Trauma in children is a serious problem that has a major medical, social, and financial impact on the society. More than 10,000 children die in the United States each year from serious injury ( 50% of all deaths in children). Nearly one in every six children ( 10 million children) visit the emergency department each year in the United States because of trauma. Boys are injured twice as often as girls.1–3 When children suffer a severe trauma, they usually sustain abdominal, head, and chest injuries, which can be potential life-threatening injuries. In the same time, most children with multiple injuries will sustain extremity injuries and fractures. Orthopedic injuries are rarely life threatening; however, they are commonly encountered in children with multiple injuries and can be a cause for long-term morbidity.4 The treatment of children with multiple injuries should follow the principles of the Advanced Life Trauma Support, and orthopedic care must never precede the treatment of more serious life-threatening injuries.3 It should be noted that children with multiple injuries have better survival than adults.5,6 The orthopedic injuries, despite that they are rarely fatal, can still be a reason for long-term morbidity and disability.4,5,7 Optimal orthopedic management should be provided to children with multiple injuries keeping in mind that their recovery is possible even in the most severely affected cases. Presence of skeletal injuries worsens the prognosis of the children with multiple injuries. The pediatric trauma score has a close relation to survival. It consists of six parameters. One of these elements is presence of skeletal injuries.8 According to this score, the presence of multiple fractures or open fracture carries a worse prognosis than presence of a single closed fracture. This article will focus on the musculoskeletal management of the multiple injuries in pediatric population. It will give an overview to both orthopedic and nonorthopedic trauma surgeons regarding the important facts related to the orthopedic aspects of the management of children with multiple injuries. Initial management of extremity injuries should include the following:3

To describe the patient population, etiology, and complications associated with thigh compartment syndrome (TCS). TCS is a rare (0.3% of trauma patients) condition of elevated pressure within a constrained space that may cause necrosis of all tissues within the compartment resulting in severe local (infection, amputation) and systemic complications (renal insufficiency, even death). Retrospective cohort This study examines the course of treatment of nine consecutive patients with thigh compartment syndrome sustained during an eight-year period at our Level 1 trauma centre, admitting more than 2,000 trauma patients yearly. Patients developing TCS were young (average 34.8 years) and likely to have a vascular injury on presentation (55.5%). A tense and edematous thigh was the most consistent clinical exam finding prompting the compartment release (77.8%). Average time from admission to the operating room was 19.8 +/- 6 hours and 3/9 (33%) were noted to have ischemic muscle changes upon compartment releases. Complications ranging from infection to amputation developed in 4/9 (44.4%) patients. TCS is associated with high energy trauma and it is difficult to diagnose in non-cooperative -- obtunded and polytrauma patients. Vascular injuries are a common underlying cause and require prompt recognition and team work including surgical intensive care, interventional radiology, vascular and orthopaedic surgery in order to avoid severe medical and legal consequences.

Up to 5% of knee fractures do not heal primarily at the expected time (delayed union) or fail to achieve healing (nonunion). The causes and treatment of disturbed bone healing in the distal femur, proximal tibia, and patella and in an increasing number of periprosthetic fractures have been discussed. Infection exclusion and/or eradication, reestablishment of axis, alignment and rotation, rigid fixation with fixed-angle devices and interfragmentary screws, bone grafting, arthrolysis, and early range of motion exercises are all necessary steps for good recovery. Illustrative cases have been presented with authors' preferences in the surgical treatment supported by recent publications.

Femoral neck fractures require urgent evacuation of intracapsular hematoma, anatomic reduction, and secure fixation with screws and cast immobilization. Extracapsular trochanteric and subtrochanteric fractures are best treated by fixed angle devices (locked plates or dynamic screw and side plate). "Length stable" low energy shaft fractures with minimal displacement or < 2 cm of shortening on presentation, are treated with one-leg spica casting (if the patient weighs < or = 50 lb. "transportable"). Unstable, complex (multifragmentary) and significantly displaced high energy shaft fractures are treated operatively. Transverse or short oblique shaft fractures in patients < 12 years may be treated with elastic intramedullary nails. Bridge plating will provide better stability in complex fractures. Children > 12 years have less risk of vascular disturbance to the proximal physis, and should have lateral transtrochanateric entry locked rigid nails. Fractures with severe soft tissue injuries could be temporized with external fixation. Distal physis and epiphyseal injuries require anatomical reduction and smooth wires and/or screw fixation (placed in such a way as to minimize further damage to the physis) and need to be augmented with a brace. Leg-length discrepancy is not a significant clinical problem in operatively treated patients. We recommend hardware removal after complete fracture healing, usually in 6 to 12 months. Implants left in the growing child could become buried deep inside of the bone, or cause "periprosthetic" fractures and/or eventually impede adult reconstruction. Minimal risks are reported for hardware removal in healthy patients with healed fractures (4 cortices bridged).

The use of computer navigation in orthopedic surgery allows for real time intraoperative feedback resulting in higher precision of bone cuts, better alignment of implants and extremities, easier fracture reductions, less radiation and better documentation than what is possible in classical orthopaedic procedures. There is no need for direct and repeated visualization of many anatomical landmarks (classical method) in order to have good intraoperative orientation. Navigation technology depicts anatomy and position of "smart tools" on the screen allowing for high surgical precision (smaller number of outliers from desired goal) and with less soft tissue dissection (minimally invasive surgery - MIS). As a result, there are more happy patients with less pain, faster recovery, better functional outcome and well positioned, long lasting implants. In general, navigation cases are longer on the average 10 to 20 minutes, special training is required and equipment is relatively expensive. CAOS applications in knee and hip joint replacement are discussed.

The large spectrum of open fractures is an amalgamation of injuries with the single variable in common of communication of the fractured bone with the outside environment, and thus an increased risk for infection. Contributing to the presence of bacteria within the fracture site is devascularized soft tissue, the degree of which can be directly attributed to the amount of energy imparted to the tissues. The currently used classification system aids in defining the degree of severity of these injuries and their subsequent risk for infection. The basic management principal for all of these injury patterns remains essentially the same, however: prevention of infection through debridement, wound management, antibiotic usage, and fracture stabilization. Frequently multiple surgical procedures will be required in order to obtain an infection free, united fracture with adequate soft tissue coverage (1).

The large spectrum of open fractures is an amalgamation of injuries with the single variable in common of communication of the fractured bone with the outside environment, and thus an increased risk for infection. Contributing to the presence of bacteria within the fracture site is devascularized soft tissue, the degree of which can be directly attributed to the amount of energy imparted to the tissues. The currently used classification system aids in defining the degree of severity of these injuries and their subsequent risk for infection. The basic management principal for all of these injury patterns remains essentially the same, however: prevention of infection through debridement, wound management, antibiotic usage, and fracture stabilization. Frequently multiple surgical procedures will be required in order to obtain an infection free, united fracture with adequate soft tissue coverage (1).

Brachial plexus injuries are devastating injuries that affect primarily young healthy males. For the total plexus injury, current surgical treatments have failed to achieve normal restoration of limb function but some practical goals are obtainable. This review article summarizes existing logic and approach for managing these catastrophic injuries.

This article reviews the history and current management concepts of flexor tendon lacerations. Classic and contemporary repair techniques are discussed. The most popular rehabilitation protocols are also reviewed.

Conventional treatments of pediatric femoral shaft fractures may result in an unacceptable rate of complications, especially in complex fractures. These fractures include high-energy injuries resulting in unstable fracture patterns, fractures in the proximal or distal third, and fractures occurring in large or multiply injured children. Our goal was to evaluate whether a minimally invasive submuscular bridge plating technique provides stability for early functional treatment (without protective casting or bracing) and predictable healing. Fifty-one patients with an average age of 10 years were studied. Sixty-seven percent had high-energy injuries and 55% had unstable fracture patterns. With an average followup of 14.2 months, all fractures united with excellent clinical results. Two (4%) significant complications occurred: fracture of one 3.5-mm LC-DCP Ti plate, and refracture of a pathologic fracture after early plate removal. Four patients (8%) had a leg-length discrepancy ranging from 23-mm short to 10-mm long. The average operative time was 106 minutes, with average fluoroscopy time of 84 seconds. Procedures were done by 15 surgeons in five university medical centers. This technique offers the advantage of adequate stability for early functional treatment and predictable healing with maintenance of length and alignment for all pediatric femoral shaft fractures.