Trauma
Trauma Overview: Motor Vehicle Collisions
Background
- Trauma causes 50% of all pediatric mortality
- For every pediatric death, 40 others are hospitalized and 1140 need emergency treatment
- Motor vehicle collisions (50%) > falls (25%) > burns (5%)
- Most common cause of fatalities are due to Head injuries
- In pediatrics, blunt trauma accounts for 90%, whereas penetrating trauma is 10%
- Male >> female (2:1)
Know normal vital signs for Pediatric Patients
- Table 1. Vitals by Age
| Age |
Heart Rate (HR) |
Respiratory Rate |
SBP (mmHg) |
DBP (mmHg) |
| Newborn |
90-180 |
30-50 |
60 +/- 10 |
37 +/- 10 |
| 1-5 Months |
100-180 |
30-40 |
80 +/- 10 |
45 +/- 15 |
| 6-11 Months |
100-150 |
25-35 |
90 +/- 30 |
60 +/- 10 |
| 1 Year |
100-150 |
20-30 |
95 +/- 30 |
65 +/- 25 |
| 2-3 Years |
65-150 |
15-25 |
100+/- 25 |
65 +/- 25 |
| 4-5 Years |
65-140 |
15-25 |
100 +/- 20 |
65 +/- 15 |
| 6-9 Years |
65-120 |
12-20 |
100 +/- 20 |
65 +/- 15 |
| 10-12 Years |
65-120 |
12-20 |
110 +/- 20 |
70 +/- 15 |
| 13+ Years |
55-110 |
12-18 |
120 +/- 20 |
75 +/- 15 |
"Broken Windshield": Head and Spine Trauma
- Background
- Direct blow of the head to the windshield
- Head injuries (most common types of injury in MVCs) may include
- Skull fractures
- Intracranial hemorrhage
- Cerebral contusions/edema
- Concussions
- Head Injuries
- Skull Fractures
- Linear skull fractures vs depressed skull fractures
- Most MVC patients have large scalp hematomas, palpable step-offs or bony deformities
- Basilar skull fractures
- Battle sign (posterior auricular or mastoid hematomas)
- Hemotympanum
- Cerebrospinal fluid otorrhea or rhinorrhea
- Periorbital ecchymoses (“raccoon eyes”)
- Cranial nerve palsies
- Often associated with intracranial injury even if GCS of 15 and normal neurological exam
- Intracranial injury
- Presentation
- Altered mental status
- Focal neurological findings on physical exam
- Focal lesions
- Epidural
- Subdural
- Intraparenchymal
- Diffuse injuries
- Cerebral edema
- Diffuse axonal injury
- Injury resulting from acceleration and deceleration forces
- Estimated up to 40% of children with severe traumatic brain injury
- Diagnostics
- CT of head
- GCS < 14
- Altered level of consciousness
- Palpable skull fracture
- Observation for several hours versus head CT
- Nonfrontal scalp hematoma
- Loss of consciousness > 5 sec
- Severe mechanism of injury
- Rollover
- Ejection from motor vehicle
- Death of another passenger
- Not acting normally
- Spine Injuries
- Cervical Spine injury
- Pediatric anatomy increases the risk of injuries of the cervical spine
- Relatively larger heads than bodies
- Weaker cervical musculatures
- Increased ligamentous laxity
- Immature vertebral joints with horizontal articular facets
- Children < 8 years old are more likely to sustain injuries to the upper cervical spine
- Children under the age of 2 rarely have cervical spine injuries
- Clear Cervical spine
- Reliable physical examinations
- Awake, alert and cooperative with GCS of 15
- Note: increased risk in children with certain medical conditions
- Down syndrome, Klippel-Feil syndrome, and specific mucopolysaccharidosis
- PECARN predictors of cervical spine injury in children
- Altered mental status
- Focal neurologic deficit
- Complaint of neck pain
- Torticollis
- Predisposing medical condition
- Substantial injury to the torso
- High risk motor vehicle crash
- Imaging
- Plain radiographs (sensitivity of 90% for identifying injuries)
- Consider CT
- Abnormal physical examination findings
- Abnormal radiographs
- Inadequate cervical spine radiographs
- Inconclusive plain radiographs
- Normal radiographs with persistent pain
- MRI
- Neurologic symptoms with normal cervical spine Xray and CT
- Thoracolumbar Spine injury
- Low incidences in children
- “Seat-belt syndrome”
- Lumbar compression fractures
- Chance fractures: flexion-distraction injuries
- Due to flexion-distraction injuries
- Posterior spinal ligaments rupture
- Transverse fractures of the spinous processes, pedicles and vertebral bodies
- General Considerations
- For any concerns of spine injuries
- Obtain CT of the respective spine without contrast
- Keep patient calm and immobilized
- Spinal Cord Injury Without Radiographic Abnormality (SCIWORA)
- Definition
- Spinal cord injuries that occur without identifiable bony or ligamentous injury on plain radiographs or computed tomography scans
- Presentation
- Vital sign abnormalities
- Neck pain
- Back pain
- Focal neurologic deficits (numbness, tingling, sensory deficits, weakness, or paralysis)
- Transient deficits or resolved deficits
- Majority of cases in cervical spine region due to
- Hyperextension injury
- Hyperflexion injury
- Longitudinal distraction injury
- Spinal cord infarction
- If concern for SCIWORA, patients should undergo imaging with MRI
- Facial Fractures
- Bony facial injuries are associated with substantial morbidity
- Facial fractures are associated with a 63% higher mortality rate
- Most common facial fractures
- Mandible (32.7%)
- Nasal (30.2%)
- Maxillary and zygoma (82.6%)
- Associated Injuries
- Facial soft tissue injury
- Ocular injury
- Brain injury
- Skull base fracture
- Obtain facial and orbital CT for any significant facial injuries
- Mandibular fractures: panoramic radiography is the study of choice
"Knee Hits Dashboard": Knee and Pelvic Trauma
- Knee Trauma
- Hits dashboard and can cause:
- Knee dislocation
- Patella fracture from direct impact
- Popliteal disruption
- Two impact points against the dashboard - tibia and femur
- If tibia hits dashboard and stops first
- Femur remains in motion and overrides it
- Dislocated knee, torn ligaments, tendons, and other supporting structures
- Frequent association with injury to the popliteal artery
- May lead to blood clots and decreased blood flow to the area distal to the knee
- Establish tissue perfusion immediately
- If femur is point of impact
- Energy is absorbed on the bone shaft causing a fracture
- Continued forward motion of the pelvis onto the femur that remains intact can override the femoral head
- Causes posterior dislocation of the acetabular joint
- Neurovascular compromise possible
- Popliteal artery
- Iliac artery
- Monitor pulses distal from the injury
- Treatment for physeal fractures
- Non-displaced
- Displaced
- Intra-articular Salter-Harris type III/IV: anatomic open reduction internal fixation
- Extra-articular fractures: varus/valgus realignment
- Pelvic Trauma
- Compression fractures may occur when increased pressure is placed on the lateral walls of the pelvis
- The pelvic bones or the ring of the pelvis are affected and usually 2 fractures occur in the ring
- Shear fractures
- Involve ilium and sacral area
- Tears joint open
- Anterior to the symphysis pubis compression fracture occurs after the compression is over and pushing in on both sides fractures symphysis
- Obtain X-rays of the hip, pelvis, and femur
- If concerns regarding the vascular status: consider a CT with contrast for completeness
"Rollover": Lower Body Crush Injuries
- Background
- Lower body may be trapped under the vehicle (crush, degloved, mangled injury)
- Pulseless extremities: increase the likelihood of vascular injury
- Increased likelihood of significant complications
- Bone and nerve injuries (79%)
- Fasciotomies (27%)
- Amputations (13%)
- Vascular injury of the extremity might lead to significant morbidity/mortality
- Pelvic Fractures
- Patients with suspected pelvic fracture need rapid and specialized care
- Increased risk of internal hemorrhage and other associated injuries
- Place a pelvic binder immediately
- Evaluate vitals immediately
- Patients with pelvic fractures who present in shock have a mortality of 30-50%
- Hemorrhage may be from
- Fractured bone
- Disrupted veins
- Arteries
- Consider multi-cavity injury with hemorrhage in the chest or abdomen as well as the pelvis and long bones
- It is essential to have a multidisciplinary approach
- Manage with transfusion, anticoagulants, and therapeutic hypothermia
- Up to 40% of pelvic fractures require angio-embolization
- With bleeding from anterior branches of the internal iliac artery (obturator and pudendal arteries) with a lateral compression pattern injury
- All patients will require a CT scan to thoroughly evaluate the extent of the pelvic injury
- Lower Extremity Fractures
- Extremities become trapped, crushed and mangled
- Impact from multiple sides of the vehicle and portions of the vehicle becoming compressed
- Upon extrusion of the patient, injuries may worsen
- Assessing for distal pulses, deformities, and vital signs is important in assessing the extent of the injury
- Especially from a neurovascular point
- Plain radiographs are an ideal starting point if the patient is hemodynamically stable
- Compartment Syndrome
- Incidence of compartment syndrome from tibial shaft fractures is 11.6% in children older than 14 years of age involved in an MVA
- Assess for the five P's: Pallor, Pain, Paresthesia, Poikilothermic, Pulseless
- Consider compartment syndrome in the forearm, tibial injuries, and the foot
- In trauma, rhabdomyolysis may be the result of the trauma, therefore the following labs should be evaluated
- Creatine phosphokinase (CPK)
- Renal function studies
- Urinalysis
- Urine myoglobin
- Intracompartmental pressure measurements
- Standard for diagnosis of compartment syndrome
- Should be done immediately when suspecting compartment syndrome as a diagnosis
- Imaging may be helpful to rule out other etiologies
- Standard radiography will assist with determining fractures
- CT may be useful if suspecting pelvic or thigh compartment syndrome
- Treatment of choice: early decompression
"Broken Steering Wheel"
- Background
- Thoracic trauma is common and is associated with a high morbidity
- About 20% of all trauma deaths involve chest injury
- Most chest wall and intrathoracic injuries do not require major surgical intervention; can be managed with
- Simple tube thoracostomy
- Mechanical ventilation
- Aggressive pain control and other supportive care
- Two types of blunt force from MVCs that cause thoracic injury
- Compression
- Rib fractures when force exceeds the thoracic cage strength
- Maximal weakness of the chest wall is at 60° rotation from the sternum where the ribs are the flattest
- Shearing
- Causes soft tissue and vascular injury from rapid acceleration or deceleration
- Tearing or rupture of vascular organs and blood vessels can occur, and be lethal (e.g., aortic transection)
- Rib Fractures
- Background
- In children, rib fractures indicate a much higher force causing the injury than in adults
- Children's chest walls are more compliant than adults
- Diagnostics
- History/Physical Exam
- Complain of pain on inspiration and dyspnea
- Tenderness on palpation
- Crepitus
- Chest wall deformity
- Imaging
- Rib radiographs
- Bedside ultrasound
- Treatment
- Pain control
- Admission if ≥ 3 ribs fractured
- Common Injuries Associated With Rib Fractures
- Aortic Injury
- Etiology/Risk Factors
- Rapid deceleration injury as in an MVC
- Approximately 95% of patients die before reaching the hospital
- Diagnostics
- Upper extremity hypertension, interscapular murmurs, diminished/absent pulses in upper or lower extremities
- If suspected obtain a radiograph
- Radiographic signs of mediastinal pathology
- Straightening of the mediastinal borders with loss of the anteroposterior window
- Mediastinal diameter greater than that of the hemothorax
- Right shift of on orogastric tube off the vertebral column
- Radiographic signs of aortic disruption
- Widened mediastinum
- Left pleural effusion
- Apical capping
- Depression of the left main bronchus
- Rightward shift of an orogastric tube off the vertebral column
- Fractures of the first or second rib or scapula
- Diagnostic procedure of choice
- Aortography if stable
- Computed tomography alternative
- Treatment
- Open repair surgical intervention
- Pulmonary Contusions
- Most common pulmonary injury
- From high energy trauma on lung parenchyma
- Can occur in pediatric patients without rib fracture often
- Diagnostics
- History/Physical Exam
- Hypoxemia
- Hypoventilation
- Imaging
- Consolidation on chest radiography
- No need for computed tomography
- Treatment
- Aggressive pulmonary toilet
- Pain management
- Oxygen for hypoxia
- Pneumothorax
- Diagnostics
- Common in children with blunt trauma
- Decreased/absent breath sounds
- Hypotension usually with tension pneumothorax
- Immediate Treatment
- Needle decompression through the second intercostal space at midclavicular line
- Tube decompression
- Hemothorax
- Diagnostics
- History and Physical Exam
- Common in children with blunt trauma
- Decreased/absent breath sounds
- Hypotension with massive hemothorax
- Immediate treatment
- Needs evacuation with tube decompression
- Flail chest
- Diagnostics
- History/Physical Exam
- Most serious of blunt chest wall injuries
- Upon inspiration, flail segment is pulled inward by negative intrathoracic pressure
- With exhalation, positive pressure forces segment to protrude outward
- Results in ventilation-perfusion mismatch, atelectasis, and progressive shunting
- Imaging
- Chest radiograph or chest CT is necessary
- Treatment
- Positive pressure Oxygen
- Pain control
- Sternal Fracture
- Diagnostics
- History/Physical Exam
- Localized sternal pain
- Dyspnea is present in 15-20%
- Assess for other complications
- Rib fractures
- Flail chest
- Pneumothorax, hemothorax
- Pulmonary contusion
- Blunt cardiac injury
- Pericardial tamponade
- Vascular injury
- Pain over fracture site and readily reproducible
- Crepitation or displacement is rare, unless sternum is disrupted with unstable fragments
- Soft-tissue edema or ecchymosis in 40-55% of patients
- Imaging
- Radiographs: with sternal views to enhance visualization of sternum
- Bedside ultrasound: is as sensitive as plain radiographs
- CT scan: most common imaging to make the diagnosis
- Electrocardiogram: to assess for cardiac contusion
- Treatment
- Supportive oxygen
- Cardiac monitoring
- Intravenous access
- Initial analgesia is treatment of choice
- Encourage deep breathing to decrease pulmonary complications
- Cardiac Contusion
- Background
- Myocardial contusion is the most common of cardiac injuries
- Bruising due to rupture or hemorrhage of small vessels in the myocardium
- Right ventricle is at greatest risk due to its location
- Cardiac output may decrease
- Valvular dysfunction
- Decreased preload
- Increased afterload
- Direct injury of the tricuspid or mitral valve
- Diagnostics
- History/Physical Exam
- Pain in the ribs or breastbone
- Palpitations
- Syncope
- Nausea or vomiting
- Short of breath
- Shock
- Needs to be differentiated from tension pneumothorax, neurogenic, and hypovolemic
- Imaging
- Echocardiography shows
- Ischemic changes
- Atrial premature contractions
- Ventricular premature contractions
- Wall motion abnormalities
- Other Tests/Criteria
- CK-MB isoenzyme may be elevated
- Electrocardiogram
- Dysrhythmias
- Diffuse changes in the ST segment or T waves
- ST segments may be elevated or depressed
- T wave may be flattened or inverted
- Ectopy
- AAST Injury Scale
- Grade I
- Blunt cardiac injury with minor EKG abnormality
- Nonspecific ST of T wave changes or
- Premature atrial or ventricular contractions or
- Persistent sinus tachycardia
- Blunt or penetrating pericardial wound without cardiac injury, tamponade, or cardiac herniation
- Grade II
- Blunt cardiac injury with heart block or ischemic changes without cardiac failure
- Penetrating tangential cardiac wound, up to but not extending through endocardium, without tamponade
- Grade III
- Blunt cardiac injury with sustained or multifocal ventricular contractions
- Blunt or penetrating cardiac injury with
- Septal rupture or
- Pulmonary or tricuspid incompetence or
- Papillary muscle dysfunction or
- Distal coronary artery occlusion without cardiac failure
- Blunt pericardial laceration with cardiac herniation
- Blunt cardiac injury with cardiac failure
- Penetrating tangential myocardial wound, up to but not through endocardium, with tamponade
- Grade IV
- Blunt or penetrating cardiac injury with
- Septal rupture or
- Pulmonary or tricuspid incompetence or
- Papillary muscle dysfunction or
- Distal coronary artery occlusion producing cardiac failure
- Blunt or penetrating cardiac injury with aortic or mitral incompetence
- Blunt or penetrating cardiac injury of the right ventricle, right or left atrium
- Grade V
- Blunt or penetrating cardiac injury with proximal coronary artery occlusion
- Blunt or penetrating left ventricular perforation
- Stellate injuries, less than 50% tissue loss of the right ventricle, right or left atrium
- Grade IV
- Blunt avulsion of the heart
- Penetrating wound producing more than 50% tissue loss of a chamber
- Treatment
- Manage hypotension
- If stable admission for cardiac monitoring
- Upper Abdominal Injuries
- Background
- Difficult to assess initially because the abdominal exam is often unreliable and inaccurate with high rate of missed abdominal injuries
- Serial abdominal exams are essential to exclude evolving abdominal problem
- Physical exam of abdominal wall may show indications of abdominal injury
- Abrasions and contusions (seat belt sign)
- Abdominal distention
- Tenderness
- Aerophagia leading to massive gastric distention
- Hemoperitoneum
- Splenic Injury
- Background
- Most frequently injured intra-abdominal organ in children
- Results from direct blow to the left upper quadrant
- Diagnostics
- History/Physical Exam
- Left shoulder pain (Kehr’s sign), from diaphragmatic irritation by blood from the spleen
- Left upper quadrant abrasions
- Tenderness
- Abdominal distension
- Labs/Test
- CBC +Diff, CMP, Type and Cross
- Evaluate amount of blood loss
- Imaging
- Abdominal/pelvic computed tomography scan if patient is stable
- Treatment
- If hemodynamically stable
- If hemodynamically unstable despite aggressive resuscitation
- Liver Injury
- Background
- Second most common injured organ
- More severe than splenic injuries because they tend to re-bleed
- Diagnostics
- History/Physical Exam
- Right shoulder pain (Kehr’s sign)
- Upper abdominal or right lower chest pain
- Labs/Tests
- CMP – elevated transaminases are highly suggestive of liver injury
- Imaging
- Abdominal/Pelvic CT mainstay of evaluation
- Treatment
- Typically nonoperative with careful serial reexaminations
- Indications for nonoperative management
- Hemodynamic stability
- Absence of peritoneal signs
- Indications for exploratory laparotomy
- Hemodynamic instability
- Transfusion required within 2 hours of presentation
- Associated retrohepatic vena cava or major hepatic vein trauma
- Pancreatic Injuries
- Background
- Rare; most are missed or underestimated initially
- Mechanism: compression of the pancreas against the rigid spinal column
- If isolated injury there may be a delay of hours to days before the onset of abdominal symptoms
- Diagnostics
- History/Physical Exam
- Abdominal pain
- Nausea
- Vomiting
- Fever
- Labs/Tests
- Lipase > 1800 IU/L correlates with major pancreatic injury
- Imaging
- Abdominal CT identify traumatic injury to the pancreas
- Visualized transection
- Thickening of the gland with edema
- Peri-pancreatic fluid collections
- Ductal dilatation
- Treatment
- Determined by injury severity, location, and the presence or absence of associated abdominal injuries
- Currently no clear recommendation in pediatric patients
- Pseudocyst formation is the main complication of nonoperative management
- Duodenal Injuries
- Background
- Rare type of injury
- Two forms
- Force of trauma disrupts the vessels between the submucosa and muscularis
- Causes development of an intramural hematoma, which may obstruct the duodenal lumen
- History/Physical Exam
- Abdominal pain
- Nausea
- Vomiting
- Hematemesis / bilious emesis
- Abdominal distention
- High output in the nasogastric tube
- Labs/Tests
- Elevated serum transaminases, amylase, and lipase
- Imaging
- CT is only diagnostic in 60% of cases of duodenal perforation
- Treatment
- Nasogastric decompression
- Surgical
- Small Intestine Injuries
- Background
- Much less frequently injured than either the spleen or liver
- Only 2-5% of children with blunt abdominal trauma will have intestinal injury
- Jejunum is the most commonly injured segment of the bowel > duodenum > ileum
- Diagnostics
- History/Physical Exam
- Difficult to diagnose
- Progressive symptoms
- Peritonitis
- Fever
- Tachycardia
- Diminished urine output over 12-24 hours
- Labs/Tests
- CBC +Diff
- CMP
- Serial Liver transaminases
- Imaging
- Abdominal radiography
- CT abdomen
- Nonspecific bowel injury
- Moderate-to-large amounts of unexplained fluid
- Unexplained extraluminal air
- Bowel wall enhancement
- Bowel wall thickening
- Bowel dilatation
- Extravasation of contrast
- Multiple fluid-filled loops of bowel
- Treatment
- Broad spectrum antibiotics
- Intravenous fluid resuscitations
- Admit
- Pain management
- Oral or IV NSAIDS
- Oral and IV narcotics
- Intercostal nerve blocks with local anesthetics
Rear-End Collision
- Cervical Spine Hyperextension Injury
- Background
- 25% of cervical spine injuries
- Subtle radiographic signs - lateral radiograph and sagittal CT reformations
- Mild anterior intervertebral disk space widening
- Anterior vertebral body avulsion fragments
- Facet malalignment
- Diagnostics
- History/Physical Exam
- Posterior neck pain on palpation of spinous processes
- Limited range of motion associated with pain
- Weakness, numbness or paresthesias along affected nerve roots
- Spinal shock
- Flaccidity
- Areflexia
- Loss of anal sphincter tone
- Fecal incontinence
- Priapism
- Loss of bulbocavernosus reflex
- Neurogenic shock
- Hypotension
- Paradoxical bradycardia
- Flushed, dry and warm peripheral skin
- Autonomic dysfunction
- Ileus
- Urinary retention
- Poikilothermia
- Imaging
- Cervical spine radiography
- CT of the cervical spine
- Treatment
- Keep in cervical spine precautions with neck brace
- Consultation of orthopedic or neurosurgeon
- Central Cord Syndrome
- Background
- Acute cervical spinal cord injury with greater impairment of motor function in the upper extremities than in the lower ones
- Bladder dysfunction and variable amount of sensory loss below the level of injury
- Diagnostics
- History/Physical Exam
- Upper and lower extremity weakness
- Varying degrees of sensory loss
- Pain and temperature sensations
- Light touch and position may be impaired below the level of injury
- Neck pain and urinary retention
- Physical exam usually limited to the neurological system
- Upper motor neuron weakness in the upper and lower extremities
- Impairment in the upper extremities > lower extremities
- Sensory loss is variable
- Muscle stretch reflexes may be absent initially, but may return
- Imaging
- MRI
- Direct evidence of spinal cord impingement from bone, a disc, or a hematoma
- CT of the cervical spine
- Spinal canal compromise and allows indirect approximation of the degree of spinal cord impingement
- Radiography
- Fractures and dislocations
- Treatment
- Neck stabilization
- Consultation of orthopedic or neurosurgeon
Seat Belt Trauma
- Lap Belts
- Background
- Often due to lap belts worn incorrectly
- Lumbar spine fracture
- Low incidences in children
- “Seat-belt syndrome”
- Lumbar compression fractures
- Chance fractures
- Flexion-distraction injuries
- Due to flexion-distraction injuries
- Posterior spinal ligaments rupture
- Transverse fractures of the spinous processes, pedicles, and vertebral bodies
- Hollow Viscus Injuries
- Duodenal Injuries
- Background
- Rare type of injury
- Two forms
- Force of trauma
- Disrupts the vessels between the submucosa and muscularis
- Causes development of an intramural hematoma, which may obstruct the duodenal lumen
- Diagnostics
- History/Physical Exam
- Abdominal pain
- Nausea
- Vomiting
- Hematemesis / bilious emesis
- Abdominal distention
- High output in the nasogastric tube
- Labs/Tests
- Elevated serum transaminases, amylase, and lipase
- Imaging
- CT is only diagnostic in 60% of cases of duodenal perforation
- Treatment
- Nasogastric decompression
- Surgical
- Small Intestine Injury
- Background
- Much less frequently injured than either the spleen or liver
- Only 2-5% of children with blunt abdominal trauma will have intestinal injury
- Jejunum is the most commonly injured segment of the bowel > duodenum > ileum
- Diagnostics
- History/Physical Exam
- Difficult to diagnose
- Progressive symptoms
- Peritonitis
- Fever
- Tachycardia
- Diminished urine output over 12-24 hours
- Labs/Tests
- CBC +Diff
- CMP
- Serial liver transaminases
- Imaging
- Abdominal radiography
- CT abdomen
- Nonspecific bowel injury
- Moderate-to-large amounts of unexplained fluid
- Unexplained extraluminal air
- Bowel wall enhancement
- Bowel wall thickening
- Bowel dilatation
- Extravasation of contrast
- Multiple fluid-filled loops of bowel
- Treatment
- Broad-spectrum antibiotics
- Intravenous fluid resuscitations
- Admit
- 3-point Belt Restraints
- Rib Fractures
- Background
- In children rib fractures indicate a much higher force causing the injury
- Pediatric chest walls are more compliant than adults
- Diagnostics
- History/Physical Exam
- Complain of pain on inspiration and dyspnea
- Tenderness on palpation
- Crepitus
- Chest wall deformity
- Imaging
- Rib radiographs
- Bedside ultrasound
- Treatment
- Clavicle Fractures
- Background
- Common and heals easily the majority of time
- Some complications are possible
- Classification system by Allman
- Group I fractures: Middle third injuries
- Group II fractures: Distal third injuries
- Group III fractures: Proximal third injuries
- Diagnostics
- History/Physical Exam
- Cradling the injured extremity
- Shortened shoulder
- Swelling, ecchymosis and tenderness over the clavicle
- Abrasion over the clavicle
- Crepitus from the fracture
- Difficulty breathing
- Tenting and blanching of the skin at the site of the fracture
- Neurovascular injuries
- Imaging
- Clavicular radiographs
- Bedside ultrasound
- Arteriography if suspect vascular injury
- Treatment
- Vast majority heal with nonoperative management
- Figure-of-eight brace or shoulder sling
- Surgical indications (orthopedic surgery consult)
- Complete fracture displacement
- Severe displacement causing tenting of the skin with risk of puncture
- 2 cm of shortening of the fractures
- Comminuted fractures with a z-shaped fragment
- Neurovascular compromise
- Displaced medial clavicular fractures
- Polytrauma
- Open fractures
- Concomitant glenoid neck fracture
- Fracture with interposed muscle
- Sternal Fractures
- Diagnostics
- History/Physical Exam
- Localized sternal pain
- Dyspnea is present in 15-20%
- Assess for other complications
- Rib fractures
- Flail chest
- Pneumothorax, hemothorax
- Pulmonary contusion
- Blunt cardiac injury
- Pericardial tamponade
- Vascular injury
- Pain over fracture site and readily reproducible
- Crepitation or displacement is rare, unless sternum is disrupted with unstable fragments
- Soft-tissue edema or ecchymosis in 40-55% of patients
- Labs/Tests
- Electrocardiogram to assess for cardiac contusion
- Imaging
- Radiographs with sternal views to enhance visualization of sternum
- Bedside ultrasound is as sensitive as plain radiographs
- CT scan is the most common imaging to make the diagnosis
- Treatment
- Supportive oxygen
- Cardiac monitoring
- Intravenous access
- Initial analgesia is treatment of choice
- Encourage deep breathing to decrease pulmonary complications
- Pulmonary Contusions
- Background
- Most common pulmonary injury
- From high energy trauma on lung parenchyma
- In pediatric patients often without rib fracture
- Diagnostics
- History/Physical Exam
- Hypoxemia
- Hypoventilation
- Imaging
- Consolidation on chest radiography
- No need for computed tomography
- Treatment
Related Topics
References
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Contributor(s)
- Hughes, Michelle, DO
Updated/Reviewed: November 2023