truma

Pediatric Polytrauma ManagementHeike Jakob, Thomas Lustenberger, Dorien Schneidmller, Anna L. Sander, Felix Walcher,Ingo Marzi1

AbstractCaring for pediatric trauma patients requires anunderstanding of the distinct anatomy and patho-physiology of the pediatric population compared toadult trauma patients. Initial evaluation, manage-ment, and resuscitation are performed as a multidis-ciplinary approach including pediatric physicians,trauma surgeons, and pediatric intensive care physi-cians. Head injury severity is the principle determinantof outcome and mortality in polytraumatized children.Abdominal injuries rarely require surgery in contrast toadults, but need to be detected. Spine and pelvicinjuries as well as injuries of the extremities requireage-adapted surgical procedures. However, the degreeof recovery in polytraumatized children is oftenremarkable, even after apparently devastatinginjuries. Maximal care should, therefore, be renderedunder the assumption that a complete recovery will bemade.

Key WordsPediatric polytrauma Injury pattern Traumaroom management Critical care

Eur J Trauma Emerg Surg 2010;36:32538DOI 10.1007/s00068-010-1125-3

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

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

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

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

1 Department of Trauma, Hand and Reconstructive Surgery, JohannWolfgang Goethe University Medical School, Frankfurt/Main,Germany.

Received: June 14, 2010; accepted: June 15, 2010;Published Online: July 29, 2010

European Journal of Trauma and Emergency Surgery Focus on Pediatric Polytrauma

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

Assessment of the patients breathing followsestablishment of the airway. Infants and small childrenare primarily diaphragmatic breathers; consequently,any compromise of diaphragmatic excursion signifi-cantly limits the childs ability to ventilate. Severe gastricdilation due to the swallowing of air may cause respira-tory difficulties or complicate the abdominal examina-tion. Gastric decompression with a naso- or orogastrictube should be employed in appropriate cases.

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

As in adults, a focused assessment sonography intrauma (FAST) is performed during the primaryevaluation of the injured child [14]. A recent reviewdemonstrated the sensitivity of FAST examination tobe 3088% and the specificity to be 42100% in

pediatric trauma patients [15]. In children in particular,a lack of free intraperitoneal fluid does not excludesignificant organ injuries. The majority of children withhemoperitoneum do not necessarily require operativeintervention [16, 17].

Computed tomography (CT) scanning of the head,chest, abdomen, spine, and pelvis is the preferredtechnique for imaging hemodynamically stable injuredchildren or for imaging hemodynamically stable, intu-bated patients with suspicious injury mechanisms (Ta-ble 1) [18]. However in particular in the awakepatient a thorough physical examination and evalu-ation of the trauma mechanism may permit theavoidance of a complete CT diagnostic, reducing theradiation burden. Nevertheless, despite the seven timesincreased radiation exposure in polytrauma CT scanscompared to conventional X-rays, long-term adverseeffects have not been proven yet. In particular in theseverely injured patient, the shorter diagnostic work-up time and valuable information on intracorporalinjuries may beneficially influence outcome [19](Figures 1 and 2).

Pediatric Scoring SystemsMany trauma scoring systems have been used to assesschildren following polytrauma. The Injury SeverityScore (ISS), an anatomical scoring system that pro-

Table 1. Computed tomography (CT) diagnostic during the initial assessment.

Technical considerations Specific diagnostic considerations

CT brain and cervical spine Age-based CT slice thicknessSequential techniquei.v. contrast if clinical suspicion of vascular injuryCoronary reconstruction of skull and facial bones

Brain and skull Intracranial hemorrhage Edema Vascular injury FractureCervical spine Fracture, assessment of stability Luxation

CT chest and thoracic spine Age-based i.v. contrast dosageAge-based CT slice thicknessMultiplanar reconstruction of the spine

Parenchymal injuriesContusionsPneumo-/hemothoraxPosition of thoracostomy tubePericardial fluidVascular injuryFracture, assessment of stabilityLuxation

CT abdomen, lumbar spine,and pelvis

Weight-based i.v. contrast dosageAdequate delay times (early phase for arterial injuries,portal venous phase as standard, late phase for kidney injuries)

Solid organ injuriesFree fluidRetroperitoneal injuries and retroperitoneal bleedingHollow viscus injuriesFracture, assessment of stability

Jakob H, et al. Pediatric Polytrauma Management

326 Eur J Trauma Emerg Surg 2010 No. 4

vides an overall score for patients with multiple inju-ries, is reproducible and useful in pediatric traumapatients [2022]. An ISS of 16 or more is usually takento indicate a polytrauma.

The Pediatric Trauma Score (PTS) is a physiolog-ical score emphasizing the childs weight and airway.Several studies have confirmed that the PTS is a validtool for predicting the mortality of a traumatically in-jured child [2325]. Mortality is estimated at 9% with aPTS > 8 and at 100% with a PTS 0.

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

Head InjuriesHead injuries have been reported in 17% of childrenwith polytrauma [26], representing the most commoncause of long-term disability [27, 28]. Compared to

adults, the pediatric population is more susceptible totraumatic brain injury (TBI) because the more pliable,thinner, immature skull provides less protection to theintracranial contents. Weak cervical musculature and aproportionally increased head mass also bias thepediatric population toward TBI. In addition, myeli-nation occurs between 6 and 24 months of age, makingthe brain very soft and prone to disruption prior to thecompletion of this process.

Injuries to the brain are classified as primary orsecondary. Primary injuries are inflicted immediatelyby trauma, while secondary injuries result from hypoxia,hypotension, hypercarbia, anemia, hyperglycemia,infections, seizures, or increased intracranial pressure(ICP) in addition to the primary injury. Following TBI,the incidence of increased ICP is far higher in childrenthan in adults (80 vs. 50%) [29], constituting a signifi-cant source of secondary brain injury (Figure 3). Ele-vated ICP may be caused by hematoma, increasedcerebral blood volume, or increased brain volume, andmay cause a reduction in cerebral perfusion pressure(CPP). Target CPP levels are 6080 mmHg in older

Figure 1. Standardized initialassessment and resuscitationof the polytraumatized pediat-ric patient (adapted from Franket al. [62] and Helm et al. [63]).

Table 2. The pediatric Glasgow Coma Scale (GCS) [58, 59].

Score Eye opening Verbal response Motor response

6 Normal, spontaneous, obeys commands5 Age-appropriate words, social smile, fixes and follows Localizes pain4 Spontaneous Cries, but consolable Withdraws from pain3 To voice Persistently irritable Flexion posture to pain2 To pain Restless, agitated Extension posture to pain1 None None None


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

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

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

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

Severe traumatic brain injury

Operation, Decompression

Chest trauma with hemo-/ tension-pneumothorax

Thoracostomy tubeOperation

Abdominal trauma with presence of free intra-abdominal fluid

Damage Control LaparotomyPacking

Pelvic trauma Pelvic binder, sheet wrapFixateur externe

Ongoing bleeding:Embolization Pelvic tamponade

Extremity trauma with active bleeding

Compression bandageVascular clampOperationlife before limb

Hemorrhagic shock Volume substitution therapyTransfusionCoagulation factor replacementWarm blanket

Goals:

Regaining sufficient cardiovascular functionReversal of coagulopathyNormalization of body core temperatureEarly decision regarding the therapeutic approach (treat first what kills first)

Minimizing blood loss

Figure 2. Acute managementof life-threatening injuries andhemodynamically unstablepediatric patients.

Table 3. Age-appropriate CPP thresholds in severe traumatic braininjury (according to Fritz et al. [60] and Jhr et al. [61]). (CPP: cerebralperfusion pressure).

Age group (years) CPP threshold (mmHg)

01 6016 6065613 70> 13 7080



hematomas resulting in intracranial hypertensionshould be evacuated within the first 3 h followinginjury, as long-term results significantly worsenthereafter [30]. A decompressive craniectomy shouldbe considered in children with cerebral edema andmedically uncontrolled intracranial hypertension [31].Nutritional support and treatment of postinjuryseizures are further important aspects of the care of thebrain-injured child.

After initial hemodynamic stabilization, a TBIrequiring operative intervention takes priority. As inadults, the severe TBI in children is the most commoncause of death and is an important determinant pre-dicting outcome (Figure 4).

Indications for operative interventions in pediatrictraumatic brain injuries (TBIs):

Increased ICP due to space-occupying intracranialhemorrhages requires immediate operative intervention.

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

Chest InjuriesChest injuries account for 5 to 12% of admissions topediatric trauma centers [32] and thoracic trauma hasbeen reported in 8 to 62% of pediatric polytraumacases [26, 27]. While a 5% mortality rate for isolatedchest trauma has been reported, this figure increases to25% in the presence of concomitant head or abdominalinjuries [32]. Thoracic injuries are important variablespredicting outcome and play a cornerstone role in themanagement of pediatric trauma [33].

Children exhibit distinct patterns of chest injuriescompared to adults [34]. The pediatric thorax has agreater cartilage content and incomplete rib ossification,

Figures 3a to 3c. A 3 years and 3 months old girl was airlifted to our hospital after a fall from the fourth floor of a building. Admissioncomputed tomography (CT) scan of the head demonstrates traumatic brain injury with severe brain edema obliterating the ventricles (a).Intracranial pressure (ICP) monitoring was initiated on admission day (b). Due to increasing brain edema and subsequent uncontrollableintracranial hypertension, bilateral decompressive craniectomy was performed on day 2 after trauma (c).

Minor injury w/o ongoing bleeding or signs of increasing cerebral edema

Conservative

Intensive careHyperventilationFluid restrictionBarbituratesICP monitoring

Intracranial hematomas with increasing ICP Operative Evacuation

Cerebral edema / uncontrollable intracranial hypertension

Operative Decompressive craniectomy

Figure 4. Current treatmentprocedures for pediatric braininjuries.



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

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

Pulmonary contusions remain the most commonform of pediatric thoracic trauma; the diagnosis ismade by chest X-rays in approximately 90% of cases,with half of the cases demonstrating rib fractures,hemothorax, and/or pneumothorax on radiographs[32]. Pulmonary contusions may lead to atelectasis,consolidation, and progressive inflammation, possiblyresulting in pneumonia, ventilationperfusion mis-match, and respiratory insufficiency. The risk ofdeveloping pneumonia in cases of severe pulmonarycontusions is 2030%, supporting the use of earlyantibiotic treatment. In contrast to adults, a kinetictherapy is, in general, not necessary.

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

Tracheobronchial injuries are usually located in thelower trachea or upper bronchus. Multiple findingsmay include pneumothorax, hemothorax, pneumome-diastinum, subcutaneous emphysema, or persistent airleak from a chest tube. If the injury involves less thanone-fourth of the bronchus diameter, nonoperativetherapy with frequent bronchoscopic examination maybe suitable (Figure 6).

Indications for operative intervention in pediatric chesttrauma:

Persisting hemodynamics compromising thoracos-tomy tube output.

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

Abdominal InjuriesAbdominal injuries are reported in 8 to 27% of pedi-atric polytrauma patients [26, 35]. Because children aregenerally healthy, with good physiological reserves,they may initially remain clinically stable, despite sig-nificant injuries. Tachycardia is the earliest (and oftenthe only) sign of hemorrhagic shock with imminenthemodynamic decompensation.

Figures 5a and 5b. Severebilateral lung contusions andpneumothorax (a) in a 16-yearold girl following a motorvehicle accident. Abdominal CTscan additionally shows freeintraperitoneal fluid and asplenic laceration (b), whichwas successfully treated non-operatively.

Pneumo-/Hemothorax Chest Tube

Ongoing bleeding Surgery

Tracheobronchial injury Bronchoscopic examination

Figure 6. Current treatment procedures for pediatric chest trauma.



Anatomical differences in children make themmore vulnerable to major abdominal injuries fromminor forces. Compared with the adult patient, thechilds intra-abdominal organs are proportionally largerand in closer proximity to each other. The childs smalland pliable rib cage and the undeveloped abdominalmusculature provide little protection for major organs.

In the hemodynamically unstable patient, imme-diate operative intervention is indicated followingcompletion of the primary or secondary surveys,respectively. In less critically ill patients, further diag-nostic evaluation for intra-abdominal injuries is gen-erally performed by CT scan.

Liver and spleen injuries are commonly seen inpolytraumatized children. The vast majority of theseinjuries can be managed non-operatively with successrates of up to 95% [3638]. Selective, non-operativemanagement requires hemodynamic stability and ab-sence of peritoneal signs. Those patients should bemonitored closely with serial clinical examinations andserial hematocrits for evidence of ongoing bleeding.Failure of non-operative treatment usually occurswithin the first few hours of admission. Although themajority of children do not require surgery for splenicor hepatic injuries, children presenting hemodynamicinstability belong in the operating room for hemor-rhage control. Organ-preserving techniques are pre-ferred in adequately resuscitated patients that do notdemonstrate ongoing hemorrhagic shock. Splenorrha-phy and partial splenectomy are techniques to controlbleeding while preserving splenic parenchyma. Sple-nectomy may be required in the critically ill child or inthe case of a completely shattered spleen. Hepator-rhaphy, perihepatic packing, or suture ligation ofbleeding vessels are preferred over extensive hepaticresections.

The operative management of liver injuries isbased on the damage control concept. Patients with

a major hepatic laceration, surgically uncontrollablebleeding, coagulopathy, or hypothermia require peri-hepatic packing [36]. Definitive operative treatment ofinjured liver vessels or bile ducts is performed afterachieving hemodynamic stabilization and reversal ofcoagulopathy.

Following primary life-saving operative interven-tions of abdominal injuries, the diagnostic evaluationshould be completed.

Hollow viscus injuries are frequently encounteredin restrained children involved in a motor vehicleaccident. This injury mechanism is often indicated byabdominal wall ecchymosis (seatbelt sign), with asudden increase in the intraluminal pressure resultingin blowout or perforation of the intestine. CTscanning is diagnostic in only 60% of bowel perfora-tion cases and may reveal free fluid without evidenceof solid organ injuries [39]. Close observation andserial physical examination should guide ambiguousfindings, and fluid around the duodenum and pan-creas may be a predictive sign. Once diagnosed, thesurgical treatment of perforations involving greaterthan 50% of the circumference usually requires seg-mental resection with primary anastomosis, whereasperforations of less than 50% of the circumferencecan be repaired primarily. Only in cases of severeabdominal contamination or rectal injuries is a two-stage procedure with temporary creation of a colos-tomy indicated.

Pancreatic injuries are rare, comprising less than5% of all pediatric abdominal injuries, and whosediagnoses are frequently delayed. The diagnosis ofpancreatic injury is suggested by an elevated amylaselevel and the clinical sign of significant epigastricpain. Only in extensive pancreatic injuries wasearly partial resection associated with improved out-comes as compared to conservative management [40](Figure 7).

Liver / splenic injury

Hemodynamically unstable

Immediate operatione.g. abdominal packing

Hemodynamically stable

Non-operativeSerial clinical examinations, blood values

Hollow viscus injury

Immediate operative intervention

Figure 7. Current treatmentprocedures for pediatricabdominal trauma.



Pelvic TraumaThe immature pelvis has greater elasticity in thesacroiliac joint and the symphysis, making fracturesdependent on higher energy forces. Pediatric pelvicfractures consequently accompany multiple injuries[41, 42]. Clinical signs of pelvic fractures includesuperficial hematomas above the inguinal ligament orthe scrotum (Destots sign), a decrease in the distancebetween the greater trochanter and the pubic spine ascompared to the contralateral side (Rouxs sign) inlateral compression fractures, and a large hematoma ora palpable fracture line discovered on rectal examina-tion (Earles sign).

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

Acetabular fractures in children are infrequent andevidence-based studies regarding the treatment ofpediatric acetabular fractures are rare. Injury of thegrowth plate might result in growth arrest and sub-sequent subluxation of the femoral head. Conse-quently, an adequate diagnostic evaluation is necessaryto determine the management strategy on an individ-ual basis.

Treatment of pediatric acetabular fractures:

In acetabular fractures, anatomical reduction isnecessary to achieve good long-term results. Thepreferred approach is screw osteosynthesis [44].

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

Head, chest, and visceral trauma are often combinedwith pediatric pelvic fractures [46]. The urogenitalsystem, especially the perineum, vagina, rectum, andbladder, should receive specific evaluation during theinitial physical examination, as those injuries are oftenmissed and can lead to potentially serious conse-quences. Bladder injuries may require urgent repair inthe case of intraperitoneal rupture, or delayed repairversus observation for extraperitoneal injury (Fig-ure 8).

Spinal TraumaSpine fractures are rare in children, representing only12% of all pediatric fractures [47]. This low incidenceis due not only to the plasticity of the pediatric spine,but also to the usually severe (if not fatal) associatedinjuries. The disproportionately large head size andrelatively weak neck muscles, the horizontal orienta-tion of the upper cervical facet joints, and ligamentouslaxity place the upper cervical spine (C0C2) at

Stable fracture Conservative

Unstable fracture OperativeExternal fixationPlate osteosynthesis

Ongoing bleeding OperativeExtraperitoneal packingExternal fixation

Intraperitoneal bladder injury Operative

ReconstructionOsteosynthesis

Figure 8. Current treatmentprocedures for pediatric pelvictrauma.



high risk for injury in children younger than 12 years ofage.

Incomplete ossification and physiological hyper-mobility of the pediatric cervical spine contribute toimaging findings that can be confused with pathologicalconditions. Increased anterior displacement of C2 onC3 (pseudosubluxation) may be mistaken for a cervicalspine injury; this condition may be found in patients upto 16 years old. Pseudosubluxation of C3 on C4 occursless frequently, while an increased distance betweenthe dens and the anterior arch of C1 occurs inapproximately 20% of young children. Normal wedg-ing of an intervertebral space or the C3 body andnormal translucencies of the dens may also be mis-taken as spinal trauma and fractures, respectively [48].

Atlanto-occipital dislocation is a rare and oftenfatal injury [49]. These patients are usually polytraumavictims with severe head injuries who present with arange of clinical neurological issues, from cranial nervedysfunction to varying degrees of quadriplegia andcomplete loss of neurological function below the brainstem [50]. Early reduction and definitive immobiliza-tion using a halo cast alone or with supplementalinternal fixation and posterior fusion should be per-formed [51, 52].

Odontoid fractures are a common pediatric cervi-cal spine injury; however, neurological deficits are rare[53]. These fractures usually displace anteriorly, withthe dens posteriorly angulated. Displaced odontoidfractures in children reduce easily following mildextension and posterior translation. Healing is rapidand immobilization with a halo cast can be completedin 610 weeks.

Traumatic ligamentous instability usually occurs inthe upper cervical spine (C2/C3) in younger children.Treatment consists of closed reduction and haloimmobilization for approximately 8 weeks. However,in rare cases, posterior cervical fusion with subsequentMinerva jackets or halo immobilization is necessary.

C3C7 fractures are more common in older chil-dren and adolescents than in younger children [54].The typical injury patterns include compressionfractures of the vertebral body, which can be treatedwith Philadelphia immobilization. Persistent instabil-

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

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

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

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

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

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

Stable fracture Conservative

Unstable fractureNeurologic deficits Operative LaminectomyInternal fixation

Figure 9. Current treatmentprocedures for pediatric spinaltrauma.



quire emergency care. Stable osteosynthesis of thefracture is performed by, firstly, repair of the extremityartery, veins secondly, and, finally, tissue coverage isperformed.

Fractures of the epi- and metaphysis are mostlytreated by K-wire osteosynthesis. Some cases requireadditional or alternative application of an externalfixator. Depending on the fracture pattern and char-acteristics, as well as the age of the child, open reduc-tion and internal fixation using screw and/or plateosteosynthesis may be an option. Diaphyseal fracturesare predominantly fixed using flexible intramedullaryrods, such as elastic stable intramedullary nailing. Plateosteosynthesis of diaphyseal fractures during adolescenceshould, at most, be considered as a temporary stabiliza-tion using minimally invasive techniques [55]. However,early definitive osteosynthesis of extremity fracturesshould be a goal of pediatric patient management.

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

treated by decompression of the afflicted compart-ments by the incision of their fascia. The stabilizationof fractures is subsequently performed as describedabove. Vacuum-assisted closure devices or artificialskin are used to temporarily cover tissue defects orfasciotomy sites.

Open fractures and open joint injuries are pri-marily washed out, debrided, and subsequently stabi-lized. In cases of severe, open articular fractures, a two-stage management may be necessary.

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

Figures 10a to 10f. A 16-year-old boy was admitted to thetrauma room after a jump fromthe second floor of a building.Shock room CT revealed severetraumatic brain injury withsubarachnoid hemorrhage, in-traparenchymal hematomas,and skull fracture, as well assevere chest trauma with lungcontusions on the right side.Admission X-rays demonstratea fracture of the right femoralneck (a), and a right distal ra-dius fracture (b). During theinitial procedure, intracranialpressure (ICP) monitoring wasinstalled, a thoracostomy tubewas inserted, the femoral neckfracture was stabilized by screwosteosynthesis (c, d), and astabilization of the distal radiusfracture using K-wires wasperformed (e, f).



placed distal forearm fractures can be addressed bycasting.

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

Children often recover remarkably well from whatinitially appear to be devastating injuries to the centralnervous system or other organ systems. Consequently,optimal orthopedic care must be undertaken with theassumption that the injured child will completely re-cover (Figure 11).

The complications after trauma are given inTable 4.

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

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

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

To avoid secondary lung damage (pneumothoraxor acute respiratory distress syndrome), ventilation isbased on pressure control, which provides peak inspi-ratory pressure throughout inspiration. Initially,relaxation may be required to reach the therapeutictarget of arterial pO2 > 100 mmHg. In brain-injuredpatients, the positive end-expiratory pressure shouldbe minimized to allow sufficient drainage from thecervical venous system; however, the pressure shouldnot fall below 3 cm H2O. Again, PiCCO monitoringmay be a valuable tool in patient management.

ConclusionCaring for pediatric trauma patients requires anunderstanding of the distinct anatomy and patho-physiology of the pediatric population compared toadult trauma patients. Initial evaluation, manage-ment, and resuscitation require a multidisciplinaryapproach including trauma surgeons, anesthesiolo-gists, and pediatric intensive care physicians. Headinjury severity is the principle determinant of out-come and mortality in polytraumatized children.Nevertheless, the degree of recovery in polytrauma-tized children is often remarkable, even after appar-ently devastating injuries. Maximal care should,therefore, be rendered under the assumption that acomplete recovery will be made.

Open fracture Operative

Closed diaphyseal fracture

OperativeOsteosynthesisExternal fixation

Joint fracture OperativeReductionOsteosyntesis

Compartment syndrome Operative

DebridementExternal fixation

Figure 11. Current treatmentprocedures for pediatricextremity trauma.



Table 4. Complications after trauma in the pediatric patient.

Traumatic brain injury Diffuse brain edemaCoagulopathyThromboembolic eventsApallic syndromePosttraumatic epilepsyPostoperatively: Increase of ICP BleedingIncreased risk of complications with GCS < 8

Chest trauma PneumoniaAcute respiratory distress syndrome (ARDS)Abscess, empyema

Abdominal trauma Postinjury organ failure due to abdominal malperfusion during hemorrhagic shockSecondary hemodynamic instability in cases of non-operatively treated liver and splenic injuriesPeritonitis due to hollow viscus injuries or protracted intestinal wall necrosisDelayed solid organ rupturePostoperatively: Re-bleeding Infections/wound dehiscence (abdominal wall) Abscess Adhesions, posttraumatic ileus Abdominal wall herniaLate complications:Mainly due to missed injuries, mostly of the intestine, following blunt abdominal trauma

Spinal trauma Growth disturbance/deformity in cases of injured growth plateProgressive deformity in case of persisting instability and neurological symptomsPosttraumatic paralysisFusion of spinal segments following damage of end platesPostoperatively: Progression of neurological decits Re-bleeding Implant dislocation

Pelvic trauma Early complications: Blood loss due to intra-abdominal or retroperitoneal injuries (fracture, presacral venous plexus) Peritonitis following disruption of the pelvic oor, rectal injuries Urinary incontinence

Late complications: Growth disturbance (fusion of pubic symphysis or iliosacral gap) Acetabular dysplasia with hip luxation

Postoperatively: Re-bleeding Neurovascular injury Implant dislocation

Extremity trauma Compartment syndromeInfectionSoft tissue defectImplant failurePremature growth plate closure, growth arrestNon-unionLeg length discrepancyNerve injury, motoric dysfunction



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

interest in relation to this article.

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Address for CorrespondenceProf. Dr. Ingo MarziDepartment of Trauma, Handand Reconstructive SurgeryJohann Wolfgang Goethe University Medical SchoolTheodor-Stern-kai 760590 Frankfurt/MainGermanyPhone (+49/69) 6301-6123, Fax -6439e-mail: [email protected]



Pediatric Polytrauma ManagementAbstractIntroductionInitial Assessment and ResuscitationPediatric Scoring SystemsHead InjuriesChest InjuriesAbdominal InjuriesPelvic TraumaSpinal TraumaExtremity TraumaPediatric Critical CareConclusionConflict of interest statementReferences

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