Simple to Complex
Broken Finger
Pelvic Facture
Factors Predicting Injury Severity
and Outcomes
Injury Mechanism
– High Impact
MVA
Fall from Height
Motorcycle and ATV
– Low Impact
Ground Level Fall
Sports Accident
Factors Predicting Injury Severity
and Outcomes
Concurrent Injuries
–
–
–
–
Head Injury
Visceral Injuries
Burns
Soft Tissue
Factors Predicting Injury Severity
and Outcomes
Associated Injuries
– Vascular
– Neurologic
Factors Predicting Injury Severity
and Outcomes
Comorbidities
Systemic
Musculoskeletal
Orthopedic Emergencies
The Big Seven!
Open Fracture
Compartment syndrome
Vascular Compromise
Deteriorating Neurologic Exam
Acute Dislocation Major Joint
Femoral Neck fracture
Open or Septic Joints
Open Fractures
Any fracture where the bone is exposed to
the environment through a soft tissue
defect. Graded I,II, III based on severity of
soft tissue wound.
Require urgent cleansing and surgical
debridement to prevent infection, and
promote healing
Open fracture
Compartment syndrome
Soft tissue injury and
subsequent swelling that
exceeds the capacity of
the fascial space or
muscle compartment
causing increasing
pressure in the muscle
compartment. Ultimately
cutting off circulation and
damaging the muscles
and nerves
Compartment Syndrome
Symptoms and Signs
Pain
– Out of proportion to injury
– Pain with passive muscle stretch
Paresthesia
Pallor
– Cool, mottled, loss of capillary refill
Pulselessness
Paralysis
Compartment Syndrome
Diagnosis and Treatment
Physical exam
– Most reliable in awake patient
Compartment pressure measurements
FASCIOTOMY!!!
Fasciotomy
Fractures with associated
vascular Compromise
Immediate vascular insufficiency
– Reduce (align) fracture
– If vascular perfusion not restored explore,
repair or consult
Initial pulse lost aster reduction
– Vessel caught in fracture site. Explore, repair
or consult
Vascular Injuries
Deteriorating Neurologic Exam
Static Neurologic Deficit
– Can observe or explore at time of fracture
treatment
Deteriorating Neurologic Deficit
– Nerve compressed, stretched or entrapped
– Reduce fracture and explore nerve before
permanent damage
Common Nerve Injuries
Femoral Neck Fractures
Blood supply to femoral head very tenuous
Prolonged loss of blood to femoral head
causes permanent damage … Avascular
Necrosis (AVN)
Emergent reduction and stabilization
reduces risk of AVN
Pediatric Femoral Neck Fractures
Avascular Necrosis
Dislocations
Shoulder
Elbow
Hip
Knee
Ankle
Open Joint
Common orthopedic injuries
that are not as urgent as the
look
(Or The surgeon may say they
are to get into the OR quicker)
Badly Displaced fractures
Growth Plate Fracture
Salter Harris
Classification
Salter Harris 1
Salter Harris 2
Salter Harris 3
Salter Harris 4
Intraarticular fractures
Static Neurologic deficit
Nerve Palsey
Complete Spinal Cord
Injury
Other Orthopedic considerations
Child Abuse
>50% long bone
fractures in
nonambulatory
children.
20% Recurrence
Rate.
1-5% Mortality.
Child abuse fracture Patterns
Polytrauma
ARDS
Shock
Fat Emboli
Multidisciplinary Approach
Paramedics and Transport
Emergency Room
Trauma Service
Intensives Care Unit
Neurosurgery
Orthopedics
Damage Control Orthopedics
Provisional Stabilization During
Resuscitation period
Summery
Orthopedic trauma can very from simple sprains
strains and minor fractures to major multisystem
polytrauma.
Recognition of orthopedic emergencies and
urgencies can help triage and manage the care
of all patients in a trauma center setting.
Orthopedic injuries are common, recognizing the
common pitfalls is critical to avoiding serious
complications.
A team approach is best!!!!!!!!
Thank You!