Damage control orthopedics versus early total care of femur fracture in a national cohort of pediatric patients with traumatic brain injury

Abstract

Background

Long bone fracture is one of the most common concomitant injuries in pediatric traumatic brain injury (TBI) patients, requiring surgical intervention in the form of intramedullary nailing (IMN), open reduction and internal fixation (ORIF), or temporary external fixation, otherwise known as damage control orthopedics (DCO), for transient stabilization before definitive repair. There are no definitive guidelines for femur fracture management in polytrauma TBI pediatric patients. This study investigates the outcomes of patients with TBI and femur fractures who underwent DCO versus early total care (ETC), hypothesizing that delayed fracture fixation is associated with worse outcomes.

Methods

Pediatric patients admitted with TBI who underwent femur fracture repair between 2016 and 2020 were investigated using the National Inpatient Sample database. Clinical outcomes, healthcare utilization data, baseline demographics, and comorbidities were collected. All Patient Refined Diagnosis Related Groups (APR-DRG) severity was defined for each case. The injury severity scale (ISS) was developed using ICD-10-CM codes for injury. High ISS was defined as greater than 75th percentile. DCO patients were compared with ETC patients. Inpatient death, prolonged LOS, and high total charges were the primary outcomes evaluated. Multivariate binary logistic regression analysis was used to evaluate for independent predictors of primary outcomes.

Results

A total of 6,775 pediatric TBI patients under the age of 21 who underwent repair of femur fracture were identified. The average age was 15.5 years (range: 0–21 years) and there were 2,065 (30.5 %) females. DCO to treat femur fractures was employed in 1,010 (14.9 % of patients). Patients undergoing DCO were significantly more likely to have extreme illness severity (OR = 3.049), early trauma complications (OR = 2.273), and respiratory complications (OR = 2.255). DCO was independently associated with prolonged length of stay (LOS) (OR = 1.263), high total charges (OR = 1.786), and inpatient death (OR = 2.796).

Conclusion

This study found that DCO is associated with worse outcomes, likely secondary to injury severity and underlying neurologic injury of patients undergoing DCO. These findings suggest it is time to definitively outline the timing and modality of femur fracture repair for the polytrauma pediatric patient with TBI.

Level of evidence

III.