Complications in Pediatric Orthopedics

Complications in Pediatric OrthopedicsAvoiding complications is a major operative objective. Orthopedists have been divided into risk avoiders and risk acceptors. Be a risk avoider when managing children. Complications are fewer in the pediatric age group because the child is more physiologically resilient. For example, thrombophlebitis and cardiopulmonary problems are uncommon in children. Complications sometimes cannot be prevented, whereas others are secondary to poor technique. Still others are due to technical problems, such as inadequate correction, loss of position or fixation, or pressure sores from a tight cast.

It is usually possible to avoid complications if the risks are identified prior to the treatment and preventive measures are taken in advance. For example, when planning a proximal tibial osteotomy, be aware that the procedure is associated with peroneal nerve palsies and compartment syndromes. These complications can often be prevented by:

  • altering the level of osteotomy, performing rotational osteotomies in the distal rather than proximal level
  • performing a prophylactic fasciotomy
  • splitting the cast
  • careful postoperative monitoring.

As another example, when pinning a slipped capital femoral epiphysis, be aware of the risks of joint penetration and postfixation fracture. Fixing with a single central pin reduces the risk of joint penetration. Making the entry point proximal reduces the risk of post-op fractures. Entry points at or below the lessor trochanter are associated with a risk of fracture through the site of pin penetration of the lateral cortex.

Other high-risk procedures include procedures using external fixation, or major procedures such as spine operations, extension osteotomies of the distal femur, unstable slipped capital epiphysis cases, procedures on myelodysplasic, or poorly nourished children, among others.

Wound Infections

Wound infections are less common in children than adults. The risk of infection is greatest in operations of long duration; infections are most serious if the procedures involve bones and joints.

Prophylactic antibiotics can often prevent infection and should be administered intravenously at the beginning of the operative procedure. The single dose is adequate unless the procedure is prolonged.

Clinical signs of wound infections develop as early as 24 hours in streptococcal infections. The more common staphylococcal infections appear after 3-4 days. The child with a wound infection often shows systemic signs of fever and malaise, and the wound becomes more swollen, warm, and erythematous. The fever from infection must be differentiated from the common benign postoperative fever that commonly occurs after most procedures. Such fever resolves in a day or two. Be concerned if a secondary temperature elevation occurs. It should be considered a sign of an infection until proven otherwise.

If the child shows systemic signs of infection, search for the cause. Examine the ears and throat. Listen to the lungs. Window the cast and examine the wound. Perform a urinalysis. Culture the urine, blood, and wound. If the child is ill, start antibiotic therapy while the cultures are incubating. If the wound is infected, it should be opened, cultured, and drained under sterile conditions in the operating room. Close the wound after the infection is controlled.

Skin Problems

Skin problems may be due to irritation under the cast and are common in infants immobilized for hip dyplasia. Prevent skin problems by keeping casts as dry as possible. The inflammation resolves once the cast is removed.

Tourniquet Irritation

Tourniquet “burns” can usually be prevented by avoiding prep solution from seeping under the tourniquet. Treat as a burn.

Pressure Sores

Pressure sores are most common in children with neuromuscular problems. Anesthetic skin and the child’s difficulty in communicating are major contributing factors. Take added precautions in patients with myelodysplasia and cerebral palsy. Pressure sores occur in characteristic locations: the heels [A], trochanters, sacrum, and other bony prominences. They can usually be prevented by careful casting techniques. Apply thick padding, avoid a snug cast, and window the cast over the heels if necessary. During the postoperative period, rotate the patient frequently, and inspect areas at risk, such as the sacrum, often. In communicative patients with intact sensation, ask about localized pain, such as over the lateral malleolus. Cast pressure pain is often described as a burning pain. Detecting pressure sores is sometimes difficult. Be concerned if a foul odor is present. The stench of devitalized tissue is different from the usual fecal-urine odor. Sniffing the cast or wound is a simple and effective test. Operative related pressure sores will heal if the wound is kept clean and protected from pressure or abrasion. Identify pressure sores early so they can be healed by the time the cast is removed.

Stiffness

Joint stiffness as an operative complication is uncommon in children. Simple postoperative stiffness is temporary and resolves as the child resumes activity. This makes physical therapy unnecessary. Persistent stiffness usually results from joint damage due to compression, ischemia, or infection. Manage joint stiffness by active range-of-motion exercises and observation. If improvement plateaus and the stiffness produces disability, consider performing an arthrolysis and employing continuous passive motion or special splints to maintain the correction gained. Generally expect to retain about half of the range of motion obtained intraoperatively.

Pin Migration

Smooth pins may migrate long distances in the body. They have been found in the mediastinum and in the heart. Migration is best prevented by bending the end of the pin. Bend the protruding end of the pin to a right angle and cut the pin off about 1 cm from the bend.

Pin Tract Infections

Pin tract infections are usually due to motion around the pin, or tension on the adjacent soft tissue, producing necrosis. Both of these problems are usually preventable. After placing the pin, if the skin is tented, incise the skin to relieve the tension. Stabilize the pin-skin junction. Immobilize the limb in a cast. Pin tract infections may be cultured and treated with antibiotics. Open drainage is seldom necessary.

Cast Syndrome

The cast syndrome refers to a spectrum of disorders caused by compression of the second portion of the duodenum. This is sometimes referred to as the “nutcracker effect.” The clinical manifestations vary from partial duodenal obstruction to bowel infarction. Predisposing factors include hyperextension of the trunk, supine positioning, and poor nutritional status. Each tends to increase the nutcracker-like squeeze of the artery and aorta on the duodenum. This syndrome may develop in a hyperextended body cast or prolonged supine positioning. Treat by removing the cast, prone positioning, and increasing caloric intake.

Motor Regression

Most children experience some temporary motor regression following immobilization after operative procedures. In children with neuromuscular disorders, the regression is much more profound. In severely disabled adolescents, recovery may be incomplete, and full return to the preoperative motor level never achieved. For example, the adolescent with cerebral palsy who is a marginal walker preoperatively may not return to walking after a long recovery from a triple arthrodesis, hip, or spine procedure. Regression can be minimized by upright positioning, an active exercise program, and shortening the period of immobility.

Compartment Syndromes

Compartment syndromes, or ischemia from tight casts, should be promptly diagnosed. The symptoms may be minimal and are relative silent in children. Following any major procedure distal to the elbow or knee, the cast should be prophylactically bivalved and spread. Perform a prophylactic anterior and lateral compartment release whenever a proximal tibial osteotomy is performed.

Pathological Fractures

Postoperative pathologic fractures are most common in children with reduced sensitivity and flaccid paralysis. The risks are greatest in the child with myelodysplasia. Fractures occur most commonly at the distal femoral level following cast removal. These fractures are difficult to prevent. Minimize the period of immobilization, load the limb by standing the child in the cast, and use special caution in applying physical therapy after cast removal.

Deep Vein Thrombosis

Deep vein thrombosis is most common in spinal surgery, spinal trauma with paralysis, and in children with predispositions such as those with protein C deficiency, vascular malformations, and so on. They usually occur in adolescents. External compression devices on limbs during surgery reduce the risk.

Toxic Shock Syndrome

Toxic shock syndrome is a rare but catastrophic complication that occurs usually 2–3 weeks following surgery. TSS is a reaction to toxins from staphylococcal and streptococcal infections. About half occur in menstruating girls. Sudden onset of fever, vomiting, diarrhea, rash, and hypotension are common. Multisystem organ failure may occur. Fatality rates in orthopedic patients are about 25%.

Hypertension

Hypertension is common following certain orthopedic procedures that cause stretching or lengthening of extremities. In these procedures, monitor the child’s blood pressure.

Avascular Necrosis

Avascular necrosis is a serious complication that may follow treatment of developmental dysplasia of the hip, acute slips, traumatic dislocated hips, displaced transcervical femoral fractures, lateral condylar fractures, radial neck fractures, and other problems. With this known risk, warn the parents and document in the chart an awareness of the risk and measures to avoid AVN before undertaking management. In many cases, no effective prevention is available. ln others, such as for lateral condylar fractures, careful operative technique avoiding excessive soft tissue dissection may prevent the complication.

Arterial Injury

Injuries to veins and small arteries can usually be controlled by pressure and time. In contrast, major arterial injuries may be limb-threatening. Unless you are skilled in vascular repair, ask a colleague with this expertise for assistance. If excessive pulsatile bleeding occurs, control by local pressure, pack the wound, and wait several minutes. While waiting, improve exposure, optimize the lighting, and have suction ready. If bleeding continues, the injured vessel can usually be found and ligated. For more severe injuries, proximal control and arterial repair may be necessary. Arteriography may delay the repair. Less common are aneurysms following operative procedures. Aneurysms may become evident weeks or months postoperatively.

Bad Scars

Ugly scars are far too common following procedures in children. Poorly placed, excessively long and sloppily closed operative scars last a lifetime. Bad scars embarrass children, limit their selection of clothing, and restrict activities. Most are preventable.

Lack of Compliance

Children often exceed limits placed on postoperative activities. Families may not return for scheduled clinic visits. Often the child or family is blamed for the complication; however, it may be due to poor medical care. Take precautions based on the assumption that the child will do whatever is possible. Be creative. Use fixation unlikely to cause problems with removal. Make casts excessively strong or activity-inhibiting by design. If families miss appointments, employ a tickler system to automatically generate recall action.

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