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Trauma Overview: Falls

Trauma

Trauma Overview: Falls

Background 1

  1. 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)
  2. Falls are the second leading cause of unintentional injury deaths worldwide
    • 37.3 million falls that are severe enough to require medical attention, occur each year 2
    • 15% of patients present in shock, often from vascular rupture, tension pneumothorax or spinal cord injury 3
    • Prognostic factors
      • Patient age
        • Older people have the highest risk of death or serious injury
        • Children are a high-risk group, because of developmental behaviors, such as “risk-taking”
      • Height of fall
      • Circumstances of fall
      • Body part first hitting ground
        • Head is the most frequently injured body region (70%) > chest, abdomen, extremities > neck
    • Estimate fall height
      • 1 story = 12 feet
      • Falls > 20 feet need to be assessed at a trauma center
      • 4 story height fall = 50% mortality
      • 7 story height fall = 90% mortality

Know normal vital signs for Pediatric Patients

  • Table 1. Vital Signs 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

Supine Impact

  1. Background
    • 23% mortality rate
    • Axial and appendicular musculoskeletal injuries, retroperitoneum injuries, renal artery thrombosis
  2. Axial and Appendicular musculoskeletal Injuries
    • Diagnostics
      • History/Physical Exam
        • Evaluate for deformities, focal pain
        • Upper extremities (type of fractures in descending order of commonality) 4
          • Radial and ulnar shaft fractures
          • Distal end radius fractures
          • Supracondylar fracture
          • Intercondylar fracture
          • Shoulder dislocation
          • Radial head/neck fractures
          • Lateral condyle fracture
          • Metacarpal fracture
        • Lower extremities (type of fractures in descending order of commonality)
          • Intertrochanteric/subtrochanteric fracture, femur
          • Tibia and fibula
          • Calcaneus
          • Femur shaft
          • Intra-capsular fracture, femur neck
          • Hip dislocation
          • Assess neurovascular status distal from injury
      • Imaging
        • Radiography for fractures
        • CT angiography if concerns for vascular compromise
  3. Retroperitoneum
    • The most likely source of hemodynamic instability
  4. Renal Artery Thrombosis
    • Background
      • Bilateral injury is rare
        • Unilateral renal artery thrombosis usually involves the left kidney
      • Three sequential mechanisms
        • Stretch lesion leading to intimal tear or fracture
        • Sub-intimal dissection leading to arterial thrombosis
    • Diagnostics
      • History/Physical Exam
        • Non-specific
        • Renal colic (abdominal/flank pain)
        • Progressive renovascular hypertension
        • Changes in renal function
        • Symptoms of kidney infarction
      • Labs/Tests
        • Urinalysis
          • Assessing for hematuria
        • Intravenous pyelography
          • Prior to any renal exploration
          • To determine: status of renal function, presence/extent of any urinary extravasation
      • Imaging
        • CT abdomen/pelvis with intravenous contrast
        • Angiography
          • Aid in the diagnosis and treatment of renal injuries
          • May further define injury in patients with moderate IVP abnormalities
    • Treatment
      • Revascularization within 12 hours is important
      • Observe vs. surgical repair

Prone Impact

  1. Background
    • 57% mortality rate
    • Typically seen
      • Deceleration injuries
      • Closed head injuries
      • Cervical spine injuries
  2. Deceleration Injuries
    • Facial Fractures
      • Background
        • 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/zygoma (82.6%) 5
        • Associated Injuries
          • Facial soft tissue injury
          • Ocular injury
          • Brain injury
          • Skull base fracture
      • Diagnostics
        • Imaging
          • Obtain facial/orbital CT: for any significant facial injuries
          • Mandibular fractures: panoramic radiography is the study of choice
    • Chest-Aortic Rupture
      • Very uncommon
      • Evaluate with CT of mediastinum
    • Abdominal Injury
      • Most common solid organ injuries
        • Liver
        • Spleen
      • No difference between various age groups
    • Hollow Viscus Perforation
      • Background
        • Rare; mostly in the younger age groups
        • ≤ 14 years
        • 15-55 years
        • Children more susceptible to solid organ injuries
          • Poor protection by the underdeveloped and pliable rib cage
          • Weak abdominal wall muscles
      • Diagnostics
        • Labs/Tests
          • CMP, CBC +Diff
          • BUN/Cr, electrolytes
          • Specific markers as appropriate
        • Imaging
          • CT/MRI abdomen
  3. Closed Head Injuries
    • Background
      • Brain contusion is the most common intracranial injury > subdural hematoma > epidural hematoma
      • Subarachnoid hemorrhage occurs more often in patients > 65 years, than in the younger age groups 6
    • Diagnostics
      • CT of head
  4. Cervical Spine Injuries
    • Diagnostics
      • History/Physical Exam
        • Flexion fractures noted
        • Anterior subluxation
        • Bilateral facet joint dislocation
        • Wedge/compression fracture
        • Clay-shoveler fracture
      • Imaging
        • Plain cervical spine radiographs initially
        • CT cervical spine for more detailed findings

Upright Impact

  1. Background
    • Lower extremity trauma, usually not life-threatening
      • Typically involves fractures of
        • Pelvis
        • Femur
        • Tibia/fibula
    • Foot trauma
      • Calcaneal fractures
    • Spine trauma
    • Open fractures may occur as well
  2. Lower Extremity Trauma
    • Pelvic Fractures
      • Background
        • 12.4% incidence in one study 7
        • Common in buttock landings
        • Occur in 20-30% of all falls
        • More prominent > 15 years of age
      • Diagnostics
        • Young Classification
          • Grade I: associated sacral compression on side of impact
          • Grade II: associated posterior iliac fracture on side of impact
          • Grade III: associated contralateral sacroiliac joint injury
        • Labs/Tests
          • CBC +Diff
          • Urinalysis for hematuria
        • Imaging
          • Plain Radiography for basic screening
            • Uncovers 90% of pelvic injuries
          • CT of abdomen/pelvis
            • Best imaging for evaluation of pelvic anatomy and intraperitoneal bleeding
      • Treatment
        • Address life-threatening issues first
        • Apply external compression device to stabilize pelvis and control any hemorrhage
          • Avoid excessive movement of the pelvis
        • Fluid replacement and analgesics
        • Orthopedic surgeon consult
          • If urethral injury consult urologist
    • Femur Fractures
      • Background
        • Increased incidence > 65 years
        • Ranges from nondisplaced stress fractures to severe comminuted fractures
        • Very vascular and can result in significant blood loss into the thigh
        • 40% of isolated fractures may require transfusion
      • Diagnostics
        • History/Physical Exam
          • Evaluate pelvis, hips and knees
          • Distal neurovascular assessment is necessary
          • Palpate site of symptoms
          • Swollen thigh
          • Limited range of motion
          • Pain usually radiates into the groin
        • Labs/Tests
          • CBC
          • CMP
          • PT/apt
          • Urinalysis
          • Type and crossmatch
        • Imaging
          • Radiographs of
            • Chest
            • Spine
            • Anteroposterior pelvis
            • Anteroposterior-lateral femur, hip, and knee
      • Treatment
        • Analgesia
        • Stabilization: inline longitudinal traction
        • Definitive treatment is surgical alignment by orthopedic surgeon
    • Tibia Fractures
      • Background
        • Approximately 8% in all age ranges
      • Diagnostics
        • History/Physical Exam
          • Keep high on differential in multisystem trauma
          • Severe pain
          • Inability to bear weight on affected leg
          • Visible malformation
          • Numbness or paresthesia
          • Assess for
            • Concomitant injury
            • Overlying skin
            • Neurovascular status
            • Concomitant compartment syndrome
        • Tibial Shaft Fracture Classification
          • Type A: unifocal fractures
            • A1: spiral fracture
            • A2: oblique fracture
            • A3: transverse fracture
          • Type B: Wedge fractures
            • B1: intact spiral wedge fracture
            • B2: intact bending wedge fracture
            • B3: comminuted wedge fracture
          • Type C: Complex fractures
            • C1: spiral wedge fractures
              • C1.1 (2 fragments)
              • C1.2 (3 fragments)
            • C2: segmental fractures
              • C2.3 (highly comminuted fractures)
        • Imaging
          • Anteroposterior and lateral radiographs of the injured leg
          • CT for further fracture pattern definition
      • Treatment
        • Analgesia
        • Minimal displacement
          • Long posterior splint with the knee in 10-150 flexion and ankle flexed at 900
        • Unstable fractures
          • Orthopedic surgery for surgical fixation
  3. Foot Trauma
    • Calcaneal Fractures
      • Background
        • Diagnosed with Bohler’s salient angle
          • Angle formed by intersection of
            • Line from the highest point of the posterior articular facet to the highest point of the posterior tuberosity and
            • Line from the former to the highest point on the anterior articular facet
          • < 20 degrees suggests fracture
          • 7 common fracture patterns
        • Management
          • Need CT to assess sub-talar joint
          • Surgically reconstructed or conservative management
  4. Spine Trauma
    • Diagnostics
      • History/Physical Exam
        • General
          • Pain at level of injury
          • Deformity of spine
          • Swelling/bruising over injured area
          • Limited range of motion
          • Assess for concomitant neurological injury
          • Determine whether stable or unstable
        • Thoracolumbar Spine Fractures
          • Most common skeletal fracture associated with falls
          • 80% incidence
          • L1 > L2 > T12
          • CT is useful in determining stability
          • “Battleship fracture”: simultaneous fracture of the lumbar spine and tarsal or metatarsal bone
        • Spinous Process Fractures
          • Extremely common, especially > 15 years
          • Associated spinal injury
          • Transverse spinous process attached to muscles and ligaments
          • Likely injury may also cause internal bleeding
          • Lung, kidney, spleen, liver
          • Lumbar spine > thoracic spine > cervical spine
          • Neurological injury
          • Loss of function of bladder and/or bowels
          • Loss of sensation and/or strength in the arms/hands, legs, feet and toes
      • Imaging
        • Radiography of spine for obvious fractures
        • CT of spine to determine possible levels of compression and more detailed fractures
        • MRI assess intervertebral disc problems
    • Treatment
      • Analgesia
      • Stable fracture: spinal bracing
      • If neurological injury or lack of stability: surgery
  5. Open Fracture Management
    • Thorough irrigation
    • Debridement of necrotic tissues
    • Tetanus immunization and prophylaxis
    • Prophylactic IV antibiotic Indications
      • Type I: Open fracture with wound < 1 cm in length
        • Cefazolin
      • Type II: open fracture with laceration > 1 cm, without extensive soft tissue damage, flaps or avulsion
        • Add an Aminoglycoside
      • Type III: open segmental fracture, open fracture with extensive soft tissue damage or traumatic amputation
        • Add an aminoglycoside
      • Farm injury: dirty wound
        • Add penicillin or clindamycin

Related Topics

References

  1. Guice KS, Cassidy LD, Oldham KT. Traumatic injury and children: a national assessment. J Trauma. Dec 2007;63(6 Suppl):S68-80
  2. World Health Organization (WHO). Falls. Available at: http://www.who.int/mediacentre/factsheets/fs344/en/. [Accessed January 2017]
  3. Weir E. Accidental falls from heights. CMAJ. Aug 21, 2001;165(4):468
  4. Gulati D, Aggarwal AN, Kumar S, Agarwal A. Skeletal injuries following unintentional fall from height. Ulus Travma Acil Cerrahi Derg. Mar 2012;18(2):141-146
  5. Imahara SD, Hopper RA, Wang J, et al. Patterns and Outcomes of Pediatric Facial Fractures in the United States: A Survey of the National Trauma Data Bank. J Am Coll Surg. Nov 2008;207(5):710-716
  6. Demetriades D, Murray J, Brown C, et al. High-Level Falls: type and Severity of Injuries and Survival Outcome According to Age. J Trauma. Feb 2005;58(2):342-345
  7. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. Jul 2002;195(1):1-10

Contributor(s)

  1. Hughes, Michelle, DO

Updated/Reviewed: January 2017