|Year : 2013 | Volume
| Issue : 3 | Page : 135-139
A study of management of fracture shaft femur in children in a rural population
Soumya Ghosh1, Souvik Bag1, Soma Datta2, Arunima Chaudhuri3, Debasis Singha Roy1, Abhijit Biswas3
1 Department of Orthopedics, Burdwan Medical College Hospital, Burdwan, West Bengal, India
2 Department of Pathology, Burdwan Medical College Hospital, Burdwan, West Bengal, India
3 Department of Physiology, Burdwan Medical College Hospital, Burdwan, West Bengal, India
|Date of Web Publication||19-Oct-2013|
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Femoral shaft fractures account for 1.6% of all bony injuries in children, and the mode of treatment for children between 6 and 16 years of age is still debatable. Objectives: To compare the merits and demerits of operative and conservative managements of fracture shaft femur in children in a rural population in a developing country. Materials and Methods: Forty patients in the age group of 6-14 years with transverse fractures of shaft of the femur and two different treatment protocols were selected. The patients treated in skeletal traction or fixed traction in Thomas' splint were included in one group and patients who were treated operatively with titanium elastic nails comprised the other group. Data was analyzed using Chi-square test. Results: The commonest cause of injury was motor vehicle accident, accounting for 70% of the cases, with left femur (60%) more commonly injured. All fractures in the operative group united clinically by 8 weeks and radiologically by 10 weeks, and, in the conservative group, by 9 weeks clinically and 12 weeks radiologically. The difference was statistically significant. Shortening and angular mal alignments were found more commonly in the conservative group, and the difference was significant. The follow-up for 1 year of all cases were uneventful. Conclusion: Internal fixation with titanium elastic nails provides better results than conservative treatment in traction.
Keywords: Conservative and operative management, fracture shaft femur
|How to cite this article:|
Ghosh S, Bag S, Datta S, Chaudhuri A, Roy DS, Biswas A. A study of management of fracture shaft femur in children in a rural population. J Sci Soc 2013;40:135-9
|How to cite this URL:|
Ghosh S, Bag S, Datta S, Chaudhuri A, Roy DS, Biswas A. A study of management of fracture shaft femur in children in a rural population. J Sci Soc [serial online] 2013 [cited 2020 Jul 11];40:135-9. Available from: http://www.jscisociety.com/text.asp?2013/40/3/135/120055
| Introduction|| |
Femoral shaft fractures account for 1.6% of all bony injuries in children. Low-velocity trauma leads to transverse fractures, while higher ones cause comminuted or segmental fractures. ,, In children aged ≤5 years, early closed reduction and application of a spica cast is the ideal method for treatment.  In skeletally mature adolescents, use of antegrade solid intramedullary nail has become the standard of treatment. ,, The mode of treatment for children between 6 and 16 years of age is still debatable. Conservative management of femoral fractures in children with traction followed by hip spica, skin, or skeletal traction had yielded good results in the past. Compared with younger children, patients in the intermediate age-group have a higher risk of shortening and malunion when managed conservatively; therefore, early operative fixation is advocated. ,,,,, The methods used for operative management includes fixation with Ender's nails, titanium elastic nailing system (TENS) and interlocking nails (ILN) to conventional plating and external fixators. ,,,,
Decreased hospitalization, low cost of implants, less potential damage to growth centers, decreased blood loss and operative time suggest that TENS has a merit over other operative procedure. ,,,, But this procedure requires a C-arm facility, which is not present at all centers and causes radiation exposure. ,
The femur is subject to significant bending, axial, torsional stresses that can exceed three to four times body weight during normal activities. The biomechanical principal of the Titanium Elastic Nail is based on the symmetrical bracing action of two elastic nails inserted into the metaphysis. This produces flexural stability, axial stability, translational stability, and rotational stability. , Traction used for stabilizing femur fractures is used with the intention to overcome the muscle spasm and maintaining the alignment of the fracture fragments by stretching the soft tissues. The muscles in spasm tend to draw the distal part of the body in a proximal direction. A traction force applied to the affected part of the body will overcome muscle spasm only if force acting in the opposite direction i.e., counter-traction is applied at the same time as the traction force. ,,,
Femoral shaft fractures have been classified on the basis of the anatomical location, fracture morphology, degree of comminution, and either open or closed. The fracture may be described as proximal 1/3 rd , middle 1/3 rd , or distal 1/3 rd in location or at the junction of these regions. Fractures can be transverse, short oblique, long oblique, spiral, or comminuted. Open fractures are classified according to Gustilo's system.  The presence or absence of neurological or vascular injury should be documented and is part of the fracture description. The most common femoral fracture in children (over 50%) is simple transverse, closed, non-comminuted injury.  The present study was conducted to compare the merits and demerits of operative and conservative managements in a rural population in a developing country.
| Materials and Methods|| |
The study was conducted in a tertiary care hospital in West Bengal after taking clearance from the ethical committee and proper consent. Forty patients within the age group of 6-14 years with transverse fractures of diaphysis of the femur were selected [Figure 1]. They were randomly assigned from a table of random numbers into two different treatment protocols after taking proper informed consent. The patients treated in skeletal traction or fixed traction in Thomas' splint were included in one group and the patients who were treated operatively with titanium elastic nails comprised the other group.
Patients weighing <50 kg within the age group 6-14 years with duration of fracture not more than 2 weeks were selected.
Patients with open fracture, any associated fracture in the same limb, pelvic fracture and associated serious internal organ injury and soft tissue injury and fractures with vascular injury were excluded.
Management with traction ,,,
The patient was put on a simple surface traction with a weight, appropriate for the weight of the patient. The foot-end of the bed was simultaneously raised to provide the counter traction.
For traction in Thomas' splint, the measurements taken were the oblique circumference of the thigh immediately below the gluteal fold and ischial tuberosity, which corresponds roughly with the internal circumference of the padded ring and the other measurement from the crotch to the heel. About 10 cm were added to this measurement, and it corresponded to the length of the inner-side bar. The limb was then kept in 30° of abduction and was elevated on a pillow. The important point to note was that the splint was used to maintain the reduction acquired after manipulation and not to obtain the reduction.
For skeletal traction in Bohler-Braun Splint, upper tibial traction was applied with a sterilized Steinmann pin and a Bohler's stirrup was attached to it. The weight that was applied was approximately 10% of the body weight of the patient. The foot-end was elevated as per the calculation of 1 cm for each kilogram of weight hung. The limb was kept in a position of 30° of abduction. Check radiographs were obtained with the limb in traction to assess the quality of reduction.
Static quadriceps and hamstring exercises were started as early as possible. Ankle movement was encouraged to prevent stiffness and equinus deformity of the joint.
Repeat radiographs were obtained at 4 weeks and the status of the fracture was assessed. If proper healing was documented then the traction was removed and active knee bending exercises were started. Patient was allowed partial weight bearing at 6 weeks and full-weight bearing at 8-10 weeks.
Operative management with titanium elastic nails ,,,,,
The patients were put on a simple surface traction with a weight with the foot end of the bed raised to provide the counter traction. After relevant investigations and pre-anesthetic check-up, the patients were put up for operation.
The patient was positioned in the supine position on the fracture table. Traction was applied using the fracture table foot holder. The image intensifier was positioned on the lateral side of the affected femur for AP and lateral views of the leg from knee to hip. Trial reduction was then attempted under C-arm guidance and proper rotational alignment was determined. A prophylactic antibiotic was administered intravenously.
Titanium elastic nails
Titanium elastic nails are available in 5 different diameters, 2.0, 2.5, 3.0, 3.5, and 4.0 mm, and 440 mm in length. The narrowest diameter of the medullary canal was measured with a ruler. The proper nail diameter is no more than 40% of the width of the canal as per Flynn et al.  Two nails of the same diameter were selected so that the opposing bending forces are equal, avoiding mal alignment. Femoral fractures in children are typically stabilized with two nails inserted in a retrograde manner from medial and lateral entry points above the distal epiphysis.
Both nails were contoured into a bow shape with the nail tip pointing to the concave side of the bowed nail. The apex of the bow was kept at the level of the fracture. An incision was made on the lateral or medial aspect of the distal femur, starting 3 cm above the epiphysis and extending distally for 2.5 cm. The entry point for the nail was 2.5-3.0 cm proximal to the epiphysis. A pointed straight awl was used to penetrate the near cortex. The awl was inserted vertically down to the bone. With rotating motion, the awl was lowered to a 45° angle relative to the shaft axis and penetration of the cortical bone at an upward angle was continued. The nail was inserted with hand as far as possible. The nail was then hammered in up to the fracture site. The femur was then opened on the opposite side and another nail of the same diameter was inserted similar to the first nail and advanced to the fracture site [Figure 2].
The fracture was manipulated with hand or occasionally the small F-tool used and reduction assessed by fluoroscopy. When the nail that appeared to be easier to pass on fluoroscopy was advanced through the fracture and, in most cases, it resulted in alignment of proximal and distal fragments. Following that the second nail was also advanced through the fracture site. The tip of the medial nail was supposed at the level of lesser trochanter and tip of the lateral nail was supposed to advance to the greater trochanter. The nails were cut to the assessed length and hammered in to their final positions. The distal ends were then bent 10-15° away from the cortex for easy removal on a later date.
The patient was kept non-weight-bearing for 2 weeks. A long-leg back slab was applied for patient comfort. After 2 weeks, the back slab along with the skin sutures was removed. Active knee bending exercises were allowed. The patient was allowed partial weight bearing with axillary crutches after 4 weeks. Radiographs were obtained after 6 weeks and progression to full-weight bearing was done depending on the status of fracture and the amount of callus formation. The patient was planned for implant removal after consolidation of the fracture, which was on an average of 1 year from the date of injury. All patients in the study were assessed for complications, both major and minor, according to Flynn's criteria [Table 1]. , Data was analyzed using chi-square test. P < 0.05* was considered as significant and P < 0.01 ** as highly significant.
| Results|| |
There was no significant difference between the groups in terms of demographic data, fracture type, pattern, and co-morbidities at the time of presentation. The commonest cause of injury was motor vehicle accident, accounting for 70% of the cases, with left femur (60%) more commonly injured than the right one (40%). All fractures in the operative group united clinically by 8 weeks and radiologically by 10 weeks, and, in the conservative group, by 9 weeks, clinically and 12 weeks radiologically. The conservative group also reported significantly higher degrees of angular mal alignment than the operative group. None of the patients had limping or abnormal gait as their shortening was well compensated by pelvic obliquity. One case that was treated by skeletal traction had pin-tract infection, which resolved on a course of oral antibiotics and local pin-tract care within a week and did not require removal of the pin. Two cases treated by Thomas' splint developed pressure sores in the groin, which resolved within a week on proper toileting of the area. One case treated with TENS, which had developed nail protrusion through the skin, required another operation for trimming of the nail. The follow-up of 1 year for all cases were uneventful with operative group showing significantly better results [Table 2].
|Table 2: Final post-operative assessment based on Flynn et al. criteria[6,8]|
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| Discussion|| |
Femoral shaft fracture is a major pediatric orthopedic injury, more common in boys, and occur in an interesting bimodal distribution with a peak during the toddler years and again in early adolescence. ,,,, In the present study, most of these fractures (70%) were attributable to high energy mechanisms, with motor vehicle accidents being the cause, rest were due to fall from a height. The age of the patients ranged from 6-14 years. Males outnumbered females in the ratio 2.3:1.
The ideal device for the treatment of most femoral fractures in children should be a simple, load-sharing internal splint that allows mobilization and maintenance of alignment and extremity length until bridging callus forms. Both Ender nails and titanium elastic nails offer these features. The titanium flexible nail with its newer design and improved material, however, provide better inherent stiffness resulting in adequate strength and elasticity as compared to the older Ender's nails. ,,,,,
In early childhood, the femur is relatively weak and is prone to fracture. In adolescence, high-velocity trauma is required to reach the stresses necessary for fracture. The etiology of femoral fractures in children varies with the age of the child. Abuse was the cause of only 1% of lower extremity fractures in children older than 18 months, but 67% of lower extremity fractures in children younger than 18 months. In older children, femoral fractures are most likely to be caused by high-energy injuries, motor vehicle accidents account for over 90% of femoral fractures in this age-group. The Waddell triad of femoral fracture, intra-abdominal or intrathoracic injury, and head injury are associated with high-velocity automobile injuries. ,,,,
Traction used in the treatment of femoral shaft fractures fails to provide adequate stability. Patients in this group tend to have higher degrees of angulation as compared to those treated operatively. Moreover, higher rates of limb length discrepancy in this group show the limited control over overriding of the fragments. There is always an impending risk of distal femoral epiphysis separation on application of excessive traction force.
In 2006, Mani et al., compared the stability afforded by Ender stainless steel nails, titanium elastic nails, and one-plane unilateral external fixators for the fixation using a synthetic adolescent midshaft femur fracture model. They found that, compared with the external fixation constructs, all 4 flexible nail constructs demonstrated higher torsional stability.  Decreased hospitalization, low cost of implants, less potential damage to growth centers, and decreased blood loss and operative time suggest that TENS has a merit over other operative procedures.
The limitation of this study is the small sample size and limited case study material available for analysis. Further studies with larger samples are planned in near future.
Studies have shown that pediatric femoral fractures treated operatively with titanium elastic nails achieved recovery milestones faster than patients treated with traction, corroborating with the present findings. , Fracture union occurred earlier in the surgical group than in the spica group and thereby different studies concluded that titanium elastic nailing led to better outcomes as compared to hip spica casting in terms of earlier union, lower rates of malunion, shorter rehabilitation milestones, and better functional outcome scores. ,,,
| Conclusion|| |
Internal fixation with titanium elastic nails provide better results, at least in the short term, than conservative treatment in traction. Long-term follow-up was not done, hence, commenting on the final outcome would be inappropriate keeping in mind the remodeling potential in the patients of the study group.
| References|| |
|1.||Allison P, Dahan-Oliel N, Jando VT, Yang SS, Hamdy RC. Open fractures of the femur in children: Analysis of various treatment methods. J Child Orthop 2011;5:101-8. |
|2.||Sheikh SI, Ullah M, Khan A, Iqbal J. Ender's nail for diaphyseal long bone lower limb fractures in children. J Rawalpindi Med Coll (JRMC) 2012;16:25-7. |
|3.||Bali K, Sudesh P, Patel S, Kumar V, Saini U, Dhillon MS. Pediatric femoral neck fractures: Our 10 Years of Experience. Clin Orthop Surg 2011;3:302-8.. |
|4.||Pulate A, Jadhav A, Shah NB. Study of the outcome of titanium elastic nail system in diaphyseal femoral fractures in children. J Maharashtra Orthop Assoc 2012;7:6-8. |
|5.||Akilapa O. Elastic stable intramedullary nail for paediatric femoral fractures. Webmed Cent TRAUMA 2012;3:WMC003325. |
|6.||Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-59. |
|7.||Hedlund R, Lindgren U. The incidence of femoral shaft fractures in children and adolescents. J Pediatr Orthop 1986;6:47-50. |
|8.||Flynn JM, Skaggs DL, Sponseller PD, Ganley TJ, Kay RM, Leitch KK. The operative management of pediatric fractures of the lower extremity. J Bone Joint Surg Am. 2002;84:2288-300. |
|9.||Stans AA, Morrissy RT, Renwick SE. Femoral shaft fracture treatment in patients age 6 to 16 years. J Pediatr Orthop 1999;19:222-8. |
|10.||Beaty JH, Austin SM, Warner WC, Canale ST, Nichols L. Interlocking intramedullary nailing of femoral-shaft fractures in adolescents: Preliminary results and complications. J Pediatr Orthop 1994;14:178-83. |
|11.||Letts M, Jarvis J, Lawton L, Davidson D. Complications of rigid intramedullary rodding of femoral shaft fractures in children. J Trauma 2002;52:504-16. |
|12.||Gustilo RB, Mendoza RM, Williams DM. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 1984;24:742-6. |
|13.||Flynn JM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, et al. Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am 2004;86-A:770-7. |
|14.||Saikia K, Bhuyan S, Bhattacharya T, Saikia S. Titanium elastic nailing of femoral diaphyseal fractures in children in 6-16 years of age. Indian J Orthop 2007;41:381-5. |
|15.||Mam MK, Dwayer DJ, John B. Fracture shaft of femur in children-Results of treatment. Indian J Orthop 2001;35:28-30. |
|16.||Mani US, Sabatino CT, Sabharwal S, Svach DJ, Suslak A, Behrens FF. Biomechanical comparison of flexible stainless steel and titanium nails with external fixation using a femur fracture model. J Pediatr Orthop 2006;26:182-7. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]