Samara Regional Clinical Hospital by the name of M.I. Kalinin

Samara, Russia

 

During recent years one can observe the persistent increasing rates of road traffic accidents that inevitably result in higher amount of children with polytrauma [1]. The term “polytrauma” is combining one. It includes such concepts as multiple, concomitant, combined trauma, i.e. two or more injuries in one patient, and each injury requires specific treatment [2].

Polytrauma is characterized with specific severity of clinical manifestations, which are accompanied by significant disorder of vital functions, diagnostic difficulties and difficulty in choosing treatment tactics. Polytrauma is one of the main causes of death in children. The data about mortality in children varies significantly [3, 4]. It is related to the fact that in most Russian cities patients are transferred to different medical facilities, depending on leading injury or organizational aspects of assistance [5]. With increasing number of patients with multiple and concomitant injury one can observe increase in severity of locomotor injuries. Comparative analysis of disability testifies the specific severity of state in patients with polytrauma. Disability rate is 1.9 % for isolated locomotor injuries, 10 % for multiple locomotor injuries, and, finally, 32.7 % for concomitant injuries to locomotor system and internal organs (head, chest, abdominal organs) [6].

Many factors are associated with good outcomes of treatment for such patients: organizing assistance at prehospital stage, early transportation to specialized hospital, rendering specialized assistance at hospital stage.

During rendering assistance for patients with polytrauma the first priority task is life salvage, restoration of vital organ functioning and correction of traumatic shock. Another important task is stabilization for injured locomotor segments and restoration of their anatomic functional state. Therefore, in management of patients one can separate resuscitative, curative and restorative periods. Discussion is related to choosing favorable term and adequate volume of surgical interventions. In our study we rely on damage control concept, i.e. minimal, life saving, short procedures are carried out on the first day. Afterwards intensive care is performed until full stabilization of hemodynamic and other indices is achieved. After 1-2 days low invasive operations for internal organs are performed, after 5-7 days ‒ low invasive osteosynthesis [7]. Most operations for locomotor system are performed after elimination of shock and dangerous complications in acute period of traumatic disease [6].

We present a clinical case of a child (age of 10). The patient and the official representative were informed and they gave their consent for participation in the study and description of this case. This study corresponds to the ethical standards of the bioethical committee which are developed according to Helsinki declaration ‒ Ethical Principles for Medical Research with Human Subjects 2000 and the Rules for Clinical Practice in Russian Federation confirmed by the Health Ministry Order, 19.06.2003, #266.

The patients S., male, age of 10, was admitted to the admission department of the pediatric department, Samara Regional Clinical Hospital by the name of Kalinin. On 21.06.2013 he was admitted by the emergency aid team 45 minutes after the road traffic accident. The injured child was hit by a car on the traffic way. During transportation the emergency aid team performed transport immobilization for the left upper extremity with transport universal splint, for the left lower extremity ‒ with Cramer’s ladder splint; the infusion therapy was initiated (saline solutions).

Samara Regional Clinical Hospital is a level I trauma center. The pediatric traumatology department provides 24 hour emergency specialized qualified assistance for children aged of 0-15 living in Samara and the regional districts, with skeletal injuries of different location, with extensive extremity wounds, polytrauma accompanied by shock, including children from road accident sites. The alerting system for patient transport has been adjusted. There is a separate entrance with the rampant for emergency aid car, with the shortest distance to the anti-shock operating room.                       

On admission the patient was examined by the team including an intensivist, a pediatric surgeon, a traumatologist, a neurosurgeon and a pediatrician. The initial examinations were performed: head CT, X-ray examination for the pelvis, the chest, for the left humerus in two views, the left femur in two views, ultrasonic examination for abdominal organs, small pelvis and pleural cavities.

According to the examination the diagnosis was made: polytrauma; closed displaced fracture of the left humerus in the middle one-third; closed displaced fracture of the left femur in the lower one-third; closed fractures of the left and right iliac bones; closed fractures of pubic and ischial bones to the right; scratches in the occipital region; contusions and scratches of soft tissues of shoulder, hip and leg to the left; traumatic shock of degrees I-II. The X-ray images of the fractures of humerus, femur and pelvis are presented in the figure 1.

Figure 1

The X-ray examination of the patient S. on admission: humerus ‒ A, femoral bone ‒ B, pelvis ‒ C

On admission the multidisciplinary team examined the state of the child as severe, conditioned by the injuries and course of traumatic shock. Treatment tactics was developed at collegial level. First and foremost the solution about admission to the intensive care unit was made.

The complex treatment for polytrauma was carried out in the ICU: infusion therapy (colloid solutions), antibacterial therapy, adequate anesthesia, hemostasis. The scratches were treated with aseptic solutions. Closed reposition and correction of displacement of the humerus and the femoral bone was performed. Turner splints were applied for the left upper extremity and for the left lower extremity from tiptoes to the lumber region. The soft immobilizing belt was applied for the pelvis. The patient was put up in the Volkovich position. The blood values on admission were: red blood cells ‒ 3.96; hemoglobin ‒ 105; hematocrit ‒ 31 %; thrombocytes ‒ 308; leukocytes ‒ 11.9; ESR ‒ 10.

After stabilizing the patient’s state (up to stable severe state) the child was transferred to the traumatology department on the next day. Anti-shock therapy was continued for 5 days. The posttraumatic neuritis symptoms for the radial and middle nerves were found. Therapy for improving neural conductivity was initiated (dibazol, proserin, B group vitamins).

Pelvic computer tomography was carried out for identifying appropriate treatment (Fig. 2). The study allowed 3D evaluation of the pelvic injury and identification of bone integrity disorders, which were not found with X-ray technique.

Figure 2

Pelvic CT examination of the patient S. before surgery

According to computer tomography results the clinical diagnosis was updated: polytrauma; closed fracture of pelvic bones with pelvic ring disordered integrity (displaced fracture of right iliac wing, displaced fracture of right pubic and ischial bone, non-displaced fracture of left iliac wing, partial rupture of right sacroiliac joint); closed displaced fracture of left femoral bone in middle and lower third; closed displaced fracture of left humeral in middle third; posttraumatic neuritis of radial and middle nerves to the left; scratches in occipital region, humerus and leg to the left; traumatic shock of degree I.                                    

 After achieving positive trends in the patient’s state (stabilizing SAP at the level not lower than 90 mm Hg, pulse ≤ 100, hematocrit – 30 %, hemoglobin ‒ 100 g/L) the following procedures were performed on June, 27, 2013: 1) external fixation device for pelvic bones and the left femoral bone; 2) left humerus closed fixation with titan elastic nails (TEN).

During external fixation the first stage was presented in view of stabilizing the left pelvic ring and the left femoral bone. Three Schanz nails were introduced into the left iliac bone: two nails were introduced through the iliac crest and one through supraacetabular region. Two Schanz nails were introduced to proximal part of the left femur (one nail in the upper third, the second one ‒ on the border of the upper and middle third). Three Ilizarov pins were conducted through left femoral distal metaphysis into the distal part. Ilizarov external device was mounted on the pins. Schanz pins and Ilizarov device were connected with the bars in the left iliac bone. With the electronic optical transducer the traction and closed reposition of the left femur in the external device were carried out. After achieving the satisfactory state of the left femoral fragments the external fixation device modules were fixed elaborately. The second stage was pelvic ring stabilization. Two Schanz nails were introduced into the right iliac bone: one nail ‒ through the iliac crest, the second nail ‒ in supraacetabular region. The bars connected the nails in the right iliac bone and the external device module. Under electro-optical transducer control the closed reposition was performed. The external fixation device was properly fixed during satisfactory position of the fragments. The figure 3 shows the X-ray images of the pelvic and the left femur in the external fixation device.

Figure 3

X-ray images of pelvis and the left femur in the external fixation device after surgery 

Closed osteosynthesis for the left humerus was performed according to the standard technique with titan elastic nails. 1.5 cm incision was made along the external surface in the lower one-third of the left shoulder. The surgical outcomes are presented on the figure 4.

Figure 4

X-ray images of humerus after TEN osteosynthesis

Presurgical blood values were as indicated below: red blood cells ‒ 3.49; hemoglobin ‒ 106; leukocytes ‒ 11.0; ESR ‒ 10.  

After the operating room the child was transferred to the intensive care unit. After the surgery the red blood values decreased: hemoglobin ‒ 70; red blood cells ‒ 2.33; hematocrit ‒ 20.8 %. Blood component transfusion was performed: fresh frozen plasma ‒ 300 ml, packed red cells with low concentrations of leukocytes and thrombocytes ‒ 263 ml. Next day (June, 28, 2013) the red blood values improved: hemoglobin ‒ 86; red blood cells ‒ 2.92; hematocrit ‒ 26.2 %. The child was transferred to the room in the traumatology department. The patient was in the ICU for a day. At the moment of transfer the state was assessed as middle severity. The positive trends were noted during the following 5 days. The adaptation to the external fixation device was successful. Self-being, sleep and appetite improved. The patient’s state was satisfactory. The postsurgical course was without complications. Primary adhesion was observed for all wounds. The sutures were removed on day 10. Remedial gymnastics was carried out without vertical load.

Remounting the external fixation device was carried out for the left hip joint release on 20^th day after the surgery (July, 20, 2013). The semi-ring was mounted on the upper third of the femur. The bars between the pelvic module and the femoral module were removed. The telescopic bars were used for fixation of the semi-ring and the ring on the femur.

On day 21 the vertical position was allowed with support to the right lower extremity. The child was trained for crutch walking. The admission period was 28 bed-days.

At the moment of admission:

Complete blood analysis: red blood cells ‒ 4.61, hemoglobin ‒ 136, leukocytes ‒ 6.4, eosinophil cells ‒ 4, rod nuclear cells ‒ 0, segmentated cells ‒ 53, lymphocytes ‒ 40; monocytes ‒ 3; ESR ‒ 10.       

   Clinical urine analysis: light yellow color, protein ‒ 0.066, glucose ‒ negative, relative density ‒ 1016, squamous epithelium ‒ 2-3, leukocytes ‒ 3-6, oxalates ‒ little amount.

The radiologic control for the left humerus was performed 6 weeks later, for the pelvis and the left femur ‒ 8 weeks after the surgery.

After 4 months (October, 30, 2013) the external fixation device was dismounted from the pelvis and the left femur. The flexible nails were removed from the left humerus. After the external fixation device removal one could observe limiting range of motion in the knee joint (up to 110°). The child received the course of complex restorative treatment including remedial gymnastics and physical procedures. The range of motion restored completely two months later. The load to the lower extremity and walking without crutches were allowed 6 months after the surgery. The figure 5 demonstrates the radiologic outcomes of treatment. The functional outcomes are presented in the figure 6.

Figure 5

X-ray outcome of treatment

Figure 6

Functional outcome of treatment

Therefore, adequate and timely stabilization for injured segments and intensive care for polytrauma allow achieving favorable anatomic and functional outcomes.