Train Injuries In The Pediatric Age Group
Philip Blazer, M.D. and John P. Dormans, M.D.
Between 1984 and 1994, seventeen children (thirteen boys and four girls), were treated for injuries sustained in train accidents. The average age at the time of injury was eleven years (range six to sixteen years) and there were sixteen survivors of the trauma. Presenting injuires included ten complete amputations and ten near-complete amputations..(??? Grade IIIc injuries) on admission. There were two patients with extremity injuries not at the site of amputation, and three patients had non-orthopaedic injuries. One child with an open skull fracture was the only mortality in the series as well as the only child not to suffer an amputation. All open injuries were treated with operative irrigation and debridement and broad spectrum antibiotics. The average number of surgical procedures for the survivors during the initial hospitalization was 5.7 (range three to sixteen). One child with a high above-knee amputation underwent replantation of the extremity using a rotationplasty Six of the amputated extremities were revised to higher levels after the initial debridement or completion of a near-amputation and prior to definitive wound closure. Nine amputation stumps have required susbsequent operations after the initial hospitalization. The average length of initial hospital stay for the survivors was thirty-three days (range often to sixty-one days) with an average cost** of $61,159 (range $16,640 to $164,823.00).
**when available, and in US Dollars.
The literature on train injuries is limited. Emergency rescue and evacuation following mass injuries has been addressed, as well as the frequent antecedent psychosocial dysfunction in the victims. (2-7) The patterns of injury reported have varied depending upon the institution(s) involved in the survey. Series in urban areas, for example, have shown a high percentage of commuter and self-inflicted injuries.(3) Most of the literature focuses on the adult population. There has been a review of railyard injuries in children, however, this article focused predominantly on a particular explanation of a pattern of injury seen in four children by these authors. (8) We report on our experiences with train injuries in the pediatric population.
MATERIALS AND METHODS
Between 1985 and 1994, seventeen children were treated at two level one trauma centers in a large metropolitan center. One of the hospitals is a pediatric trauma center. The patients were identified through a review of the hospitals trauma registries Children pronounced dead at the scene and those injured when a car was struck by a train were excluded. Variables recorded include the age, sex, mechanism of injury, circumstances surrounding the injuries, injuries sustained, operations performed during the acute hospitalization, subsequent operations, level of amputation(s), complications, cost and length of hospitalization. Complete information was available on 15 patients with financial information unavailable on one patient (#12) and partial clinical data unavailable on one patient (#8).
Thirteen boys and four girls were identified with an average age of eleven years, (range of 6 to 16 years) (Table 1. ) The mechanism of the injury was identified in fifteen children and was related to "horseplay" in ten and three children were injured traveling to or from school. At presentation there were ten complete amputations, (three above-knee amputations (AKAs), two below-knee amputations (BKAs), two upper extremity amputations and three partial foot amputations) and ten near-complete amputations, (five BKAs, one AKA and four partial foot amputations). The near-complete amputations were all nonviable, Gustillo and Anderson grade IIIC open fractures with residual skin or other soft tissues attachments to the amputated part. Four patients suffered amputations of two extremities, three bilateral lower extremity injuries and one bilateral upper extremity.
Two patients sustained extremity injuries which were not amputations. Patient #5 sustained an open Salter-Harris I fracture of the proximal tibia and patient #1 sustained an avulsion of the ASIS Two patients sustained head trauma; patient #10 had an open skull fracture and a subdural hematoma and was the only mortality in the series and patient #3 sustained a concussion. Four patients had skin injuries with three described as lacerations and one boy having an avulsion of the skin overlying his sacrum.
All patients arrived within eight hours of injury and were taken immediately to the operating room. Open fractures and amputations were treated with operative debridement and irrigation, and broad spectrum antibiotics were started.
The average number of operative procedures during the initial hospitalization was 5.4, (range 1 to 13 procedures). The majority of these procedures were for repeat irrigation and debridement. One child was treated with irrigation and debridement and emergent replantation of the extremity with a Van-Ness type rotation plasty for a high AKA.
During the acute hospitalization five of the amputated extremities were revised from the level performed on the day of admission. One of these revisions was for gross wound sepsis. The others were performed on routine "second look" procedures which revealed extension of the area of necrotic muscle and soft tissue. One incomplete forefoot amputation was initially amputated at the Lisfranc level and was revised to a Syme's One BKA was revised to a knee disarticulation. One BKA was revised to a knee disarticulation and subsequently re-revised to an AKA. One hindfoot amputation was revised to a BKA and re-revised to a knee disarticulation. One forefoot which was not amputated on the day of admission was amputated on day 10, # (14). There were seven operations of revision of amputation levels.
Four patients developed gross wound sepsis with documental bacterial cultures, and two of these went on to have systemic bacteremia. Other complications included two late cases of osteomyelitis, three deformities interfering with prosthetic use and one chronic skin ulceration.
The patients final amputation levels included five BKA's, four forefoot amputations, three AKAs, three knee disarticulations, one Syme's amputation, one Chopart amputation, one shoulder disarticulation, one above elbow amputation and one replantation. The average number of hospital days was 31 with a range of 2 to 61 days. The average cost of the acute hospitalization was $61,159.00 with a range of $16,64000 to $164,823.00.
To date, nine children have required ten subsequent operations on second admissions as a result of these injuries. Two patients (#s 1 and 3) were discharged with granulating wounds which were subsequently treated with split thickness skin grafts One patient (#6) has required debridement of a chronic osteomyelitis of the tibia and simultaneous excision of the proximal fibula for difficulty with prosthetic wear. Three children (patients #6,12,17) required revision of amputation stumps for overgrowth and patient #12 has undergone a second stump revision.
The medical literature on train accidents has largely focused on injuries in adult patients. However, train-related injuries involving children appear to represent a substantial percentage of the total number of injuries. The percentage of children has varied in other series from 5(7) to 22%.(4) The demographics of the children in our study agree with those previously reported, with thirteen of seventeen of our children being boys with an average age of 11 years. (1,4,8) Train accidents have been among the more common causes of traumatic amputations in children and have estimated to account for up to 15% of traumatic childhood amputations. [Lamber, 1972 #3} The circumstances surrounding railway trauma in the pediatric population is distinct from the adult population. Adults with train injuries were likely to be intoxicated trespassers or railway employees. Nixon reported on 84 fatalities among 211 cases of all types of train related trauma. Twenty per cent of the fatalities were among railway workers and intoxicated pedestrains accounted for an additional 17%.(4) 13% of adult fatalities were felt to be suicides. The patterns of injury reported in this series included head injury in 14% of patients and 13% with long bone fractures. Only 1.2% suffered amputations. Although children comprised 8% of the injured group, they accounted for 100% of the mortality from pedestrian accidents. The circumstances of injury of children in this rural Australian setting varied from our series as none of the children in this series were purposefully playing in a railyard.
Moore described the experience with train pedestrian accidents from the Carolinas Medical Center in 1991. They reported on 15 patients with an age range of 17 to 58 years, with 12 of 15 victims having had documented alcohol levels greater than l00mg/dl. (3) There were 10 traumatic amputations in 8 of the 15 victims. Eight of the ten amputations were ultimately revised to a higher level of amputation than at presentation. Nine of the fifteen patients suffered multisystem trauma.
Thompson in 1983 discussed a mechanism of injury seen in four children in railyard amputations.The injuries were sustained when children were attempting to board a moving train and slipped while climbing up the rear ladder of the train. Two of these four children sustained bimembral amputations. They emphasized the relationship between emotional and psychosocial problems found in juvenile amputees and recommended taking these difficulties into account when considering definitive management of amputated extremities.
Our experience reveal that the children who survive train injuries are likely to have mostly lower extremity injuries. The majority of these injuries are amputations, (20 of 22 orthopaedic injuries in our series). The nine survivors in our series had one concussion and no other head, spinal, thoracic or abdominal injuries. We also confirmed Thompson's observation of the substantial risk of bimembral injuries with four of seventeen children suffering bimembral amputation. Our data concur with other published data on the care of these traumatic amputations with multiple debridements and frequent revision to higher levels of amputation. (3). Seven operations for revision to a higher amputation level were performed in our seventeen patients. The likelihood of later requiring further surgical procedures was also noted to be substantial with nine of sixteen survivors in the series requiring surgical procedures at a later date.
The Financial cost of these injuries is substantial, with acute hospitalization costs averaging $61,000. This underestimates the true financial cost as rehabilitation, later procedures and outpatient care were not included in these figures. There was a direct correlation between cost and duration of hospitalization.
Review of the available literature reveals that there is a variation in experience of morbidity seen from train injuries dependent upon the population studies. Other reports have focused on the role of railway workers, alcohol and suicide in these injuries. Our experience with pediatric injuries in a major metropolitan center emphasizes the devastating orthopaedic and, in particular, extremity soft tissue complications sustained by children in these injuries. The pediatric survivors of train versus pedestrian accidents are likely to suffer mainly orthopaedic trauma, the majority of which are lower extremity amputations. The high percentage of these injuries sustained while the children were at play around the railroad emphasizes the need for improved methods of prevention of these injuries by limiting access to railroad areas.
Resident, University of Pennsylvania, Department of Orthopaedic Surgery
Assistant Professor, University of Pennsylvania, Department of Orthopaedic Surgery
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