A CLINICAL CASE OF SUCCESSFUL TREATMENT OF A CHILD WITH POLYTRAUMA
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
The problem of treatment of polytrauma became one of the key problems in the worldwide medicine. It is explained by increasing number of such injuries, as well as by the specific severity of condition of patients, difficult diagnostics and treatment, high mortality and variety of such injuries. The comparative analysis of disability shows the specific severity of condition in patients with polytrauma. It is 1.9 % for single injuries to the locomotor system, 10 % for multiple injuries, 32.7 % for associated injuries to the locomotor system and internal organs (the head, the chest and the abdomen) [1].
Among pediatric population the posttraumatic mortality is 28.7 %. Its main causes are road traffic accidents. Road traffic injuries take lives of 16,400 children and young people (age before 20) in the European region each year. It consists 38 % of the whole mortality from sudden injuries in this age group and almost 6 % of the total world pediatric mortality [2]. Arrangement of treatment at the hospital stage is one of the most important stages of treatment. Improving quality of medical aid for patients with polytrauma is associated with initiation of specific medical aid in departments of multi-profile hospitals with a possibility of realization of full complex examination and treatment of patients [3]. The quality of diagnostics and results of treatment are significantly improved with delivery of patients with severe injuries to the specialized facility with availability of various specialists [4, 5].
Surgical treatment is one of the most topical and disputable issues of polytrauma treatment. It includes several problems: surgical indications, surgical volume, terms and conditions of realization. Currently, most researchers have concluded that surgical treatment of injuries in polytrauma should be realized as early as possible. Operations are considered as anti-shock measures, despite of additional trauma [5]. Early stabilization of fractures decreases the systemic manifestations of inflammation including systemic inflammatory response syndrome, sepsis and multiple organ insufficiency. Early stabilization decreases pain and risk of secondary neurovascular injury, and stimulates mobilization [1].
The presented clinical case is an example of treatment of a patient with polytrauma with use of the low invasive techniques of fixation of opened fractures of the long bones.
The inclusion criteria for the patient were presence of the written consent from the parents which was reviewed and approved at the meeting of the ethical committee of Regional Clinical Center of Miners’ Health Protection.
The patient T., female, age of 12, was riding a motorcycle as a passenger. The driver lost control and knocked against the tree. After the road traffic accident the child was admitted to the Belovo City Clinical Hospital No.8. The following procedures were conducted: primary surgical preparation of the wound of the hip and the leg, mounting of the skeletal traction system. The fractures were not fixed. The patient was transferred to Regional Clinical Center of Miners’ Health Protection on May 30, 2016. The transportation was conducted by the specialized team (including the intensivist and the traumatologist) of our center in 30 hours after trauma. The transportation time was 40 minutes. The transportation was realized with Kashtan anti-shock suit, infusion therapy (saline solutions, HES, total volume of 700 ml), use of narcotic analgetics. At the moment of admission the general state was severe because of the injury, course of traumatic shock, acute blood loss, posthemorrhagic anemia and pain syndrome.
After admission the patient was examined by the medical team: the pediatric traumatologist, the pediatric surgeon and the neurosurgeon. The examination included spiral CT of the brain, the thoracic organs and the pelvic bones. The diagnosis at the moment of admission: “Polytrauma. An opened fracture of the distal one-third of the right femur with displacement of fragments. An opened fracture of the proximal one-third of the tibial bone of the right leg with displacement of fragments. A partial rupture of the sacroiliac joint to the right. The rupture of the pubic symphysis. Surgically prepared wounds of the right hip and the right leg. Contused scratches of soft tissues in the frontal region. Traumatic shock of degree 2” (Fig. 1-3).
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Figure 1 X-ray image of the right lower extremity upon admission |
Figure 2 X-ray image of pelvic bones upon admission |
Figure 3 MSCT of the sacroiliac joint upon admission
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The child was admitted to the intensive care unit for initiation of intensive presurgical preparation including blood and plasma transfusion, infusion therapy with saline solutions, analgesia, introduction of protease inhibitors; antibacterial therapy was initiated.
3 hours and 15 minutes after admission the patient was transferred to the surgical room. Narcosis was endotracheal. Diagnostic laparoscopy was conducted: no abdominal injuries were found. The sutures were removed from the wounds of the extremities. There was the boundary necrosis in the region of the sutures. The wounds approached the regions of fractures of the femur and the tibia. Secondary surgical preparation of the wound of the right hip and the leg, opened reposition, osteosynthesis of the right hip with tense nails and draining were conducted. Opened reposition, osteosynthesis of the right tibia with tense nails and draining were performed (Fig. 4, 5).
Fixation of the pelvic bones was delayed since the duration of the surgical intervention was 3 hours. After 24 hours the second stage of the surgical intervention under endotracheal narcosis was conducted – fixation of the pelvic bones with the external fixation device (Fig. 6).
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Figure 4 X-ray images of the right leg after osteosynthesis: a) frontal view; b) lateral view
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Figure 5 X-ray images of the right leg after osteosynthesis: a) frontal view; b) lateral view |
Figure 6 X-ray image of pelvic bones after osteosynthesis
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The child was transferred from the surgery room to the intensive care unit where she received the treatment during the following 3 days. Artificial lung ventilation lasted for 4 hours in early postsurgical period. Epidural space catheterization, analgesia with morphine and continuous infusion of naropin were conducted. Transfusion therapy (the total volume of transfused red blood cells was 250 ml, fresh frozen plasma – 300 ml), infusion therapy with glucose-saline solutions (up to 2,500 ml per day), partial parenteral nutrition, antibacterial therapy, protease inhibitors, H2-blockers, anticoagulants, disaggregants, diuresis stimulation, daily dressings and irrigation of drains were conducted.
After 4 days well-being and condition improved significantly: sleep restoration, improving appetite, normalizing body temperature. The wounds healed with primary intention. The course of remedial gymnastics for working out the joints of the lower extremities was initiated on the second day in the traumatology and orthopedics unit. Satisfactory volume of motions in the injured extremity restored after 21 days. The child was trained to independently move with additional support to the crutches at 32 days after the injury (Fig. 7).
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Figure 7 The appearance of the patient
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CONCLUSION
The complex treatment of multiple skeletal trauma including timely low invasive fixation of fractures, full infusion therapy and early initiation of rehabilitation significantly improves the quality of the patient’s life and favors full restoration of lost functions.