Severe Infraclavicular Displacement of a Proximal Humerus Fracture with Concomitant Olecranon Fracture in a Pediatric Patient.

Proximal humerus fractures with severe medial displacement of the humeral head are rare in adults and especially so in children. Concomitant vascular/neurovascular injury is even more uncommon but must be considered as the associated complications can carry significant morbidity. We present a case of a 12-year-old transported to the ED after a mountain bike accident in which she lost control and hit a cement wall, injuring her left upper extremity (LUE). Despite a normal vascular/sensory exam, imaging demonstrated a left comminuted proximal humerus fracture with the humerus displaced medially into the thoracic inlet as well as concern for left subclavian vessel injury. Given the possibility of vascular injury and the severe humeral head displacement, she was taken to surgery with orthopedic and vascular surgical teams. Although surgical exploration did not reveal vascular injury, this case underlines the importance of maintaining a high index of suspicion for neurovascular injury with such fractures as prompt intervention may reduce the likelihood of complications. This case also underscores the need for further research into the management of pediatric proximal humerus fractures in early adolescence.

Universally poor outcomes of pediatric traumatic arrest: a prospective case series and review of the literature.

OBJECTIVE: Few data are available on traumatic cardiopulmonary arrest in children. Efforts at resuscitation typically result in heavy utilization of finite resources with little understanding of which characteristics, if any, may be associated with success. The objectives of this study were to describe the outcome of children in traumatic cardiac arrest and to identify patients for whom aggressive resuscitation may or may not be warranted. METHODS: Data were analyzed from a previous study of prehospital pediatric airway management in Los Angeles and Orange Counties, Calif, over a 33-month period. Patients included in this secondary analysis were younger than 13 years and found pulseless and apneic after having had an injury. Data sources included prospective, phone interviews with paramedics after transfer of care to the receiving facility, and chart review to determine outcome. Two main outcomes were assessed: survival and neurological function as measured by the Pediatric Cerebral Performance Category. RESULTS: The emergency medical services responded to 118 traumatic arrests during the study period. Of these victims, only 6 (5%) survived. Median Injury Severity Score was 25 with an interquartile range of 16 to 75. The survivors all were neurologically impaired with a median Pediatric Cerebral Performance Category of 5 (interquartile range, 4-5). CONCLUSIONS: Children who had trauma resulting in cardiac arrest have universally poor outcomes, and survivors have severe neurological compromise. We are unable to identify a subset of patients for whom aggressive resuscitation is indicated. This is the largest prospective study of pediatric traumatic arrest to date.