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Hemodynamic significance of pediatric femur fractures
J M Lynch1, M J Gardner, B Gains
1Department of Pediatric Surgery, Children's Hospital of Pittsburgh, PA 15213-2583, USA.
Insights
Pediatric femur fractures rarely cause significant bleeding. Hemodynamic instability or falling hematocrit levels in children with femur fractures indicate other injuries requiring investigation.
Area of Science:
- Pediatric Traumatology
- Orthopedic Surgery
- Emergency Medicine
Background:
- Femur fractures in children can be associated with significant blood loss.
- Determining the extent of bleeding is crucial for appropriate management.
Purpose of the Study:
- To investigate the occurrence of hemodynamically significant bleeding following pediatric femur fractures.
- To differentiate blood loss attributable to femur fractures versus other injuries.
Main Methods:
- Retrospective chart review of pediatric patients with femur fractures over 30 months.
- Data collection included demographics, injury mechanisms, Injury Severity Score (ISS), hemodynamic status, and transfusion requirements.
- Analysis of hematocrit levels at presentation and 24 hours post-injury.
Main Results:
- 178 children with 182 femur fractures were analyzed.
- No child with an isolated closed femur fracture showed hemodynamic instability or required transfusion.
- Hemodynamic insufficiency and transfusion needs were exclusively observed in multiply injured patients, often linked to associated injuries like severe liver trauma or hemothorax.
Conclusions:
- Isolated closed femur fractures in children are not typically associated with hemodynamically significant bleeding.
- Clinicians should investigate alternative sources of blood loss in pediatric patients presenting with hemodynamic instability or declining hematocrit levels alongside a femur fracture.
Purpose:
To determine whether hemodynamically significant bleeding occurs after pediatric femur fractures.
Method:
A retrospective chart review was performed; demographic and injury data were collected for all patients with the diagnosis of femur fracture over a 30-month period at a level/ pediatric trauma center. Included were patients with multisystem injury and patients with femur fractures as the only injury. The incidence of hemodynamic insufficiency, the reasons for and timing of transfusions, and the changes in hematocrit levels over time were evaluated.
Results:
One hundred seventy-eight children were identified (182 femur fractures). There were 116 boys and 62 girls, and the mean age was 6.04 +/- 4.5 years (range, 1 month to 19 years). The mechanisms of injury included falls (46), pedestrian/ motor vehicle accidents (43), motor vehicle crashes (19), sports accidents (22), abuse (10), and miscellaneous (38). The mean Injury Severity Score (ISS) was 5.88 +/- 3.93 (range, 4 to 29). There were no deaths. The length of hospital stay was 8.13 +/- 9.37 days (range, 1 to 43 days). Prehospital treatment included early immobilization. Fracture treatment was according to recognized orthopedic techniques based on age, size, and fracture configuration. The mean hematocrit in the emergency department was 34% +/- 3.5% (range, 27.8% to 44.4%) and 32% +/- 6.6% (range, 16.9% to 47.8%) at 24 hours. 67 patients (38%) suffered multiple injuries. Mean ISS for this group was 9.4 +/- 5.0 (range, 5 to 29). Four patients had hemodynamic insufficiency at the time of admission. All were in the multiple-injury group Seven of these 67 patients (10%) required transfusion-three in the first 24 hours (two in the emergency department [associated with severe facial/scalp bleeding] and one in the operating room [associated with severe liver injury]) and four after the first 24 hours (three associated with intraoperative orthopedic procedures and one with a hemothorax). The mean age of those who underwent transfusion was 8.29 +/- 4.79 years, and their mean ISS was 13.71 +/- 4.61. All patients who required transfusion had been injured in motor vehicle crashes or in pedestrian/motor vehicle accidents. One hundred eleven children had isolated closed femur fractures. No patient in this group had evidence of hemodynamic insufficiency or required transfusion. The initial mean hematocrit was 34.5% +/- 2.7%, and the mean 24-hour hematocrit was 34.6% +/- 3.2%. We found that (1) no child with an isolated closed femur fracture had evidence of hemodynamic instability, or showed significant blood loss as evidenced by a decreasing hematocrit at 24 hours, and (2) in this series, evidence of hemodynamic insufficiency and/or the need for transfusion was found only in multiply injured children.
Conclusion:
Hemodynamic instability or evidence of a declining hematocrit in the child should not be attributed to a closed femur fracture and that other sources of blood loss must be found.