FEMORAL FRACTURES - ARE CHILDREN AT RISK FOR SIGNIFICANT BLOOD-LOSS

Objective: To quantify the frequency of blood loss necessitating trans fusion and identify the clinical factors predictive of severe hemorrha ge in children with femoral fractures. Design: Retrospective review of computerized discharge diagnoses and medical records between January 1, 1987, and July 31, 1992. Setting: Tertiary care children's hospital . Patients: Children younger than 18 years of age, discharged between January 1, 1987, and July 31, 1992, with a final diagnosis of femur fr acture. Results: The 257 patients ranged in age from birth to 18 years with a mean of 6.5 years; 183 (71%) were male. Fractures were closed in 250 (98%) and represented isolated injuries in 225 (87%) patients. The mean systolic blood pressure (SBP) was 119 mmHg, the mean heart ra te (HR) was 114 beats/min, and the mean hematocrit (Hct) was 35.2% on arrival. Eight (2.9%) patients had a SBP less than 90 mmHg, all of whi ch were normal values for age. There were 19 patients with a HR, >150, all were <4 years old with a mean SBP of 110 mmHg and a mean Hct of 3 5.6%; none required transfusion. There were 18 patients with a Hct <30 %, 4/18 or 22% required transfusion. Seven of the 257 patients (2.7%) received blood transfusions. All were male, with closed fractures, who were older (11.7 +/- 4.9 vs 6.3 +/- 4.7 years) than the 250 nontransf used patients (P = 0.004). There were no significant differences in pr esenting vital signs, Hct, type of fracture, or time required to get t o the emergency department. Five of the seven transfused patients pres ented with a Hct <30% as compared to 13 of the 250 nontransfused patie nts (P < 0.00002). Two of the transfused patients had isolated femoral fractures; one with hemophilia and the other with a prior femoral fra cture. The remaining five patients were multiple trauma victims, with significant injuries in addition to femoral fractures. Conclusions: Ot herwise healthy pediatric patients with isolated femoral fractures rar ely lose sufficient amounts of blood to necessitate blood transfusion. The majority may be managed by observation alone. Multiple trauma (mu ltiple fractures, pelvic disruptions, retroperitoneal injuries) and un derlying disorders are indications for careful monitoring, Hct determi nation, and cross match for blood. Patients who are older, present wit h a Hct <30%, or who have multiple traumatic injuries have a relativel y greater risk of needing a transfusion.