A CLINICAL CASE OF EMERGENCY MEDICAL CARE FOR 11-MONTH-OLD CHILD WITH POLYTRAUMA Skryabin E.G., Bukseev A.N., Àkselrov Ì.À., Myasnikov V.A. Zakharov A.M., Mezhevich G.G., Popov A.V.
Tyumen State Medical University,
Regional Clinical Hospital No.2, Tyumen, Russia
The problem of arrangement of urgent medical care for children at the age of 0-2 with injuries to bones, muscles and internal organs is still important [1]. Such injuries usually demonstrate multiple and concomitant patterns since they appear as result of serious road traffic accidents and fallings from height [2]. He proportion of children at the age < 3 with such injuries is 3.5 % [3] – 4.5 % [4] of all cases of pediatric polytrauma.
There is a negative public response relating to young children falling from height though the window mosquito net in almost all big cities of our country [5].
Objective – to present for wide audience of traumatologists-orthopedists and pediatric surgeons a clinical case of urgent medical care for a child of the first year of life who received a serious associated injury as result of falling from the height of the ninth floor though the window with mosquito net: fractures of eight long bones, traumatic brain injury, thoracic and abdominal injuries.
MATERIALS AND METHODS
The clinical materials for this article were the experience with arrangement of urgent medical care for a boy S. at the age of 11 months who was admitted to the admission and diagnostic unit of the big multi-profile hospital on 29 May 2018.
According to the data from the emergency service team, the boy fell from the window through the mosquito net from the height of the ninth fall. The bystanders found the child lying on the pavement near the eleventh-floor building. They called to the emergency medical service. The call was accepted at 18:41. The child was admitted to the admission and diagnostic unit at 18:57.
The examination included the whole complex of diagnostic measures according to the standard examination for polytrauma. So, for objective confirmation of bone and articular abnormality, multispiral computer tomography with the whole body mode was used.
The legal representative (the mother) of the patient was informed and gave the permission for participation in the study and for description of the case in special medical literature. The study was approved by the ethical committee of Tyumen State Medical University. All stages of the study corresponded to the laws of RF and to regulatory documents of Tyumen State Medical University with compliance to Helsinki Declare –Ethical Principles for Medical Research with Human Subjects 2000, and the Rules for Clinical Practice in the Russian Federation confirmed by the Order No.266 of Health Ministry of RF, 19 June 2003.
RESULTS AND DISCUSSION
In the intensive care unit, the child was examined by the pediatric intensivist, the traumatologists-orthopedist, the surgeon, the neurosurgeon, the maxillofacial surgeon, the otolaryngologist and the pediatrist. The condition was estimated as extremely severe. The consciousness level was coma I. The pupils were of the same size, with normal photo response. The muscular tone was low. There was not any response to external stimuli. The skin was pale. There were some deformations in the middle one-third of the hip and ulnar joints. There were multiple scratches on the body and extremities. The oral cavity contained a lot of blood. The pulse was palpated on the peripheral arteries. The arterial pressure – 50/20 mm Hg. The heart rate – 150 per min. Cardiac tones were rhythmical. The respiratory rate – 20 per min. Auscultation: harsh respiration, both-sided, with rattling in all fields. The abdomen was soft, palpated in all parts. Peritoneal symptoms were unclear. No defecation or urination during the examination. The urine was discharged with the catheter. It was clear and light (20 ml). According to severe condition, the child was intubated, artificial lung ventilation was initiated. All anti-shock procedures were continued.
The examination included paraclilical studies, ultrasonography of abdominal and thoracic cavities, MSCT with whole body mode (Fig. 1).
Figure 1
The result of multispiral computer tomography with the whole body mode of the child S., age of 11 months: fractures of right and left femoral bones, fractures of right and left humeral bones and of right and left forearms.
The diagnosis was made on the basis of the examination: “the associated injury. Closed traumatic brain injury. Moderate brain concussion. Soft tissue bruise of the head. A blunt abdominal injury. Splenic rupture. Liver rupture. Closed chest injury. Contusion of both lungs. Closed oblique and transverse fracture of diaphysis of the right femoral bone with displacement. Closed displaced transcondylar fracture of the right humerus. Secondary opened supracondylar fracture of the left humerus. Closed displaced fractures of distal metaepiphyses of both bones of the right forearm. Closed triple fracture of the lower mandible. Closed fracture of the upper mandible (Le-For II). Closed fracture of the left malar arch without displacement. Closed fracture of the anterior wall of maxillary antrum to the left and to the right. Closed fracture of cells of the sieve bone. Hemosinus. A tear-contused wound of frenulum of the upper lip. Contusion of the left auditory pathway. Nasal bleeding. Traumatic shock of degree 3”.
According to ISS [6], the total sum of injuries was 41 points (3rd degree of severity), with 50 % of life threat at all stages of treatment.
According to vital indications, the child was admitted to the surgery room. Laparoscopy was refused due to unstable hemodynamics and respiratory disorders. Abdominal puncture with blood collecting was conducted for diagnostic purpose. Mid-line laparotomy was conducted. The revision of abdominal organs showed some multiple and bleeding ruptures (up to 1 cm of depth) of the spleen along its length which were the indications for splenectomy. A splenic fragment of 0.5 × 0.5 cm (divided and washed in saline) was implanted into the omentum according to the technique accepted in the clinic. The liver revision found three bleeding lineal ruptures in the segments 5-8. They were sutured with rectangular sutures. The bleeding was arrested. Subsequent revision showed some hematomas on the surface of the jejunum, in the root of mesentery, in the head and the tail of pancreas. The surgery was completed with draining of omental bursa, supra- and subhepatic space and in the bed of the spleen. The surgery lasted for 1 hour and 40 minutes.
Immediately after cavital surgery, considering the multiple injuries to the long bones, a collegial decision was made to conduct the surgical stabilization – low invasive closed osteosynthesis with metal constructs. Closed intramedullary fixation of fractures of the right and left femoral bones was conducted with elastic nails with the standard technique under control of the electronic optical transducer. After closed reposition, the fractures of humeral bones were fixed with two crossing K-wires. The fractures of the lower one-third of the right radial bone and both bones of the left forearm after reposition were fixed with pins. The total duration of all operations for superior and inferior segments of extremities was 55 minutes. Plaster immobilization was not used.
After surgery, the child was transferred to the intensive care unit to continue the anti-shock measures. All necessary procedures were realized during 20 days (analgesia, hemostatic, disaggregant, metabolic and antibacterial therapy) and corresponded to the recommendations from profile specialists. Artificial lung ventilation lasted for 17 days, including 9 days with tracheostomy cannula for prevention of bronchial and pulmonary complications.
The control X-ray examination of the operated extremities showed the satisfactory condition of bone fragments of all bones and adequate fixation of metal constructs. The postsurgical wounds healed with primary tension.
Beginning from the tenth days after surgery, the child could move his extremities, from the day 21 – he could overturn and crawl in the bed, with full supporting to knee joints and hand joints.
The general amount of bed-days was 27. With recommendations for adherence to bed rest, he was discharged for outpatient management. The control clinical and radiological study of the operated extremities of the child S. was conducted by the operating surgeon after 17 weeks from the injury moment (Fig. 2).
Figure 2
Appearance of the child’s lower extremities: a) frontal view; b) posterior view; c) left-sided view.
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Figure 2a: Appearance of the child’s lower extremities: frontal view |
Figure 2b Appearance of the child’s lower extremities: posterior view |
Figure 2c Appearance of the child’s lower extremities: left-sided view. |
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During the examination, the child’s mother did not inform of any complaints. The visual appearance of the axis of the upper and lower extremities was correct. The volume of paired segments and their length were equal, the contractures in big joints were absent. Popliteal and gluteal folds were symmetrical. There were not any vascular and neurological disorders in the extremities. The boy was active. He could walk independently with full support to plantar surfaces of his feet. The metal constructs did not cause any complaints. Migration did not happen (Fig. 3).
Figure 3
X-ray images of right femoral bone (a), left femoral bone (b), right humeral, radial and ulnar bones (c), left humeral, radial and ulnar bones (d) of the child S. Consolidated fractures of bones of extremities. Condition after metal osteosynthesis.
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Figure 3a X-ray images of right femoral bone of the child S. Consolidated fractures of bones of extremities. Condition after metal osteosynthesis. |
Figure 3b X-ray images of left femoral bone of the child S. Consolidated fractures of bones of extremities. Condition after metal osteosynthesis. |
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Figure 3c X-ray images of radial and ulnar bones of the child S. Consolidated fractures of bones of extremities. Condition after metal osteosynthesis. |
Figure 3d X-ray images of radial and ulnar bones of the child S. Consolidated fractures of bones of extremities. Condition after metal osteosynthesis. |
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According to the literature data, children of the first year of life show the union of long bone fractures after 6-8 weeks from the injury [7, 8]. In this clinical case, more than 17 weeks passed from the injury moment. Fractures of all bones united. It was confirmed by clinical and radiologic examinations. The child’s parents were offered to remove the metal constructs. It was achieved after 7 weeks from that moment. The boy was one and a half of a year.
The surgery for removal of metal constructs was without technical difficulties, without use of X-ray technique, and with minimal blood loss. Four days later, the child was discharged. He was followed up by the traumatologist- orthopedist in the local polyclinic according to the place of residence up to the moment of suture removal.
The result of treatment of the patient S., the age of 1.5, who suffered from the severe associated injury as result of falling from the height of the ninth floor, was estimated as good. The clinical symptoms of good results of the treatment were absence of complaints from the side of the parents, the normal external view of the extremities (physiological axis, length, volume), full supporting ability, full range of movement in adjacent joints, absent neurological and vascular disorders, and normal walking habits. The radiological symptoms of good results of the treatment were presented by correct axis of extremity segments and by absence of deformations, and absent fracture lines in X-ray images.
The described diagnostic and curative techniques, according to our opinion, are optimal and were chosen according to severity of the injuries after falling.
The whole-body MSCT allowed fast confirmation of the diagnosis and selecting the management. The literature data shows that patients with polytrauma demonstrate better survival with whole-body MSCT as compared to CT for separate parts of skeleton [9]. Such type of MSCT often identifies some hidden injuries, which are not reported by a patient owing to severity of his/her condition, and which remain unidentified up to the concrete time point [10]. Dushin D.Yu. et al. [11] analyzed the high volume of information in special medical literature. They concluded that whole-body MSCT is a method of choice for diagnosis of traumatic injuries since it has the highest sensitivity and specificity and allows making a fast and correct decision on management of a patient.
On the basis of the result of whole body MSCT, it was decided to conduct the surgery for the injured bones of the child S. (age of 11 months) after completion of abdominal surgery. Since the characteristics of injuries to femoral, humeral, ulnar and radial bones allowed low invasive techniques of closed fixation with minimal blood loss and under control of electronic optical transducer, it was decided to conduct the closed fixation, resulting in slight prolongation of narcosis with consideration of multiple injuries.
The selection of optimal time and volume of surgical interventions for injured children is the central problem in the clinical course of multiple and associated injuries [12].
We adhere to the opinion by Agadzhanyan V.V. et al. [1], Sinitsa N.S. et al. [2] on surgical stabilization of all identified skeletal bones in polytrauma at early stage of treatment. It prevents such manifestations of traumatic disease as respiratory distress syndrome, DIC, sepsis, multiple organ dysfunction and worsening traumatic shock.
In the described clinical follow-up, the use of intramedullary nails for closed fixation of diaphyseal fractures of femoral bones was substantiated by pathogenetical conditions. A single nail (not a pair) was used for each segment. It was sufficient for correct positioning of fixed fragments of bones up to the moment of union, considering the fact that the child could not walk before the injury. The use of K-wire for closed fixation of injured distal metaphyses and epiphyses of upper extremity bones, in compliance with the recommendations by Sinitsa N.S. et al. [2], also gave the good anatomical and functional results.
The fractures of facial bones (mainly upper and lower mandibles) did not required for splints due to anatomical and physiological properties. It was estimated by the maxillofacial surgeon as the correct management.
CONCLUSION
The modern life does not suppose the decrease in incidence of severe skeletal injuries including ones in young children. The most optimal way for further development of pediatric traumatology is future implementation of modern diagnostic and restorative techniques with fast identification of all traumatic injuries and subsequent development of appropriate management techniques.
The analysis of medical literature shows the active implementation of digital radiologic equipment, modern devices for computer and magnetic resonance imaging. The popularity of various techniques of osteosynthesis of long bones, the pelvis and the spine has been increasing. All above-mentioned techniques allow higher amount of satisfactory and good anatomical results of management of pediatric polytrauma.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.