Traumatic pelvic fractures in children and adolescents

Although traumatic pelvic fractures in children are relatively rare, these injuries are identified in about 5% of children admitted to level 1 trauma centers after blunt trauma.1, 2, 3, 4 Such injuries differ from adult pelvic fractures in important ways and require distinct strategies for management. While the associated mortality rate for children with pelvic fractures is much lower than that for adults, the patient may require urgent surgical intervention for associated life-threatening injuries such as head trauma and abdominal injury. Unstable pelvic ring fractures should be acutely managed using an initial approach similar to that used in adult orthopedic traumatology. Although very few pediatric pelvic fractures will ultimately need surgical treatment, patients with these injuries must be followed over time to confirm proper healing, ensure normal pelvic growth, and address any potential complications. The trauma team suspecting a pelvic fracture in a child must understand the implication of such a finding, identify fracture patterns that increase suspicion of associated injuries, and involve pediatric or adult orthopedic specialists as appropriate during the management of the patient.     

Review of the evidence on the management of blunt renal trauma in pediatric patients

Due to the size and location within the pediatric patient, the kidneys are susceptible to injury from blunt trauma. While it is clear that the goal of management of blunt renal trauma in children is renal preservation, the methods of achieving this goal have not been well established in the current literature. Therefore, we have set out to summarize and clarify the current published information on the management strategies for blunt renal trauma in children. While there is extensive literature available, it consists mostly of retrospective series documenting widely varied management styles. The purpose of this review is to display the current information available and delineate the role for future studies that may allow us to develop consistent management strategies of pediatric patients, who have sustained blunt renal trauma, in a safe and cost-effective manner.     

Pattern of pediatric ocular trauma in India

OBJECTIVE: The aim of the study is to identify the causes, demographic and clinical profile and evaluate final visual outcome of pediatric ocular injuries. METHODS: Two hundred and four children aged fourteen years or less presenting to the emergency services of a tertiary care centre with ocular injury were included. Demographic data, nature and cause of injury, duration between injury and presentation to an ophthalmologist and the diagnosis were recorded. Evaluation of visual acuity, anterior segment and fundus were done. All patients were appropriately managed and followed up on days 1, 7, 1 month, 3 and 6 months. RESULT: Majority of injuries occurred in children of 5 years and older (87.7%). There were 133 (65.1%) boys and 71 (34.9%) girls. Forty-nine (24%) cases presented within 6 hours of injury while 70 (34.3%) presented after more than 24 hours after trauma. Most common cause of injury was bow and arrow (15.2%) followed by household appliances(14.3%). Closed globe injuries accounted for 42.2% injuries, open globe for 53.9% and 3.9% were chemical injuries. Best corrected visual acuity of 6/12 or better was achieved in 79 eyes (91.86%) in closed globe group. However, only 17 eyes (15.45%) in open globe group could achieve this. CONCLUSION: Most ocular injuries in children are preventable and occur from unsupervised games like bow and arrow and firecracker, which can lead to significant visual loss.     

Pattern of pediatric ocular trauma in India

Objective : The aim of the study is to identify the causes, demographic and clinical profile and evaluate final visual outcome of pediatric ocular injuries.Methods : Two hundred and four children aged fourteen years or less presenting to the emergency services of a tertiary care centre with ocular injury were included. Demographic data, nature and cause of injury, duration between injury and presentation to an ophthalmologist and the diagnosis were recorded. Evaluation of visual acuity, anterior segment and fundus were done. All patients were appropriately managed and followed up on days 1, 7,1 month, 3 and 6 months.Result : Majority of injuries occurred in children of 5 years and older (87.7%). There were 133 (65.1%) boys and 71 (34.9%) girls. Forty-nine (24%) cases presented within 6 hours of injury while 70 (34.3%) presented after more than 24 hours after trauma. Most common cause of injury was bow and arrow (15.2%) followed by household appliances (14.3%). Closed globe injuries accounted for 42.2% injuries, open globe for 53.9% and 3.9% were chemical injuries. Best corrected visual acuity of 6/12 or better was achieved in 79 eyes (91.86%) in closed globe group. However, only 17 eyes (15.45%) in open globe group could achieve this.Conclusion : Most ocular injuries in children are preventable and occur from unsupervised games like bow and arrow and firecracker, which can lead to significant visual loss.     

Pediatric blunt splenic trauma: a comprehensive review

Abdominal trauma is a leading cause of death in children older than 1 year of age. The spleen is the most common organ injured following blunt abdominal trauma. Pediatric trauma patients present unique clinical challenges as compared to adults, including different mechanisms of injury, physiologic responses, and indications for operative versus nonoperative management. Splenic salvage techniques and nonoperative approaches are preferred to splenectomy in order to decrease perioperative risks, transfusion needs, duration/cost of hospitalization, and risk of overwhelming postsplenectomy infection. Early and accurate detection of splenic injury is critical in both adults and children; however, while imaging findings guide management in adults, hemodynamic stability is the primary determinant in pediatric patients. After initial diagnosis, the primary role of imaging in pediatric patients is to determine the level and duration of care. We present a comprehensive literature review regarding the mechanism of injury, imaging, management, and complications of traumatic splenic injury in pediatric patients. Multiple patients are presented with an emphasis on the American Association for the Surgery of Trauma organ injury grading system. Clinical practice guidelines from the American Pediatric Surgical Association are discussed and compared with our experience at a large community hospital, with recommendations for future practice guidelines.     

Multiple trauma in pediatric patients

We analyzed the causes and diagnoses, the treatment, short and long-term outcome of a consecutive series of 70 pediatric polytrauma patients. From 1989 to 1996, 70 children (aged 10 months to 16 years, mean 7.4 years) presented with multiple trauma. A follow-up investigation was performed 4.2 years (mean) after the accident. Traffic accidents (68%) were the leading cause of injuries. Among all injuries (mean ISS 24.6 range 17–57), injuries of the head/neck area were most frequent (87%) followed by extremity fractures (76%) and 135 operations were performed on 55 children, mostly for fracture stabilisation. All multiple injured children survived. At discharge 25 children were still impaired (36% of 70). At follow-up 58 patients were revisited, 11 (19% of 58) presented with impairments, 8 of those (73% of 11) following severe head trauma. This study showed a 10% rate of late impairment due to the severity of the primary head trauma.     

Laparoscopic diagnosis of blunt abdominal trauma in children

This study evaluates the safety and role of laparoscopy in the diagnosis of blunt abdominal trauma in children. Laparoscopy was performed in five patients aged 3 to 13 years because of persistent abdominal pain after blunt trauma. A laparotomy was not indicated from the physical examination, laboratory data, or radiologic findings. With the patient under general anesthesia, a 10-mm trocar was inserted through the umbilical fossa and the intra-abdominal organs were observed for 10–60 min under an insufflation pressure of 10–12 mmHg. The patients remained hemodynamically stable without pneumothorax development. Three patients underwent laparatomies: one, who had blood in the omental sac, had a duodenal injury with hemorrhagic necrosis and underwent a resection; one with ascites and high amylase levels had an injury of the main pancreatic duct and underwent resection of the pancreatic tail; and one who had fresh blood in the upper abdomen and Douglas' pouch had a splenic hemorrhage and underwent hemostasis. The other two had serous or serosanguinous ascites and recovered without surgery. In patient 1, the same amount of information might have been obtained from a barium study. In patient 2, the pancreatic transection might have been diagnosed from ascites shown on serial computed tomograms. Patient 3 might also have been treated successfully non-surgically. It hus appears that laparoscopy may be a safe diagnostic method for blunt abdominal trauma in children, however, this small series has yielded insufficient information to assess its usefulness in making the diagnosis and the decision for laparotomy. Further studies are required to ascertain whether it will make any significant difference in the form of management.     

Urethral trauma in children

We report our 12-year experience in the management of urethral injuries in nine children, six boys and three girls. The most common mechanisms of injury were motor vehicle accidents, followed by straddle injuries. All the injuries in boys involved the anterior urethra, and in girls the proximal or mid-urethra. There were associated injuries in five, including three pelvic fractures. All children were investigated with a retrograde urethrogram. Four were treated non-operatively with insertion of a urethral catheter. Of the remaining five, one had drainage of a penile haematoma, one cystourethroscopy, two insertion of urinary and suprapubic catheters, and one open cystotomy and passage of a guide wire with antegrade passage of a urethral catheter. Complications included one urinary tract infection, one urethral fistula, one urethrovaginal fistula, and two urethral strictures. Final outcome was satisfactory in all nine children. Accepted: 3 February 2000     

Blunt trauma causing diaphragmatic rupture in children

Six children have been admitted over the last 10 years with blunt abdominal trauma causing diaphragmatic rupture. Four were acute presentations, with the emphasis on cardio-respiratory symptoms. There was a high incidence of associated injuries. Early laparotomy and repair of the diaphragm was performed successfully, and three out of four patients survived. Two patients presented late with gastrointestinal tract symptoms. A thoracotomy was necessary to free the adherent herniated bowel in one case. The peripheral nature of the lesion in children suggests that avulsion, aggravated by the increased elasticity and recoil of the thoracic cage, may play a major role in pathogenesis. Diaphragmatic rupture must be excluded in all severe cases of blunt abdominal trauma. Offprint requests to: R. A. Brown     

Minimizing pediatric healthcare-induced anxiety and trauma

Frequently, episodes of care such as preventive clinic visits, acute care, medical procedures, and hospitalization can be emotionally threatening and psychologically traumatizing for pediatric patients. Children are often subject to psychological trauma, demonstrated by anxiety, aggression, anger, and similar expressions of emotion, because they lack control of their environment. This sense of helplessness, coupled with fear and pain can cause children to feel powerless in healthcare settings. These emotional responses can delay important medical treatment, take more time to complete and can reduce patient satisfaction. Healthcare professionals are uniquely positioned to prevent healthcare-induced trauma and reduce healthcare-induced anxiety. This article introduces a new way to choice, agenda, resilience and emotion (CARE) for pediatric patients in the healthcare setting by implementing the four following treatment principles called the care process: (1) Choices: Offer power in a powerless environment; (2) Agenda: Let patients and families know what to expect and what is expected of them; (3) Resilience: Highlight strengths and reframe negatives; and (4) Emotional support: Recognize and normalize common fears and responses. Engaging the CARE principles helps patients and families feel empowered and mitigates, reduces, and may even ameliorate risk of anxiety and trauma responses.     

Transient electrocardiographic abnormalities following blunt chest trauma in a child

Blunt cardiac injury may occur in patients after suffering nonpenetrating trauma of the chest. It encompasses a wide spectrum of cardiac injury with varied severity and clinical presentation. Electrocardiographic abnormalities are frequently encountered. This article presents a case of a child who presented with complete right bundle branch block on the initial ECG at the emergency department. She suffered blunt chest trauma during a horseback riding accident. She was admitted for cardiac monitoring. The electrocardiographic abnormalities resolved within 12 hours. No signs of myocardial injury were found on repeat serum troponin measurement and echocardiography. The natural history of ECG abnormalities in the pediatric age group following blunt chest trauma is limited. Although a complete right bundle branch block may be transient in adult patients, this has not been previously reported in a children. Significant ECG abnormalities can be encountered in children following blunt chest trauma. Although a complete RBBB can be associated with severe injury to the RV, it can also occur with minor injury.     

Stricture of the common bile duct secondary to blunt abdominal trauma

A 3-year- 8-month-old girl developed obstructive jaundice associated with stricture of the distal end of the common bile duct 7 months after blunt abdominal trauma. Ultrasonography, computerised tomography, and percutaneous trans-hepatic cholangiography made the anatomical diagnosis before surgical reconstruction. Histological examination of the retroperitoneal tissue near the site of the stricture showed evidence of previous bile leakage due to rupture of the duct. Relief of obstruction was achieved by a Roux-en-Y choledochojejunostomy with complete resolution of symptoms and restoration of normal liver function. Offprint requests to: H. C. O Martin     

Bronchial rupture in children following blunt chest trauma

We present five patients with fracture of the bronchus, in whom the diagnois of bronchial rupture was first suggested because of persistent leakage of air, atelectasis of a segment of the lung or of the entire lung, mediastinal and deep cervical emphysema. In all patients the bronchoscopy was essential to confirm the diagnosis and to determine the full extent of injury.     

儿童舟骨骨折的诊治

目的 总结诊治12例儿童舟骨骨折的经验,为早期、正确地治疗儿童舟骨骨折提供参考和依据.方法 1999年1月～2006年12月间诊治12例儿童舟骨骨折,男9例,女3例,年龄10～15岁,平均12.5岁;右侧10例,左侧2例.根据改良Herbert舟骨骨折分型,12例患儿中A1型1例,A2型3例,B1型1例,B2型2例,B3型1例,D1型3例,D2型1例.4例新鲜稳定型骨折、2例新鲜不稳定骨折以及2例D1型骨折予以石膏外同定治疗;1例骨折块移位>1mm的B2型骨折闭合复位失败后予以切开复位内固定术;1例B3型及1例D1型骨折分别行经皮DTJ空心螺钉内同定术;1例D2型骨折行切开复位、克氏针、螺钉内固定、游离髂骨移植术.结果 石膏外同定治疗的8例患儿均于术后平均7.2周获得了临床骨愈合,术后所有患儿均无腕痛,患手握力平均恢复至健侧的91%,患侧腕关节屈伸活动度平均恢复至健侧的93%.经手术治疗的4例患儿于术后平均7.8周(B2型5周,B3型5.5周,D1型7周,D2型12周)获得了骨愈合,除1例D2型有轻度腕痛外其余3例均无腕关节症状,术后患手握力恢复至健侧的平均90%,患侧腕关节屈伸活动度恢复至健侧的平均91%.所有手术患儿切口均Ⅰ期愈合,无感染等并发症的发生.结论 儿童舟骨骨折临床及X线表现相对较隐匿,早期正确的诊断和确切的外固定是预防骨折不愈合和骨不连的关键,植骨+内固定是舟骨骨不连的有效治疗手段.     

Mandibular fractures in association with chin trauma in pediatric patients

The combination of chin trauma and bleeding from the ear should alert the physician to the possibility of a mandibular fracture. Not all hemotympanums represent basilar skull fractures, especially when they occur in association with chin trauma. Diagnosis of mandibular condylar fractures or temporomandibular joint disruptions can be very difficult. A high index of suspicion and a proper choice of imaging modalities are necessary to ensure a timely diagnosis.     

Tracheobronchial rupture in a child following blunt trauma

A 6-year-old boy sustained a crush injury to the upper chest that resulted in a linear laceration of the membranous part of the lower trachea and right main stem bronchus. He presented with extensive subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum. The diagnosis was indicated by a CT scan of the chest and confirmed by bronchoscopy. The trachea was intubated in the operating room after rigid bronchoscopy. Intraoperative leakage of gas from the tracheobronchial laceration was minimized by single left-lung manual ventilation and application of moist packs to the site of tracheal injury. Surgical repair was achieved with interrupted sutures of non-absorbable material; a pedicle pleural flap was used to buttress the suture line. The patient was discharged in good condition after 1 week. Complete healing of the anastomosis was attested at bronchoscopy 2 months postoperatively. The rarity of tracheobronchial lacerations in childhood is noted on review of the literature. Emphasis is placed on early recognition and expeditious management of tracheobronchial lacerations. Rarely, these lacerations have been reported to heal spontaneously.