Chapter 20. Trauma

Clinical Summary

Pediatric head trauma occurs commonly with most being minor; however, seemingly low-risk presentations may have intracranial injuries, and thus it is important to maintain a high index of suspicion. The Glasgow Coma Scale (GCS) quantifies neurologic findings and allows uniformity in description and communication among team members involved in taking care of the patient. A GCS score of 14 to 15 is categorized as mild head injury; a GCS score of 9 to 13 as moderate head injury and GCS score less than 9 as severe head injury.

Emergency Department Treatment and Disposition

Stabilize airway with cervical spine immobilization, breathing and circulation as indicated followed by evaluations for disability and exposure. Moderate hyperventilation, if signs of impending herniation, and fluid resuscitation, if evidence of hypotension, are critical.

Treat any seizures with a benzodiazepine or fosphenytoin, and consider using the latter prophylactically, if intracranial hemorrhage is present. Obtain laboratory tests including CBC type and cross-match, electrolytes, and coagulation profile in patients with serious head injuries. Consider obtaining ethanol level and toxicologic screen in adolescents. Order C-spine imaging in all patients with midline neck pain or neurologic deficits, and in all unconscious patients. Obtain a head CT scan (without contrast) if loss of consciousness, GCS score <13, penetrating injury, a high-risk mechanism of injury, clinical signs of basilar or depressed skull fracture, a posttraumatic seizure, a large scalp hematoma (especially parietal/temporal), repetitive vomiting, prolonged lethargy, amnesia, past history of bleeding diathesis (eg, hemophilia), significant past medical history (eg, shunts) or suspected abusive head injury. Leave any penetrating foreign bodies of the head in place for operative removal; consult neurosurgery emergently for such cases and for any abnormalities seen on the head CT scan.

Admit patients with abnormal CT findings, witnessed loss or change of consciousness, penetrating injuries, focal or abnormal neurologic examination, abusive injuries, evidence of depressed or basilar skull fracture, other significant associated injuries, persistent symptoms (even with a normal CT scan), amnesia, or an unreliable caretaker at home. Refer to the American Academy of Pediatrics guidelines for minor head injury for patients aged <2 years, and for patients aged 2 to 20 years. Discharge other patients with written instructions that are clear to the caretaker, including the directive to return to the emergency department (ED) immediately if the patient develops any of the following: (1) excessive sleepiness or difficulty in awakening; (2) confusion or abnormal behavior; (3) progressive headache; (4) progressive vomiting or nausea; (5) abnormal gait; (6) ataxia; (7) unequal pupils, double vision, or any visual disturbance; (8) convulsions; and (9) bleeding or watery drainage from the nose or ear.

Pearls

1. Diffuse brain injury (concussion or diffuse axonal injury) is the most common type of head injury.

2. Prevent secondary brain injury in patients presenting with head trauma or multiple trauma.

3. Patients with epidural hematoma may present with the classic lucid interval and acutely deteriorate (“talk and die”).

The authors acknowledge the special contributions of Ayman Chritah, Karen L. Stavile, Kevin J. McSherry, David Listman, Binita R. Shah and Eileen C. Quintana, to prior edition.

Clinical Summary

Skull fractures occur as a result of a direct impact to the calvarium and are important to diagnose because of their association with intracranial injury. The parietal bone is involved most frequently. Linear fractures are most common (about 75%), followed by depressed and basilar fractures. Approximately 30% of children with depressed skull fractures have an associated intracranial injury. Typical head injury mechanisms include falls, sports injuries, and motor vehicle collisions. The morbidity and mortality from closed head injuries increase when there are associated extracranial injuries. Skull fractures are classified by appearance, location, degree of depression, and whether there is an associated scalp laceration. Comminuted skull fractures are multiple linear fractures. Open skull fractures are rare but increase the risk of central nervous system infection. Physical examination findings for skull fractures include hematoma, a palpable step-off or skull defect or crepitus. Most linear skull fractures heal without complications.

Emergency Department Treatment and Disposition

For a detailed approach to head trauma, see Head Trauma section. Order non contrast head CT scan for identification of skull fractures and any associated intracranial pathology (while radiographs may rule in a fracture, they cannot exclude intracranial injury). Clinical assessment is more difficult in children <2 years of age and especially those <3 months old while they are also more susceptible to injury from even minor trauma. Children of this age are also at greater risk of being victims of abuse, developing a growing fracture and having intracranial injuries. Maintain a higher index of suspicion and a lower threshold for obtaining a CT in this age group.

Consult neurosurgery for patients with depressed, basilar, or widely diastatic skull fractures, and admit them for observation with frequent neurologic checks. Admit all patients with persistent neurologic deficits, persistent vomiting, suspected nonaccidental injury or unreliable guardians.

Pearls

1. Consider admission with skull fracture if patient is <6 months of age, large scalp swelling over the fracture, known high-energy mechanism of injury, or concerning fracture location (eg, crossing a suture, extending into posterior fossa, or in a dural venous sinus or a vascular groove).

2. Normal variants such as vascular grooves, open metopic sutures, posterior fossa sutures, and accessory sutures may mimic skull fractures.

Clinical Summary

Basilar skull fractures (BSFs) are injuries that involve the base of the skull, typically involving the petrous portion of the temporal bone (but can involve any skull base). Patients present with distinct clinical findings (80% of cases) that include Battle sign (postauricular ecchymosis suggesting a mastoid fracture), raccoon eyes or periorbital ecchymosis (intraorbital bleeding from orbital roof fractures), hemotympanum, cerebrospinal fluid (CSF) rhinorrhea or otorrhea or cranial nerve palsies, tinnitus, hearing loss, anosmia, nausea, vomiting vertigo, or nystagmus. BSFs with underlying dural tears have an increased association with CSF leaks and thus an increased risk of intracranial infection (eg, Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae). Other complications include hearing loss (conductive or sensorineural in up to half of the children).

Emergency Department Treatment and Disposition

For a detailed approach to head trauma, see Head Trauma section. Obtain head CT scan, including imaging of the temporal bone (about 40% of BSFs are missed by CT scan). Admit children to ICU with BSF for monitoring and consult neurosurgery.

Pearls

1. BSF usually results from a considerable force; always exclude brain injury.

2. Do not pass nasogastric tube (may lead to inadvertent passage through an injured cribriform plate).

3. Cranial nerve palsies (eg, I, VII, VIII, X) may be seen immediately or a few days after the injury.

Clinical Summary

Subdural hematoma (SDH) develops as a result of venous bleeding from bridging veins between the dura and the arachnoid membranes. SDHs are seen with significant mechanisms of injury and are often associated with underlying brain injury (eg, intracerebral hematomas, contusions). They may be bilateral and occur more commonly than epidural hematoma. Abusive head injury is a common etiology, especially when the child is <2 years of age. Presenting symptoms include irritability, vomiting, altered mental status, seizures, focal neurologic signs, and if young, a very full fontanelle. Predisposing factors for development of SDHs include osteogenesis imperfecta, glutaric aciduria type I, arachnoid cysts, cerebral atrophy, history of hydrocephalus, or bleeding disorders.

Emergency Department Treatment and Disposition

For a detailed approach to head trauma, see Head Trauma section. Obtain noncontrast head CT scan and neurosurgical consultation. Obtain baseline laboratory tests, including CBC, prothrombin time (PT)/partial thromboplastin time (PTT) with international normalized ratio (INR), a bleeding time, and type and cross. With suspicion of child abuse, obtain liver transaminase levels (occult abdominal trauma), and notify child protective services. Hospitalize patients to ICU for close monitoring. Even in the most critically injured children, surgical intervention may not be helpful. When necessary to operate, a craniotomy or craniectomy will effectively evacuate subdural hemorrhage in roughly 80% of patients.

Pearls

1. Majority of SDHs in infants and children <2 years old are caused by inflicted head injuries, and children may present with very nonspecific clinical signs.

2. SDHs are seen as areas of increased density that appear concave (or crescent-shaped), covering and compressing the gyri and sulci over an entire hemisphere.

Clinical Summary

Epidural or extradural hematoma (EDH) is collection of blood between the dura and overlying calvarium. Common causes include low-velocity impact (falls) and nonaccidental injury, motor vehicle collisions (adolescents), and occasionally forceps delivery in neonates. Delayed EDH may occur in poly-trauma patient. EDHs may be of arterial or venous origin. Temporal EDHs are often due to injury to the middle meningeal artery (about 80%) or injury to the middle meningeal vein and dural sinus. In children, there are fewer temporal EDHs and the most common sites are frontal, parietooccipital, and posterior fossa. A patient with EDH may present with an asymptomatic period (lucid period) followed by headache, vomiting, and altered mental status that may progress to signs and symptoms of uncal herniation (fixed or dilated pupil on the same side as EDH and hemiparesis on the opposite side).

Emergency Department Treatment and Disposition

For a detailed approach to head trauma, see Head Trauma section. Rapid diagnosis is critical for successful management. Order a noncontrast head CT scan that will reveal typical biconvex or lenticular increased density of fresh blood. EDH is usually unilateral and localized and does not cross suture lines (as the outer layer of dura attaches to the skull there, preventing blood from expanding past it). Consult neurosurgery emergently; evacuation of EDH is necessary if there is any evidence of worsening mental status, an expanding bleed, or midline shift. Hospitalize patients to ICU if EDH is small and patient is asymptomatic for close monitoring and serial head CT scans.

Pearls

1. Expanding EDHs are potentially life-threatening and often lead to herniation, if not recognized promptly.

2. Infants and young children have a higher frequency of venous EDHs.

3. Younger children with open sutures may not be symptomatic until their condition is critical.

4. EDHs may occur without evidence of an overlying fracture making the diagnosis challenging.

Clinical Summary

Brain contusions (intracerebral hematomas) result from direct external contact forces or from the brain striking the inner surface of the skull during an acceleration/deceleration type of trauma. A classic coup injury will occur at the site of impact, and a contrecoup injury will occur at a site remote to the impact site. Most contusions occur in the frontal and temporal lobes (may occur anywhere in the brain). These areas of bruising are associated with localized edema, ischemia, and mass effect.

Emergency Department Treatment and Disposition

For a detailed approach to head trauma, see Head Trauma section. Order a noncontrast head CT or MRI. The latter is more sensitive in discovering cerebral contusions since CT may not reveal nonhemorrhagic contusions or small petechial hemorrhages. Consult neurosurgery and admit patients to ICU with CT evidence of cerebral contusion or neurologic signs or symptoms or unreliable caretakers. Patients with simple concussions/nonhemorrhagic contusions with no neurologic symptoms can be sent home with good instructions explaining what to watch for in case of cerebral injury.

Pearls

1. Patients with brain contusions may present with focal neurologic signs and/or confusion and an impaired level of consciousness.

2. MRI is the modality of choice to diagnose nonhemorrhagic cerebral contusions.

3. Brain contusions may delay the recovery process of a concussion.

Clinical Summary

Mild traumatic brain injury (TBI) is a fairly common and important public health problem. It is usually benign but can have serious short and long-term sequelae. A concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. The hallmarks of concussion are headache and confusion with or without amnesia, often without a history of loss of consciousness. Frequently observed signs/symptoms of a concussion are vacant stare, unrelenting headache, memory deficits, incoordination, inability to focus, perseveration, slurred or incoherent speech, emotional extremes, and disorientation. Early posttraumatic seizures (within the first week after a head injury) occur in fewer than 5% of mild or moderate TBIs and are associated with a higher risk of posttraumatic epilepsy.

Emergency Department Treatment and Disposition

For a detailed approach to head trauma, see Head Trauma section. Not all patients with mild head injury need a CT scan. Observe these patients for at least 24 hours with attention to the increased risk of intracranial complications. Admit patients who have GCS score <15, any abnormality on CT scan, history of a seizure, any abnormal bleeding parameters or a home environment where the patient cannot be checked on regularly. If a patient is discharged, instruct the caregiver to seek medical care if there is difficulty waking the child, vomiting, a worsening headache, deteriorating vision, restlessness or confusion, weakness or numbness, or any evidence of urinary or bowel incontinence.

Recommend that the child not play full contact sports for at least 1 week after all symptoms have stopped. Consult neurology and/or sports medicine specialist for patient and caregiver counseling to help avoid the “second hit” phenomenon where patients develop permanent neurologic symptoms after a second concussion soon after the first event.

Pearls

1. A mild TBI/concussion is an injury to the brain that results from acceleration/deceleration or a blunt force and generally does not show up on any radiologic imaging modality.

2. Patients who suffer a TBI need to be evaluated by a professional, and thoughtful advice needs to be given regarding return to play.

Clinical Summary

Nasal septal hematomas are collections of blood between the avascular septal cartilage and perichondrium and are almost always associated with facial trauma such as from motor vehicle collisions, sporting injuries, or assault. Intranasal surgery may also cause such an injury. Buckling forces result in tearing of the submucosal vessels underlying the perichondrium. Because the perichondrium is the sole blood supply to the cartilage, hematomas result in avascular necrosis of the cartilage if not drained promptly. Stagnant blood may promote bacterial proliferation and abscess formation as well. Accompanying fracture of the 2- to 4-mm-thick septal cartilage may lead to the formation of bilateral hematomas. Common complaints include nasal obstruction, pain, and epistaxis. Fever is less frequent in the acute phase, but may mark the progression of a hematoma to an abscess. Associated physical findings include external nasal deformity and significant tenderness to palpation. Early diagnosis and drainage is critical to prevent consequences of cartilaginous ischemia, including septal perforation and saddle-nose deformity. Failure to manage these collections may result in more serious complications, including intracranial abscesses, orbital cellulitis, meningitis, and cavernous sinus thrombosis.

Emergency Department Treatment and Disposition

Perform a physical examination with a nasal speculum and a headlight. An asymmetric septum with a blue or red hue confirms the diagnosis and direct palpation along the septum with a gloved finger or cotton-tipped applicator will reveal swelling or fluctuance. Use endoscopic nasal examination with a fiberoptic scope to better visualize the hematoma and better determine its extent.

Perform incision and drainage as soon as possible; this may require ENT consultation and may need to be done in an operating room, especially in young children. Incise the mucosa over the area of greatest fluctuance without involving the cartilage. If bilateral hematomas are present, stagger the incisions to avoid iatrogenic perforation. Suction clots and purulent fluid and collect cultures. Place a small passive drain, such as a cut penrose or large vessel loop, under the septal flap to prevent reaccumulation and suture it to the edge of the incision. Place small bilateral anterior packs in the nostrils to provide tamponading pressure and prevent recollection. The packs may be removed within 2 to 3 days. Initiate antibiotics that cover gram-positive and β-lactamase producing organisms. Obtain a CT scan of the brain and sinuses in any patient with signs of systemic infection to rule out septal abscess. Refer patients for follow-up with an otolaryngologist to remove packing and drains within 5 to 7 days. Patients will also need annual follow-up for monitoring of septal developmental abnormalities due to potential septal cartilage destruction.

Pearls

1. Septal hematomas in children can occur with minor trauma, including simple falls or altercations. Younger children, including infants and toddlers, presenting with septal hematomas without concomitant injuries should raise the suspicion of child abuse.

2. Abscess formation is the most common complication of septal hematomas; failure to manage this collection may result in serious complications including intracranial abscesses, orbital cellulitis, meningitis, and cavernous sinus thrombosis.

Clinical Summary

Nasal fractures are the most common facial fractures in children and must not be confused with nasoorbitoethmoid (NOE)–type injuries, which are far less numerous. Typical etiologies of nasal trauma include falls, sports injuries, motor vehicle collisions, and physical confrontations. The nasal bones articulate with the nasal septum, which can also be fractured. Patients may complain of pain and nasal obstruction. Significant obstruction may result in mouth breathing and new-onset snoring. Fracture/dislocations of the nasal bones are typically associated with swelling and ecchymosis in the region and occasionally an overlying laceration. Many patients will also present with epistaxis.

Emergency Department Treatment and Disposition

Manage immediate life-threatening injuries first and stabilize airway, breathing, and circulation. Perform a complete physical examination, including a nasal speculum examination to exclude septal hematoma. Control epistaxis with cold packs and light pressure and consider use of topical decongestants to help control bleeding and aid visualization as well. If these methods do not stop the bleeding, use nasal packing. Document mucosal lacerations, septal deviation, or septal hematoma.

Order plain films or maxillofacial noncontrast CT when the history and physical findings suggest injuries more complex than a nondisplaced, isolated nasal fracture.

Refer patients with nasal pyramid deformity or obstruction to a facial trauma surgeon for closed nasal reduction under general anesthesia within 3 days. Because healing in children is faster than in adults, closed nasal reduction should be planned 4 to 7 days after the injury to be effective and avoid sequelae.

Patients may be discharged with analgesics such as acetaminophen or narcotics and discharge instructions to avoid nose blowing and heavy lifting or physical exertion. Instruct patients to use cold packs to decrease swelling. Prescribe prophylactic antibiotics that cover gram-positive bacteria to prevent toxic shock syndrome to all patients with nasal packing.

Pearls

1. Effective management of nasal fractures prevents secondary deformity and the need for additional reconstructive procedures.

2. Manage simple nondisplaced nasal fractures conservatively with ice packs to reduce swelling and analgesics.

Clinical Summary

The mandible is one of the most frequently fractured bones in children, and falls and motor vehicle collisions are the most common causes. In older children, mandible fractures may result from sports injuries and interpersonal violence. The condyle is the most common fracture site, representing up to 50% of all mandible fractures. In 20% of patients, both condyles will be fractured. Older children are potentially exposed to higher velocity/higher impact injuries, with resulting greater degrees of displacement and comminution. There is a significant rate of associated neurologic or other injuries among these patients.

Jaw pain and lip or tooth numbness may be present secondary to injury to the inferior alveolar nerve and there may be associated dental injuries or tooth avulsions that must be documented. Physical examination may reveal trismus and pain with jaw opening, floor of mouth swelling, or hematoma. Some fractures may result in retrognathia and tongue collapse with airway obstruction. Intraoral lacerations may also be seen. Deviation of the jaw with opening can suggest the presence of a condylar fracture with occlusion shifted as well. Ecchymosis over the chin or lacerations of the ear canal are external signs associated with some mandibular fractures.

Emergency Department Treatment and Disposition

Perform a complete physical and stabilize the patient as a first priority, including a facial trauma survey with palpation of the bony craniofacial skeleton for step-offs, mobile bony segments or crepitus, and a neurosensory assessment with attention to cranial nerve function, particularly the trigeminal nerve. Obtain panoramic radiograph or panorex if the patient is able to sit upright. If the patient cannot sit or c-spine immobilization is needed, a plain-film mandible series may be shot although maxillofacial CT scan (with axial and coronal reconstruction) is more commonly used. Multiplane protocols allow better visualization of fracture fragments or dislocations. If physical examination findings suggest a possible mandible fracture but plain radiographs are negative, consider obtaining a CT to rule out Greenstick or incomplete fractures. If other facial fractures are present, a CT scan is mandatory.

Consult facial trauma surgery for all mandible fractures and dentistry if associated dental trauma is present. Obtain a chest radiograph in patients with avulsed teeth that cannot be accounted for to rule out tooth aspiration. Provide temporary stabilization of fractured mandibular segments with circumdental wires, such as a bridle wire, until definitive management is planned. In young children, this requires sedation and is most easily accomplished in a procedure suite or the operating room.

Admit patients with floor of mouth swelling, associated midfacial fractures, pain resulting in poor oral intake, severe associated soft tissue injury requiring operative repair or pain that is not well controlled with oral analgesia. All other patients may be discharged with appropriate follow-up and adequate analgesia. Acetaminophen with codeine or other opioid narcotics are appropriate choices. Mandibular fractures in children heal more quickly than in adults, so follow-up appointment should be scheduled within 24 to 72 hours if open reduction is being considered. Provide antibiotics that cover oral flora for a minimum of 7 days and instruct patients to adhere to a soft diet.

Pearls

1. Mandible fractures can occur in predictable patterns (eg, combination of a symphyseal fracture with bilateral condylar fractures, a body fracture with a contralateral condylar fracture, parasymphyseal fractures with unilateral or bilateral condylar fractures). Exclude a possibility of a second fracture with appropriate imaging and clinical examination.

2. Exclude condylar fracture in a patient with chin ecchymosis, chin laceration, or a history of a blow to the chin from a punch, a fall, or the chin hitting the dashboard of an automobile.

Clinical Summary

Fractures of the midface and upper face with various degrees of bony disruption are usually caused by motor vehicle accidents, falls, and interpersonal violence. There are several important anatomical features of the pediatric craniofacial skeleton. The paranasal sinuses are not fully formed at birth. Before the development of the maxillary sinuses, pure Le Fort pattern fractures are rare. Similarly, frontal sinus fractures are rare until at least school age as postnatal development of the frontal sinus is not significant until the adult size is attained in adolescence. The lack of frontal sinuses and prominence of the calvaria in infants and toddlers results in a higher proportion of frontal skull and skull base fractures.

Maxilla/Le Fort Fractures

The Le Fort fracture patterns describe fracture lines that occur with some reproducibility after impact forces delivered to the maxilla. Varying degrees of midfacial retrusion and elongation are the hallmarks of these bony disruptions. The Le Fort I fracture line runs just above the maxillary alveolus from the rim of the pyriform aperture laterally ending at the pterygoid plates posteriorly. Patients will present with malocclusion—often an anterior open bite—and the alveolus will be mobile when manipulated. The Le Fort II fracture is also known as a pyramidal fracture. These fracture lines begin at the root of the nose where the nasal bones articulate with the frontal bones and run inferolaterally across the medial orbital walls to the lateral maxilla. The Le Fort III fracture is also referred to as craniofacial separation. This high fracture line results in maxillary separation from the cranial base. Step-offs and bony mobility will be palpable at the fracture sites. Hypesthesia of the second division of the trigeminal nerve (V2) is a common finding. Significant epistaxis may be a presenting feature in Le Fort II/III fractures, CSF rhinorrhea from a concomitant skull base injury may also be present. Many patients have marked midfacial edema and periorbital ecchymosis. Patients may also complain of visual acuity change, diplopia, or other ocular symptoms related to the fracture’s disruption of the bony orbit.

Naso-Orbital Ethmoid Fractures

Several physical findings distinguish naso-orbital ethmoid (NOE) fractures from other midface fractures. The fractured segment of bone that results from an NOE fracture is demarcated medially by the nasal cavity, laterally by the orbit, and superiorly by the anterior skull base. This segment of bone is the site of attachment of the medial canthal tendon. The 3 types of fractures, as described by Markowitz, are defined by worsening severity of comminution of this central region, with the most severe resulting in marked comminution and avulsion of the medial canthal tendon from the bone. Physical findings include extraocular muscle restriction resulting in diplopia, nasal obstruction (lateral nasal wall impingement), epiphora, telecanthus (lateral displacement of the medial canthus) and loss of nasal dorsal support with telescoping. The proximity of the skull base and frontal sinus results in frequent simultaneous injuries of these regions.

Frontal Sinus Fractures

Frontal sinus fractures are rare under the age of 6 years, as pneumatization of the frontal bone is not significant until then. Forehead lacerations, deformity, and hypesthesia of the first division of the trigeminal nerve (V) are physical findings associated with fractures of the anterior table of the frontal sinus. Fractures of the posterior table of the frontal sinus can result in dural lacerations and leakage of the CSF from the nose. CSF rhinorrhea is a presenting feature in 18% to 30% of frontal sinus fractures and should be actively sought by holding the patient’s head in a dependent position and looking for clear fluid leakage. A significant percentage of children with frontal sinus fractures will have an additional craniofacial fracture or intracranial injury.

Emergency Department Treatment and Disposition

Provide hemodynamic resuscitation and secure the airway first. Order CT imaging of the head and facial bones (axial and coronal planes). Request ophthalmologic consultation for any midfacial fractures that involve the orbit, or in any patient with a change in visual acuity or positive findings on the initial ocular assessment. Document visual acuity, pupillary reflexes, and extraocular muscle motility.

Consult otolaryngology for all patients with unresolving epistaxis. Approach patients with skull base fractures who require intranasal packing to control bleeding with extreme caution to avoid worsening of the cranial base injury. Obtain otolaryngology and neurosurgery evaluations for all patients with CSF rhinorrhea. If possible, collect the fluid and send for glucose and β2-transferrin to confirm its origin.

Débride, clean, and repair minor facial lacerations in the emergency department. Repair more extensive lacerations in the operating room where better anesthesia and hemostasis can be achieved. It may be possible to use lacerations to access underlying fractures, obviating the need to make additional incisions. In these cases, irrigate the wounds and dress it with sterile gauze. Provide prophylactic antibiotics against gram-positive bacteria and anaerobes.

Admit patients with midfacial trauma as there is a high incidence of associated neurologic injuries or other injuries distant to the head and neck. Discharge only those with the mildest injuries after evaluation by the facial trauma team with arrangements made for close follow-up.

Pearls

1. NOE fractures can be misdiagnosed as simple nasal bone fractures. Overlying edema and inability to examine anxious or uncooperative patients are obstacles to diagnosis.

2. High impact forces, massive midfacial swelling, V2 sensory disturbance, and ocular signs and symptoms raise suspicion of a midfacial fracture rather than an isolated nasal fracture.

3. Involve the facial trauma surgeons early to avoid complications of facial growth restriction, subsequent procedures, and suboptimal function.

Clinical Summary

Orbital blowout fractures involve the thin bones of the floor and medial wall of the orbit while the orbital rim remains intact. These typically result from impact by a projectile larger than the orbit, such as a ball or fist. Because of the high incidence of concomitant intraocular injury, an ocular examination must always be performed on patients who have sustained orbital trauma. Common signs and symptoms include lid edema and ecchymosis, diplopia, enophthalmos, and infraorbital nerve hypesthesia. Air leakage from the sinuses may manifest as orbital emphysema, which will demonstrate crepitus on palpation of the lids or globe proptosis if severe. Binocular diplopia can occur if there is gaze restriction due to extraocular muscle swelling or entrapment.

Emergency Department Treatment and Disposition

Obtain a CT scan of the orbits with axial and coronal reconstruction in all cases of suspected orbital fracture. Coronal sections offer the best view of the orbital floor. Examine the CT carefully for a “white eye” fracture, which is a trapdoor fracture with entrapment of the inferior rectus muscle. There is usually minimal loss of the floor integrity and a lack of blood in the maxillary sinus. However, on clinical examination there is significant limitation on vertical globe excursion associated with nausea, vomiting, bradycardia, or syncope. Immediate repair, usually within 24 hours, is indicated; consult a facial trauma surgeon urgently. If trapdoor fractures and entrapment are not present, discharge the patient with instructions not to blow his or her nose and to apply ice packs to the orbit for the first 24 to 48 hours. Nose blowing can cause intraorbital air entry from the paranasal sinuses that can lead to compressive optic neuropathy visual loss. Provide nasal decongestants and broad-spectrum antibiotics for 7 days.

Pearls

1. Double vision is the most common complaint of patients with orbital blowout fractures.

2. Decreased motility due to entrapment is most commonly seen on superior excursion, though it may be seen in any direction.

3. As the swelling and hemorrhage within the orbit subside, eye movements will improve and the double vision will improve or resolve.

4. Consult surgery for open reduction of large fractures, nonresolving double vision, enophthalmos of 2 mm or more, or clinical entrapment.

5. In cases of extraocular muscle entrapment, urgent surgical consultation is necessary to prevent muscle ischemia, chronic motility disturbance, and diplopia.

Clinical Summary

Facial fractures are less common in children than in adults, and are more likely to occur in children older than 6 years of age. Midface fractures, which include the zygomas, are rare in children because of the elastic properties of the pediatric skeleton. The midface is stationed between the mandible and cranium, which absorb the impact of most traumatic forces directed to this area. Paired zygomas provide midfacial width and cheek projection and with their 4 suture attachments comprise the zygomaticomaxillary complexes (ZMCs). The zygomaticomaxillary suture is part of the lateral buttress (zygomaticomaxillary), which along with the medial buttress (nasomaxillary) and posterior buttress (pterygomaxillary) forms the 3 vertical support columns that absorb the forces of mastication. The term tripod fracture is the result of fractures involving the zygomaticomaxillary, zygomaticofrontal, and zygomaticotemporal sutures. However, a ZMC fracture is in fact a quadripod fracture because the fourth suture, the zygomaticosphenoid suture, is also involved.

Patients with zygomatic fractures present with a loss of malar projection (which can be seen from a bird’s-eye or worm’s-eye view), and bony step-offs at the orbital rim, frontozygomatic suture, or temporozygomatic suture. Possible ocular findings include enophthalmos, exophthalmos, restricted gaze, and diplopia. Other associated findings include hypesthesia of maxillary division of the trigeminal nerve and trismus (difficulty opening the mouth because of impingement of the coronoid process from a posteriorly displaced ZMC fracture).

Emergency Department Treatment and Disposition

Stabilize airway, breathing, and circulation and the cervical spine, and perform a full head and neck examination. Plain radiographs are of limited value. Order a high resolution (at most 1.5 mm thickness) maxillofacial CT scan with axial and either true coronal or reconstructed coronal view as this is the best imaging modality to evaluate midfacial fractures. Three-dimensional reformats may also be helpful when available. If the patient has a mobile or displaced ZMC or zygomatic arch fracture with a cosmetic or functional deformity, consult a facial trauma surgeon. Manage patients with isolated nondisplaced or minimally displaced zygomatic arch or ZMC fractures with supportive care, observation, and instructions to follow up in 7–10 days.

Pearls

1. The ZMC provides facial width and cheek bone shape.

2. The ZMC is a quadripod complex and not a tripod structure because of its articulation with the temporal, maxillary, frontal, and sphenoid bones.

3. ZMC or zygomatic arch fractures that cause cosmetic or functional deformities will likely require surgical intervention.

Clinical Summary

Facial injuries that involve the soft tissue can result from either blunt or penetrating trauma, and may occur in isolation or with associated facial skeletal fractures. Soft tissue injuries can range from simple lacerations to avulsion injuries with significant tissue loss. Animal bites can also be a cause of soft tissue injuries of the face in children. Interpersonal violence resulting in stabbing or human bites are additional causative factors in adolescents. Several specific subsites have unique presentations that must be recognized and managed appropriately.

Penetrating injury to the cheek can result in transsection of the parotid or Stensen’s duct that runs horizontally, just inferior to the zygomatic arch, and parallel to the buccal branch of the facial nerve, explaining the concurrence of facial nerve injuries in a significant number of duct injuries. Wound exploration may reveal pooling of saliva, especially on parotid massage, suggesting injury. Confirm the diagnosis by cannulating the duct from its intraoral opening with a lacrimal probe. The tip of the probe will be visualized within the wound.

Injuries of the lateral cheek/preauricular region, especially near the tragus of the ear, can result in the main trunk of the facial nerve being severed. The temporal branch of the facial nerve, which is responsible for forehead movement, is vulnerable along a path from the tragus to the lateral brow. The marginal mandibular branch may be transected when the injury occurs in the region of the lower border of the mandible. Paralysis of this branch results in elevation of the corner of the mouth. The zygomatic and buccal branches are vulnerable in the midcheek region. Inability to close the eye and drooping of the upper lip are the sequelae, respectively. It is imperative that all facial nerve branches are evaluated prior to any manipulation of the wound. Penetrating injuries of the lateral cheek may also result in trauma to the external carotid artery with acute hemorrhage.

Injury to the ear is complicated by the involvement of cartilage or soft tissue loss. Composite tissues losses (skin and cartilage for example) require special attention if successful reimplantation or partial salvage of the tissue is to be achieved.

Eyelid lacerations, periocular trauma, and injury to the nasal lacrimal system constitute several possible soft tissue injuries. Excessive tearing (epiphora) is one cardinal sign that the nasal lacrimal ductal system is not functioning.

Scalp trauma includes simple lacerations to complex avulsions with exposed calvarial bone. Scalp avulsions often occur between the galea aponeurosis layer and the periosteum of the skull; however, the entire scalp layer may be missing, leaving exposed bare bone. Scalp injuries can be associated with massive hemorrhage (5 arterial branches that provide blood supply to the scalp emanate from both internal and external carotid arteries).

Emergency Department Treatment and Disposition

First stabilize airway, breathing, and circulation following Advanced Trauma Life Support (ATLS) protocols. Next begin evaluation of the facial trauma and provide tetanus and antibiotic prophylaxis with coverage of gram-positive organisms and anaerobes if the injury involves the nasal, pharyngeal, or oral cavities. Use simple pressure, gauze packing, hemostatic agents, or vessel ligation for hemostasis at the wound site. If there is massive hemorrhage from a significant arterial bleed, perform vessel exploration and ligation in the operating room. In some severe instances, obtain interventional radiology consultation for embolization.

Explore all wounds under sterile conditions after copious irrigation with sterile normal saline and close all wounds that can be safely repaired in the emergency department, optimally in a separate treatment area for privacy, minimization of patient/caregiver anxiety, and proper lighting and instrumentation. Facial wounds heal very well given their excellent blood supply; primary closure up to 24 hours after the injury is acceptable. Consider the use of conscious sedation to facilitate the repair. Otherwise, a low threshold for intraoperative repair should be adopted in the pediatric population.

If parotid duct injury is suspected, consult otolaryngology or plastic surgery. If a duct injury is confirmed, send the patient to the operating room for repair.

Diagnosis of a facial nerve injury is easiest when the patient is conscious and can follow commands. Consult the facial trauma team if there is a mechanism that may have resulted in facial nerve injury in an unconscious or unresponsive patient to coordinate the timing of wound exploration. It is possible for a seemingly minor penetrating trauma to be underestimated in the light of more serious injuries. Intraoperative exploration and repair of nerve transections should occur within 3 days of the injury.

Repair lacerations of the ear that extend through the skin to the cartilage without tissues loss by reapproximating the cartilage followed by soft tissue repair. If skin is absent and cartilage is exposed, use soft tissue advancement to avoid the need for daily wound care with antibiotic ointment and sterile dressing. If ear tissue is avulsed, reattach it primarily noting that avulsed ear tissue longer than 1.5 cm is not likely to survive. Other options include delayed reconstruction or banking the cartilage (removing the outer layer of skin) underneath the temporal scalp so that it can be used in the future secondary repair as a structural graft. For large, near total ear avulsion injuries, consult otolaryngology or surgery for microvascular techniques of reattachment.

Similar tenets of repair apply to the nose as to the ear, particularly if there is a composite injury. Use layered closure of wounds (nasal lining, cartilage, deep soft tissue, and skin).

Consult ophthalmology for all periocular trauma for a comprehensive examination of the globe. If possible, consult oculoplastic surgery for evaluation and management of patients with these delicate injuries to avoid secondary complications.

Repair extensive scalp injuries in the operating room and consult neurosurgery for concomitant skull or intracranial injury. Even seemingly minor degrees of tissue loss are challenging wounds to close as scalp tissue is quite inelastic. If repair can be accomplished in the ED, use layered closure with attention to repair of the galea aponeurosis and then the skin to prevent soft tissue depressions. Use pressure dressings or passive drains as needed.

Pearls

1. Salivary duct injuries require surgical subspecialist consultation to repair.

2. Auricular avulsions are injuries where initial intervention makes a significant impact on outcome. If the avulsed ear can be salvaged, it should be put on ice immediately.

Clinical Summary

Emergency physicians frequently care for children with lip lacerations. Common causes of lip trauma include falls, sports-related injuries, assaults, motor vehicle collisions, and animal or human bites. Patients may present with isolated lip lacerations or with lip wounds that occur in conjunction with other oral-maxillofacial injuries. It is important to appreciate the anatomic boundaries of the lip. The vermilion border marks the transition between the dry mucosa of the lip and the facial skin. Lip lacerations that extend beyond the vermilion border require meticulous evaluation and repair in order to achieve optimal cosmetic results.

Emergency Department Treatment and Disposition

Lip lacerations that result in disruption of the vermilion border require special care in order to avoid cosmetic deformity. Wound repairs with even small degrees of malalignment at the vermilion border will have an unacceptable cosmetic result. Thorough wound evaluation and preservation of the anatomic alignment of the vermilion border are the key elements in achieving optimal wound closure.

Carefully evaluate the laceration and the intraoral cavity for underlying alveolar fractures or loose, missing, or damaged teeth. Anesthetize the wound using a regional nerve block to prevent deformation of the wound edges and shape. Irrigate the wound and place the first suture to approximate the edges of the vermilion border. If the injury extends to the orbicularis oris muscle, repair the musculature with buried absorbable sutures, taking care to maintain good alignment. Use similar absorbable sutures to close the defect inside the vermilion border. Next, approximate the skin edges. In young children, use rapidly absorbable sutures on all tissues to avoid the additional anguish of suture removal. In older children, use monofilament nonabsorbable sutures on skin beyond the vermilion border, which should be removed in 3 to 5 days.

Pearls

1. Coloring the wound edges with a surgical skin marker or methylene blue will aid with proper alignment of the vermilion border.

2. Injected local anesthesia may distort anatomy and interfere with wound margin approximation. An infraorbital nerve block can be used for the upper lip, and a mental nerve block will anesthetize the lower lip.

3. Gentle traction applied to the initial anchoring suture placed at the vermilion border can help approximate underlying tissue and facilitate wound closure.

Clinical Summary

Tongue lacerations most commonly occur after a fall or a collision with a person or object. Sports-related injuries are common in adolescents. Injury often occurs as the tongue is trapped between the teeth. The tongue is a highly vascular, muscular organ, and bleeding following injury can be profuse. In addition, lingual edema and hematomas must be monitored closely, as they have potential to cause upper-airway compromise and respiratory distress.

Emergency Department Treatment and Disposition

First, stabilize the airway and control bleeding. Inspect the wound for embedded teeth or foreign bodies and irrigate. Lingual lacerations tend to heal rapidly because of the rich vascular supply, and small, superficial, linear lacerations generally heal without intervention. Primary closure of tongue lacerations is indicated in select cases to avoid functional or cosmetic deformity. Indications include lacerations longer than 1 cm that involve the muscular layer or bisect the whole tongue, lateral tongue lacerations, lacerations with persistent bleeding, large avulsion-type injuries, and lacerations with a high potential for cosmetic deformity if not repaired (ie, “anterior split tongue”).

Provide topical anesthesia by applying lidocaine (4%)–soaked gauze for 5 minutes, or for larger lacerations, with local infiltration or a regional nerve block. A lingual nerve block is less painful than local anesthesia and provides anesthesia to the anterior two-thirds of the tongue. Some patients may require procedural sedation or general anesthesia for repair. Use a gauze sponge to better grasp the tongue during application of anesthesia and wound repair. Alternatively, if the tip of the tongue is anesthetized, use a towel clamp or a temporary suture to help stabilize the tongue.

Use absorbable sutures for wound repair, place stitches wide and deep, and tie loosely. Edema of the tongue can be severe in the first 48 hours and tight sutures may increase lingual edema or produce local tissue necrosis. All 3 layers (inferior mucosa, muscle, and superior mucosa) can be closed. Alternatively, some recommend closing only the muscular layer and allowing the mucosa to heal on its own. Approximating the muscle generally provides adequate hemostasis. The use of routine antibiotic prophylaxis for tongue injuries is controversial. Consider antibiotic treatment for complex, contaminated wounds. Instruct patients to eat a soft diet for 2 to 3 days and rinse their mouths after each meal to prevent food from getting trapped in the defect.

Pearls

1. Bury knots whenever possible as the constant motion of the tongue easily unties sutures in the oral cavity. Alternatively, each suture should be tied with at least 4 locking square knots.

2. Consider using a bite block during laceration repair to protect both the patient and the physician.

3. A sublingual hematoma may indicate the presence of a mandible fracture.

Clinical Summary

The temporomandibular joint (TMJ) is formed by the articulation of the condyle of the mandible and the temporal bone. The TMJ may dislocate anteriorly (most common), posteriorly, laterally, or superiorly. The direction of TMJ dislocation refers to the position of the condyle in relation to the temporal fossa. Unilateral or bilateral TMJ dislocations may occur. TMJ dislocation results in stretching of the ligaments and severe spasm of the muscles that control jaw movement. Trismus prevents the condyle from returning to the temporal fossa. Unilateral dislocation is most common, but symmetric bilateral dislocation may occur.

TMJ dislocations typically occur after extreme jaw opening following yawning or lengthy dental procedures. They can also occur following blunt trauma. Anterior traumatic TMJ dislocations present in the same fashion as nontraumatic dislocations. The patient presents with jaw or mouth pain, trismus, drooling, difficulty speaking, and malocclusion. Posterior and superior traumatic dislocations are usually due to a direct blow to the chin and are often associated with injury to the external auditory canal, CN VII and VIII, and the skull base. Lateral dislocations are secondary to trauma to the side of the face and are associated with mandibular fractures.

Emergency Department Treatment and Disposition

Begin with a thorough head and neck examination to evaluate for associated injuries and any facial asymmetry. In unilateral dislocation, the jaw deviates to the side opposite the dislocation. Inspect the mouth for intraoral lacerations, which may indicate open fractures. Obtain a CT scan for all traumatic dislocations to evaluate for fractures, or alternatively a panoramic radiograph.

Use procedural sedation for reduction and place the patient in a seated position in a chair with his or her head against a wall. With gloved hands, place the thumbs on the patient’s inferior molars and exert bilateral, steady force. If the dislocation is directed anteriorly, direct the force inferiorly and posteriorly.

Consult oral maxillofacial surgeons for any complicated TMJ dislocations that cannot be easily reduced with closed reduction or for those with superior dislocations, open dislocations, and associated fractures or cranial nerve injuries. Refer patients with uncomplicated dislocations for outpatient follow-up with oral maxillofacial surgery within a few days.

Pearls

1. Traumatic TMJ injuries in children may have an impact on future facial growth.

2. Patients with prior TMJ dislocations are prone to recurrence.

3. When performing closed reduction, avoid injury to the thumbs, which may occur when the patient’s jaw snaps closed postreduction. This can be accomplished by wrapping the clinician’s thumbs with gauze.

Clinical Summary

Penetrating anterior neck injuries are a diagnostic and management challenge. The high density of vital structures in a confined area makes the neck vulnerable to significant vascular, aerodigestive, and neurologic injuries. Mechanisms of injury include gunshots, stabbing, and injuries secondary to miscellaneous sharp objects. The degree of blast effect from gunshot wounds is related to mass, velocity, and range of the bullet. Traditionally, the anterior neck has been subdivided into 3 anatomic zones, based on the accessibility of underlying structures. Zone I lies between the clavicles and the cricoid cartilage. Zone III injuries are contiguous with the cranium and are found below the skull but above the angle of the mandible. Zone II injuries involve the midportion of the neck between the cricoid and angle of the mandible, making it the most surgically accessible, as both proximal and distal vascular control can be easily obtained. Classifying an external wound to a particular zone does not ensure that the trajectory of the penetrating implement, and injuries to underlying structures, is confined to that anatomic zone.

Emergency Department Treatment and Disposition

Stabilize the airway and evaluate ventilation and hemostasis of vascular injuries. Early airway management is vital, as blood or air dissecting through the deep fascial layers of the neck can quickly distort the anatomy and cause airway compromise. Perform tube thoracostomy expeditiously to relieve hemothoraces and pneumothoraces. Control active bleeding with direct pressure and avoid clamping bleeding vessels, as this may result in unintended injury to neurologic or other vascular structures. If the patient is hemodynamically unstable or has obvious signs of airway injury, immediate surgical repair is indicated.

On initial physical examination, determine whether or not the penetrating injury has violated the platysma muscle. All wounds deep to the platysma are significant injuries that require diagnostic evaluation and surgical consultation. Identify clinical signs and symptoms suggestive of vascular, aerodigestive, and neurologic injuries. Clinical signs are typically divided into hard and soft signs of injury. Hard signs are more often associated with significant injury. Hard signs include active arterial bleeding, expanding hematomas, diminished or absent pulses, air or bubbling in the wound, bruits or thrills, emergency department hypotension, massive hemothorax, lateralizing signs, hemoptysis, hematemesis, and tracheal deviation.

Management decisions in hemodynamically stable patients not requiring immediate surgery are guided by mechanism of injury, wound location, signs and symptoms, and preferences based on availability of specialized personnel. Evaluate and treat zone I and III injuries by selective, nonoperative management based on imaging studies. Zone II injuries can be managed with selective nonoperative management or surgical exploration.

Pearls

1. Transcervical gunshot wounds are twice as likely to cause significant injuries as those that do not cross the midline.

2. Shotgun wounds usually involve multiple zones of the neck.

3. A benign physical examination may not be adequate to exclude the presence of injuries. Use diagnostic imaging or surgical exploration for wounds that have violated the platysma.

4. Penetrating esophageal injuries are often initially asymptomatic. Delayed recognition of esophageal injuries can result in severe neck space infections or mediastinitis.

Clinical Summary

Almost 10% of all spinal injuries that occur in children happen before age 15 with the vast majority being caused by blunt trauma from motor vehicle collisions. More than 60% of all spine injuries involve the 7 cervical vertebrae. Other common causes of cervical spine injuries (CSIs) include falls, inflicted injury (including assaults and child abuse), and sports injuries. The incidence of CSI secondary to penetrating injury is very low in young children but increases during adolescence and approaches the adult incidence in the late teenage years. There is a 2:1 predominance in boys to girls. Luckily, CSI in children is relatively uncommon, with only 1% to 2% of all pediatric trauma patients suffering CSI. This injury has significant morbidity, and a high index of suspicion for these injuries is appropriate in all trauma patients.

Contrary to prior literature, recent literature has shown that upper cervical spine injury is more common in all pediatric age groups. Motor vehicle collisions and certain clinical findings are associated with a higher chance of CSI in children. These clinical findings include altered mental status, focal neurologic deficit, neck pain, torticollis, and substantial torso injury. There are also several predisposing conditions for CSI; these include Down syndrome, Klippel-Feil syndrome, achondrodysplasia, mucopolysaccharidosis, Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta, Larsen syndrome, juvenile rheumatoid arthritis, juvenile ankylosing spondylitis, renal osteodystrophy, rickets, and previous history of CSI or cervical spine surgery.

The cervical spine can be conceptualized as 3 distinct columns: anterior, middle, and posterior. The anterior column is composed of the anterior longitudinal ligament and the anterior two-thirds of the vertebral bodies with their interposed annulus fibrosus and vertebral disks. The middle column is composed of the posterior longitudinal ligament and the posterior one-third of the vertebral bodies with their interposed annulus fibrosis and vertebral disks. The posterior column contains the bony elements formed by the pedicles, the transverse processes, the articulating facets, the laminae, and the spinous processes. In order to maintain stability, 2 of the 3 columns must remain intact. Any injury or combination of injuries that affects at least 2 or more of these columns is unstable.

Emergency Department Treatment and Disposition

Treat all trauma patients as if they have a spinal injury until it is excluded, and keep in mind that the elastic nature of the pediatric cervical spine makes it is possible to have a spinal cord injury without radiographic evidence of fracture or dislocation. Order spine CT or plain radiographs to evaluate potential spine injuries. If head CT is ordered to rule out intracranial injury, extension of the study to include the cervical spine is the most practical method of assessment for CSI. If plain films are used, obtain a minimum of a supine lateral view, an anteroposterior (AP) view, and an open-mouth odontoid view. Ensure that the lateral spine radiograph shows all 7 cervical vertebrae and includes the C7/T1 junction for the film to be considered acceptable. Absence of fracture on CT or plain radiographs does not rule out traumatic injury to the spinal cord. Up to 50% of children with spinal cord injury found on MRI have no fractures on primary radiologic survey.

Pearls

1. Assess all children for CSI emergently if they have neurologic symptoms (eg, focal neurologic deficit, signs of neurogenic shock, altered mental status, urinary retention or priapism), significant head or torso trauma, or a palpable step-off in the cervical spine.

2. Obtain MRI for all patients with neurologic deficits but no initial radiographic abnormalities to diagnose ligamentous injury or changes in spinal cord attenuation.

Clinical Summary

Fractures of the first cervical vertebra, also known as Jefferson fractures or fracture of the “atlas” result in disruption of the C1 ring, typically into 4 parts and less commonly into 2 or 3 parts. The mechanism of injury is due to axial compression forces on C1 as it is crushed between the occipital condyles of the cranium and the body of C2 and is almost always caused by an axial blow to the head, most commonly associated with diving accidents or roll-over motor vehicle collisions. This is an unstable fracture due to a loss of bony connection and interrelation from the cranium and the lower spine. A high index of suspicion is warranted for associated C2 fractures as these are often seen with Jefferson fractures. Other fractures of the C1 ring have little clinical significance.

Emergency Department Treatment and Disposition

Immobilize the cervical spine and obtain C-spine series and odontoid view plain radiographs, which are positive if it shows one or both of the lateral masses of C1 laterally displaced over the body of C2. Order a CT for fracture visualization and to rule out other fractures of the cervical spine. Consult neurosurgery emergently for patients with Jefferson fractures and carefully observe spinal cord precautions as C1 spinal cord injuries are often associated with respiratory failure. Provide adequate analgesia while maintaining the ability to monitor the patient’s mental status and neurologic status.

All of these patients require admission to the hospital usually in a surgical ICU. Treatment consists of good analgesia if the patient is not already sedated and intubated along with spinal immobilization. Decisions for surgical management of the fracture should be made in conjunction with neurosurgery.

Pearls

1. Injury of the spinal cord at the C1 level presents with retained sensation on the face and motor control of the facial muscles from the cranial nerves with loss of sensation and motor function of the rest of the body.

2. This fracture pattern is often associated with vertebral artery injury.

3. Respiratory failure requires endotracheal intubation until a surgical airway can be achieved.

Clinical Summary

The odontoid process of C2 (also known as the dens) is a bony projection off the superior aspect of the C2 body that articulates with the anterior ring of C1. These 2 bones are kept in tight approximation by the thick transverse ligament (also known as the cruciate ligament) that stabilizes the C1/C2 articulation. Fractures that affect the ability of the transverse ligament to keep the atlantoaxial articulation tight lead to C1/C2 instability and risk of cord injury.

Odontoid fractures are divided into 3 types based on the involvement of the transverse ligament and the body of C2. Type I odontoid fractures are avulsions of the tip of the dens at the insertion site of the alar ligament. These fractures are mechanically stable but are sometimes associated with atlantooccipital dislocation, which is a life-threatening injury. Type II odontoid fractures consist of a horizontal fracture at the base of the dens separating the dens (and the transverse ligament) from the rest of C2. This is the most common type of odontoid fracture. It is considered an unstable fracture as the transverse ligament along with the dens and C1 is separated from the body of C2 and the rest of the spine. Type III odontoid fractures exhibit a fracture plane extending down into the body of the axis (C2) and are unstable.

Emergency Department Treatment and Disposition

Immobilize the cervical spine and consult neurosurgery emergently for patients with Type II and III odontoid fractures. Observe patients carefully as they have an unstable C1-C2 junction that can lead to cord trauma, which may be associated with respiratory muscle paralysis and respiratory failure.

As with Jefferson fractures, all of these patients require admission to the hospital usually in a surgical ICU. Treatment consists of good analgesia if the patient is not already sedated and intubated along with spinal immobilization. Type I odontoid fractures are usually managed conservatively with a cervical collar that the patient can be discharged with and wear until the fracture heals. Type II and III dens fractures are more likely to result in nonunion when patients have >10 degrees of angulation or >5 mm of translation; therefore, surgical arthrodesis is preferred over external fixation devices such as a halo.

Pearls

1. Type I odontoid fractures are not that dangerous in and of themselves but are associated with the devastating injury of atlantooccipital dislocation.

2. The odontoid, or open-mouth, view will often reveal odontoid fractures, but CT is a better imaging modality when supplemented with coronal and sagittal reconstructions.

3. Type II odontoid fractures may be difficult to see on axial CT images because the fracture plane is often parallel to the image acquisition plane. Reconstructed coronal images will usually reveal such fractures.

Clinical Summary

Traumatic spondylolisthesis of C2 is also known as “hangman’s fracture” and occurs most commonly in high-energy motor vehicle collisions. Axial loading and lateral flexion are the typical forces involved. Traumatic spondylolisthesis of C2 always results in bilateral C2 pedicle fractures but can differ in the degree of disruption of the disc and ligaments. The amount of distraction and lateral flexion affects the amount of ligamentous disruption. The more tearing of the anterior and posterior ligaments, the more distraction of C2 on C3 and the higher the chance of spinal cord injury.

Emergency Department Treatment and Disposition

Stabilize the cervical spine and obtain emergent neurosurgical consultation. Provide careful observation and assess possible spinal cord involvement with MRI. Barring spinal cord injury, these fractures can often be managed on an outpatient basis with cervical traction. Note that spinal cord injury at this level may be associated with respiratory compromise.

Pearls

1. Hangman’s fractures affect 2 columns of the spine, and are therefore unstable.

2. Due to a relatively larger anteroposterior diameter of the spinal canal at this level these fractures are not commonly associated with severe spinal cord injury.

3. When associated with unilateral or bilateral facet dislocation at the level of C2, this injury is unstable and has a high rate of neurologic complications.

Clinical Summary

Extension teardrop fractures result from sudden hyperextension, which is often seen in blows to the forehead and rear-impact motor vehicle collisions. With this mechanism of injury, the anterior longitudinal ligament stretches and is disrupted and avulses off a small fragment of bone, creating the typical fracture pattern. This usually occurs at the lower cervical levels and is stable as long as the neck remains in flexion. The injury is highly unstable with the neck in extension due to disruption of the anterior stabilizers of the spine.

Emergency Department Treatment and Disposition

Immobilize the cervical spine and order radiographs, which if positive will show a small avulsion of the inferior aspect of the anterior surface of the vertebral body. Prevent extension of the neck when possible and consult neurosurgery promptly. Perform a careful neurologic assessment to assess for spinal cord injury. Treatment of these fractures is cervical orthosis, unless more aggressive measures such as fixation are needed because of other cervical injuries.

Pearls

1. This injury may also be associated with the central cord syndrome because of buckling of the ligamenta flava into the spinal canal during the hyperextension phase of this injury.

2. If these patients require intubation, careful prevention of neck extension with manual in-line stabilization or fiberoptic intubation is imperative.

Clinical Summary

Flexion teardrop fractures manifest with a displaced anteroinferior bony fragment. The mechanism of injury is forced flexion such as in a blow to the back of the head or deceleration motor vehicle collision. Severe flexion of the spine causes a compression-like fracture of the anterior aspect of the vertebral body, and a fragment is displaced anteriorly, which resembles a teardrop. The anterior longitudinal ligament may be disrupted and the anterior vertebral body crushed. Additionally, as flexion continues, the posterior ligamentous complex and bony articulations are disrupted and begin to open up or “fan” out, potentially stretching/injuring the cord. With this mechanism, all 3 spinal columns are damaged, making this innocuous-appearing teardrop fracture one of the most unstable cervical spine injuries placing patients at significant risk for spinal cord injury.

Emergency Department Treatment and Disposition

Immobilize the cervical spine with mild traction and obtain plain films and urgent neurosurgical consultation. A careful neurologic assessment is critical to assess for spinal cord injury. These fractures represent complete destabilization of spinal integrity and therefore require urgent neurosurgical evaluation for possible open reduction and internal fixation.

Pearls

1. Watch patients with flexion teardrop fractures above the C5 level for respiratory compromise.

2. Intubate with minimal movement of the cervical spine or with a fiberoptic device.

Clinical Summary

This is a rare but devastating, severely unstable spinal injury where the occipital condyles are no longer articulating with the ring of C1. It is seen most often in very young children because of their large head size relative to body size and weak spinal muscles. The typical cause of injury is sudden deceleration in motor vehicle collisions, falls, and being struck in the head with a high-energy object. The mechanism of injury can be hyperextension, hyperflexion, distraction, or severe rotary forces. The complete disruption of ligamentous relationships between the spine and the cranium causes stretching of the brainstem and usually results in fatality as a result of respiratory arrest. If not immediately fatal, this dislocation is associated with severe neurologic morbidity.

Emergency Department Treatment and Disposition

Immobilize the cervical spine and consult neurosurgery emergently. Order cervical spine plain films, which will show excessive space between the cranium and the ring of C1 best seen on the lateral view. Avoid traction as it will most likely worsen neurologic injury. Assume these patients are in imminent respiratory failure and intubate with as little neck motion as possible. Prompt fixation is critical as neurologic injury is severe.

Pearl

1. Consider surgical airway management if fiberoptic intubation is not possible.

Clinical Summary

SCIWORA is a neurologic syndrome characterized by neurologic deficits without bony abnormality on plain radiographs or CT scan. The vast majority of patients with SCIWORA have myelopathy, and the injury occurs because of the elastic nature of the pediatric spine. SCIWORA is more common in younger children and can account for up to one-third of neurologic deficits in pediatric trauma victims. The mechanism of this injury is usually hyperextension or flexion but can be rotational, lateral bending, or distraction as well. Although the degree of instability depends on which ligaments are torn or stressed, most are considered stable though they can be associated with severe neurologic deficits.

Emergency Department Treatment and Disposition

Immobilize the cervical spine and consult neurosurgery promptly. Monitor neurologic status closely. Most cases are treated with 3 months of spinal immobilization.

Pearls

1. A normal CT or plain radiograph is not adequate to rule out a spinal cord injury in patients with altered mental status.

2. Monitoring of neurologic status is critical as these injuries may be caused by spinal cord hemorrhage and can progress.

Clinical Summary

Bilateral facet dislocation is an extreme form of anterior subluxation caused by excessive cervical spine flexion. This hyperflexion results in ligamentous disruption and allows for marked anterior displacement of the spine at the level of injury resulting in compromise of the spinal canal. The upper vertebrae’s inferior articulating facets pass anterior to and above the superior articulating facets of the lower vertebrae and become “perched” there. There is often associated disk herniation, which further impinges on the spinal cord and can cause additional neurologic insult.

Emergency Department Treatment and Disposition

Immobilize the cervical spine and consult neurosurgery promptly. Order lateral plain films, which will show anterior displacement that is more than half the anteroposterior diameter of the vertebral body along with disarticulation of the facet joint. Reduction of the dislocation is best done by neurosurgery as further neurologic damage may occur if the injured disk retropulses into the canal during cervical traction. Perform a careful neurologic assessment to assess for spinal cord injury before and after reduction. Treatment is typically traction reduction followed by stabilization.

Pearls

1. A significant number of bilateral facet dislocations are accompanied by disk herniation.

2. Any injury above C5 can be associated with respiratory compromise.

Clinical Summary

Unilateral facet dislocation is a stable injury caused by simultaneous flexion and rotation. Patients often present with their head cocked to one side with the inability to straighten it out. The inferior articular facet of a vertebra passes above and anterior to the superior articular facet of the vertebra below it and gets “locked” in the intervertebral foramen. Although the posterior ligament is usually torn, the “locking” of the facet into the intervertebral foramen makes this injury stable, and it is seldom associated with neurologic deficits.

Emergency Department Treatment and Disposition

Order plain films, which will show anterior displacement of the spine that is less than one-half of the diameter of a vertebral body. The cervical spine anteroposterior view will show a discontinuity in the line connecting the spinous processes at the level of the dislocation. Provide analgesia and consult neurosurgery or orthopedics promptly. These injuries may occasionally be reduced in the ED by the consultant under sedation with simple traction.

Pearls

1. If the displacement is more than one-half the diameter of the vertebral body, consider bilateral facet dislocation and provide immediate cervical immobilization.

2. This injury can be confused with torticollis but should be considered after acute neck trauma.

Clinical Summary

Anterior subluxation is an uncommon cervical spine injury that occurs when ligaments surrounding the posterior elements are disrupted but the anterior longitudinal ligament remains intact. Because the anterior and middle spinal columns remain intact, this injury pattern is considered mechanically stable. Isolated anterior subluxation is rarely associated with neurologic sequelae; however, cases with associated neurologic deficit have been reported.

Emergency Department Treatment and Disposition

Immobilize the cervical spine and order plain films that are positive when no fractures are seen and the lateral cervical film shows widening (fanning) of interspinous processes and an offset of the anterior and posterior contour lines of the vertebral bodies. Avoid neck flexion as significant displacement can occur and impingement on the spinal cord may occur. Consult neurosurgery promptly for evaluation in the ED.

Pearls

1. Anterior subluxation with a flexion mechanism is stable in extension but potentially unstable in flexion.

2. This injury can be confused with pseudosubluxation, which is a normal variant and usually occurs at the C2-C3 level in young children.

3. In true anterior subluxation, the spinolaminar line will be disrupted at the level of the injury while in pseudosubluxation this line will retain its smooth contour.

Clinical Summary

Clay shoveler’s fracture is a stable injury that usually occurs after abrupt flexion of the neck combined with lower neck muscular contraction as is seen with rapid torso/shoulder rotation. This violent muscular contraction results in avulsion of the longer spinal processes and affects C7 more often than T1 and T1 more often than C6. This fracture can also be seen after direct blows to the spinous process or after forced flexion of the head and neck. Patients present with severe tenderness over the fractured spinous process and a step-off may also be present. As the fracture does not disrupt any of the 3 spinal columns, it is considered stable. This fracture alone should not be associated with neurologic impairment. If neurologic deficits exist, other injuries should be sought.

Emergency Department Treatment and Disposition

Obtain plain films, which will show the avulsed spinal process on the lateral view. Provide pain control and neurosurgical or orthopedic outpatient follow-up. Consider providing a cervical orthotic device for patient comfort. If significant trauma was also present, additional injuries should be actively sought, as this fracture can be caused by forced flexion and flexion is a common mechanism for other more severe cervical spine injuries.

Pearl

1. Plain films can miss this fracture if they do not adequately visualize the C7-T1 junction as most of these injuries occur in this region of the cervical spine.

Clinical Summary

Dental caries are characterized by demineralization of the tooth enamel and dentine. Patients with dental decay have opaque areas of enamel with grayish hues that change into brownish cavitations as decay progresses. Dental caries, though initially asymptomatic, are painful when the decay impinges on the pulp and inflammation develops. Destruction of enamel and dentin by caries results in bacterial invasion of the pulp to produce pulpitis.

Dentoalveolar abscesses are acute infections with localization of pus in the apical structures surrounding the teeth resulting in periapical abscess (pulpitis) or periodontal abscess. Periapical abscesses are infections originating in the dental pulp that is exposed by dental caries, and these are the most common type of dental abscess in children. Pulpitis can progress to necrosis, with bacterial invasion of the alveolar bone, causing abscess formation. A periodontal abscess involves the supporting structures of the teeth (periodontal ligaments, alveolar bone), and is less common in children, usually occurring with impaction of a foreign body in the gingiva.

Odontogenic infections are typically caused by the oral flora that is found in dental plaque. Such pathogens typically include aerobic and anaerobic gram-positive cocci and anaerobic gram-negative rods (eg, Bacteroides, Fusobacterium, Peptococcus, Peptostreptococcus spp, and viridans streptococci).

Though uncommon in children, Ludwig’s angina may occur when abscesses of the second and third mandibular molars perforate the mandible and spread into the submandibular and submental spaces. Ludwig’s angina manifests as swelling of the mouth floor with elevation and posterior displacement of the tongue. The infection usually begins unilaterally but quickly spreads to include the entire neck and may produce a brawny edema of the suprahyoid region of the neck. Most commonly, patients present with neck and dental pain with swelling, odynophagia, dysphagia, dysphonia, trismus, tongue swelling, or airway obstruction.

Emergency Department Treatment and Disposition

If Ludwig’s angina is present, stabilize the airway. Treat fluctuant masses with incision and drainage by creating an opening into the offending tooth. A dentist should extract the tooth if necessary. Initiate antibiotic therapy, usually penicillin or clindamycin. Provide adequate analgesia and consult dentistry or oral maxillofacial surgery promptly. Laboratory studies and radiographs are not necessary, though they may be helpful in identifying caries, impacted or broken teeth, and changes to the bony structure. Admit patients who are unable to take fluids orally or to handle secretions, as well as those with complications (eg, facial or mandibular cellulitis with potential airway compromise) or signs of systemic infections of failure of outpatient therapy.

Pearls

1. Treat infections of primary teeth aggressively; untreated, these infections can damage the developing unerupted permanent tooth bud.

2. Odontogenic infections are polymicrobial in nature and are typically caused by normal oral flora.

Clinical Summary

Tooth fractures are classified by the Ellis system. A class I Ellis fracture is through the enamel, whereas a class II fracture is through enamel and dentin. Class III fractures involve the enamel, dentin, and pulp and lead to increased sensitivity and infection.

A tooth concussion is consistent with minor traumatic injury to the supporting structures of the tooth. There may be increased sensitivity to percussion but there is no evidence of loosening or actual displacement of the tooth. Subluxation of a tooth is more severe than a concussion; there will be some loosening of the tooth without displacement. Luxation of a tooth implies increased mobility the lateral plane. Caution must be taken not to miss a fracture of the tooth socket. Intrusion of a tooth is a traumatic impaction into the socket by an axial force and it may be associated with a root fracture. An extruded tooth is one that is outwardly displaced. An avulsed tooth is completely displaced out of its socket and is associated with periodontal ligament damage.

Emergency Department Treatment and Disposition

Manage class I Ellis fractures conservatively by referring to dentistry for potential filing or cosmetic repair. Treat patients who have class II Ellis fractures with antibiotics and consult dentistry from the ED; cosmetic repair is usually indicated. Consult dentistry emergently for patients with class III Ellis fractures. Provide temporary coating, and antibiotics should be initiated in the ED. Refer patients with concussed teeth for a nonemergent dental consultation and advise them to avoid food or beverage with extremes of temperature.

Treat patients with subluxed teeth based on potential pulpal necrosis, which in turn depends on the degree of mobility. Consult dentistry for both primary and permanent subluxed teeth and splinting of the tooth if there is >2 mm of mobility. With full luxation, there is increased risk of pulpal necrosis; consult dentistry for repositioning and bracing of the affected tooth in the ED.

For intrusion of teeth dental consultation and follow-up are indicated. If a primary tooth is intruded on a permanent tooth, extraction of the intruded tooth is likely indicated. Caution parents that endodontic treatment or root canal may be necessary for the permanent tooth.

Consider extraction of severely extruded teeth in the ED to prevent aspiration. Reposition and splint the extruded tooth and obtain dental consultation and follow-up.

Reimplant avulsed permanent teeth as quickly as possible (ideally within 30 minutes of avulsion) but do not reimplant primary teeth. Keep the tooth moist, preferably in Hank’s balanced salt solution but milk, water, or saliva also can be used. Avoid touching the root and do not scrub the tooth, just rinse it gently. Place the tooth in the socket and maintain firm pressure, then have the patient bite down firmly on folded gauze. Consider local anesthesia or dental blocks to make this process more comfortable. Ensure dental follow-up as root canal is usually necessary.

Pearls

1. Provide broad-spectrum antibiotic coverage for any injury that leaves nerves or pulp exposed to saliva.

2. Primary teeth should never be reimplanted.

Clinical Summary

Because children have incompletely calcified, pliable ribs that require greater force to fracture, such injuries are uncommon in this age group. The compliant chest wall allows impacting forces to be transmitted directly to the underlying pulmonary parenchyma, without causing bony injury. When rib fractures are present, this indicates a high energy mechanism and severe underlying injuries should be suspected.

Flail chest occurs when a segment of the chest wall is separated from the rest of the thoracic cage. This is defined as at least 2 fractures per rib in 2 or more adjacent ribs. The flail segment paradoxically moves inward because of the normal negative intrapleural pressure of inspiration. Though this movement of the chest wall does increases the work of breathing, the major cause of hypoxemia is the underlying injury to the pulmonary parenchyma. Nearly all patients with flail chest have pulmonary contusions, which are the most common cause of respiratory failure following blunt chest wall trauma. Chest wall pain and inefficient ventilation further contribute to ventilatory failure.

Patients present with pain, dyspnea, tachypnea, hypoxia, chest wall tenderness/ecchymosis, and subcutaneous emphysema. Decreased breath sounds and dullness to percussion should raise suspicion of a hemopneumothorax. The diagnosis of flail chest is established most readily on chest radiograph.

Emergency Department Treatment and Disposition

Stabilize the airway and provide ventilatory support with supplemental oxygen. Provide adequate analgesia and begin a complete diagnostic workup directed at evaluation and treatment of associated thoracic and abdominal injuries. Obtain a portable chest radiograph to identify obvious pulmonary injuries that require immediate intervention and chest and abdominal CT scans to identify other occult injuries. Consider an intercostal nerve block if systemic analgesics do not provide adequate pain control. If there is severe lung injury and ventilatory fatigue, initiate mechanical ventilation.

Admit patients with rib fractures or flail chest to an intensive care unit for close monitoring of their respiratory status and observation for associated injuries. Provide adequate analgesia and chest physiotherapy to help prevent atelectasis and pneumonia.

Pearls

1. Unexplained rib fractures in children raise suspicion for child abuse. Consider an inconsistent history and multiple rib fractures in various stages of healing child abuse until proven otherwise.

2. The initial chest radiograph may underestimate the degree of underlying pulmonary contusion.

3. Subtle flail segments are best appreciated by palpation of the chest during spontaneous ventilation.

Clinical Summary

Blunt or penetrating chest trauma can result in air accumulation in the pleural space. As the air volume continues to expand, normal ventilation becomes impaired and lung collapse progresses, leading to a ventilation-perfusion mismatch, resulting in hypoxia. Small pneumothoraces are often well tolerated and children may manifest few if any symptoms. The most common presenting complaints are chest pain and shortness of breath. Children with larger pneumothoraces may also show tachycardia, cyanosis, and decreased breath sounds on the affected side. Hyperresonance to percussion may also be noted. Subcutaneous emphysema is occasionally present when both pleural layers have been violated.

Tension pneumothorax occurs when there is a “one-way valve” air leak from the lung or through the chest wall. Progressive pleural air accumulation causes elevated intrathoracic pressure leading to mediastinal shift and compression of the great vessels and contralateral lung, which results in respiratory distress, tachycardia, and hypotension. Patients may present with ipsilateral decreased breath sounds and hyperresonance to percussion, jugular venous distention (JVD), and tracheal deviation to the opposite side. Pediatric patients do not always manifest classic signs and symptoms and the clinical presentation is often subtle. The relatively short neck and increased soft tissue in children may make detection of tracheal deviation difficult. Consider tension pneumothorax in any pediatric patient with hypoxemia, tachycardia, and signs of shock.

Emergency Department Treatment and Disposition

When traumatic pneumothorax is diagnosed clinically, provide the highest concentration of supplemental oxygen available and prepare to place a thoracostomy tube emergently. If the patient is hypotensive, perform immediate needle decompression (typically in the midclavicular line in the second intercostal space), which converts the tension pneumothorax to a simple pneumothorax, and perform thoracostomy urgently for definitive treatment of the simple pneumothorax. If there are no contraindications to moving the patient, obtain an upright chest radiograph or use ultrasound to confirm suspicion of a pneumothorax.

Pearls

1. JVD may be absent in patients with tension pneumothorax and active bleeding and hypovolemia.

2. Young children are more susceptible to tension pneumothorax because of their relatively more mobile mediastinum.

3. Auscultate the lungs in the axilla as the more easily transmitted breath sounds in children across the chest and upper abdomen make clinical detection of a pneumothorax more difficult.

4. In the supine position, air in the pleural space tends to collect anteriorly and inferiorly, rather than in the apical location. The presence of a deep costophrenic angle (deep sulcus sign) on a supine film may be the only sign of pneumothorax.

Clinical Summary

Bleeding from the lung parenchyma, chest wall or an intercostal vessel causing blood accumulation in the pleural space causes hemothorax. This is rare in infants and children as increased compliance of the ribs allow dissipation of traumatic forces. Hemothorax is most often associated with severe-impact blunt mechanisms such as high-velocity motor vehicle collisions or falls from moderate to extreme heights. Hemothorax secondary to penetrating injury is also rare in infants and young children, but the incidence increases dramatically in adolescents. Patients with a hemothorax may exhibit few or no symptoms initially. As bleeding progresses, patients become hypoxic, tachycardic, and hypotensive. Physical examination often reveals decreased breath sounds and dullness to percussion on the affected side. A concomitant pneumothorax is often present with a hemothorax.

Emergency Department Treatment and Disposition

Obtain an immediate portable chest radiograph in all patients with a significant mechanism of injury or clinical signs or symptoms of hemothorax. Use thoracostomy to decompress the pleura and drain blood from the pleural space. Place the chest tube laterally, in the midaxillary line at about nipple level, and directed posteriorly, and connect the chest tube to an underwater-seal apparatus. Obtain a repeat chest radiograph to confirm proper positioning of the chest tube. Monitor the volume of blood drained and any ongoing blood loss, which usually stops spontaneously. Operative intervention is indicated when the initial evacuation of blood is >10 to 15 mL/kg of body weight or there is persistent blood loss >2 to 4 mL/kg per hour. Admit all patients with hemothorax to the ICU for close hemodynamic monitoring.

Pearls

1. Estimate appropriate chest tube size by the patient’s age plus 16 or 4 times the size of the appropriately sized endotracheal tube for intubation.

2. Hemothorax is often an indicator of multisystem injury. Perform a thorough diagnostic workup to avoid missed injuries.

Clinical Summary

Pulmonary contusions are the most common thoracic injury in children. Most are secondary to blunt mechanisms, typically, motor vehicle–related injuries. The pulmonary capillaries are damaged and this causes accumulation of blood in the alveoli leading to progressive edema, atelectasis, consolidation, and ventilation/perfusion mismatch.

Patients with pulmonary contusions may have few external signs of injury. Bruising of the thoracic wall or fracture may often be absent. Clinical presentation depends on the degree of pulmonary injury. Initially, patients may be asymptomatic or they may present with cough, chest pain, hemoptysis, tachypnea, or hypoxemia. Rarely respiratory failure is present. Symptoms often progress over the next 48 hours because of continued bleeding and edema formation in the alveolar spaces.

Emergency Department Treatment and Disposition

Maintain a high index of suspicion for pulmonary contusion in all cases of pediatric blunt chest trauma. Order chest radiographs or a CT scan. Plain films are helpful in making the diagnosis but may not be sensitive enough to detect early contusions. Chest CT is more sensitive for pulmonary contusions as well as being helpful in diagnosing associated thoracic and abdominal injuries. Measure arterial blood gas and pulse oximetry to help assess ventilation and oxygenation. Treatment is supportive for most pulmonary contusions and includes analgesia, supplemental oxygen, fluid restriction, incentive spirometry, and observation. Admit patients with a high-risk mechanism of injury, an abnormal initial chest radiograph, or a large contusion seen on CT to the ICU for aggressive pulmonary toilet and close monitoring of respiratory status. Patients with large contusions that develop significant pulmonary shunting may require endotracheal intubation and mechanical ventilation.

Pearls

1. A normal initial chest radiograph does not rule out a pulmonary contusion.

2. Pulmonary contusion in conjunction with rib fractures is associated with a high energy injury.

3. Pneumonia is the most common complication of pulmonary contusion.

Clinical Summary

Traumatic airway obstruction is caused by penetrating or blunt trauma to the airway itself, or from complications of other injuries. Relatively smaller airway diameter, less cartilaginous support, and relatively large tongue and epiglottis make the pediatric airway more susceptible to obstruction. The airway may be occluded with secretions, blood, teeth, foreign bodies, or edema or narrowed by external compression such as from hematoma formation in the neck with great vessel injury or from subcutaneous air. Increased rate of respiration, nasal flaring, accessory muscle use, or presence of respiratory fatigue all indicate serious respiratory compromise. Cyanosis is a late sign of respiratory distress. Stridor, gurgling, whistling, or grunting increase the likelihood of upper airway occlusion.

Emergency Department Treatment and Disposition

Airway obstruction is immediately life threatening and must be recognized and corrected before completing the primary survey. Additional resuscitation will fail if restoration of ventilation and oxygenation are ineffective or significantly delayed. If rapid removal of the obstruction is not possible, secure a surgical airway and mechanical ventilation. Use suction to clear secretions and open the airway with the jaw thrust maneuver if cervical spine injury is suspected. High-flow oxygen should be provided. If signs of obstruction are still present, obtain plain films of the chest and neck to look for thoracic injuries or foreign bodies. Consider further evaluation with helical CT, laryngoscopy, or bronchoscopy. Consider rare but severe injuries, for example, tracheobronchial tree injury. Consult pediatric trauma surgery and ENT as quickly as possible.

Pearls

1. The short length of an infant’s trachea may easily result in intubation of the right mainstem bronchus.

2. Place a 1-inch-thick layer of padding beneath a child’s torso and shoulders for neutral head alignment that is essential to maintain a patent airway. The child’s large occiput will cause passive flexion of the cervical spine, which can compromise airway patency.

3. Young infants are preferential nasal breathers. Trauma that results in nasal obstruction can lead to significant respiratory distress.

Clinical Summary

Blunt aortic injuries (BAIs) are rare in children and are usually associated with rapid deceleration mechanisms. Shearing forces and luminal compression occur against points of fixation, such as the ligamentum arteriosum. These injuries are most commonly caused by high-speed motor vehicle collisions or less often by falls from heights. Multisystem trauma is common, and nearly all patients have associated injuries. BAI has a high mortality and most patients will die before reaching the ED.

Patients often have few or no symptoms related to their BAI; they may have chest or back pain, but symptoms can easily be attributed to associated injuries. There may be no external evidence of chest trauma. Physical findings associated with BAI include a “seatbelt sign,” upper extremity hypertension or blood pressure differential, decrease or loss of upper or lower extremity pulses, a new heart murmur and hypotension. Paraplegia is a significant complication of BAI.

Emergency Department Treatment and Disposition

Stabilize airway, breathing, and circulation and obtain a chest radiograph, which may demonstrate only subtle changes. Mediastinal widening is the most consistent finding. Loss of a defined aortic knob, deviation of the esophagus or main bronchus, apical cap, hemothorax, or uncommonly, first or second rib fractures may also be present. A more consistent finding than rib fractures in children with BAI is pulmonary contusion. If the patient has a high-risk trauma mechanism or the chest radiograph is suggestive of aortic injury, order a CT scan of the chest, aortography, or transesophageal echocardiography (TEE). TEE is particularly useful in assessing small defects, or when the diagnosis is in doubt after CT angiography or aortography.

Use intravenous (IV) short-acting β-blockers to control blood pressure in those without closed head injury until definitive treatment. Decreasing the shear stress on the arterial wall may minimize risk of rupture. Operative repair is required in BAI and may include endovascular stents in select situations for older children. Consult trauma surgery as quickly as possible.

Pearls

1. Maintain a high index of suspicion for BAI as the compliant chest wall in children may result in minimal or no external evidence of chest injury.

2. A normal chest radiograph does not rule out BAI.

3. Thymic prominence in young children makes interpretation of the mediastinal shape difficult.

Clinical Summary

Traumatic diaphragm rupture (TDR) is rare in children, and occurs most commonly in motor vehicle collisions in which the patient was restrained only by a lap belt. The sudden increase in intra-abdominal pressure may cause diaphragmatic tears, avulsions, or ruptures. Penetrating injuries may also involve the diaphragm. Any penetrating injury below the level of the nipple poses a risk of diaphragmatic injury.

Clinical presentation is dependent on the size and location of the rupture. Patients with small ruptures are usually asymptomatic. Those with larger ruptures and herniation of abdominal contents into the thoracic cavity may present with chest pain, decreased breath sounds on the side of the rupture and respiratory distress. Bowel sounds may be heard on the affected side of the thorax. Displacement or compression of mediastinal structures can result in cardiovascular collapse.

Diaphragmatic herniation most commonly occurs on the left side because of the protective effects of the liver on the right. The most common site of injury is the left posterolateral aspect, where the diaphragm is weakest. Missed diaphragmatic injuries may go undiagnosed for years. Long after the initial injury, patients may develop bowel obstruction or strangulation that is secondary to bowel herniation through an unrecognized diaphragmatic defect.

Emergency Department Treatment and Disposition

Timely diagnosis requires a high index of suspicion. Without visceral herniation, symptoms are minimal. Order a chest radiograph and a CT scan of the chest and abdomen. Plain films may show only subtle abnormalities, such as an abnormal diaphragmatic contour. Note that a herniated liver may be easily mistaken for a raised hemidiaphragm. Larger defects may present with more obvious findings, such as intrathoracic visceral herniation or a nasogastric tube that remains in the thorax despite return of gastric contents. Diaphragmatic injuries are notoriously difficult to diagnose and may be missed on CT. If TDR is strongly suspected, consider exploratory laparotomy, laparoscopy, or thoracoscopy to make the diagnosis.

Maintain adequate ventilation and intubate the patient if there is severe respiratory distress. Place a nasogastric tube for gastric decompression. Diaphragmatic tears do not heal spontaneously and surgery is required for definitive repair, regardless of the size of the defect. Consult surgery early and admit all patients with diaphragmatic injuries.

Pearls

1. Children restrained only by lap belts are at higher risk for TDR than those who are fully restrained with 3-point restraints.

2. Diaphragmatic rupture has been seen after minor blunt trauma and it is postulated that the timing of impact during the respiratory cycle may be more important than the magnitude of force.

3. Infants and young children are preferential diaphragm breathers. Any impairment of diaphragmatic mobility can compromise ventilation.

4. The left side of the diaphragm is more prone to injury. However, right-sided injuries are less obvious and more easily missed.

Clinical Summary

Tracheobronchial tree injury (TBTI) is rare and most commonly caused by blunt trauma secondary to high-impact motor vehicle collisions. These injuries generally result from severe rapid deceleration or direct forces that occur when the child’s elastic chest wall compresses the trachea and main bronchi against the vertebral bodies. In blunt trauma, rupture generally occurs in areas where the trachea is most fixed. In the majority of cases, TBTI is localized near the carina, or less frequently at the cricoid cartilage. TBTI from penetrating trauma is usually in the cervical region. TBTI frequently occurs in conjunction with other thoracic injuries. Overall mortality is high.

Children with TBTI often show only minimal symptoms initially and are less likely to have rib fractures, making TBTI a frequently missed or delayed diagnosis. Patients may complain of chest pain, dyspnea, or hemoptysis. Subcutaneous emphysema, stridor, decreased breath sounds, or cyanosis may be present.

Emergency Department Treatment and Disposition

Maintain a high index of suspicion in all patients with significant thoracic trauma. Order a chest radiograph, which may show pneumothorax, pneumomediastinum, and subcutaneous emphysema. Treat any pneumothorax with tube thoracostomy and consider large airway injury if the lung fails to reexpand, or if there is a persistent air leak in the water seal or persistence of pneumomediastinum.

A high-resolution CT may confirm the diagnosis. Consider bronchoscopy to further assess the extent of the defect and aid in selective endotracheal intubation. Definitive management almost always involves surgical repair. Conservative treatment is reserved only for small lesions in patients without respiratory symptoms. Outcome is influenced by the extent of injury and the length of time delay in making the diagnosis. Consult surgery urgently and admit all patients with TBTI.

Pearls

1. When possible, do not use positive pressure ventilation as it may worsen an injury by increasing air leakage from a tear, and that can lead to tension pneumothorax.

2. Endotracheal intubation can convert a partial tracheal tear into a complete transection.

3. The “fallen lung” sign on plain film is seen when the involved lung drops to the dependent portion of the thoracic cavity as it hangs from only its vascular attachments at the hilum. This is indicative of complete bronchial transection.

Clinical Summary

Abdominal injuries account for approximately 22% of mortality in pediatric trauma. Up to 20% of children who present with a normal blood pressure but a Glasgow Coma Scale score ≤10 have associated intra-abdominal injuries. Abdominal trauma is the leading cause of initially unrecognized fatal injuries in children. The most common causes of pediatric abdominal trauma are motor vehicle accidents and penetrating trauma. Falls account for a small number of abdominal injuries and typically lead to injury in children <2 years of age. Children’s smaller bodies result in dissipation of traumatic forces over more organs, making multisystem trauma more likely. Solid abdominal organs are proportionately larger in children leading to increased risk of direct injury. Young children have relatively less developed abdominal muscles and a more protuberant abdomen with less shock-dampening fat. The urinary bladder is an intra-abdominal organ in young children making it more likely to be injured. Head injury is relatively more frequent in children with abdominal trauma, making the history and localization of pain and tenderness to palpation more difficult to determine. Physical examination also may be difficult or unreliable in infants aged <1 year, children swallowing large amounts of air from excessive crying leading to abdominal distension, and with usage of illicit substances or spinal cord injury. Hematuria is an important sign in pediatric trauma and may indicate renal, hepatic, or splenic injuries. However, hematuria may be absent in up to 50% of patients with renal pedicle injuries and isolated ureteral injuries. Maintain a high index of suspicion for intra-abdominal trauma when there are lower rib fractures (causing splenic or hepatic injury), testicular injuries, pelvic fractures, or spinal cord injury (decreased sphincter tone, priapism, hypotension, relative bradycardia, and decreased strength/sensation).

Emergency Department Treatment and Disposition

Stabilize airway, breathing and circulation first and then proceed to rapidly identifying life-threatening conditions. Monitor cardiovascular status, obtain vascular access, provide fluid resuscitation, bladder catheterization (if no evidence of urethral injuries) and order plain films, CT, and ultrasound as needed before proceeding to definitive care. Whenever possible, obtain a history regarding the exact mechanism of injury to assist in making early and correct diagnoses. Examine the abdomen on arrival; repeat the abdominal exam serially, preferably by the same clinician. In hemodynamically stable children with blunt abdominal trauma, obtain baseline hemoglobin (Hgb), serum amylase, liver enzymes (LFTs), urinalysis and a type and screen or cross-match. In children who are hemodynamically stable, unsuspected injury may be identified by the presence of hematuria or elevated transaminases. With suspected pancreatic injury, consider serial serum amylase and lipase values (commonly elevated with blunt abdominal trauma but sensitivity for pancreatic injury increases with serial values).

Plain abdominal radiographs are usually not helpful but may show an elevated hemidiaphragm, displaced gastric bubble or free abdominal gas or help to identify and localize foreign bodies and detect pneumoperitoneum in penetrating trauma. Bedside ultrasonography (the FAST exam) is useful to rule in intra-abdominal fluid and organ damage; however it does not accurately detect hollow viscus injury. Quality is diminished by bowel gas and fat and is operator dependent. Negative ultrasound does not exclude intra-abdominal injury. Abdominal CT is the superior imaging modality in both blunt and penetrating trauma as it is both sensitive and specific in diagnosing intra-abdominal and retroperitoneal injuries. Use and type of contrast (IV, oral, or both) vary among centers (eg, oral contrast not used by some centers as it prolongs scan time, induces vomiting without significantly aiding diagnosis). CT scan will identify (and assist in grading) most significant solid organ injuries including hepatic, splenic, adrenal, and renal injuries as well as the vast majority (˜96%) of hollow viscus injuries. Emergent abdominal and pelvic CT scan is indicated with any suspected blunt abdominal trauma, significant fluid resuscitation with or without obvious source of blood loss, multisystem trauma, or an Hgb of <10 g/dL without obvious blood loss and/or hematuria. In patients with isolated microscopic hematuria, obtain renal imaging if there is another indication to obtain abdominal CT (eg, severe pain or dropping hematocrit).

Consider peritoneal lavage for discriminating between mesenteric injury (may be missed by CT) and bowel perforation. Immediate clinical symptoms of mesenteric injuries include hypotension secondary to hemorrhage, abdominal distention, pain and tenderness.

The goal of treatment is to maintain the Hgb values above 10 g/dL. Nonoperative management is appropriate when there is hemodynamic stability despite solid organ injuries. Laparotomy is indicated if 40% to 50% of the patient’s blood volume has been replaced in the first 24 hours. If blood products are used to resuscitate patients with any of these injuries, patients are at risk for transfusion-related coagulopathies. Admit patients with documented abdominal injuries or multiple organ system injuries to the ICU and admit any child with a significant mechanism of injury for observation. Consider transfer to a designated trauma center if specialty expertise is unavailable.

Pearls

1. Signs of abdominal injury include ecchymosis, abrasions, seat-belt marks, abdominal distension, tenderness, rigidity, mass, and Kehr sign (pain in left shoulder induced by palpation of left upper quadrant).

2. The most frequently injured organs in blunt trauma are spleen and liver followed by kidney, stomach, and intestines.

3. Children may maintain a normal BP even with a significant amount of blood loss (up to 25%). Persistent tachycardia can be due to blood loss or a variety of other factors (eg, fear, pain).

4. Initial Hgb/Hct values might be normal despite significant blood loss; serial monitoring is extremely valuable.

5. A metabolic acidosis is seen in children in hypovolemic shock. The base deficit is a useful marker for the presence of abdominal trauma requiring surgery.

Clinical Summary

The spleen is the most commonly injured organ in blunt abdominal trauma. Patients may present with diffuse abdominal tenderness, left upper quadrant pain (LUQ), or referred left shoulder pain. Bruising on the left flank/abdominal wall may be present. Kehr sign, pain in the left shoulder induced by palpation of the LUQ, is often found in patients with splenic injuries. The Organ Injury Scaling Committee of the American Association for the Surgery of Trauma has put forward a grading system for splenic trauma.

Emergency Department Treatment and Disposition

For a detailed approach to abdominal trauma, see Abdominal Trauma section. Plain abdominal films may show a medially displaced gastric bubble. A CT scan with IV contrast is more sensitive and specific for evaluation and grading the injury. Laparotomy is indicated when there is persistent hemodynamic instability or active bleeding requiring >40 mL/kg of blood to be transfused.

The decision to proceed to surgical repair is based on hemodynamic instability. Admit patients and follow the American Pediatric Surgical Association–published guidelines for the length of hospital stay for children with splenic and hepatic injuries. A 24-hour stay in the ICU is recommended for grade IV and V spleen or liver injuries followed by 5 days in the hospital. For grade I, II, and III spleen or liver injuries, it is recommended that the patient be observed in the hospital for 2, 3, and 4 days, respectively. Restricted activities (eg, no contact sports) are recommended for 6, 5, 4, and 3 weeks for grades V/IV, III, II, and I injuries, respectively, as well.

Pearls

1. Nonoperative management is preferred if the patient is hemodynamically stable; the goal is preservation of spleen to avoid future infectious risk.

2. Less than 10% of children with spleen injuries require surgery.