Surgical treatment strategies in pediatric trauma patients: ETC vs. DCO-an analysis of 316 pediatric trauma patients from the TraumaRegister DGU®

Early total care or damage control orthopaedics for major fractures ? Results of propensity score matching for early definitive versus early temporary fixation based on data from the trauma registry of the German Trauma Society (TraumaRegister DGU®)

PURPOSE

Damage control orthopaedics (DCO) und early total care (ETC) are well-established strategies for managing severely injured patients. There is no definitive evidence of the superiority of DCO over ETC in polytrauma patients. We conducted this study to assess the probability of a polytraumatised patient undergoing DCO. In addition, the effect of DCO on complications and mortality was investigated.

METHODS

We analysed data from 12,569 patients with severe trauma (Injury Severity Score ≥ 16) who were enrolled in the trauma registry of the German Trauma Society (TraumaRegister DGU®) from 2009 to 2016 and had undergone surgery for extremity or pelvic fractures. These patients were allocated to a DCO or an ETC group. We used the propensity score to identify factors supporting the use of DCO. For a comparison of mortality rates, the groups were stratified and matched on the propensity score.

RESULTS

We identified relevant differences between DCO and ETC. DCO was considerably more often associated with packed red blood cell (pRBC) transfusions (33.9% vs. 13.4%), catecholamine therapy (14.1% vs. 6.8%), lower extremity injuries (72.4% vs. 53.5%), unstable pelvic fractures (41.0% vs. 25.9%), penetrating injuries (2.8% vs. 1.5%), and shock (20.5% vs. 10.8%) and unconsciousness (23.7% vs. 16.3%) on admission. Based on the propensity score, patients with penetrating trauma, pRBC transfusions, unstable pelvic fractures, and lower extremity injuries were more likely to undergo DCO. A benefit of DCO such as reduced complications or reduced mortality was not detected.

CONCLUSION

We could identify some parameters of polytrauma patients used in the trauma registry (Traumaregister DGU®), which led more likely to a DCO therapy. The propensity score did not demonstrate the superiority of DCO over ETC in terms of outcome or complications. It did not appear to adequately adjust for the variables used here. Definitive evidence for or against the use of DCO remains unavailable.

Hydrotherapy for Patients With External Fixation: Effect on Infectious Events

BACKGROUND

Surgery to achieve long bone lengthening and deformity correction in skeletally immature patients is traditionally performed through external fixators. The incidence of infection during treatment is high. Hydrotherapy is highly beneficial during external fixation management, but the infection rates may impact its utilization. The objective of this paper is to document the incidence and duration of infection in patients who participated in a full hydrotherapy program when performed under medical supervision and in accordance with strict follow-up protocols.

METHODS

In this retrospective study, we documented the key characteristics of patients who participated in hydrotherapy after lower limb external fixation surgery including age, sex, diagnosis and surgery site, the incidence and duration of pin site infections, and the percentage of cases, which were able to comply with a full hydrotherapy protocol.

RESULTS

The hydrotherapy pool met all daily water quality metrics. Thirty-four children (19 males and 15 females) had a mean±SD age of 10.9±4.6 years. Of the cases, 80% were unilateral and 20% were bilateral. Diagnoses included congenital hereditary (eg, achondroplasia), congenital nonhereditary conditions (eg, fibular hemimelia), and acquired conditions (eg, traumatic). The location of osteotomy site was quite evenly spread between the femur and the tibia/fibula. Three out of the 34 patients were unable to receive hydrotherapy due to continuous secretions; 2 patients did not miss any sessions. The mean number of treatments was 3 per week. During the entire period, a total of 1200 treatments were performed for these patients with only 32 cancellations (about 3%) due to secretions or other signs of infection. Spearman correlation coefficients showed significantly high correlations between the duration of external fixation and the duration of hydrotherapy. There are no significant correlations between infections and other factors (sex, age segment, whether the problem is unilateral or /bilateral, diagnosis, and duration of treatment).

CONCLUSIONS

This is the first report, to our knowledge, that documents the low prevalence of infectious events during hydrotherapy treatment and demonstrates its feasibility.

LEVEL OF EVIDENCE

Level III; retrospective, comparative study.

Case series: Factors of mortality in pediatric patients with pelvic fractures

OBJECTIVE

No algorithm exists to guide the orthopedic treatment of pediatric patients with pelvic fractures, as most analytic studies have been conducted in adults. The goal of this study was to identify prognostic factors of pelvic fractures, and suggest whether early total care can be safely provided.

METHODS

A retrospective trauma database for pediatric pelvic fractures from 2002-2018 was gathered, and patient charts were reviewed.

RESULTS

A total of 128 patients were evaluated for pelvic trauma; 99 injuries were secondary to motor vehicle accidents (MVA) (77%), and 19 were secondary to falls (15%). Patients were more likely to be male (71%), older (33% aged 15-16 years, 2% aged 0-1 years), to experience a head trauma (55%), to be treated conservatively (70%), and to survive their trauma (91%). About half of the patients (49%) experienced an additional extremity trauma. When exploring the prognostic factors, mortality was associated with thoracic trauma (72% vs. 27%, p<0.05); a lower reduction of neutrophils levels 48 hours after the initial trauma (-1.34 vs. -7.7, p<0.05); a more significant reduction upon arrival of Prothrombin Time (72% vs. 37%, p<0.01), and an increment of International Normalized Ratio (2.29 vs. 1.26, p<0.01) and Partial Thromboplastin Time (79 vs 28, p<0.01). There was also a higher demand for Fresh Frozen Plasma (24% vs. 9%, p<0.05); Upon presentation, there was a higher Injury Severity Score (49 vs. 21, p<0.001), and a lower systolic Blood Pressure (96 vs. 118, p<0.05); The deceased did not have a very prolonged stay in the hospital (3 days vs. 12 days, P<0.01); Mortality was not significantly associated with either Early Total Care or Damage Control Orthopedics.

CONCLUSIONS

Prognostic factors in pediatric patients with pelvic fractures parallel those of the adult population. Pediatric patients tendentiously outlive their pelvic trauma, whether the course of action taken by their surgeons is Conservative by nature, Early Total Care or Damage Control Orthopedics.

The July Phenomenon and Pediatric Trauma

BACKGROUND

The July Phenomenon describes concerns that patients presenting early in the academic year experience worse outcomes. Given the standardized approach to pediatric trauma patients, we hypothesized that the July Phenomenon would not impact morbidity or mortality.

METHODS

A retrospective review of patients ≤16 Y presenting to a level I pediatric trauma center between March 2009 and March2019 was performed. Pediatric patients admitted during the study period were compared for differences in outcome by month of presentation. The primary outcome was mortality. Secondary outcomes were complications, and length of emergency department, hospital and Intensive Care Unit stay. Multivariable regression was used to evaluate the effect of month of admission on outcomes.

RESULTS

A total of 6,135 patients were evaluated, with 605 patients presenting in July. Univariate analysis failed to demonstrate consistently increased mortality, complications, or length of emergency department, hospital or Intensive Care Unit stay in July compared to months later in the academic year. On multivariate analysis, admission in July was not an independent predictor of worse outcomes.

CONCLUSIONS

In this level I pediatric trauma center, pediatric trauma patients presenting earlier in the academic year have similar outcomes to those presenting later, and there is no evidence of a July Phenomenon in this population.

Laboratory Markers in the Management of Pediatric Polytrauma: Current Role and Areas of Future Research

Severe trauma is the most common cause of mortality in children and is associated with a high socioeconomic burden. The most frequently injured organs in children are the head and thorax, followed by the extremities and by abdominal injuries. The efficient and early assessment and management of these injuries is essential to improve patients' outcome. Physical examination as well as imaging techniques like ultrasound, X-ray and computer tomography are crucial for a valid early diagnosis. Furthermore, laboratory analyses constitute additional helpful tools for the detection and monitoring of pediatric injuries. Specific inflammatory markers correlate with post-traumatic complications, including the development of multiple organ failure. Other laboratory parameters, including lactate concentration, coagulation parameters and markers of organ injury, represent further clinical tools to identify trauma-induced disorders. In this review, we outline and evaluate specific biomarkers for inflammation, acid-base balance, blood coagulation and organ damage following pediatric polytrauma. The early use of relevant laboratory markers may assist decision making on imaging tools, thus contributing to minimize radiation-induced long-term consequences, while improving the outcome of children with multiple trauma.