Femoral fractures: are children at risk for significant blood loss?

OBJECTIVE: To quantify the frequency of blood loss necessitating transfusion and identify the clinical factors predictive of severe hemorrhage 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 fracture.

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 rate (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 which 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 35.6%; 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 nontransfused patients (P = 0.004). There were no significant differences in presenting vital signs, Hct, type of fracture, or time required to get to the emergency department. Five of the seven transfused patients presented with a Hct < 30% as compared to 13 of the 250 nontransfused patients (P < 0.00002). Two of the transfused patients had isolated femoral fractures; one with hemophilia and the other with a prior femoral fracture. The remaining five patients were multiple trauma victims, with significant injuries in addition to femoral fractures.

CONCLUSIONS: Otherwise healthy pediatric patients with isolated femoral fractures rarely lose sufficient amounts of blood to necessitate blood transfusion. The majority may be managed by observation alone. Multiple trauma (multiple fractures, pelvic disruptions, retroperitoneal injuries) and underlying disorders are indications for careful monitoring, Hct determination, and cross match for blood. Patients who are older, present with a Hct < 30%, or who have multiple traumatic injuries have a relatively greater risk of needing a transfusion.