The Management of Trauma in Childhood and Adolescence

Trauma is one of the leading causes of death in children and adolescents and is responsible for many long-term disabilities even following optimal therapy and intensive rehabilitation. If fracture care is included in the scope of duty of a pediatric surgeon, trauma care amounts for about one-third of the daily work. Therefore, the management of trauma is placed in the middle of the surgical spectrum.

Traumatic brain injuries are at the top of most trauma statistics. Without doubt computed tomography (CT) is the first line diagnostic procedure in severe and medium injuries. But there is an ongoing debate about the necessity of CT in the evaluation of a low-grade brain injury. Is there any indication for a conventional X-ray of the skull? Is ultrasound used too seldom? Does every child need a CT scan before it is discharged, independent from age and clinical findings? Is MRI only useful in the midtime course? Sorantin et al[1] from Graz, Austria and Jena, Germany point out the state of the art in pediatric radiology.

Most thoracic injuries are part of a multisystemic injury or polytrauma. The absolute number of thoracic injuries is low in Europe, but it is the most underestimated injury in childhood. Rib fractures are seldom because of the elasticity of the thoracic cage. Therefore, the most lung contusions arise even without rib fractures. Pulmonary insufficiency is not a common cause of posttraumatic death, but prolonged hypoxia may impair the recovery from brain injury. Van As[2] from Cape Town, South Africa shows diagnostic and therapeutic algorithms to update the recommendations in this sensitive field of pediatric emergency care.

The conservative treatment of blunt abdominal organ injuries has meanwhile reached a very high standard and touches the 100% level in specialized departments. The indication for explorative laparotomy is pushed far backward. We have evidence-based data to manage liver and spleen injuries up to grade IV without operation, and an increasing number of reports mentions nonoperative management in patients with kidney and pancreatic injuries as well as in polytrauma patients. Only the progressive bleeding from an injured organ artery is still a challenge, and Schuster and Leissner[3] from Augsburg, Germany give an extensive insight in the options of interventional measurement and present results from the literature and from their own experience.

Fractures of the limbs show an increasing incidence, and the number of operative interventions is increasing as well. A method adequate to children like elastic-stable intramedullary nailing is one of the factors inducing this change in treatment modality, but on the other side the patient's demand for early unlimited activity and school attendance pushes fracture care with early stability for movement or for weight bearing forward. Today, the treatment of diaphyseal fractures uses often a surgical method. Lieber and Schmittenbecher[4] from Tübingen and Karlsruhe, Germany collected the literature statements on this topic and compared them with their own procedures in their level III pediatric trauma centers.

The spectrum of injuries changes with age. While many knee injuries in younger age are characterized by contusions and lacerations or (in more severe trauma) by fractures including the avulsion of the anterior cruciate ligament (fracture of the tibia eminence), adolescent patients may show ligamentous ruptures quite possible with open growth plates. The treatment of these injuries is a matter of debate. Unanswered questions extend from the necessity of any reconstruction to the best moment of such an operation, and from the preferred method of replacement to the direction of drilling the hole for it. Ziebarth et al[5] from Berne, Switzerland are representants of one of the most active pediatric trauma centers in central Europe and present their own procedure as well as the state of scientific discussion.

Trauma is one of the most challenging parts of pediatric surgical work. It was a great honor for me to be invited as a guest editor for this issue presenting a lot of important information on one of my personally privileged parts in the exciting field of pediatric surgery.

• References

• 1 Sorantin E, Wegmann H, Zaupa P, Mentzel H-J, Riccabona M. Computed tomographic scan in head trauma: what is the rational in children?. Eur J Pediatr Surg 2013; 23 (6) 444-453
• 2 van As AB, Manganyi R, Brooks A. Treatment of thoracic trauma in children: literature review, Red Cross War Memorial Children's Hospital data analysis, and guidelines for management. Eur J Pediatr Surg 2013; 23 (6) 434-443
• 3 Schuster T, Leissner G. Selective angioembolization in blunt solid organ injury in children and adolescents: review of recent literature and own experiences. Eur J Pediatr Surg 2013; 23 (6) 454-463
• 4 Lieber J, Schmittenbecher PP. Developments in the treatment of pediatric long bone shaft fractures. Eur J Pediatr Surg 2013; 23 (6) 427-433
• 5 Ziebarth K, Kolp D, Kohl S, Slongo T. Anterior cruciate ligament injuries in children and adolescents: a review of the recent literature. Eur J Pediatr Surg 2013; 23 (6) 464-469