COMPARATIVE EVALUATION OF SURGICAL TREATMENT OF FRACTURES OF LONG BONES IN CHILDREN WITH POLYTRAUMA
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
At the present time one can observe some significant increasing amounts of patients and higher rates of severe degrees of injuries in children. As for pediatric mortality, the mortality as result of injuries is 28.7 %, with road traffic accidents as the main causes [1]. At the moment of admission most patients are characterized with severe or extremely severe states with some events of traumatic shock. Therefore, success in management of polytrauma is considerably related to the advantages in critical care medicine and intensive care [2]. The wide variety of types of multiple and concomitant injuries suppose some difficulties for identification of the main dominating injury. Rapid confirmation of precise diagnosis and rational therapy is critical for life or death of the patient. Currently, management of fractures in children with polytrauma demonstrates a trend to surgical treatment [3]. Wide clinical implementation of low traumatic surgical techniques gives some possibilities for early osteosynthesis of fractures in children with polytrauma [3], especially, intramedullary osteosynthesis with tense nails [4, 5, 6]. However, in each individual case the physician solves a multidimensional task: estimation of severity of state of a suffered child, choice of optimal diagnostic methods, estimation of risk of probable surgical interventions, selection of the most effective methods of treatment [3].
Therefore, severe state of patients with polytrauma, difficulties in estimation of a dominating injury in acute period of the injury, difficulties while selecting an optimal method of treatment and high rate of lethal outcomes condition the relevance of the problem.
Objective – to improve the results of treatment of fractures of long bones in children with polytrauma.
MATERIALS AND METHODS
The group of clinical observation included 101 children with diagnosed polytrauma who were treated in Regional Clinical Center of Miners’ Health Protection during 2000-2012. The inclusion criteria were presence of the informed consent from the parents after review and approval during the meeting of the ethical committee of Clinical Center of Miners’ Health Protection.
The boys presented the significant proportion – 65 children (64.4 %). The main age group was 7-14 years – 64 (63.7 %) children, 42 boys, the mean age of 11.2 ± 0.23, 22 girls, the mean age of 9.8 ± 0.45. The table includes the characteristics of the children.
| The mechanisms and patterns of injuries in the children with polytruma | ||||||||
57 (56.4 %) children had the skeletal injuries in combination with traumatic brain injury. Traumatic brain injury was in 23 (22.8 %) children without skeletal injuries. The fractures of the pelvic bones were in 17 children. Pelvic osteosynthesis with external fixation device was necessary in 3 cases. The spinal injuries were in 8 children, with surgical treatment in 2 cases. 43 patients received diagnostic laparoscopy after admission. In 15 cases laparoscopy was completed with laparotomy owing to identification of some abdominal injuries. There were no abdominal injuries in 28 children after diagnostic laparoscopy. 13 patients had thoracic injuries, with pleural drain in 10 cases, and thoracotomy and lung suturing in 1 patient with severe thoracic injury. The patients with dominating traumatic brain injuries received 19 procedures of cranial trepanation. Surgical preparation of the wounds of various locations was made in 43 cases, with 36 cases of primary preparation. Secondary surgical preparation was made for 7 children who were transferred from other medical facilities. A tracheostome was made for 8 children.
The greatest proportion of the procedures of long bone fixation was realized in late period after 24 hours. It is associated with late transfer from other hospitals. Based on the damage control principles, long bone osteosynthesis for the patients with polytrauma was postponed in 11 cases, and it was made after surgical treatment of the dominating injury (traumatic brain, abdominal and thoracic injuries) and patient’s state stabilizing. Surgical techniques were the main methods for fractures of the long bones in the patients with polytrauma. 72 osteosynthesis procedures were carried out for 51 children. The main amount of operations per one patient was 1.4.
8 patients (7.9 %) with polytrauma died. All lost children were admitted in critical, agonal state according to the scale by Pape. They were of school-going age (9-15 years). All of them suffered from road traffic accidents. 1 child (age of 5) suffered from the road traffic accident. 1 child (age of 3) died as result of catatrauma after falling from the fifth floor. First of all, all children received treatment of traumatic brain injury and abdominal injury (according to damage control principles). The period of stay in the intensive care unit was 5-7 days.
Depending on the technique of osteosynthesis, the relationship between the time intervals of ICU stay was examined. Such dependence was reviewed at the example of osteosynthesis of the long bones of the lower extremities. The collected data was analyzed with Statistic 6.0. Student’s test was used for estimation of reliability of intergroup differences. The critical level of significance was 0.05. The quantitative variables were presented as Ì ± m, where M – mean arithmetic, m – an error.
RESULTS
External fixation was used for 9 fractures of the femoral bone. The mean time of ICU stay was 4 ± 0.7 bed-days. The mean time of stay in the department of pediatric traumatology was 22.8 ± 3.6 bed-days.
Intramedullary fixation was used for 17 fractures of the femoral bone in 15 children (2 patients with fractures of both femoral bones). One case (the patient at the age of 18) included fixation with PFN and locking. The age of the youngest child was 2 years and 2 months. The mean age of stay in the specialized unit was 18.3 ± 2.43 bed-days.
Transosseous fixation was used for 6 fractures of the femoral bone. The mean time of ICU stay was 12.75 ± 9.3 bed-days. This technique was used for extensive skin damages, severe associated injuries and open fractures of the femoral bone. There were 4 open fractures with extensive injuries to soft tissues. It resulted in long terms of hospital stay.
External fixation was carried out for 5 fractures of the leg bones. The mean time of ICU stay was 4.8 ± 1.3 bed-days. The mean time of stay in the specialized unit was 29.8 ± 2.1 bed-days. One case was associated with non-complete rupture of the extremity at the level of the middle one-third of the leg.
Transosseous fixation was used for 13 fractures of the leg in 12 children. The mean time of ICU stay was 8.8 ± 2.9 bed-days. The mean time of stay in the specialized department was 76.6 ± 17.6 bed-days. The duration of hospital stay was conditioned by extensive injuries to soft tissues and the associated injury.
Intramedullary fixation was used for 10 fractures of the leg bones. The mean time of ICU stay was 4.5 ± 1.9 bed-days. The mean time of stay in the specialized unit was 18.8 ± 3.2 bed-days.
DISCUSSION
Therefore, the study shows that transosseous osteosynthesis technique was used for open fractures of the long bones with extensive injuries to soft tissues and was related to long terms of admission (up to 116 bed-days).
External fixation was used for closed fractures of the long bones and was accompanied by lesser terms of hospital stay (up to 29 bed-days).
Intramedullary fixation was used for closed fractures of the long bones and it significantly reduced hospital stay (up to 18 bed-days).
The analysis showed that in comparison with external fixation administration of intramedullary osteosynthesis reduced hospital stay from 22.8 to 18.3 bed-days (p < 0.05) for fractures of the femoral bone, and from 29.8 bed-days to 18.8 bed-days for leg fractures (p < 0.05).
CONCLUSION
Administration of low invasive osteosynthesis techniques for fractures of the long bones, i.e. intramedullary fixation, in children with polytrauma significantly reduces hospital stay.