The Child With Injuries To The Extremities Or The Spine Flashcards
What proportion of childhood injury does skeletal injury account for?
10-15%
What proportion of skeletal injuries involve physeal disruptions?
15%
Is extremity trauma often life threatening?
Not commonly in the multiply injured child.
Treat the life threatening injuries first before managing skeletal trauma.
But fractures / skeletal trauma needs to be managed well otherwise it affects rehabilitation.
How are children’s bones physiologically different from those of adults, and what implication does this have?
Children’s bones are more elastic
=> transmit force to soft tissues.
Do not underestimate the degree of soft tissue trauma.
When should extremity injury be assessed and treated?
Unless life threatening, extremity injury should be assessed during secondary survey and treated during the definitive care phase (during stabilisation after reassessment and system control).
Describe how extremity injuries in children relate to the risk of blood loss.
EXTREMITY INJURY
CHILDREN
BLOOD LOSS
NB: blood loss begins at the time of injury, can be hard to estimate degree of pre-hospital blood loss
- Single, closed extremity injury
- may produce enough blood loss to cause hypovolaemic shock
- not usually life threatening
- Closed femoral #
- loss of 20% intravascular volume into thigh
- if open - even more
- Pelvic fractures
- relatively uncommon in children
- energy may be transmitted to the vessels causing haemorrhage
Describe the history that should be sought in extremity trauma.
EXTREMITY TRAUMA
- History: AMPLE
- Allergies
- Medication
- PMH & immunisations
- Last meal
- Environment and Events incl. Mechanism of Injury + EXTREMITY
- PERFUSION (prior to hospital arrival)
- DEFORMITY (“)
What extremity injuries are life threatening and should be sought in the primary survey of extremity trauma and resuscitated immediately?
EXTREMITY TRAUMA
LIFE THREATENING INJURIES
CAH (I’ve been hit by a car)
- Crush injury (abdo/ pelvis)
- Amputation (traumatic, of an extremity)
- Haemorrhage (massive)
Describe the presentation, primary survey and resuscitation of crush injuries to the abdomen and pelvis.
CRUSH INJURIES TO THE
ABDOMEN AND PELVIS
- Presentation
- pelvis bones in children more cartilagenous & flexible => transmit force to internal organs
- fractures only occur with significant impact
- pelvis more narrow => less protection to internal organs
- pelvic fracture can lead to life threatening blood loss & hypovolaemic shock due to disruption of internal organs & vessels
- Resistant to Rx until
- injured vessels occluded
- pelvic disruption stabilised
- May be missed if fracture closed
- Often diagnosed on pelvic XR or if resistant hypovolaemia
- Mx
- SPLINT PELVIS (pelvic splint or improvised device)
- Minimal manual handling - 20 degree tilt method to move pt if necessary
- TRANEXAMIC ACID (15 mg/kg)
- MHP (MASSIVE HAEMORRHAGE PROTOCOL)
- ORTHO opinion + consider IR if no abdo injury requiring laparotomy
- Imaging
- CT first line
Describe the presentation, primary survey and resuscitation of traumatic amputation of an extremity.
TRAUMATIC AMPUTATION
- Presentation
- partial or complete
- partial = most life threatening (completely transected vessels go into spasm vs. partially transected do not)
- Mx (control haemorrhage)
- Simple measures
- pneumatic tourniquets
- elasticated compression bandage and dressing (helps to preserve tissue viability)
- MHP (Major haemorrhage protocol)
- 2 x large bore IV
- UNCONTROLLED bleeding –> fluids 5-10 ml/kg aliquots
- BlEEDING points CONTROLLED –> more aggressive volume replacement
- NO bleeding –> DRESS the stump in a sterile dressing soaked in normal saline & SPLINT + ELEVATE limb
- IVAB w/i 1 hour
- check TETANUS status
- ORTHO + PLASTIC SURGEONS
- RE-IMPLANTATION
- Specialist centres
- Amputated part viable for
- 8 hrs Room temp
- 18 hrs if cooled
- Method
- clean
- wrap in moist, sterile towel
- place in sterile plastic bag + seal
- insulated box filled with crushed ice + water
- avoid direct contact b/w ice and tissue
- transfer with child to specialist centre
- if not performed –> keep for grafting of other injuries
- Simple measures
Describe the presentation, primary survey and resuscitation of massive, open, long-bone fractures.
MASSIVE, OPEN, LONG-BONE #
PRIMARY SURVEY + RESUS
- Presentation
- significant + life-threatening blood loss
- open fractures bleed twice as much as closed fractures (no tamponade from surrounding tissues)
- e.g. single open femoral shaft # causes loss of 20-30% circulating blood volume
- Mx
- Simple measures
- PRESSURE at # site
- SPLINTING
- TOURNIQUETS
- MHP
- 2 x large bore IV
- fluid boluses
- IVAB w/i 1 hr
- TETANUS status
- ORTHO
- IR - angiography -> if major vessel rupture -> VASCULAR SURGEONS
- Simple measures
What conditions cause limb-threatening injury and should be sought during the secondary survey in children with injuries to the extremities?
INJURIES TO THE EXTREMITIES
LIMB-THREATENING INJURY
SECONDARY SURVEY
_Very F****ed Child_
- Vascular injury
- Fracture - Open
- Compartment syndrome
Describe the secondary survey and emergency management of vascular limb injury.
VASCULAR LIMB INJURY
SECONDARY SURVEY + EMERGENCY Mx
- Vascular damage is caused by:
-
Traction
- –> intimal damage or
- –> complete destruction
-
Penetrating injuries (missile or end of fractured bone)
- Bleeding - indicated by:
- brisk bleeding from an open wound
- rapidly expanding mass
- Complete and partial tears - in complete tears the vessel contracts so prolonged bleeding is less likely
- Nerves - run alongside vessels and may also be damaged
- Bleeding - indicated by:
-
Traction
- Examination
- Pulse
- present (clinically or on Doppler) does not R/O vascular injury
- diminished - do not attribute to spasm
- Signs of vascular injury - PLEASE HELP STOP CONTINUOUS BLEEDING
- Pulses - abnormal
- Haematoma - rapidly expanding
- Sensation - decreased
- CRT - prolonged
- Pulse
- Mx
- ALIGN fracture
- SPLINTS - check not restrictive
- VASC. SURGEONS + ANGIOGRAPHY
- REASSESS - vascular damage not always immediately apparent
Describe the secondary survey and emergency management of compartment syndrome.
COMPARTMENT SYNDROME
SECONDARY SURVEY AND EMERGENCY Mx
- Pathophysiology
- Cause
- crush injury (most common)
- simple fracture
- misplaced IO infusion
- blood or fluid accumulates in the fascial compartment
- interstitial pressure in compartment rises above capillary pressure
- local muscle ischaemia
- intracompartmental pressure rises above arterial pressure
- distal pulses disappear
- irreversible changes in the muscle bed
- Volkmann’s ischaemic contracture (if unrecognised)
- Cause
- Signs of compartment syndrome (4 x P, 2 x S)
- Pain - accentuated by passively stretching muscles
- Pallor
- Pulselessness (NB if distal pulses absent, intracompartmental pressure is above arterial pressure & irreversible changes have usually already occured to the muscle bed)
- Paralysis
- Sensation - decreased
- Swelling
- Mx
- Release any constricting bandages/ splints
- SURGICAL FASCIOTOMY
Describe the secondary survey and emergency management of open fractures.
OPEN FRACTURES
SECONDARY SURVEY AND EMERGENCY Mx
- If there is an open wound within the vicinity of the fracture, assume it communicates with the #
- Classification of open wounds
- degree of soft tissue damage
- amount of contamination
- neurovascular damage present or absent?
- Mx
- remove gross contamination
- cover with sterile, saline-soaked dressing
- take a photo (reduces the number of times dressing need to be removed)
- do NOT ligate bleeding points - may damage adjacent nerves
- DIRECT PRESSURE
- IVAB (BOAST 4 = British Ortho Association Standards for Trauma)
- TETANUS STATUS
- SURGICAL DEBRIDEMENT (w/i 6 hrs) - ORTHO + PLASTICS
Describe the management of suspected spine injury.
ALGORITHM FOR SPINAL IMAGING, REFERRAL AND CLEARANCE
- IMMOBILISATION:
- CONSCIOUS
- MILS (Manual In Line Stabilisation) as tolerated
- May be agitated if fear/ pain/ hypoxia
- Immobilisation not too rigid - increases leverage on the neck if child struggles
- encourage parents to stay at bedside
- explain at a level appropriate for the child
- member of staff remains with child at all times for reassurance, ensure minimal movement and airway maintained
-
UNCONSCIOUS - FULL PROTECTION
- also if uncooperative/ high risk mechanism of injury/ uncertain history
- MILS
- Head block + tape (visual aid - spine not cleared)
-
TRANSPORTATION
- as above plus
- sand bags
- vacuum mattress
- scoop stretchers
- avoid
- axial loading
- spinal boards - only in the short term for extrication
- as above plus
- IMAGING
-
YES - if any of the following: TU - SPINE
- Tenderness - posterior midline spinal
- Unable to assess
- Sedative drugs
- Painful distracting injury
- Intoxication/ Altered mental state/ drowsy/ uncooperative
- NEurological deficit or pain - focal
- REFERRAL TO A SPINAL INJURY SPECIALIST - WHEN -
- Imaging abnormal or uncertain
- Specific concerns e.g. focal pain/ tendderness, drowsy/ uncooperative/ unable to assess
- CLINICALLY CLEARING THE CERVICAL SPINE
- If T-Spine NEGATIVE i.e.
- T - NO posterior midline cervical Tenderness on direct palpation
- S - NO Sedative drugs
- P - NO Painful distracting injuries
- I - NO Intoxication / reduced alertness
- NE - NO NEurological deficit or pain - focal
- then LOW RISK of cervical spine injury
- then ASSESS MOVEMENT
- rotate neck 45 degrees L + R
- controls head
- tolerates rotation of trunk
- bears weight when vertical
- Midline posterior pain? –> IMMOBILISE + IMAGE
- NO pain –> Immobilisation no longer required
