Les urgences orthopédiques pédiatriques regroupent principalement les lésions traumatiques et les infections ostéo-articulaires. La prise en charge de ces enfants nécessite une intervention chirurgicale, le plus souvent sous anesthésie générale. La majorité de ces urgences sont différables de quelques heures à quelques jours, ce qui permet d’optimiser le circuit de prise en charge (ambulatoire, en journée, équipe dédiée), tout en diminuant les risques anesthésiques et l’anxiété du patient et de ses parents. L’anesthésie pédiatrique reste une discipline anxiogène pour les anesthésistes. Sur le plan physiologique, on peut distinguer les enfants prépubères et les enfants post-pubères pour lesquels les prises en charge anesthésique et orthopédique rejoignent celles de l’adulte, quel que soit l’âge. Ainsi, dans cette mise au point, nous allons détailler les règles générales de la pratique de l’anesthésie pédiatrique pour la prise en charge anesthésique d’urgence orthopédique pédiatrique avant de préciser les différentes modalités spécifiques à chaque cas. Paediatric orthopaedic emergencies mainly include traumatic injuries and osteoarticular infections. The management of these children requires a surgical intervention with a general anaesthesia most often. The majority of these emergencies can be delayed from a few hours to a few days, which makes it possible to optimise the management (ambulatory, daytime, dedicated team) and to reduce the anaesthetic risks and the anxiety of the patient and his parents. Paediatric anaesthesia remains an anxiety-provoking discipline for anaesthesiologists. From a physiological point of view, a distinction can be made between pre-pubertal and post-pubertal children for whom the anaesthetic and orthopaedic management is the same as for adults, whatever their age. Thus, in this review, we will detail the general rules of paediatric anaesthesia practice for paediatric orthopaedic emergency anaesthesia management before specifying the different modalities specific to each case. 

Mise au point sur la prise en charge des urgences orthopédiques pédiatriques

The most common clinical presentation of hemophilia A and hemophilia B is bleeding in large joints and striated muscles. It is unclear why bleeding has a predilection to affect joints and muscles. As muscles and joints are involved in intermittent movement, we explored whether this phenomenon could be associated with an impact on factor VIII and IX levels. Purified proteins and a mouse model were assessed using coagulation assays, Western blot analysis and immuno-staining. Movement caused an increase in thrombin activity and a decrease in factor VIII and factor IX activity. The decrease in factor VIII activity was more significant in the presence of thrombin and during movement. Under movement condition, sodium ions appeared to enhance the activity of thrombin that resulted in decreased factor VIII activity. Unlike factor VIII, the reduction in factor IX levels in the movement condition was thrombin-independent. High factor VIII levels were found to protect factor IX from degradation and vice versa. In mice that were in movement, factor VIII and IX levels decreased in the microcirculation of the muscle tissue compared with other tissues and to the muscle tissue at rest. Movement had no effect on von Willebrand factor levels. Movement induces reduction in factor VIII and IX levels. It enables an increase in the binding of sodium ions to thrombin leading to enhanced thrombin activity and augmented degradation of factor VIII. These data suggest a potential mechanism underlying the tendency of hemophilia patients to bleed in muscles and joints.

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Rafael G. Ramos-Jimenez

Papers

Hemostatic Resuscitation in Children.