Hemodynamic Instability of the Closed Fractures Femur in Children

Background: This is a prospective Study to assess the occurrence of hypovolemic shock in children with traumatic isolated closed fractures femur. This is common in children and adolescent as result of trivial to high energy trauma. Methods: A prospective descriptive study was performed on children with traumatic femoral fractures from the 20 th of September 2015 to the 15 th August 2018. Selection of 100 patients presented with isolated closed fracture femur in children, were admitted to the Sul. Emergency Hospital. Reason was to correct the old criteria of blood transfusion immediately, without suitable indication of replacement with real blood requirements. Depend on the children clinical parameters rather than on hemoglobin or hematocrit concentration; pulse rate. Systolic blood pressure, respiratory rate, Skin capillary rell time, and the mental status. Excluded open fractures and bilateral fracture femur in children, also excluded any fracture associated with trauma to the body organ as associated injury. Results: There was no evidence of hemodynamic instability in the 100 patients of these type fractures, selection inclusion criteria of the study when compared with internationally accepted normal vital sign parameters. No any patients in the study had hemoglobin less than 8.5 g/dl, the vital sign between these groups were similar, 2-6% incidence with hemodynamic instability has found among multiple injured children with femoral fractures, has excluded from the study. Conclusions: No evidence of hemodynamic instability was found in children with traumatic isolated femoral fractures bone. The Hemoglobin and hematocrit ratios early were non dependable, later on not signicantly decreased or change to abnormal rate. Depending on vital signs parameters in the femur bone fractures patients after exclusion of bilateral fractures femur, and associated injury or patients with compound fractures, we conrmed that isolated closed femoral fractures are hemodynamically stable.

However, we must depend on the assessment of vital signs; the pulse rate beat per minute, blood pressure, respiratory rate, capillary re lling times, and mental status, for these fractures children were clear, dependable data, plus direct relationship to children with isolated fracture femur. [4] Patients child age group from all population with femoral shaft fractures represents 2% of all fractures, with an incidence of approximately 20/100,000 per year. Management options depend on a number of factors which includes patient age, fracture pattern, and the use of Pavlik harness in child below 6 months age group, spica casting, intramedullary nailing, Submuscular plating, and external xation.
Advances in treatment with different types of xation have further contributed to increased popularity of operative treatment, with bene ts of less hospitalization stays and earlier movement. [5][6][7] The severity trauma in the study of Kopp et al, [8] from moderate to severe, ve from nine patients presented in the causality hospital with shock while other were stable general condition, all these shock child are either bilateral femur fracture or associated injuries to other body organ, multisystem injuries. In the above study, most of patients were resuscitated earlier and after that send for required procedures weather earlier or later. These were con rmed post exclusion the shock state of other associated injuries or bilateral fractures femur in children, de ned the hemodynamic stability of isolated closed fracture femur in children. Keith et al. Supported the bilateral femur fracture or patients associated with other multi system organ injuries, represented the life danger emergency treated early as urgent conditions, xation with stabilization of the fracture as soon as patient life condition permit. [9] Early stabilization mandatory however, the de nitive treatment still required but further evidence still needs to be looked upon before a de nitive opinion can be established. [10] Bilateral femoral shaft fractures the percentage of mortality reach to 16% in a study by, [11] we treated these patients as early as possible without any death rate in these group patients, also with less morbidity rate. The suitable xation with early stabilization of the isolated fractures femur improved the hemodynamic stability later on. [12] The early xation with intramedullary nailing for proper stabilization of these fracture type after initial resuscitation. [13] Bilateral femur fracture patients is associated with proper evaluation of child admitted hospital for treatment of pediatric closed femoral shaft fractures in Department of Orthopaedic,, were detected closed femoral shaft fractures in children treated with open reduction internal xation, or closed reduction plus internal xation, or using external xation. Closed femoral shaft fractures in children age group less than 5 years, mostly treated by conservative method. However, child older than 11 years were treatment with open reduction plus internal xation obvious observation seen in table1, Fig. 1. Children with closed femoral fractures represent the signi cant blood loss when leading to hypovolemic shock is less obvious. [14] Falls and motor cycle accident are commonest mechanisms of trauma; represent two thirds of the traumatic injuries in older children. Fall in the ground appear as the more common traumatic injury, in younger children, up to 80% of fractures femur in children less than 5 years as result of non-injury types fractures. Transverse fractures femur good indicator of Non traumatic in younger child when compared to accidental traumatic injuries leading to spiral. [15] Fractures are identi cation plus classi cation according to shape, site, stability, and type of fractures closed or open. Fracture femur another classi cation; transverse, oblique short or long, spiral, and comminuted. The locational site of fractures femur is mandatory to de ned, as direction the displacement of fragments will lead from muscles insertion to the bone with the force that effects on the pieces of fragments within the fractures, reveal the angles and displacements in different direction plus shortening factors with age of child with these type fractures shown in table 2.
The Transverse fractures are regards as stable and part of short or long oblique. However, the comminuted or segmental fractures are classi ed as unstable". Compound or open fractures are excluded from those fractures femur of closed types .The Treatment of closed fractures femur depend on different factors which includes; age, shape of fracture, mechanism of injury, body weight of the child. [16].
Assessment plus testing of hematological state for the all patients with closed fractures femur in children, also for cross match are not required for those healthy child patients, the hypotension plus reduction in hemoglobin-hematocrit ratio have not seen in those fractures patients. The dynamic instability and severely drop in hematocrit-hemoglobin ratio are rarely seen in a child with an isolated closed femur fracture, and if available that required to inform the specialist searching for Organ trauma or associated injured. [17] Patients And Methods: A prospective descriptive study approved by IBR of the author a liated institution of Sul. Univ. was performed on children with traumatic femoral fractures from the 20th of September 2015 to the 15th August 2018, 100 patients presented with isolated fracture femur in children, were admitted to the Sul. Emergency Hospital. Reason was to correct the old criteria of blood transfusion immediately, without suitable indication of replacement with real blood requirements. Depend on the children clinical parameters rather than on hemoglobin or hematocrit concentration; these parameters are pulse rate, Systolic blood pressure, respiratory rate, Skin capillary re ll time, and the mental status.
Fluid and blood transfusion were evaluated according patients requirements; the hemoglobin and hematocrit results were obtained initially and nally after three days from the fractures. However, these are independent initially reason beyond that the hemodilution, plus body reaction lead to hemodilution happen earlier in the post trauma time, were non major difference in the nal rate from normal range so regard as exclusion criteria.
Depend on Inclusion Criteria; All children admitted to Emergency word in the Casualty Hospital Sulaimaniyah City, We collected these children depend on isolated closed fractures femur in children, all age groups, excluded the compound fractures, depend on clinical parameters. With nal diagnosis of isolated closed fracture femur, during that time complete checking of vital signs was ready within 4 hours post trauma.
Exclusion Criteria are; Which includes; Birth injury (child abuse), any fractures femur not emergency required treatment by elective method, child delayed in presentation beyond 24 hours, Predisposition factors that lead to decrease bone mineralization as a result of spasticity or muscle contracture, Osteogenesis imperfect, slipped capital femoral epiphysis, child with bilateral fracture femur, or compound fractures femur, plus any child presented with associated injury (other organ, or other part of body). We depend on the Criteria of fractures femur in children, age factors, Degree of angle displacement, Shortening distance of the fracture compare to normal one which seen Obvious on table1, Fig. 1.
The principle of management whether conservative or surgical method seen in tables 1, were dependable on clinical pictures during methodological processing assessment of child with fractures femur, the clinical pictures of expected blood loss from different traumatized patients in table 3.
We depend on volume of blood lost in mille litter in correspondence with clinical sign of blood loss on speci c site of body. The hemodynamic instability in adult patients more liability to seen than in children with closed isolated fractures femur, that reason which was explain in table 3, and table 4. According to international criteria of these type fractures which is so clear that amount of blood loss in child less than 500ml. However, for adult which was reach to 1000-1500ml, so the clinical sign in children non or occasionally presented with vasovagal syncope, in spite of the adults presented at rest may be no clinical evidence of volume loss, plus slight postural drop in blood pressure can be seen, also tachycardia with exercise. The female to male ratio is 44% -56%, blood taken from every patient presented with isolated closed fracture femur in children send for hemoglobin-hematocrit ratio. We assessed the vital signs of pulse rate beat per minute, blood pressure; respiratory rate, capillary re lling times, and mental status for these fractures were clear demonstration in Table 4.
Procedure; Clinical parameters were collated to documents when presence or absence of hypovolemic shock; these parameters must be within range of internationally standards base.

Results:
There was no evidence of hemodynamic instability in the 100 patients had been included in the selection inclusion criteria of the study when compared with internationally accepted normal vital sign parameters. The highest group age affected fracture femur between 5-12 years age group demonstration in the There is no signi cant difference between the patients who received uid bolus or blood transfusion with those patients without any access of blood or uid resuscitation shown in table 4, and 5 also demonstrated in Fig. 2, and 3.
Hemoglobin and hematocrit values were not signi cantly changes or decrease. In this study, 40% of the patients received uid bolus without any clinical evidence of hemodynamic instability, in compared the vital sign with the rest of group patient presented with isolated fracture femur in children that did not received uid bolus. No any fracture femur patient has required blood transfusion based on initial clinical evaluation of the patients plus hemoglobin and hematocrit ratio were stable. No any patients in the study had hemoglobin less than 8.5 g/dl. The vital sign between these groups were similar, 2-6% incidence with hemodynamic instability has found among multiple injured children with femoral fractures, has excluded from the study. If hemodynamic instability present must search for an alternative source of bleeding. This study has used internationally accepted standards for the assessment of hypovolemic shock. The perception of hypovolemic and decision of uid bolus resuscitation is still open to interobserver's variability seen in table 5, also in Fig. 2, and 3.Tachycardia being one of the more sensitive indicators of hypervolemia may re ect coexisting pain or anxiety in a child, making the overall assessment of hypervolemia status less certain.
The management of these fractures observed in table; 6 according to the age of child, those age group from birth to ve years, were 22 patients admitted to emergency hospital, 97% (21 patients out of 22) treated by conservative method, 3% were treated by surgical reduction plus xation, were severely displaced out of criteria in table; 1 (angles and shortening acceptable criteria). The child age group 6-10 year old were 24 patients, 65% of them ( 16 out of 24 patients) were treated by conservative method, mostly within acceptable criteria and non-displaced fractures femur, 35% (8 out of 24 patients) were treated by surgical intervention, they were displaced unstable fracture femur, out of acceptable criteria in table;2. However, child more than 11 year (54 patients out of 100) 23% of them 12 patients were treated by conservative way, 77% (42 patients) treated by surgical method with different xation implants (intramedullary exible nailing, rigid trochanteric entry nailing, and plating Submuscular plating with screws) con rmed that results in table 6, Fig. 4 .
the results were demonstrate in tables 5, Fig. 3; the child receiving indicated blood, with non-indicated blood transfusion were excluded from study, which were associated injured patients group other than fracture femur traumatic damage. However, no any isolated femur fractures received any blood transfusion. The total patients number of the study were100 patients (26 patients receiving uid, plus 74 patients were not receiving any uid or blood). From the results of vital sign, we detected no any clinical criteria requirements of blood transfusion according to the mean of vital sign of isolated fractures femur in children, these con rmation observed in tables 4, 5. Also all features represent blood loss within or less than 10% of total body volume (less than 500 ml of loss). No any features of vasovagal syncope, with preservation of all other vital sign within normal range supported in tables 3, and 4, plus Figs. 3, and 4.

Discussion:
Fractures Femur in children is the most common fractures of long bones .Treatment concentrated on the age of child, speci ed for bone age, plus size of a child affected the treatment plan. The choice of management may be determined by surgical experience and local trends in practice. The conservative management involved the major principles in most cases. However, the current practical directed toward operative xation reason beyond that primarily of early mobilization and shorter time of hospitalization. [18,19] Still the age play major roles in plan of management conservative or surgical method; this is supported in our study.
The treatment of shaft femur fractures in children still remains controversial in management, multi modalities available using different methods in treatment. the guidelines produced by American Academy of Orthopaedic Surgeons published in 2010.The intramedullary elastic nailing is presented the treatment of choice in children aged 5-11. However, other modalities using rigid nail treatment for those age groups depend on bone age and weight of child, some other center depend on non-operative management in the young age group and the use of locked intramedullary nailing in the older. The American Academy evaluated the rigid trochanteric entry nailing, Submuscular plating and exible intramedullary nailing as treatment options for children aged eleven to skeletal maturity. Early spica casting or traction with delayed spica casting for children aged 6 months to 5 years (with < 2 cm of shortening) is the management protocol for femur fractures in children. [20,21] These plans of management were supported by our results in the choice of treatment principle shown in table 7and Fig. 4.
From the results and conclusion in Journal of Trauma, in the Injury Emergency Department, Children's Hospital at Westmead, NSW of Australia, patients with additional trauma showed signi cant decreases in both hemoglobin concentrations and hematocrit levels, comparison with the patients who had only isolated femoral fractures not affected. If there is an obvious decrease in hematocrit and/or hemoglobin concentration in a child with a femoral fracture, the availability of associated traumatic injuries should be evaluated. [22] This results supported by our study of isolated fracture femur in children are hemodynamic stable, not required blood transfusion, the hemoglobin hematocrit were normal initially and later on, the requirements of blood transfusion only in associated injuries of other organ or bilateral fracture femur.
Femur fracture must be looking for the details of physical examination, with observation of associated other injured sites in the body. Hypotension rarely results from an isolated femoral fracture. Waddell's triad of femoral fracture, intra-abdominal or intrathoracic injury, plus head injury is associated with highvelocity automobile injuries. Multiple trauma patients requirements the rapid stabilization of femoral shaft fractures to facilitate overall care, this observation concentrated on associated trauma with head injury or vascular disruption. Admitted to Causality and Traumatic Departments in Ugandan teaching hospitals, between December 2016 and June 2017. This is support our study in excluded fractures femur in children associated with open or compound fractures which lead to bleeding plus features of hypotension. [23] These results were con rmed our nding of the isolated fractures femur in children is hemodynamic stable, not required blood transfusion.
All children presented with associated trauma, or other injuries to the body organ, and compound fractures were excluded from the study. Laboratory Assessment for the routine laboratory testing and cross match are not recommended for healthy patients with isolated closed femoral shaft fractures, hypotension and signi cant decreases in hematocrit have not been shown in these Children's Hospital at Westmead, NSW of Australia, patients with additional trauma showed signi cant decreases in both hemoglobin concentrations and hematocrit levels, comparison with the patients who had only isolated femoral fractures not affected. If there is an obvious decrease in hematocrit and/or hemoglobin concentration in a child with a femoral fracture, the availability of associated traumatic injuries should be evaluated. [22]This results supported by our study of isolated fracture femur in children are hemodynamic stable, not required blood transfusion, the hemoglobin hematocrit were normal initially and later on, the requirements of blood transfusion only in associated injuries of other organ or bilateral fracture femur. Femur fracture must be looking for the details of physical examination, with observation of associated other injured sites in the body. Hypotension rarely results from an isolated femoral fracture. Waddell'striad of femoral fracture, intra-abdominal or intrathoracic injury, plus head injury is associated with high-velocity automobile injuries. Multiple trauma patients requirements the rapid stabilization of femoral shaft fractures to facilitate overall care, this observation concentrated on associated trauma with head injury or vascular disruption. Admitted to Causality and Traumatic Departments in Ugandan teaching hospitals, between December 2016 and June 2017. This is support our study in excluded fractures femur in children associated with open or compound fractures which lead to bleeding plus features of hypotension. [23]These results were con rmed our nding of the isolated fractures femur in children is hemodynamic stable, not required blood transfusion. All children presented with associated trauma, or other injuries to the body organ, and compound fractures were excluded from the study. Laboratory Assessment for the routine laboratory testing and cross match are not recommended for healthy patients with isolated closed femoral shaft fractures, hypotension and signi cant decreases in hematocrit have not been shown in these fractures patients. Hemodynamic stability was detected with patients presented in the casualty hospital department of Orthopedics and Rehabilitation in USA, the patients with complete neurologic and vascular assessment of the affected limb should be performed. Vascular injuries have been less chance to occur in this group of patients with closed femur fractures, reported incidence of 0.1-2%. [24] There was no signi cant difference con rmed in table 6 found in the initial vital signs between patients who received uid bolus and those didn't received in our study. Hemoglobin and hematocrit values were not decreased with closed fractures femur in children. This evidence con rmed our results of isolated fracture femur in children of the hemodynamic stability, not required blood transfusion, plus hemoglobinhematocrit was normal initially and later on.

Conclusion:
No evidence of hemodynamic instability was found in children with traumatic isolated femoral fractures bone. The Hemoglobin and hematocrit ratios early were non dependable later on, not signi cantly decreased or change to abnormal rate. Depending on vital signs parameters in the femur bone fractures patients after exclusion of bilateral fractures femur, and associated injury or patients with compound fractures, we con rmed that isolated closed femoral fractures are hemodynamically stable. There is limitation of the data availability supporting the results of the paper. However, still have some data reporting from the paper available in the references subjects of this research. Some of these datasets established from the corresponding author on reasonable request. However, all data generated in this study are included in this published article (supplementary information les supporting this paper).

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Hemodynamic Instability of the Closed Fractures Femur in Children
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Study design;
This is prospective Study to assess the occurrence of hypovolemic shock in children with traumatic isolated closed fractures femur. This is common in children and adolescent as result of trivial to high energy trauma, treated by Multi modalities of managements.