In Reply

Letters to the Editor Polytrauma in Children—Epidemiology, Acute Diagnostic Evaluation, and Treatment by Dr. med. Monica Christine Ciorba and Prof. Dr. med. Marc Maegele in issue 9/2024

We thank our correspondents for their comments. Our review article (1) aimed to explain the diagnostic and therapeutic options for severe and complex traumatic multiple injuries in children, including the often associated coagulopathies. The publication complements the S2k guideline “Polytrauma management in childhood,” which was published in 2020 as a supplement to the S3 guideline on polytrauma and considers age-specific particularities (2).

In the context of the acute diagnosis and therapy of life threatening injuries, the described methods and algorithms apply independently of their genesis and obviously include abuse related injuries. The latter stand out less as complex multiple injuries but rather as isolated or combined injuries in the shape of fractures (contracted at different times), blunt abdominal trauma or traumatic brain injury, or thermal injuries (3). Fractures mostly affect the limbs, sternum, clavicles, shoulder blade/scapula, ribs, or pelvis. Occasionally fractures also occur in unusual locations—for example, on the metaphysis or as bucket handle tears close to the growth plate. Traumatic brain injuries are often due to shaken baby syndrome, with neurological symptoms.

All of these injuries are meant to be identified by the emergency ABCDE scheme—including an ophthalmologic exam—as described in the article (1) and are meant to accelerate further diagnostic evaluation, including multimodal imaging. If the slightest hint or suspicion of abuse arises from the medical history (potentially obtained from a third party), details of the accident, clinical examination, and diagnostic evaluation, this has to be urgently investigated, as our colleagues correctly demand. In this setting, the recommendations of the mentioned child protection guidelines for initiating further measures and cooperation with professionals working in child protection and youth welfare services and all learning environments (4).

We self-evidently agree that colleagues who treat injured children on a regular basis should always consider possible abuse and, where suspected, they should initiate appropriate medical clarification and meticulous documentation.

DOI: 10.3238/arztebl.m2024.0146

Prof. Dr. med. Marc Maegele, Dr. med. Monica Christine Ciorba
Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie
Kliniken der Stadt Köln-Merheim
Institut für Forschung in der Operativen Medizin (IFOM)
Universität Witten/Herdecke
Köln

Conflict of interest statement

MM declares that he received lecture fees and fees for participation in expert and advisory committees as well as financial support for congress participation from Abbott, AstraZeneca, Bayer, Biotest, CSL Behring, IL-Werfen/TEM-International, LFB Biomedicaments France, and Portola.

MC declares that no conflict of interest exists.

References

1. Ciorba MC, Maegele M: Polytrauma in children—epidemiology, acute diagnostic evaluation, and treatment. Dtsch Arztebl Int 2024; 121: 291–7.

2. Deutsche Gesellschaft für Kinderchirurgie: S2k-Leitlinie Polytrauma bei Kindern und Jugendlichen. AWMF-Registernummer 006/120. www.register.awmf.org/de/leitlinien/detail/006–120 (last accessed on 29 June 2023).

3. Tröbs RB, Gonzales-Vasquez R, Barenberg K: Kindesmisshandlung – nicht-unfallbedingte Verletzungen bei Kindern. Op-Journal 2010; 26: 78–83

4. AWMF: S3-Leitlinie Kindesmisshandlung, -missbrauch, -vernachlässigung unter Einbindung der Jugendhilfe und Pädagogik (Kinderschutzleitlinie). https://register.awmf.org/de/leitlinien/detail/027–069 (last accessed on 12 July 2024).