Abstract |
Introduction: Skeletal injuries account for 10% -15% of all injuries in children. Αlthough
spinal injuries are relatively rare in paediatric patients, they have a very high mortality rate
compared to other injuries. Cervical spine is most commonly affected accountig for 1%-2%
with a mortality rate from 16% -40% and a significant proportion of neurological deficits over
60%. Clinical decision tools are commonly used to guide imaging decisions in cervical spine
injury assessment. The A.P.L.S. (Advanced Pediatric Life Support), N.E.X.U.S. (National
Emergency X-radiography Utilization Study and Canadian C-spine Rules (CC-R) / NICE
(National Institute for Health and Care Excellence) are used as a guide for clinical decisionmaking
on cervical spine imaging despite limited diagnostic accuracy for their use in
paediatric populations. Pelvis injuries are rare accounting for 1-2% of all paediatric injuries.
Due to close proximity to other important organs and structures, pelvic injuries could be life
threatening. Mortality rate is 5-6.3% and is associated with other co-existing injuries (head,
liver and spleen injuries). Limb injuries are exceptionally common, occuring mainly after falls
, car accidents, during sports activities or even in cases of abuse.
Objective: The aim of this retrospective study is to determine the spinal, pelvic and limb
injuries in children and youth admitted in Paediatric Surgery Clinic and in Paediatric Intensive
Care Unit at the University Hospital of Heraklion in a 7-year period. Demographic
characteristics, incidence, mechamisms of injuries pattern of skeletal and nonskeletal
injuries, assossiated injuries ,comllications and outcomes were evaluated. In addition, clinical
decision tools A.P.L.S., N.E.X.U.S. and Canadian C-spine Rules / N.I.C.E. for the necesity of
performig imaging were estimated.
Methods: This is a retrospective, study which was conducted in Paediatric Surgery Clinic and
in Paediatric Intensive Care Unit at the University Hospital of Heraklion concerning spinal,
pelvis and limb injuries in children and youth in a 7- year period (2014-2020). According to
our inclusion criteria, patients with complete sets of collected data and who were younger
the age 18 with associated injuries of head ,abdomen and thorax were finally enrolled in this
investigation. Collected data included age, gender, mechanism of injury, pattern of injury,
associated injuries, nonsurgical and surgical treatment, functional outcome and mortality
rate of the patients. Furthermore, clinical findings, radiologic assessment of C-spine with
clinical decision tools A.P.L.S., N.E.X.U.S. and Canadian C-spine Rules / N.I.C.E. were
evaluated.
Results: 823 patients were studied, of which 582 (70.7%) were boys and 241 (29.3%) were
girls. 784 (95.7%) were admitted in the Pediatric Surgery Clinic, and 36 (4.3%) in the P. I..C.U.
The mean age was 8 ± 3.8 years and differed significantly between the sexes (boys 8.4 ± 3.9
vs. girls 7 ± 3.7 years, p <0.001). The most common types of injuries were falls (55.9%) and road accidents (28.7%). Mass transfusion protocol was activated in 6 patients (1%), while
associated head injuries were found in 337 (40.9%) children and nonsurgical treatment in
95.5%. The duration of hospitalization was 2 days (IQR 1-4). Children victims of road
accidents, children after falls from a significant height and multiple injuries of all etiologies
were treated in P.I.C.U. (p <0.001). The duration of hospitalization in the P.I.C.U. was 8 days
(IQR 4-11). In total, 2 (0.2%) children died, 12 (1.5%) had a neurological deficit, while 98.3%
(N = 809) showed complete cure or improvement.
The types of pelvic injuries were mild, immobilization occurred in 43 (5.2%) cases, and
imaging was performed in 170 (20.6%) patients (17.4% radiographs, 3.3% CT). The
radiological findings mainly concerned pelvic fractures that were treated conservatively.
Upper limb injuries were 446 (56.5%), 45.3% underwent surgical operation and lower limb
injuries were 330 (40.1%), 36% underwent surgical operation. 272 spinal injuries were
reported, from which N=86 (31,6%) concerned the cervical spine ,N = 22 (12.1%)
concerned thoracic spine, N = 9, (3.3%) concerned lumbar spine, N =1, (0.4%) concerned
sacral spine The combinated spinal injuries were N = 143, (52.6%). The spinal imaging
performed according to the A.P.L.S. criteria at 80.1%, without being affected by age
distribution or type of injury, in contrast to the N.I.C.E. criteria where the agreement rate
was 63.6%. Cervical spine imaging performed was in accordance with the A.P.L.S .criteria at
88.9%, without being affected by age distribution or type of injury, in contrast to the
N.E.X.U.S. criteria where the agreement rate was 66.5%.
Conclusions: The majority of children with traumatic skeletal injuries who were admitted in
hospital were boys, which had upper and lower limb fractures, and had an excellent clinical
outcome. Children and adolescents with severe trauma and associated injuries were
admitted in P.I.C.U.. They had a longer stay duration and increased mortality. Spinal injuries
were relatively rare and of minor severity. The A.P.L.S. spine and cervical spine imaging
criteria showed better agreement and compliance than the N.I.C.E. and N.E.X.U.S. criteria,
respectively. The perfectly adapted imaging A.P.L.S. criteria for the clearance of the cervical
spine in children have a better compliance index, so that missing cervical spine injuries that
can affect the patient outcome to be avoided and at the same time uneccessary imaging be
reduced.
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