Page 19 - 63 craniocerebral-and-spinal-trauma30-35_opt

CHAPTER 32

Musculoskeletal Trauma

Jonathan I. Groner
Michael O. Ogirima

Introduction Clinical Presentation
Musculoskeletal trauma principally includes fractures of the bones of History
the extremities; however, ligamentous injuries, joint injuries, and soft The history for most musculoskeletal injuries is obvious. Most children
tissue trauma involving muscle may also be placed in this category. with tibia fractures, for example, will present with a history of a trau-
This represents one of the major burdens of injury in children. In devel- matic event. In addition, these children typically have pain, inability to
oped countries, many extremity fractures are of little consequence and bear weight, and swelling or deformity. 2
are often regarded as a “badge of courage”; the child is immobilised in However, injured patients younger than 3 years of age must be
a plaster or fiberglass cast for a few weeks and then returns to normal evaluated carefully, as 90% of child abuse cases occur in this age
activity. In the third world, however, extremity fractures and other group. These children are nonverbal, so the history must be provided
5
musculoskeletal trauma can result in permanent disability and even life- by parents or caregivers. A history that changes over time or is told
threatening injuries. Perhaps the most serious complication of fracture differently by different adults raises suspicion of an abusive injury.
management in Africa is “bonesetter’s limbs” or “bonesetter’s gan- Likewise, a history that is not consistent with the child’s developmental
grene”, which, if it does not kill the patient, can destroy all of the soft ability should also raise concerns. Although child-abuse–related
tissue of the affected limb, leaving only contractures or exposed bones. 1
fractures are seen daily in major paediatric trauma centres across the
Demographics United States, this mechanism of injury in children is scarcely reported
Data from a large paediatric trauma centre in the United States indicate in the African literature. 6,7
that fractures are the reason for more than half of all children’s admis- Physical Examination
sions to the hospital for injuries. The most common injury mechanism Tenderness, pain, and swelling of an extremity or bony prominence are
is a fall, and the most common fracture from this mechanism is a the hallmarks of musculoskeletal trauma. The majority of long bone
supracondylar humerus fracture. The most common bone fracture seen fractures will have significant pain, tenderness at the fracture site, pain
in victims of both motor vehicle crashes and child abuse is of the femur. with passive motion, and inability to bear weight. Bruising is often not
The most common bone fracture in children up to age 10 years is to the seen acutely but may develop later.
humerus, and the most common bone fracture from age 11 to 15 years One major pitfall when examining a child for possible musculoskeletal
is to the tibia/fibula. trauma is the failure to recognise an open fracture. With some fracture
Data from other studies indicate that the most common paediatric mechanisms, a long bone fragment may transiently protrude through
long bone fracture occurs at the forearm, followed by the femur, and a break in the skin, only to retract when the extremity is returned to
then the tibia. Approximately half of all tibia fractures occur in the normal position. Therefore, any break in the skin in close proximity to
distal third of the bone, and 70% of tibia fractures occur as isolated the fracture site should be considered an open fracture.
injuries. Combined tibia/fibula fractures are most often the result of Open fractures are categorised into three types:
2
high energy trauma such as motor vehicle crashes. • Type I: Wounds are smaller than 1 cm with minimal soft tissue
2
The incidence of paediatric musculoskeletal trauma in most African damage or contamination.
countries is unknown; however, fractures are quite common in
childhood. Fractures were the second most common injury (after burns) • Type II: Wounds are greater than 1 cm but without extensive soft
among 798 injured children treated at Royal Victoria Hospital (RVH) in tissue damage.
Banjul, The Gambia. Motor vehicle crashes accounted for 50% of the • Type III: Extensive soft tissue injury can be subcategorised as hav-
3
4
fractures in one study. Penetrating trauma can cause musculoskeletal ing adequate soft tissue for coverage, inadequate coverage, or vas-
trauma as well. cular injury requiring repair.
Aetiology/Pathophysiology All patients with musculoskeletal injuries require a thorough
Most musculoskeletal trauma is caused by falls, motor vehicle crashes, neurovascular examination. It is critical to identify vascular injury
and pedestrian/vehicle injuries. Child abuse is an extremely important early, so that limb loss can be prevented. The “5 P’s” mnemonic is used
cause of these injuries in infants and young children. One US study to look for signs of vascular insufficiency in an injured limb:
demonstrated that 67% of lower extremity injuries in patients younger 1. Pain is the most sensitive sign. Note that this refers to pain in the
than 18 months of age admitted to a trauma centre were due to child distal extremity (i.e., hand or foot), not at the fracture site.
5
abuse. There is virtually no literature, however, on child-abuse–asso-
2. Paraethesias is numbness as well as loss of proprioception (position sense).
ciated musculoskeletal trauma in Africa. One of the rare studies of
3. Pallor is pale appearance of the hands or feet.
child abuse in Africa demonstrated that, of 916 paediatric autopsies
6
for “unnatural deaths”, 24 (2.6%) were attributed to child abuse. By 4. Poikolothermia is cold to the touch.
contrast, 30–50% of the paediatric fatalities at some paediatric trauma 5. Pulselessness is a late sign. Permanent muscle damage has probably
centres in the United States are due to abuse-related injuries. already occurred by the time pulses are lost.