Multiple and Combined Trauma of the Musculoskeletal System in Children: Clinical Picture, Diagnosis, and Treatment

The dissertation is devoted to the clinical picture, diagnosis, and treatment of multiple and combined trauma of the musculoskeletal system in children. On the basis of a comprehensive examination of 956 injured children, the author distributes patients into groups according to the character of the "dominant" injury and develops diagnostic and therapeutic algorithms for each subgroup of multiple and combined injuries. The work examines the specific features of multiple fractures of the bones of the extremities (monomelic, dimelic, involving three and four extremities), combined fractures of the spine and the bones of the extremities, mono-combined craniocerebral trauma with fractures of the bones of the extremities, and combined injuries of the abdominal organs and the bones of the extremities. Particular attention is given to the use of modern highly informative diagnostic methods (CT, MRI, laparoscopy, ultrasonography), to the mathematical analysis of radiometric signs of compression fractures of the vertebral bodies, to the choice of optimal therapeutic tactics with account for the severity of the victims' condition, and to the optimization of skeletal traction in the treatment of fractures of long tubular bones in children.

Relevance of the problem.

Combined and multiple trauma causes substantial economic and social damage to society. The growth of various types of injuries and the adverse consequences of trauma constitute one of the most acute problems of our time. Continuous technological progress, urbanization, and the scale of contemporary high-rise construction have increased the number of victims with polytrauma (117, 150, 155, 174). The proportion not only of isolated but also of multiple and combined injuries is rising (24, 65, 73, 77, 114, 190). However, polytrauma has been studied as an independent emergency condition only during the past 25-30 years. In this period publications began to appear devoted to multiple and combined trauma both in the adult patient population (7, 47, 56, 80, 106, 112, 142, 162, 171, 175, 189, 220, 225, 236, 239, 247, 250, 257, 314, 317, 324, 326, 328) and in the pediatric population (33, 37, 44, 54, 55, 62, 63, 93, 114, 123, 191, 226, 252, 261, 294, 322).

In recent decades a significant increase has been observed not only in the number but also in the severity of injuries in children (50, 114, 216). According to data of a number of authors (190), in recent years the number of road traffic accidents has grown by 22.0%.

According to data of domestic (7, 58, 70, 102) and foreign (239, 299) authors, the majority of victims are admitted to hospital in severe and extremely severe condition with manifestations of traumatic shock. It is absolutely clear that anti-shock therapy initiated in a timely manner and carried out in sufficient volume is of decisive importance for saving the majority of victims.

The great diversity of all possible variants and their variability in multiple and combined injuries create difficulties in diagnosing the "dominant" injury. It is characterized by the phenomenon of "mutual aggravation" (101, 114, 160). At the same time, each of the injuries aggravates the severity of the overall pathological situation, and in addition each specific injury in combined trauma runs a more severe course than in isolated trauma (7). The achievements of early diagnosis of injuries in combined trauma are directly connected with the wider use of the modern capabilities of medical technology (4, 65, 71, 291, 292, 332).

Despite the continuous improvement of methods of treating fractures, the treatment of victims with multiple and combined trauma is distinguished by its complexity, duration, multistage nature, and individual approach. In the discussion of the tactics of treating fractures in multiple and combined trauma, a preponderance of opinions in favor of the earliest possible surgical treatment is currently evident (11, 42, 52, 91, 200), which makes it possible to restore anatomical relationships better and more rapidly, ensure early mobilization of the victims, and carry out active rehabilitation. With the introduction into clinical practice of low-impact methods of treatment that do not damage the growth zones of bones, opportunities are opened for early osteosynthesis of fractures in children with multiple and combined injuries of the musculoskeletal system (8, 42, 180, 209, 249, 270, 273, 281, 283, 297). However, in each specific situation the physician has to solve a complex task that includes, first of all, assessment of the severity of the victim's condition, the degree of risk of the planned surgical manipulations, and the choice of the most effective and least traumatic methods of treatment (20, 23, 216, 246, 309).

A number of authors, while adhering to a surgical tactic in the treatment of multiple and combined fractures, at the same time point out the possibility of treating bone fractures in children by skeletal traction (23, 120, 200, 201).

Disability resulting from injuries of the musculoskeletal system and their sequelae in multiple and combined trauma is directly dependent on the severity of the sustained injury and on defects in the provision of medical care at its various stages. Despite the great advances achieved in the prevention of injuries and in the treatment and rehabilitation of victims, multiple injuries remain one of the leading causes of temporary and permanent loss of working capacity. Post-traumatic conditions leading to disability and prolonged functional disorders are observed in 38% of victims (12, 22).

In multiple and combined trauma, the indicators of mortality and disability remain high, and there is no tendency toward their reduction (37, 147, 278). Mortality in multiple and combined trauma, according to data of different authors, ranges from 7.1% to 22.0%, and it is not only a medical but also a socio-economic problem (12, 26, 95, 124, 210). Mortality in the first hours from the moment of injury, according to data of different authors, ranges from 11.0% to 77.0% (50, 129, 175, 260).

Thus, the severe condition of patients with multiple and combined trauma of the musculoskeletal system, the difficulties in determining the "dominant" injury in the acute period of trauma, the obstacles in choosing the optimal method of treatment, and the high percentage of fatal outcomes determine the relevance of the problem, the solution of which has not only medical but also socio-economic significance.

The work was carried out according to the research plan of the State Educational Institution of Higher Professional Education "Dagestan State Medical Academy of the Ministry of Health and Social Development of the Russian Federation" at the Department of Pediatric Surgery (headed by Professor G.A. Gadzhimirzaev) on the basis of the Dagestan Republican Children's Clinical Hospital named after N.M. Kurayev in Makhachkala and in the Department of Pediatric Trauma (headed by Professor V.N. Merkulov) of the Federal State Institution Central Institute of Traumatology and Orthopedics named after N.N. Priorov. The state registration number of the dissertation topic is 01200314628.

Taking the above into account, the aim of the present work is to improve the results of treatment of children with multiple and combined trauma of the musculoskeletal system on the basis of the use of highly informative diagnostic methods and the development of diagnostic and therapeutic algorithms, as well as the optimization of methods of treatment.

To achieve this aim the following tasks were set:

1. On the basis of modern diagnostic methods, to distribute the analyzed patients with multiple and combined trauma into groups depending on the character of the "dominant" injury.

2. To develop an algorithm of therapeutic tactics in multiple fractures of the bones of the extremities with the simultaneous use of conservative and surgical methods of treatment.

3. To improve the diagnosis of compression fractures of the vertebral bodies in children with multiple and combined trauma on the basis of mathematical analysis of radiometric signs and the use of modern highly informative diagnostic methods, and to substantiate a rational system of complex treatment.

4. To develop and introduce into clinical practice a diagnostic and tactical algorithm of actions in combined craniocerebral trauma and combined injuries of the abdominal organs.

5. On the basis of study of the immediate and remote results of treatment in the main and control groups of patients, to substantiate the application of the author's own modifications of methods of conservative and surgical treatment of children with combined trauma.

Scientific novelty of the study.

1. On the basis of a comprehensive examination of 956 injured children, we have developed diagnostic and therapeutic algorithms for each subgroup of multiple and combined injuries of the musculoskeletal system in children.

2. In children with combined craniocerebral trauma and combined injuries of the abdominal organs, on the basis of modern diagnostic methods (CT, MRI, laparoscopy, ultrasonography), the optimal sequence of therapeutic manipulations and the technique of their performance have been determined.

3. An analysis of the capabilities of radiological methods of diagnosis of combined injuries of the spine has been carried out, their comparative characteristics have been given, and the informativeness and effectiveness of each method have been determined. A system of complex treatment of compression fractures of the thoracic vertebral bodies has been scientifically substantiated.

For the diagnostic methods and methods of treatment of multiple and combined injuries improved by us, 10 certificates of rationalization proposals have been obtained:

- method of determining compression of the thoracic vertebral bodies in fracture — rationalization proposal certificate No. 03 — 1239, issued by DSMA on May 29, 2003;

- method of determining fracture of the thoracic vertebral bodies by the value of the numerical indices of the disc coefficient — rationalization proposal certificate No. 03 — 1254, issued by DSMA on December 25, 2003;

- method of autoplasty of a bone defect in small-fragment depressed skull fractures in children — rationalization proposal certificate No. 04 — 1264, issued by DSMA on April 7, 2004;

- method of preventing adhesion of brain matter to the soft tissues of the cranial vault after primary surgical treatment of wounds of the skull and brain — rationalization proposal certificate No. 04 — 1265, issued by DSMA on April 7, 2004;

- algorithm of diagnosis of fracture of a vertebral body in children — rationalization proposal certificate No. 07 — 1372, issued by DSMA on March 29, 2004;

- algorithm of treatment of a vertebral body fracture combined with injury of the musculoskeletal system in children — rationalization proposal certificate No. 07 — 1371, issued by DSMA on March 29, 2007;

- method of optimization of skeletal traction in the treatment of fractures — rationalization proposal certificate No. 07 — 1373, issued by DSMA on March 29, 2007;

- method of prevention of overdistraction of the injured segment in the treatment of fractures by the method of skeletal traction — rationalization proposal certificate No. 07 — 1374, issued by DSMA on April 4, 2007;

- algorithm of diagnosis and treatment of combined injuries of the abdominal organs and the musculoskeletal system in children — rationalization proposal certificate No. 07 — 1377, issued by DSMA on April 27, 2007;

- algorithm of diagnosis and treatment of combined injuries of the brain and the musculoskeletal system in children — rationalization proposal certificate No. 07 — 1389, issued by DSMA on September 15, 2007.

Practical significance of the work.

1. A detailed clinical examination of children with multiple and combined trauma of the musculoskeletal system, based on modern highly informative diagnostic methods, simplifies and facilitates the detection of the "dominant" injury in the acute period of trauma, as well as the choice of the optimal method of conservative or surgical treatment.

2. The proposed algorithms of diagnosis and treatment of injuries of the spine and abdominal organs combined with injuries of the bones of the extremities promote the early detection of the "dominant" injury and make it possible to determine the scope of surgical intervention in the acute period of trauma.

3. The use of the most informative diagnostic methods (CT, MRI, laparoscopy, etc.) in combined and multiple trauma has made it possible to determine the character of the injuries in the early period and to reduce the trauma of surgical interventions, as well as to expand the possibilities of performing organ-preserving operations.

4. A detailed clinical examination of children with spine injuries, study of the mechanism of injury, radiological signs with the use of mathematical calculations and modern diagnostic methods, CT and MRI, have made it possible to maximally improve the diagnosis of compression fractures of the vertebral bodies in multiple and combined injuries.

5. A system of optimization of skeletal traction in the treatment of fractures of the long tubular bones of the extremities has been developed.

6. Early diagnosis of injuries of the musculoskeletal system in combined and multiple trauma has ensured the most effective treatment with good anatomical and functional results.

Personal participation of the author in obtaining the results of the study.

The analyzed patients who were receiving treatment in the traumatological department of the Dagestan Republican Children's Clinical Hospital in Makhachkala were supervised and operated on by the author personally, or the author assisted in the absolute majority of cases. The dissertation author developed and introduced into clinical practice 10 rationalization proposals, took direct part in the treatment of patients with uncomplicated compression fractures of the vertebral bodies, carried out biomechanical examination, and studied the remote results of treatment of patients at the Federal State Institution Central Institute of Traumatology and Orthopedics.

An analysis was carried out of 100 case histories of children with combined injuries of the abdominal organs and the bones of the extremities who were receiving treatment in the Department of Emergency and Purulent Surgery of the Children's Clinical Hospital No. 13 named after N.F. Filatov in Moscow. The statistical processing of the results of the study and the formulation of the conclusions and practical recommendations were carried out personally by the author.

Main propositions defended.

1. In the acute period of multiple and combined trauma in children, the diagnostic and therapeutic algorithms are determined during a mandatory joint examination by a surgeon, traumatologist, neurosurgeon, and intensivist. At the same time, it is fundamentally important to distribute the patients into groups depending on the character of the "dominant" injury, using modern highly informative diagnostic methods.

2. In combined trauma, against the background of anti-shock measures, temporary immobilization (plaster casts, skeletal traction, Ilizarov apparatus) of the injured extremities is carried out, and primary attention is given to the topical diagnosis of brain and abdominal organ injuries. The final decision on the choice of the method of treatment of fractures of the musculoskeletal system should expediently be made after completion of the diagnostic and therapeutic manipulations with respect to the indicated organs and systems.

3. In multiple fractures of the bones of the musculoskeletal system, the diagnostic and therapeutic manipulations with respect to each fracture must be completed simultaneously, using the most effective and low-impact methods of fragment fixation. The operations may be performed successively by one surgical team or simultaneously by several surgical teams.

4. The mathematical values of the vertebral bodies (intervertebral coefficient — 0.79 — 0.92; disc coefficient — 0.37 — 0.43) indicate the presence of a compression fracture of the vertebral bodies. An increase in bone density in the adjacent vertebrae of more than 100 Hounsfield units on computed tomography confirms the presence of a compression fracture of a vertebral body.

5. The use of the methods of treatment improved by us, as well as of the diagnostic and therapeutic algorithms, reduces the frequency of diagnostic errors, shortens the terms of treatment, improves the immediate and remote results of treatment of injuries, and yields a significant economic effect.

Introduction of the results of the work into clinical practice and the educational process. The developed methods of treatment and the algorithms of diagnosis and treatment have been introduced into clinical practice at the Dagestan Republican Children's Clinical Hospital named after N.M. Kurayev (Makhachkala), as evidenced by acts of introduction. The methods of diagnosis and treatment of uncomplicated compression fractures of the thoracic vertebral bodies have been introduced into the work of the Pediatric Trauma Clinic of the Federal State Institution Central Institute of Traumatology and Orthopedics (Moscow) and the suburban department of the Pediatric Orthopedic Hospital No. 19 named after T.S. Zatsepin.

Methodological recommendations for physicians have been published on the topic: "Diagnosis of Compression Fractures of the Vertebral Bodies in Children." The results of the investigations are used in the educational process at the Department of Pediatric Surgery for trainees in traumatology and orthopedics and in continuing medical education cycles at the State Educational Institution of Higher Professional Education "Dagestan State Medical Academy of the Ministry of Health and Social Development of the Russian Federation."

Approval of the work. The main propositions of the dissertation were reported at: the Republican Scientific and Practical Conference of Surgeons (Makhachkala, 2001); a meeting of the Dagestan Society of Traumatologists and Orthopedists (2002); the Republican Scientific and Practical Conference "New in Surgery of Dagestan" (2003); the Scientific and Practical Conference of Pediatric Physicians of Dagestan (2004); the Scientific and Practical Conference of Pediatric Traumatologists and Orthopedists (Moscow, 2005); the Scientific and Practical Conference of Pediatric Traumatologists and Orthopedists of Russia (Saratov, 2005); the 16th Congress of Surgeons of Dagestan (2006); the 528th meeting of the Dagestan Society of Surgeons named after R.P. Askerkhanov (2006); the VIII Congress of Traumatologists and Orthopedists of Russia (Samara, 2006); the I Congress of Traumatologists of Dagestan (2006); a meeting of the Association of Traumatologists and Orthopedists of Dagestan (2007); the Interdepartmental Scientific Conference of the State Educational Institution of Higher Professional Education "Dagestan State Medical Academy of the Ministry of Health and Social Development of the Russian Federation" (May 28, 2007, protocol No. 1).

Publications. On the topic of the dissertation, 57 scientific and educational-methodological works have been published, including 7 articles printed in peer-reviewed journals recommended by the Higher Attestation Commission of the Ministry of Education and Science of the Russian Federation: Vestnik Travmatologii i Ortopedii imeni N.N. Priorova, 1996, No. 1. — Pp. 34-36; 2003, No. 4. — Pp. 84-86; 2005, No. 2. — Pp. 59-59; 2008, No. 2. — Pp. 33-37; Detskaya Khirurgiya. 2004, No. 4. — Pp. 19-21; 2008, No. 6. — Pp. 14-17; Rossiyskiy Pediatricheskiy Zhurnal 2008, No. 5. — Pp. 26-30. Ten certificates of rationalization proposals have been obtained.

Scope and structure of the work. The dissertation is presented on 265 pages and consists of an introduction, a review of the literature, six chapters of the author's own research, a conclusion, conclusions, practical recommendations, and a bibliography comprising 224 domestic and 108 foreign sources. The work is illustrated with 47 figures and 31 tables.