Management of Fracture Shaft Femur in Children According to Recent Standard Criteria in Al-Hussein Teaching Hospital at Period from April 2018 to August 2019 View PDF

Pediatric femoral shaft fractures are uncommon; they account for 1.6-2% of all pediatric fractures. They are the most common pediatric orthopedic fractures that necessities admission to the hospital. Fracture of the femoral diaphysis between the area 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle.

Anatomy

In contrast to adults, the immature skeleton is characterized by the presence of open physes, thicker periosteum, and a different biomechanical behavior in response to loading. As proximal and distal growth plates are both placed at risk during the insertion of intramedullary fixation, they must be protected to prevent varying degrees of growth disturbance. The paediatric femur, in contrast to the adult femur, has a high capacity for remodeling and as such will tolerate up to 25 degrees of angulations; up to 25 % of malrotation and. A shortening of up to 1 cm in those under the age of 10 is accepted due to overgrowth which is caused by the vessel-rich periosteum being stimulated in response to local injury [1-6].

Mechanism of Injury

• Child abuse.
• High energy injury like motor vehicle accidents.
• Gunshot wound.
• Pathological fracture (uncommon) such as Osteogensis imperfect.
• Benign lesion such as non-ossifying fibroma, aneurismal bone cyst.
• Stress fracture.

Clinical Features

• Extreme pain.
• Unable to walk.
• Obvious fracture.
• Swelling and deformity.
• Crepitance.
• Instability.
• Tenderness to palpation.
• Compartment syndrome (distal paresthesia, diminished pulse, distal weakness, pain with passive range of motion).

Classification

• Open or closed.
• Location of fracture (Sub trochanteric, Diaphyseal (proximal, mid, distal third), Supracondylar).
• Fracture pattern (Transverse, Spiral, Oblique, Comminuted, Greenstick).
• Amount of shortening.
• Angular deformity.

Diagnosis

• Plain x-ray (anterio-posterior, lateral).
• CT scan.
• Magnetic Resonance Imaging for diagnosis of small buckle fragments.

Complications

• Leg length discrepancy. Angular deformity.
• Rotational deformity.
• Delayed union.
• Nonunion.
• Muscle weakness.
• Infection.
• Neurovascular injury.
• Compartment syndrome.

Treatment

Conservative for patients below five years includes: Pavlik Harness; Traction; Hip Spica.

Surgery for patients above five years includes: Elastic nails; Plate and screws; External fixation.

Principles of fracture treatment and factors influencing treatment

The aim of fracture treatment in children is the restoration of function and a normal level of activity as quickly as possible with the minimum physical and psychological distress [7-11]. Six key principles for the treatment of paediatric diaphyseal fractures:

• The simplest treatment is the best treatment.
• The initial treatment should be definitive whenever possible.
• Anatomic reduction was not required for perfect function.
• Alignment must be restored, especially rotational alignment.
• The more growth that remained, the more remodeling was available.

The limb should be immobilized in a splint until definitive treatment had been instituted.

A prospective study of sixty child with the fracture shaft of femur were admitted to Al-Hussein Teaching Hospital in Samawa city at a period from April 2018 to August 2019 and evaluated for age, sex, side of fracture and mechanism of injury. All patients were sent for x-ray to evaluate:

• Varus-valgus angle at Anterio-posterior view.
• Anterior-posterior tilt angle at lateral view according to (AutoCAD 2007 program).
• Shortening.
• Pattern of the fracture whether it is transverse, oblique, spiral, or comminuted.
• Location of fracture whether at proximal, middle or distal part of femur. We use Fisher's exact test and Chi-square test when is applicable.

Measurements of different angles and shortening.

We treated the patients with conservative or surgical methods according to their age as shown in table 1.

Table 1: Treatment options for isolated femoral shaft fractures in children.

In this study we evaluate the outcome of the treatment by following up of the patients every two months for six months to assess the union with the x-ray and CT scan and measuring varus-valgus angle, anterior-posterior tilt angle and shortening before and after the treatment and compare the results with the standard acceptable angulations values as shown in table 2.So the outcome of treatments whether excellent, satisfactory or poor as in the figure.

Table 2: Acceptable Angulations.

In this study we evaluated the complications of treatments through the follow up of the patients such as non-union, malunion, knee stiffness, leg length discrepancy and infection in case of surgical treatment of the fractures.

A prospective study of sixty child with fracture shaft femur were admitted to Al-Hussein Teaching Hospital in Samawa city at the period from April 2018 to August 2019, we calculate the varus-valgus angulations, anterior-posterior displacement and shortening. Table 3 shows the values before the treatment, while in table 4 shows the values after treatment.

Table 3: Before treatment.

Table 4: After treatment.

Fractures shaft of femur are uncommon it account about 1.6-2 % of all pediatric fractures. They are the commonest injury which necessity admission to the hospital. In this study we admit sixty child with the fracture shaft of femur to the hospitals. The age of the patients range between four months and ten years, the age group (6-8) years is the most common as shown in figure 1 [12-18]. Males more than females and form about 70 % of cases as shown in figure 2. Spiral fracture are the most common pattern as shown in figure 3. The left side fracture are the commonest as shown in figure 4. Most of the fractures located at the middle part of the femur as shown in figure 5. Most of the fractures are caused by fall from height as shown in figure 6.

In this study there are many options of models of treatment for fracture shaft of femur in children according to their age as shown in figure 7, the patient's age below five years treated conservatively with traction, pavlik harness or hip spica due to their excellent union and remodeling as shown in table 1, while those patients with the age above five years need to surgical fixation such as elastic nails, plate and screws and external fixation to prevent shortening and malunion [19-21].

Spica cast in school age children is associated with complications like cast breakage, loose of reduction, malunion, skin complications, and prolong mobilization, quadriceps weakness and psychological effect, so the treatment shifted toward operative stabilization of the fracture.

Elastic Ender nail is the preferred operative method rather than plate and screw and external fixation especially at middiaphyseal fracture and transverse fracture because of:

• Decrease hospitalization, low cost of implants, less damaged to growth centers, decrease blood loose and operative time.
• The femur is subjected to significant bending, axial, torsional stress that exceeds three to four times body weight during normal activities, elastic nails produce flexual stability, axial stabilityand rotational stability, so this prevents shortening and malunion, but this procedure requires a C-arm facility which not present at all centers.

All the patients had union at the fracture side with the evidence of bridging callus through follow up with the x-ray and CT scan every two months and for six months.

There was highly significant association between the age of the patient and the type of treatment as shown in table 5, that's mean for patient below five years treated conservatively and the patient above five years treated surgically (according to Fisher's Exact test).

Table 5:  The association between the age group and the treatment type.

There was no significant association between the type of treatment and the outcome as shown in table 6, because this depend on the age of the patients and the other criteria such as varus-valgus, anterio-posterior displacement and shortening.

Table 6:  The association between the treatment type and the outcome.

There was no significant association between the age group and the outcome of the treatment as shown in table 7. In this table the poor outcome of treatment in patient with the age below five years is zero, while those with the above five years is eight, this explain that small children had rapid union and remodeling more than younger children but there is no significant association because the outcome not only depend on the age but there are other criteria play important roles in the outcome result such as varus-valgus angulations, anterior-posterior displacement and shortening.

Table 7: The association between the Age group and the outcome.

There was no significant association between the pattern of the fracture and the outcome as shown in table 8, so the pattern play no role in the union and remodeling of the fracture but the outcome depend on the age and other factors.

Table 8: The association between the Pattern of fracture and the outcome.

The most common complications that evaluated in our study is stiffness of the knee as shown in figure 8, so it is better to start physiotherapy as early as possible (Figure 9). Many cases which were treated surgically presented with the infections so it should be applied them in asterile antiseptic technique regarding the theatre, equipments and medical staff.

The values of varus-valgus angle, anterior-posterior tilt and shortening were assessed before and after treatment as shown in tables 3 and table 4, which proved in our study were correlated with standard acceptable angulations criteria as shown in table 2, so this proved that the standard acceptable angulations criteria are reasonable and useful in treatment of the fracture shaft of femur in children. Also we proved that the age of the patient is an important factor in treatment of these fractures.

The age is an important factor in treatment of fracture shaft of femur in children we proved that the values of the varus-valgus angle, anterior-posterior displacement angle and shortening after treatment are correlated with the standard acceptable angulations which means that these standard angulations criteria are reasonable, suitable and useful in treatment of these fractures.

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