Pediatric trauma during the COVID-19 lockdown: caregiver abuse and self-harm in a vulnerable population.

PURPOSE: This retrospective cohort study explores the impact of the COVID-19 pandemic on pediatric trauma cases in Singapore's National University Hospital from January 2015 to July 2021. The pandemic prompted unprecedented measures, altering societal dynamics. The study hypothesizes a reduction in major trauma incidents during the pandemic period. METHODS: This is a single-center retrospective study including all pediatric patients presenting with trauma-related ICD-9 codes, and an Injury Severity Score (ISS) greater than 8. Patients were stratified into two time periods: pre-pandemic (January 2015 to March 2020) and pandemic (April 2020 to July 2021) periods. RESULTS: Out of 254 pediatric trauma cases, 201 occurred pre-pandemic, and 53 during the pandemic. While overall trauma incidence remained similar, the pandemic period saw a shift in injury patterns. Home-based falls increased, vehicular accidents decreased, while deliberate self-harm and caregiver abuse rose significantly. The incidence of serious trauma attributed to non-accidental injury increased during the pandemic. CONCLUSION: The study reveals changing trauma patterns, emphasizing the importance of understanding societal impacts during pandemics. Notably cases of deliberate self-harm and caregiver abuse surged, echoing global concerns highlighted in other studies during the pandemic. The study underscores the need to preempt physical and psychological stressors in vulnerable populations during future pandemics.

Case Report: Surgical challenges and insights in a child with a blunt left diaphragmatic and pericardial rupture and heart subluxation.

Introduction: Blunt diaphragmatic rupture (BTDR) is a rare condition that can occur in children following high-energy blunt thoracoabdominal trauma. In less than 1% of the cases, pericardial rupture can coexist with a BTDR. A coexistence of BTDR and pericardial rupture can result in displacement of the heart and is associated with high mortality. Clinical presentation is non-specific and requires a high index of suspicion for early management. Case presentation: A 4-year-old child presented to the emergency unit of our hospital following high-energy trauma with severe respiratory distress. Initially, a left-side chest tube was inserted, but it resulted in no clinical improvement. A chest x-ray showed a collapse of the left lung with a herniation of bowel loops into the left hemithorax. An exploratory laparotomy was done, which revealed a 10 cm × 4 cm defect in the left hemidiaphragm with a medial extension involving the pericardium. The fundus of the stomach and left lobe of the liver were displaced into the pericardial space, pushing the cardiac apex posteriorly to the right side. Concomitantly, the transverse colon and small bowel were displaced into the left pleural space. After the reduction of the herniated abdominal viscera back into the peritoneal cavity, the pericardial sac was repaired by employing an interrupted resorbable suture, while the diaphragmatic defect was repaired by using a horizontal mattress. No other injuries were identified and the abdomen was closed in layers. Conclusion: BTDR with pericardial rupture is an elusive condition with a high mortality rate that necessitates a high index of clinical suspicion. Early surgical repair of the defect with a reduction of herniated organs can reduce morbidity and mortality.

Predicting severe outcomes in pediatric trauma patients: Shock index pediatric age-adjusted vs. age-adjusted tachycardia.

INTRODUCTION: When an injured patient arrives in the Emergency Department (ED), timely and appropriate care is crucial. Shock Index Pediatric Age-Adjusted (SIPA) has been shown to accurately identify pediatric patients in need of emergency interventions. However, no study has evaluated SIPA against age-adjusted tachycardia (AT). This study aims to compare SIPA with AT in predicting outcomes such as mortality, severe injury, and the need for emergent intervention in pediatric trauma patients. MATERIAL AND METHODS: This is a retrospective cross-sectional analysis of patient data abstracted from the Trauma Quality Improvement Program Participant Use Files (TQIP PUFs) for years 2013-2020. Patients aged 4-16 with blunt mechanism of injury and injury severity score (ISS) > 15 were included. 36,517 children met this criteria. Sensitivity, specificity, overtriage, and undertriage rates were calculated to compare the effectiveness of AT and elevated SIPA as predictors of severe injuries and need for emergent intervention. Emergent interventions included craniotomy, endotracheal intubation, thoracotomy, laparotomy, or chest tube placement within 24 h of arrival. RESULTS: AT classified 59% of patients as "high risk," while elevated SIPA identified 26%. Compared to AT patients, a greater proportion of patients with elevated SIPA required a blood transfusion within 24 h (22% vs. 12%, respectively; p < 0.001). In-hospital mortality was higher for the elevated SIPA group than AT (10% vs. 5%, respectively; p < 0.001) as well as the need for emergent operative interventions (43% vs. 32% respectively; p < 0.001). Grade 3 or higher liver/spleen lacerations requiring blood transfusion were also more common among elevated SIPA patients than AT patients (8% vs. 4%, respectively; p < 0.001). AT demonstrated greater sensitivity but lower specificity compared to SIPA across all outcomes. AT showed improved overtriage and undertriage rates compared to SIPA, but this is attributed to identifying a large proportion of the sample as "high risk." CONCLUSIONS: AT outperforms SIPA in sensitivity for mortality, injury severity and emergent interventions in pediatric trauma patients while the specificity of SIPA is high across these outcomes.

Successfully saving a child with destuctive iliac artery damage by hybrid surgery.

Non-iatrogenic trauma of the iliac artery is rarely reported but is always life-threatening. In this report, we describe the case of a child with complete transection and partial disappearance of the iliac artery caused by bicycle handlebar impalement. He experienced catastrophic hemorrhage, malignant arrhythmia, and difficulty in exploring transected vessel stumps. Aggressive infusion, blood transfusion in time, and pediatric vascular characteristics help delay the deterioration during anesthesia induction. Eventually he was successfully rescued by performing interventional balloon occlusion and open revascularization after more than 7 h post-trauma. A series of interventions and precautionary methods may benefit such severely injured patients; thus, these methods should be highlighted.

Emergency Medical Service Transport Time in Rural Farm and Non-Farm Pediatric Trauma.

OBJECTIVES: Pediatric farm injuries tend to be more severe and have poorer outcomes compared to injuries sustained in non-farm settings. Timely emergency medical service (EMS) response and transport to definitive care is crucial for optimizing outcomes for trauma patients. We aimed to determine if pediatric farm injuries were associated with longer EMS response and transport times compared to pediatric non-farm injuries in rural communities. METHODS: The 2021 National EMS Information System (NEMSIS) database was used to identify rural EMS activations where injured pediatric patients who were transported to a hospital. Median transport times for farm and non-farm injuries, as well as other components of prehospital time and use of air EMS transport, were compared between injuries on farms and injuries in non-farm rural settings. RESULTS: The analytic sample included 22,248 rural EMS activations for pediatric injuries, of which 156 (1%) were for pediatric farm injuries. For non-farm and farm injuries, the median transport times were 20 minutes and 28 minutes, respectively. Median total prehospital time was 50 minutes compared to 62 minutes, and 9.8% of patients with non-farm injuries versus 20.5% of those with farm injuries were transported to a hospital by air EMS units. After multivariable adjustment, farm vs. non-farm injury location was associated with a 4 minute increase in EMS transport time, but no difference in initial EMS response time, EMS time on scene, or use of air EMS units. CONCLUSION: Among children sustaining an injury that resulted in rural EMS activation, farm injuries were associated with prolonged transport time compared to non-farm injuries, which may contribute to worse in-hospital outcomes described to pediatric farm injuries in prior research.

Case Report: Minimally invasive repair of a traumatic abdominal wall hernia in a child with a fascial closure device.

Abdominal trauma is common in daily life, but a traumatic abdominal wall hernia (TAWH) in children is rare. A TAWH is caused by a huge external force that leads to subcutaneous muscle and fascia rupture, while the skin remains intact. As abdominal pressure increases, the abdominal contents protrude, forming a lump. A TAWH is highly susceptible to missed diagnosis because of other severe injuries. We report a case of a 2-year-old boy with a TAWH who developed a prominent subcutaneous mass on the right side of his abdomen after abdominal trauma; the size of the mass changed significantly with abdominal pressure and crying. In this case, we used a new approach of laparoscopic suture repair technique with the assistance of a fascial closure device and achieved good results. We found that this method offers the advantages of minimally invasive surgery, fast recovery, and no visible surgical incisions. There was no recurrence after 8 months of follow-up.

Total intestinal obstruction due to traumatic submucosal jejunal hematoma: A case report.

INTRODUCTION AND IMPORTANCE: Blunt abdominal trauma can result in various injuries, including intestinal hematomas causing obstruction. Traumatic submucosal jejunal hematomas are rare, especially in children, with bicycle handlebar injuries being a potential cause. Prompt recognition and appropriate imaging are crucial for accurate diagnosis and management. CASE PRESENTATION: A 10-year-old boy presented with delayed abdominal pain, vomiting, and absence of bowel movements following blunt abdominal trauma from a bicycle handlebar injury. Abdominal CT scan confirmed a submucosal jejunal hematoma, leading to exploratory laparotomy and duodenojejunostomy. CLINICAL DISCUSSION: Bicycle handlebar injuries, although seemingly minor, can cause significant internal damage, especially in children. Delayed symptoms pose a diagnostic challenge, necessitating a high index of suspicion and imaging modalities like CT scans for timely intervention. CONCLUSION: This case underscores the importance of considering traumatic submucosal jejunal hematomas in children with blunt abdominal trauma, particularly from bicycle handlebar injuries. Surgical intervention may be necessary in cases of complete intestinal obstruction, emphasizing the need for prompt diagnosis and treatment.

Validation of the Subaxial Cervical Spine Injury Classification score in children: a single-institution experience at a level 1 pediatric trauma center.

OBJECTIVE: The Subaxial Cervical Spine Injury Classification (SLIC) score has not been previously validated for a pediatric population. The authors compared the SLIC treatment recommendations for pediatric subaxial cervical spine trauma with real-world pediatric spine surgery practice. METHODS: A retrospective cohort study at a pediatric level 1 trauma center was conducted in patients < 18 years of age evaluated for trauma from 2012 to 2021. An SLIC score was calculated for each patient, and the subsequent recommendations were compared with actual treatment delivered. Percentage misclassification, sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and area under the receiver operating characteristic (ROC) curve (AUC) were calculated. RESULTS: Two hundred forty-three pediatric patients with trauma were included. Twenty-five patients (10.3%) underwent surgery and 218 were managed conservatively. The median SLIC score was 2 (interquartile range = 2). Sixteen patients (6.6%) had an SLIC score of 4, for which either conservative or surgical treatment is recommended; 27 children had an SLIC score ≥ 5, indicating a recommendation for surgical treatment; and 200 children had an SLIC score ≤ 3, indicating a recommendation for conservative treatment. Of the 243 patients, 227 received treatment consistent with SLIC score recommendations (p < 0.001). SLIC sensitivity in determining surgically treated patients was 79.2% and the specificity for accurately determining who underwent conservative treatment was 96.1%. The PPV was 70.3% and the NPV was 97.5%. There was a 5.7% misclassification rate (n = 13) using SLIC. Among patients for whom surgical treatment would be recommended by the SLIC, 29.6% (n = 8) did not undergo surgery; similarly, 2.5% (n = 5) of patients for whom conservative management would be recommended by the SLIC had surgery. The ROC curve for determining treatment received demonstrated excellent discriminative ability, with an AUC of 0.96 (OR 3.12, p < 0.001). Sensitivity decreased when the cohort was split by age (< 10 and ≥ 10 years old) to 0.5 and 0.82, respectively; specificity remained high at 0.98 and 0.94. CONCLUSIONS: The SLIC scoring system recommended similar treatment when compared with the actual treatment delivered for traumatic subaxial cervical spine injuries in children, with a low misclassification rate and a specificity of 96%. These findings demonstrate that the SLIC can be useful in guiding treatment for pediatric patients with subaxial cervical spine injuries. Further investigation into the score in young children (< 10 years) using a multicenter cohort is warranted.

Pediatric duodenal stenosis caused by posttraumatic mesenteric hematoma managed with a double elementary diet tube.

A 6-year-old male child was admitted to the hospital because of abdominal trauma and acute stomach pain. Computed tomography scan revealed a jejunal mesenteric hematoma and an enhanced intestinal wall compressed by the hematoma. The patient presented with vomiting 10 days after the injury. He underwent upper endoscopy under tracheal intubation and general anesthesia 12 days after the injury. A double elementary diet tube was inserted endoscopically with the tip placed in the jejunum beyond the stenosis and the decompressed portion of the stomach. Stenosis was improving, and the patient was discharged on the 27th day after the injury. In conclusion, a double elementary diet tube can be effective for treating posttraumatic duodenal stenosis in pediatric patients.

Analyzing computed tomography Modalities for screening pediatric patients for traumatic blunt cerebrovascular injury.

BACKGROUND: Optimal screening for BCVI in pediatric trauma patients remains debated. We hypothesized screening with CTAN would decrease the number of duplicate CT scans per patient and increase BCVI detection rate. METHODS: Local BCVI screening institutional protocol changed May 2022 to include Computed Tomography angiography neck (CTAN). We performed a retrospective review of pediatric blunt trauma patients presenting at our Level 1 trauma center between 2019 and 2023. Patients before and after implementation of universal screening were compared for demographic, clinical, radiographic, and outcome data. RESULTS: Six-hundred-eight patients were included with 368 before and 240 after the protocol change. Screening with CTAN decreased the number of duplicate neck scans (5.7%vs.2.1 â€‹%,p â€‹= â€‹0.03) and increased BCVI detection rate (0.27%v.2.5 â€‹%,p â€‹= â€‹0.01). Of the seven patients diagnosed with BCVI 2019-2023, no patients suffered any stroke-related morbidity. CONCLUSION: Universal screening for BCVI in pediatric patients with CTAN resulted in fewer scans and an increased BCVI detection rate.

Analysis of compartment syndromes in lower extremity pediatric and adolescent trauma - are there predictors of a late onset?

INTRODUCTION: Purpose of the study was to answer the question, if there are common fracture or injury characteristics, which help to identify patient at risk for a secondary compartment syndrome. MATERIALS AND METHODS: Between 2003 and 2022 all children and adolescents who were treated for a traumatic compartment syndrome in a lower extremity were retrospectively evaluated. Patient's demographics were recorded, the underlying trauma mechanism identified. Fractures were classified, treatment and complications were analyzed. We differentiated two groups of patients (early onset vs. late onset) and compared trauma mechanism, fracture location, classification and treatment between those two entities. RESULTS: Our collective consisted of 56 children and adolescents with 67 compartment syndromes, with an average age of 14.1 years (5-17). 41 (73.2 %) of the patients were male and 15 (26.8 %) female. Most people in our sample had previously been involved in traffic accidents (64.3 %), with the most common mechanism of injury being "motorbike accident" (34.3 %) and "pedestrian/cyclist accident against car" (26.9 %). There was an accumulation of fractures of the lower leg, in particular tibial shaft fractures (AO 42 and 43A; 49.3 %). In our survey, dislocated fractures and fractures of the foot always led to an early onset of compartment syndrome. The tibial shaft fracture and the surgical treatment with intramedullary nailing showed a significant frequency in the late onset group. CONCLUSIONS: Special attention should be paid to pediatric and adolescent patients with tibial shaft fracture and surgical treatment with intramedullary nailing in order to detect and treat a possible late onset of a compartment syndrome at an early stage.

A Decade of Firearm Injuries: Children Caught in the Crossfire.

INTRODUCTION: Firearm injuries (FIs) are the leading cause of preventable morbidity and mortality in pediatric patients. In this study, we aim to define evolving trends and avenues for prevention. METHODS: Following institutional review board approval, medical records of patients presenting to our two State-Designated Level 1 Pediatric Trauma Centers for treatment of FIs from 2010 to 2019 were retrospectively reviewed. Data was analyzed with Chi-Squared and Student's t-test; P-value <0.05 was significant. RESULTS: 1037 FI encounters from 1005 unique patients aged 0-21 y were included. 70.4% (n = 730) were determined to be assaults, 26.1% (n = 271) unintentional, and 1.7% (n = 18) self-inflicted injuries. Overall mortality was 4.5% (n = 45). FI victims were most commonly African American (n = 836, 80.6%), male (n = 869, 83.8%), aged 13-17 (n = 753, 72.6%), and from single-parent families (n = 647, 62.4%). The incidence of FIs increased significantly over the last 5 y of the study (2010-2014, 6.8 FIs/month), compared to 2015-2019 (averaging 10.6 FIs/month, P < 0.0001). Concurrently, FI related fatality increased from an average of 2.6 deaths/year (2010-2014) to 6.4 deaths/year (2015-2019, P = 0.064). Results were subanalyzed for pediatric patients aged 0-14 y. For the entire cohort, 12.1% (n = 116) recidivists were identified. Geographic patterns of injury were identified, with 75% of all FIs clustered in a single urban region. CONCLUSIONS: Incidence of pediatric FIs is increasing in recent years, with high mortality rates. Violence and recidivism are geographically concentrated, offering an opportunity for targeted interventions.

Pediatric Traumatic Cervical Distraction Injury: A Case Report.

Spinal cord injury due to trauma is rare in children. We report our experience with the surgical treatment of a cervical spinal cord injury in a one-year-old child with quadriplegia due to traffic trauma. The patient was a girl aged one year and five months. Physical examination findings were quadriplegia and loss of consciousness. Plain computed tomography (CT) of the cervical spine showed a vertical distraction injury of C6/7, and magnetic resonance imaging (MRI) showed spinal cord injuries of C1/2 and C6/7. Based on these findings, a diagnosis of C1/2 and C6/7 spinal cord injury (Frankel A) was made. The patient's state of consciousness did not change during the first week after injury; she was managed systemically with a ventilator. On the 10th day after the injury, her consciousness improved, and she was placed in a pediatric halo vest for weaning. However, as the alignment worsened, we operated. A 5 cm posterior incision was made at the median of C5/6/7. Only the spinous process was deployed, a Nespron tape (Alfresa Pharma Corporation, Osaka, Japan) was wrapped between C5/6 and C6/7, and an autologous iliac bone graft was placed at the C6/7 bilateral facet joint. Six months after surgery, bone fusion was complete. At one year and six months postoperatively, tetraplegia had not improved. Radiographs showed no growth disturbances despite residual alignment abnormalities.

Outcomes of early versus late irrigation and debridement of pediatric open long bone fractures.

BACKGROUND: Open long bone fractures are a major concern for pediatric patients due to the risk of surgical site infection (SSI). Early studies have recommended irrigation and debridement of open fractures within 6 hours-8 hours for the prevention of SSI. According to the American College of Surgeons (ACS) Best Practice Guidelines, in 2015, irrigation and debridement should be done within 24 hours. AIM: To identify whether early irrigation and debridement, within 8 hours, vs late, between 8 hours and 24 hours, for pediatric open long bone fractures impacts rate of SSI. METHODS: Using retrospective data review from the National Trauma Data Bank, Trauma Quality Improvement Project (TQIP) of 2019. TQIP database is own by the ACS and it is the largest database for trauma quality program in the world. Propensity matching analysis was performed for the study. RESULTS: There were 390 pediatric patients with open long bone fractures who were included in the study. After completing propensity score matching, we had 176 patients in each category, irrigation and debridement within 8 hours and irrigation and debridement between 8 hours and 24 hours. We found no significant differences between each group for the rate of deep SSI which was 0.6% for patients who received surgical irrigation and debridement within 8 hours and 1.1% for those who received it after 8 hours [adjusted odd ratio (AOR): 0.5, 95%CI: 0.268-30.909, P > 0.99]. For the secondary outcomes studied, in terms of length of hospital stay, patients who received irrigation and debridement within 8 hours stayed for an average of 3.5 days, and those who received it after 8 hours stayed for an average of 3 days, with no significant difference found, and there were also no significant differences found between the discharge dispositions of the patients. CONCLUSION: Our findings support the recommendation for managing open long bone fractures from the ACS: Complete surgical irrigation and debridement within 24 hours.

Pediatric trauma patients in Swedish ambulance services -a retrospective observational study of assessments, interventions, and clinical outcomes.

BACKGROUND: Pediatric trauma patients constitute a significant portion of the trauma population treated by Swedish Emergency Medical Services (EMS), and trauma remains a notable cause of death among Swedish children. Previous research has identified potential challenges in prehospital assessments and interventions for pediatric patients. In Sweden, there is limited information available regarding pediatric trauma patients in the EMS. The aim of this study was to investigate the prevalence of pediatric trauma patients within the Swedish EMS and describe the prehospital assessments, interventions, and clinical outcomes. METHODS: This retrospective observational study was conducted in a region of Southwestern Sweden. A random sample from ambulance and hospital records from the year 2019 was selected. Inclusion criteria were children aged 0-16 years who were involved in trauma and assessed by EMS clinicians. RESULTS: A total of 440 children were included in the study, representing 8.4% of the overall trauma cases. The median age was 9 years (IQR 3-12), and 60.5% were male. The leading causes of injury were low (34.8%) and high energy falls (21%), followed by traffic accidents. The children were assessed as severely injured in 4.5% of cases. A quarter of the children remained at the scene after assessment. Complete vital signs were assessed in 29.3% of children, and 81.8% of children were assessed according to the ABCDE structure. The most common intervention performed by prehospital professionals was the administration of medication. The mortality rate was 0.2%. CONCLUSIONS: Pediatric trauma cases accounted for 8.4% of the overall trauma population with a variations in injury mechanisms and types. Vital sign assessments were incomplete for a significant proportion of children. The adherence to the ABCDE structure, however, was higher. The children remained at the scene after assessment requires further investigation for patient safety.

Management of Pediatric Solid Organ Injuries.

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Comparison of Scoring Systems for Mortality Prediction in Pediatric Multitrauma Patients.

The aim of this study was to compare scoring systems for mortality prediction and determine the threshold values of these scoring systems in pediatric multitrauma patients. A total of 57 multitrauma patients referred to the pediatric intensive care unit from January 2020 to August 2021 were included. The pediatric trauma score (PTS), injury severity score (ISS), base deficit (B), international normalized ratio (I), Glasgow coma scale (G) (BIG) score, and pediatric risk of mortality 3 (PRISM 3) score were analyzed for all patients. Of the study group, 35% were female and 65% were male with a mean age of 72 months (interquartile range: 140). All groups' mortality ratio was 12.2%. All risk scores based on mortality prediction were statistically significant. Cutoff value for PTS was 3.5 with 96% sensitivity and 62% specificity; for the ISS, it was 20.5 with 92% sensitivity and 43% specificity; threshold of the BIG score was 17.75 with 85.7% sensitivity and 34% specificity; and 12.5 for PRISM 3 score with 87.6% sensitivity and 28% specificity. PTS, ISS, BIG score, and PRISM 3 score were accurate risk predictors for mortality in pediatric multitrauma patients. ISS was superior to PTS, PRISM 3 score, and BIG score for discrimination between survivors and nonsurvivors.

Impact of Trauma Center Type on Outcomes in Pediatric Population Following Severe Isolated Blunt Traumatic Brain Injuries: A National Analysis.

INTRODUCTION: This study aims to evaluate the association between trauma center type, verification level, and clinical outcomes in pediatric trauma patients with moderate and severe isolated blunt traumatic brain injury (TBI). METHODS: This is a retrospective cohort study utilizing the American College of Surgeons (ACS) Trauma Quality Program (TQP) Participant Use File (PUF) database from 2017 to 2021. Severely injured pediatric (<18 years) trauma patients with isolated moderate and severe TBI (AIS head >2, all other body regions <3) were included. Outcomes included in-hospital mortality, discharge disposition, intensive care unit length-of-stay (ICU-LOS), and ventilator-free days (VFDs). RESULTS: Patients treated at a level-I combined adult and pediatric trauma centers (CTCs) had significantly lower odds of in-hospital mortality than those treated at adult trauma centers (ATCs) (OR .495, 95% CI 0.291-.841, P = .009). Patients treated at level-I pediatric trauma centers (PTCs) (OR 2.726, 95% CI 2.059-3.609, P < .001) and level-II PTCs (OR 6.18, 95% CI 3.402-11.239, P < .001) were significantly more likely to be discharged home than equivalent-level ATCs. CONCLUSION: Pediatric patients with isolated blunt moderate and severe TBI treated at level-I PTCs and CTCs had reduced odds of in-hospital mortality compared to level-I ATCs. Patients at level I and II PTCs had significantly higher odds of discharge home than those at equivalent-level CTCs and ATCs.

Pediatric Floating Elbow: Case Report and Review of the Literature.

Floating elbow is defined as concomitant fracture of ipsilateral humerus and forearm. It is an uncommon injury with high potential to develop elevated forearm compartment pressures with potentially devastating neurological sequel. Several treatments have been reported. Although conservative treatment has been considered in the English literature, percutaneous or minimally invasive fixations is a goal when it is possible, soft tissue and growth plate preservation is crucial for fracture healing, mobility and bone growth.