acute management of pediatric sports related trauma

Acute Management of Pediatric

Sports Related Trauma

Jonathan R. Schiller, M.D.

Assistant Professor Department of Orthopaedics

Director Adolescent and Young Adult Hip Program

The Warren Alpert Medical School of Brown University

Hasbro Children’s Hospital and Rhode Island Hospital

November 15, 2012

Faculty Disclosures

Jonathan R. Schiller, MD

Has the following financial interest to disclose:

• Depuy-Mitek Division of Hip Arthroscopy -

Educational Consultant

• Clinical Decision Support Program -

Contributor

Not covered in this talk…

Outline - Orthopaedic Injuries

• Limb injuries

• Spine injuries

Limb Injuries

• Fractures

• Dislocations

• Soft tissue injuries

Fractures

• Fractures

– Mild or limb threatening

– Establish amount of displacement

VS

Fractures

• Open vs. closed

• Sometimes may be subtle

• Even small pinholes in the skin constitute an open

fracture

• “better to overcall”

Fractures

• Neurovascular exam

– Capillary refill, pulse

– Sensation

– Motor

• Compartment syndrome

Compartment syndrome

• Muscle in limbs

enclosed in fascial

compartments

• Swelling may

dramatically increase

pressure, leading to

myonecrosis

Compartment syndrome

• Sensory changes and pain with passive stretch

• Loss of pulse - END STAGE EVENT

Fracture Management

• Open or closed

– If open, cover with

sterile bandage

– Do not replace bone

under skin

• Neurovascular status

– If pulseless, gentle

traction to align the

extremity may restore

blood flow

Fractures

• Immobilize joint above and below and

transport

Dislocations

Dislocations

• Open or closed

• Neurovascular

structures

• Compartment syndrome

Dislocations

• Differentiate from fracture

• No crepitus, gross deformity usually a clue

• Care is the same as for fracture

– Evaluate

– Immobilize

– Transport

Dislocation

• Knee dislocation - vascular compromise – 5-30%

– Rapid evaluation – ABI, arteriogram

• Suspected dislocations - spontaneously reduce

– Immobilized and referred

Soft tissue injury

• Ligamentous disruption common

• Growing children, growth plate weak link and must be evaluated in the presence of a “torn ligament”

• Immobilization, as well as a thorough neurovascular exam are performed

• “Significant” injuries (i.e. can’t weight bear) should go to the ER for evaluation

Spine Injuries

Thoracic/Lumbar Fractures

• Fortunately, rare in the acute setting

• Can be seen occasionally in contact sports

• Evaluation for associated injuries extremely

important

– Liver/spleen

– Pulmonary/cardiac contusion

Cervical Spine

Epidemiology: Football

INCIDENCE

National FB Head & Neck

Injury Registry (1971-5)

• Cervical Fx-dis : 259 (4.1/100,000)

• Quadriplegia : 99 (1.6/100,000)

Development of Modern Helmet

• Improved head protection

• Altered playing technique

• * Increased Risk C-spine Injury

Epidemiology: Football

INCIDENCE

NCAA Rules Committee (1976)

• Banned head-first contact

Progressive decrease in rate of SCI

over next decade

– Injury Rate 1985 - 2000 = stable

• 0.45/100,000 : high school

• 1.40/100,000 : college

Epidemiology: Hockey

INCIDENCE

Rare before 1980 ; increase past 20 yrs

– CANADIAN SURVEY 1966-93 (Tator )

Spine Fracture-Dislocation

– 241 total ; 16.8/yr (1982-93)

– 90% in Cervical region

Spinal Cord Injury

– Permanent SCI : 108

– Complete lesion : 52

– Deaths : 8


CATASTROPHIC CERVICAL TRAUMA

American FOOTBALL : higher total # per year

Canadian HOCKEY : annual incidence 3 X greater

U.S. High School Data – Annual Incidence

Football : 0.68/100,000

Hockey : 2.56/100,000


CATASTROPHIC

CERVICAL TRAUMA

Major Causative Factor:

CHECK FROM BEHIND

– Head first collision w/ boards

– PREVENTIVE MEASURES:

RULE CHANGES

Recent data from Canadian

Registry : ? fewer cases

Clinical Anatomy

SPINAL CANAL

Shape of a “funnel”

Cross-sectional area

occupied by cord

• < 50% at C1

• 75% from C4-C7

Clinical Syndromes:

Fracture-Dislocations

Injury Vector :

COMPRESSION

Axial force applied to

vertex of helmet

C-spine compressed

- decelerated head

- oncoming body

Clinical Syndromes:


Injury Vector :

COMPRESSION

Cadaveric Studies

– C-spine

• straight

• colinear w/ axial load

– Response to compression:

BUCKLING

Clinical Syndromes:


Fracture Pattern:

Compressive-Flexion

Highly unstable

Often assoc. w/ SCI

Cervical Spine

• Persisent neck pain

warrants evaluation

• Any neurologic

symptoms need to be

taken seriously

• Transport to ER if

unsure for eval

• Assume the spine is

UNstable

Spine injury-evaluation

ON-SITE EVALUATION & MANAGEMENT

Primary Survey

OBJECTIVES

– Assess for life-threatening conditions

– Prevent further injury

SEQUENCE OF TRAUMA CARE :

Airway (+ c-spine protection)

Breathing and ventilation

Circulation

Disability / neurologic status

Exposure

PRIMARY SURVEY

Normal Mental Status & Cardiorespiratory Status

Athlete awake & communicative

– r/o compromise of ABC

SECONDARY SURVEY

Neurologic exam

Suspect Catastrophic Neck Injury

• Findings referable to cord damage

• Serious neck pain

• Focal spinal TTP

• Restricted cervical ROM

PRIMARY SURVEY

Altered Mental Status

Depressed LOC

• Assume C-spine Injury!!!

– Manual immobilization

– Remove facemask

PRIMARY SURVEY

Cardiopulmonary Compromise

OBJECTIVES

• Identify hypoxia

• Intervene => proper ventilation

• Avoid injury spine/n. elements

Assume catastrophic neck injury

PROTECT CERVICAL SPINE

PRIMARY SURVEY

Cardiopulmonary Compromise

AIRWAY OBSTRUCTION

• Reestablish patency

upper respiratory tract

STEPS

– If prone, logroll to supine

– Extract mouthpiece

– Remove facemask

– Jaw thrust maneuver

– Oral airway ??

- altered mental status

PRIMARY SURVEY

PULSE EVALUATION

Decreased amplitude + bradycardia

– Neurogenic shock ; cervical SCI

Rapid & thready w/ normal rhythmn

– Hypovolemic shock (? splenic injury)

Irregular rhythmn

– Cardiac dysfunction

Absent central pulses

– Need for CPR

IMMOBILIZATION & TRANSPORT

Secondary Survey complete

Log roll to backboard

Immobilize C-spine

– HELMET & SHOULDER PADS

IN PLACE

*n.b. basic science data

Spinal Injury

• Transport to emergency department for

emergency care

• Steroid protocol

• +/- surgery

Herniated Discs in Children

• Less commonly seen than in the adult

population

• Can be seen with exertion (i.e. weightlifting)

• Male slightly greater than female

• Early degenerative changes often seen on MRI

in these patients

• Patients may be predisposed :

– Congenitally narrow canal

– familial cases of HNP

• In the growing child, ring apophysis fracture

(RAF) must also be considered

• Pop in back during heavy lifting is classic

Ring Apophysis Fracture

HNP/RAF

• Usually below spinal cord level, so pathology

is of the individual nerve root

• Large central herniations can compress the

cauda equina, leading to bowel and bladder

dysfunction

• Evaluation should include sensory and motor,

as well as specific question regarding perianal

sensation

• Conservative treatment

• Surgery refractory symptoms

MRI

16 year old powerlifter…

Summary

• More and more children

each year are involved in

sports

• Recognition of the need to

prevent injuries has helped

lower the risk

• Potentially catastrophic

injuries can occur and

require prompt recognition

and treatment

Summary

• Cooperation between all

members of the health

care team is essential

acute management of pediatric sports related trauma

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