Session VII - Pediatrics

Pulmonary Complications in Pediatric Patients with a Femur Fracture

Daniel J. Hedequist, MD; Phillip Wilson, MD; Adam J. Starr, MD; Joan Walker, RN, University of Texas Southwestern Medical School, Dallas, TX

Purpose: A delay in femur fracture stabilization in multiply injured adult patients has been shown to increase the prevalence of pulmonary complications. Little is known about the effect of delayed stabilization of femur fractures in pediatric trauma patients. The purpose of this study is to assess the effect of timing of femur fracture stabilization on pulmonary complication rates in a pediatric trauma patient population.

Methods: Patients who sustained a diaphyseal femur fracture were identified using trauma registry records. Age, sex, mechanism of injury, the initial Glasgow Coma Score (GCS), and fracture pattern were recorded. Associated injuries were recorded, and Abbreviated Injury Scores/Injury Severity Scores (AIS/ISS) were calculated for each patient. The timing and method of fracture stabilization were noted. Stabilization methods included hip spica casting, rigid intramedullary nailing, Enders nailing, and external fixation. Pulmonary complications recorded were pneumonia, respiratory distress syndrome, and pulmonary embolus. Pneumonia was defined as having all of the following: WBC>13.5K, a positive chest x-ray, positive sputum cultures, and a T>38.3 degrees. Respiratory distress was defined using the Murray Lung Injury Score, and a pulmonary embolism defined using a V-Q Scan or pulmonary arteriogram. Early stabilization was defined as stabilization within 24 hours of injury. A statistical analysis was performed to determine the correlation between patient variables and the occurrence of pulmonary complications.

Results: We identified 332 patients treated at our institution between Jan.1, 1993 and Dec.31, 1997 with traumatic, non-pathologic diaphyseal femur fractures. Patients were between the ages of 0 and fifteen years of age (average=6). One hundred ninety-two patients were stabilized within 24 hours of injury, 134 patients were stabilized on a delayed basis, and 6 patients expired before stabilization. Twelve patients developed respiratory complications, 11 of these patients had pneumonia and one patient had respiratory distress syndrome. No patient sustained a pulmonary embolus. All patients who developed pulmonary complications were multiply injured (average ISS=23) and all but one had a GCS < 8 (average GCS=6). The remaining patient with GCS > 8 had a cervical spine injury with complete quadriplegia. The average head/neck AIS for patients with respiratory complications was 3.8. The patient who developed respiratory distress (ISS=50, GCS=3) expired prior to any stabilization. All other patients with a respiratory complication survived. Four of these patients were stabilized early, and the remaining seven were stabilized on a delayed basis.

Logistic regression identified GCS < 8 (p<0.0001), ISS (p<0.0001), and head/neck AIS (p<0.0001) as significant predictors of pulmonary complications. The timing of fracture stabilization did not affect the presence of pulmonary complications. A respiratory complication became more likely with an ISS > 17 or a GCS < 8. Chest, abdominal, face, skin, and multiple orthopedic injuries were not statistically associated with pneumonia. All children with a severe head injury (GCS<8) and concomitant severe chest or abdominal injury (CAIS/AAIS>3) expired.

Discussion: Pulmonary complications in pediatric femur fracture patients are rare. In this series, only patients with head or spinal cord injuries developed pulmonary complications. The timing of fracture stabilization does not appear to affect the prevalence of pulmonary complications in pediatric trauma patients.