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Managing Pediatric Orthopedic Trauma Emergencies When is it not “Just a broken bone”

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.

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Managing Pediatric Orthopedic Trauma Emergencies When is it not “Just a broken bone”

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  1. Managing Pediatric Orthopedic Trauma EmergenciesWhen is it not “Just a broken bone” Stephen A. Mendelson M.D. Director of Orthopedic Trauma Children’s Hospital Of Pittsburgh of UPMC

  2. Pediatric Orthopedic Trauma

  3. Pediatric Orthopedic Trauma

  4. Pediatric Orthopedic Trauma

  5. Pediatric Orthopedic Trauma

  6. Pediatric Orthopedic Truama

  7. Pediatric Orthopedic TraumaNonaccidental Injury

  8. 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

  9. Broken Finger Pelvic Facture Orthopedic TraumaSimple to Complex

  10. Factors Predicting Injury Severity and Outcomes • Injury Mechanism • High Impact • MVA • Fall from Height • Motorcycle and ATV • Low Impact • Ground Level Fall • Sports Accident

  11. Factors Predicting Injury Severity and Outcomes • Concurrent Injuries • Head Injury • Visceral Injuries • Burns • Soft Tissue

  12. Factors Predicting Injury Severity and Outcomes • Associated Injuries • Vascular • Neurologic

  13. Factors Predicting Injury Severity and Outcomes Comorbidities Systemic Musculoskeletal

  14. Orthopedic EmergenciesThe Big Seven! • Open Fracture • Compartment syndrome • Vascular Compromise • Deteriorating Neurologic Exam • Acute Dislocation Major Joint • Femoral Neck fracture • Open or Septic Joints

  15. 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

  16. Open fracture

  17. 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

  18. 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

  19. Compartment SyndromeDiagnosis and Treatment • Physical exam • Most reliable in awake patient • Compartment pressure measurements • FASCIOTOMY!!!

  20. Fasciotomy

  21. 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

  22. Vascular Injuries

  23. 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

  24. Common Nerve Injuries

  25. 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

  26. Pediatric Femoral Neck Fractures

  27. Avascular Necrosis

  28. Shoulder Elbow Hip Knee Ankle Dislocations

  29. Open Joint

  30. Common orthopedic injuries that are not as urgent as the look (Or The surgeon may say they are to get into the OR quicker)

  31. Badly Displaced fractures

  32. Growth Plate Fracture Salter Harris Classification

  33. Salter Harris 1

  34. Salter Harris 2

  35. Salter Harris 3

  36. Salter Harris 4

  37. Intraarticular fractures

  38. Static Neurologic deficit • Nerve Palsey • Complete Spinal Cord Injury

  39. Other Orthopedic considerations

  40. Child Abuse • >50% long bone fractures in nonambulatory children. • 20% Recurrence Rate. • 1-5% Mortality.

  41. Child abuse fracture Patterns

  42. Polytrauma • ARDS • Shock • Fat Emboli

  43. Multidisciplinary Approach • Paramedics and Transport • Emergency Room • Trauma Service • Intensives Care Unit • Neurosurgery • Orthopedics

  44. Damage Control OrthopedicsProvisional Stabilization During Resuscitation period

  45. 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!!!!!!!!

  46. Thank You!

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