Review Question - QID 8832

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Femoral Shaft Fractures - Pediatric Prognosis Timing of surgical intervention QID: 8832 (OBQ16.70)

QID 8832 (Type "8832" in App Search)

A 10-year-old boy is struck by a motor vehicle while riding his bicycle. He is brought by ambulance, and his injuries include a subdural hematoma, 2 rib fractures, and the injury shown in figure A. His weight is 90 lbs. He is found to have slightly elevated intracranial pressures. Which of the following statements is true regarding treatment of his orthopaedic injury?

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There is higher risk of pulmonary and central nervous system complications with early definitive treatment

38%

1079/2807

There is higher risk of pulmonary and central nervous system complications with late definitive treatment

13%

357/2807

There is no difference in pulmonary and central nervous system complications with early or late treatment

27%

753/2807

There is higher risk of pulmonary but not central nervous system complications with early definitive treatment

233/2807

There is higher risk of pulmonary but not central nervous system complications with late definitive treatment

13%

359/2807

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The patient is a polytrauma patient with closed head injury and elevated intracranial pressure and a right femur fracture. In the pediatric population, there is no difference in pulmonary or central nervous system (CNS) complications with early versus late femur fracture fixation.

The management of orthopaedic injuries in a poly-trauma patient is dependent on several patient and injury-related fractures. While there is robust data of early total care versus damage control orthopaedics in the adult population, such research is less common in pediatrics. Depending on the age and weight of the child, definitive treatment can vary from hip spica casting to reamed intramedullary nailing. The effects of individual treatments on pediatric pulmonary and CNS outcomes is unknown. Data driven decisions for timing of definitive treatment, such as lactate, base deficit, urine output, etc (as seen in adult population), is not as well studied.

Brundage et al. reported on the timing of femur fracture fixation on polytrauma patients. Their data suggests that fixation within 24 hours, even in the setting of concomitant chest or head trauma, improves outcomes. Fixation from day 2 through 5 leads to increased risk of pulmonary and systemic complications.

Mendelson et al. retrospectively reviewed early and late management of pediatric femur fractures in polytrauma patients with concomitant head injury. They found no appreciable difference in CNS and orthopaedic-related outcomes in early versus late fixation except that the late fixation group had a longer length of hospital stay.

Hedequist et al. retrospectively reviewed pulmonary complications in pediatric patients with femur fractures. They found an overall low rate of pulmonary issues and no statistical difference in complications in patients treated early (<24 hours) and late (>24 hours).

Figure A is an AP radiograph showing a transverse midshaft femur fracture.

Incorrect Answers:
Answer 1,2,4,5: Studies in pediatric trauma patients show no difference in pulmonary and CNS complications with early versus late definitive treatment of femur fractures. The overall burden of pulmonary complications appears to be lower as compared to adults.