The "Bergamo Approach" for Pediatric and Adolescent Polytrauma-A One-Center Experience.

Abstract

Introduction. Pediatric polytrauma (PPT) and major trauma in pediatric patients (PMT) present unique challenges compared to adult trauma care due to distinct anatomical and physiological differences. PPT/PMT remains the leading cause of death in children, responsible for over 50% of pediatric deaths and 15% of pediatric hospital admissions due to its long-term effects. This single-institution study focuses on the initial management of PPT/PMT from an orthopedics and traumatology point of view. Material and Methods. In the present study, data of PPT/PMT managed in one single institution, an academic level I pediatric trauma center, in patients <18 years of age, were analyzed over different periods. Over a 10-year period, diaphyseal femur fractures were analyzed as indicators of damage control (DCO) versus definitive treatment. Over a 4-year period (2021-2024), the associated lesions of PPT (head injuries, thoracic and abdominal lesions, spine lesions, major blood vessel lesions, and major musculoskeletal injury) were analyzed. Over a 1-year period (2019), the overall in-hospital mortality and admission rates in the pediatric intensive care unit were analyzed. Results. In the 10-year period, among 298 diaphyseal femur fractures, 46/298 (15%) were classified as PPT in which DCO was performed according to age as follows: in the age-group 15-17 years 23/23 (100%) with temporary external fixation (ExFix); in the age group 12-14 years, 9/14 (64%) with ExFix and 5/14 (26%) and elastic stable intramedullary nails (ESINs); in the age group 5-11 years, 1/5 (20%) with ExFix and 4 with ESIN; in the age group 0-4 years, 2/4 (50%) with ESIN and 2/4 (50%) with a cast. In the 4-year period, PPT/PMTs were associated with 60% head injury, 25% thoracic lesion(s), 18% abdominal lesion(s), 16% spine injury, 5% lesion of a major blood vessel, and 30% major musculoskeletal injuries. In 2019, there were 193 patients admitted to the emergency room as PPT/PMT: 115 were ≤12 years old and 78 were >12 years old. On admission, 46% were admitted to the pediatric intensive care unit, and 65% were admitted to the department of traumatology as inpatients. The in-hospital mortality rate was 7%. Discussion and Conclusions. In our institution, pediatric trauma is assessed using the Pediatric Trauma Score (PTS), and the workup follows the ATLS guidelines with a dedicated trauma team. The role of the orthopedic surgeon during the primary evaluation of PPT/PMT is to contribute to stopping bleeding and hemorrhagic shock. In PPT/PMT, DCO in adolescents is superimposable to adults, whilst in babies and children, DCO is still performed, but it is not a form of temporary external fixation.