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

  • Klemens HorstEmail author
  • Hagen Andruszkow
  • Christian David Weber
  • Miguel Pishnamaz
  • Matthias Knobe
  • Felix Marius Bläsius
  • Philipp Lichte
  • Rolf Lefering
  • Frank Hildebrand
Original Article



External fixation within the damage control concept in unstable multiple trauma patients is widely accepted. Literature about its usage in the pediatric trauma population, however, is rare. The aim of the present study was to elucidate the factors associated with the application of external fixation in the severely injured child.


Patients with severe trauma aged 0–54 years documented in the TraumaRegister DGU® were included in this study. Demographic data, pattern of injury, injury severity, use of the damage control orthopedics (DCO) or early total care (ETC) concept, duration of mechanical ventilation, intensive care stay, and total hospital stay as well as the occurrence of complications and mortality were evaluated. Statistical evaluation was performed using SPSS (Version 21.0.0) using Chi square tests and linear regression models.


While injury severity was comparable between children and adults, type of accident and injury patterns showed significant differences, Overall, the majority of surgical fracture stabilization in AISExtremity ≥ 3 injuries followed the DCO concept in adults (60.3%) and the ETC protocol in children (49.4%). Conservative treatment was chosen for only 11.6% of all children and 9.6% of all adults. An increasing injury severity, AISExtremity ≥ 3 and AISExtremity ≥ 3 in ≥ 2 body regions, and a more advanced age were found to be independent factors in the use of the DCO concept in children.


Use of external fixation increases with age and plays a minor role in the very young trauma population. However, this does not produce a difference in outcome between children and adults.


ETC DCO Children Severely injured 



American College of Chest Physicians


Abbreviated injury score


Central nervous system


Computer tomography


Damage control orthopedic surgery


Elastic intramedullary nailing


Early total care


Intensive care unit


Intensive care medicine


Multi organ failure


Multi organ dysfunction syndrome


Injury Severity Score


Sequential Organ Failure Assessment Score


TraumaRegister DGU®



The article was proofread by, Devonshire Business Centre, Works Road, Letchworth Garden City, SG6 1GJ, United Kingdom. Furthermore, the authors would like to thank the internal review of the TR-DGU for their substantial contribution.

Author contributions

Conceived and designed the study: KH, HA, CDW, MP, PL, FMB, MK, RL, and FH. Performed the study: KH, HA, and FMB. Analyzed the data: KH, CDW, MP, PL, and FH. Wrote the paper: KH, CDW, and MP. Contributed substantially to manuscript revision: all authors. Read and approved the final manuscript for publication: all authors.



Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

Not applicable.

Informed consent

The TR-DGU gave permission for publication. All authors read and approved the final manuscript and gave permission for publication.


  1. 1.
    Pediatric trauma. Advanced trauma life support for doctors (ATLS) Student course manual. 9th ed. Chicago: American College of Surgeons; 2012. pp. 246–70.Google Scholar
  2. 2.
    Peden M, Oyegbite K, Ozanne-Smith J, Hyder AA, Branche C, AKMF R. World report on child injury prevention. 2008. Accessed 30 May 2017.
  3. 3.
    Banerjee M, Bouillon B, Shafizadeh S, Paffrath T, Lefering R, Wafaisade A. Epidemiology of extremity injuries in multiple trauma patients. Injury. 2013;44(8):1015–21. Scholar
  4. 4.
    Pape HC, Tornetta P 3rd, Tarkin I, Tzioupis C, Sabeson V, Olson SA. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009;17(9):541–9.Google Scholar
  5. 5.
    Klassen TP, Hartling L, Craig JC, Offringa M. Children are not just small adults: the urgent need for high-quality trial evidence in children. PLoS Med. 2008;5(8):e172. Scholar
  6. 6.
    Capizzani AR, Drongowski R, Ehrlich PF. Assessment of termination of trauma resuscitation guidelines: are children small adults? J Pediatr Surg. 2010;45(5):903–7. Scholar
  7. 7.
    TraumaRegister DGU. 20 years TraumaRegister DGU((R)): development, aims and structure. Injury. 2014;45(Suppl 3):6–13. Scholar
  8. 8.
    Vincent JL, de Mendonca A, Cantraine F, Moreno R, Takala J, Suter PM, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26(11):1793–800.Google Scholar
  9. 9.
    Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101(6):1644–55.Google Scholar
  10. 10.
    Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101(6):1644–55.Google Scholar
  11. 11.
    Lefering R, Huber-Wagner S, Nienaber U, Maegele M, Bouillon B. Update of the trauma risk adjustment model of the TraumaRegister DGU: the Revised Injury Severity Classification, version II. Crit Care. 2014;18(5):476. Scholar
  12. 12.
    Reichmann I, Aufmkolk M, Neudeck F, Bardenheuer M, Schmit-Neuerburg KP, Obertacke U. Comparison of severe multiple injuries in childhood and adulthood. Unfallchirurg. 1998;101(12):919–27.Google Scholar
  13. 13.
    Remmers D, Regel G, Neumann C, Pape HC, Post-Stanke A, Tscherne H. Pediatric polytrauma. A retrospective comparison between pediatric, adolescent and adult polytrauma. Unfallchirurg. 1998;101(5):388–94.Google Scholar
  14. 14.
    Burdi AR, Huelke DF, Snyder RG, Lowrey GH. Infants and children in the adult world of automobile safety design: pediatric and anatomical considerations for design of child restraints. J Biomech. 1969;2(3):267–80.Google Scholar
  15. 15.
    Richter T, Ragaller M. Ventilation in chest trauma. J Emerg Trauma Shock. 2011;4(2):251–9. Scholar
  16. 16.
    Hoekelman RA, Pless IB. Decline in mortality among young Americans during the 20th century: prospects for reaching national mortality reduction goals for 1990. Pediatrics. 1988;82(4):582–95.Google Scholar
  17. 17.
    Gill AC, Kelly N. Overview of pediatric injury prevention: epidemiology; history, application. In: UpToDate. 2016. Accessed 04 Aug 2017.
  18. 18.
    O’Brien PJ. Fracture fixation in patients having multiple injuries. Can J Surg. 2003;46(2):124–8.Google Scholar
  19. 19.
    Pape HC, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. Am J Surg. 2002;183(6):622–9.Google Scholar
  20. 20.
    Bruce B, Stone J. External fixation in pediatric trauma. Curr Orthop Pract. 2011;22(2):157–61. Scholar
  21. 21.
    Humphrey JA, Gillani S, Barry MJ. The role of external fixators in paediatric trauma. Acta Orthop Belg. 2015;81(3):363–7.Google Scholar
  22. 22.
    Aronson J, Tursky EA. External fixation of femur fractures in children. J Pediatr Orthop. 1992;12(2):157–63.Google Scholar
  23. 23.
    Schalamon J, Petnehazy T. The management of traumatic fractures in children. Minerva Pediatr. 2009;61(2):185–92.Google Scholar
  24. 24.
    Hurme T. Children’s limb fractures. Duodecim. 2015;131(5):457–63.Google Scholar
  25. 25.
    Tolo VT. External fixation in multiply injured children. Orthop Clin N Am. 1990;21(2):393–400.Google Scholar
  26. 26.
    Jafarpour S, Nassiri SJ, Bidari A, Chardoli M, Rahimi-Movaghar V. Principles of primary survey and resuscitation in cases of pediatric trauma. Acta Med Iran. 2015;53(4):242–5.Google Scholar
  27. 27.
    MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma. 2002;52(4):641–9.Google Scholar
  28. 28.
    Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246(3):491–9. (discussion 9–501).Google Scholar
  29. 29.
    Stahel PF, Heyde CE, Wyrwich W, Ertel W. Current concepts of polytrauma management: from ATLS to “damage control”. Orthopade. 2005;34(9):823–36. Scholar
  30. 30.
    Waydhas C, Nast-Kolb D, Trupka A, Zettl R, Kick M, Wiesholler J, et al. Posttraumatic inflammatory response, secondary operations, and late multiple organ failure. J Trauma. 1996;40(4):624–30 (discussion 30–31).Google Scholar
  31. 31.
    Harwood PJ, Giannoudis PV, van Griensven M, Krettek C, Pape HC. Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma. 2005;58(3):446–52 (discussion 52–54).Google Scholar
  32. 32.
    Calkins CM, Bensard DD, Moore EE, McIntyre RC, Silliman CC, Biffl W, et al. The injured child is resistant to multiple organ failure: a different inflammatory response? J Trauma. 2002;53(6):1058–63. Scholar
  33. 33.
    Proulx F, Joyal JS, Mariscalco MM, Leteurtre S, Leclerc F, Lacroix J. The pediatric multiple organ dysfunction syndrome. Pediatr Crit Care Med. 2009;10(1):12–22. Scholar
  34. 34.
    Husain B, Kuehne C, Waydhas C, Lewan U, Ose C, Nast-Kolb D, et al. Incidence and prognosis of organ failure in severely injured children and adult patients. Eur J Trauma Emerg Surg. 2006;32:548. Scholar
  35. 35.
    Lefering R. Strategies for comparative analyses of registry data. Injury. 2014;45(Suppl 3):83–8. Scholar
  36. 36.
    Lefering R. TraumaRegister® DGU—Annual Report 2015; 2015.Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Klemens Horst
    • 1
    Email author
  • Hagen Andruszkow
    • 1
  • Christian David Weber
    • 1
  • Miguel Pishnamaz
    • 1
  • Matthias Knobe
    • 1
  • Felix Marius Bläsius
    • 1
  • Philipp Lichte
    • 1
  • Rolf Lefering
    • 2
  • Frank Hildebrand
    • 1
  1. 1.Department of Trauma and Reconstructive SurgeryRWTH Aachen UniversityAachenGermany
  2. 2.IFOM, Institute for Research in Operative Medicine, Faculty of HealthUniversity Witten/HerdeckeCologneGermany

Personalised recommendations