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Damage control orthopedics applied in an 8-year-old child with life-threatening multiple injuries: A CARE-compliant
Viktoria Amanda Pfeifle1, Simone Schreiner2, Daniel Trachsel3
1University Children's Hospital Basel (UKBB), Department of Pediatric Surgery, 4056 Basel.
Insights
Damage control orthopedics is feasible in pediatric polytrauma. This staged approach managed severe injuries in an 8-year-old girl, enabling functional recovery despite long-term complications.
Area of Science:
- Pediatric Orthopedics
- Trauma Surgery
- Surgical Critical Care
Background:
- Damage control surgery is a staged approach for polytraumatized patients, involving initial stabilization, intensive care unit (ICU) management, and definitive repair.
- This study evaluates the feasibility and outcomes of the damage control orthopedic approach in a pediatric polytrauma case.
Observation:
- An 8-year-old girl sustained severe polytrauma, including bilateral lung contusion, pelvic and multiple limb fractures, and a femoral neck fracture, after a fall from height.
- Initial management involved emergent orthopedic stabilization (closed reduction, K-wire fixation, external fixation, screw osteosynthesis) followed by ICU care for hemodynamic and respiratory stabilization.
Findings:
- The patient developed growth arrest, osteonecrosis, and slipped capital femoris epiphysis, resulting in leg length inequality.
- Despite these sequelae, the patient achieved functional recovery, walking unaided and participating in school sports, with improvement in sciatic nerve injury.
Implications:
- The damage control orthopedic strategy can be effectively applied in managing complex pediatric polytrauma.
- Adherence to damage control principles is crucial for optimizing outcomes in critically injured children, even with long-term complications.
Rationale:
Damage control is a staged surgical approach to manage polytraumatized patients. The damage control approach comprises three steps. First, bleeding is controlled and fractures are stabilized temporarily; second, vital parameters are stabilized and the child is rewarmed in the intensive care unit; and third, the child is reoperated for definitive repair of injuries. We aimed to describe the feasibility of the damage control orthopedic approach in a child.
Patient Concerns:
An 8-year-old girl fell from the balcony of the 5th floor onto concrete pavement and was admitted to our accident and emergency ward in a stable cardiorespiratory state, but with gross deformity of the lower limbs, left thigh, and forearm.
Diagnoses:
The child had sustained multiple injuries with severe bilateral lung contusion, pneumothorax, fracture of first rib, liver laceration, stable spine fractures, transforaminal fracture of sacrum, pelvic ring fracture, displaced baso-cervical femoral neck fracture, displaced bilateral multifragmental growth plate fractures of both tibiae, fractures of both fibulae, displaced fracture of left forearm, and displaced supracondylar fracture of the humerus.
Intervention:
In the initial operation, we performed closed reduction and K-wire fixation of the right tibia, closed reduction and external fixation of the left tibia, open reduction and screw osteosynthesis of the femoral neck fracture, closed reduction and K-wire fixation of the radius, and closed reduction of the supracondylar fracture. Subsequently, we transferred the girl to the pediatric intensive care unit for hemodynamic stabilization, respiratory therapy, rewarming, and treatment of crush syndrome. In a third step, 10 days after the injury, we managed the supracondylar fracture of the humerus by closed reduction and K-wire fixation.
Outcomes:
Growth arrest of the left distal tibial growth plate and osteonecrosis of the femoral head and neck, slipped capital femoris epiphysis (SCFE), and coxa vara of the right femur led to balanced leg length inequality 2 years after the injury. The lesion of the left sciatic nerve improved over time and the girl walked without walking aids and took part in school sports but avoided jumping exercises.
Lessons:
We emphasize the importance of damage control principles when managing polytraumatized children.
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