31.8.12 Comparison of Treatment of Fracture Shaft of Femur in Children with Titanium Elastic Nail VS Hip Spica Casting

Original Article

 

Treatment of Fracture Femur with Elastic Nail VS Hip Spica Casting

Comparison of Treatment of Fracture Shaft of Femur in Children with Titanium Elastic Nail VS Hip Spica Casting

 Muhammad Iqbal Buzdar1, Zulfiqar Ahmad1, Muhammad Imran Haider1 and Muhammad Ishfaq2

ABSTRACT

Objective: Evaluate the validity of titanium elastic nailing technique in treatment of femoral shaft fracture in children and comparison to hip spica casting.

Study Design: Randomized control trial study.

Place and Duration of Study: This study was conducted at the Orthopedics department of QAMC/BV hospital Bahawalpur in one-year duration from January 2019 to January 2020.

Materials and Methods: Fifty children of age 5-15 year presented with femoral shaft fracture at emergency department were included and the study patients were allocated in two groups by lottery method. Supracondylar femur Subtrochanteric fractures were excluded. Data analysis was done by using SPSS version 23. Mean and standard deviation was calculated for numercal data and frequency percentages were calculated for categorical data.

Results: Mean coronal plane angulation, sagittal plane angulation, rotational malalignment, LLD at 1 year
follow-up, union, non-weight-bearing, full weight-bearing and schooling lost, of TEN Group was 2.76
±1.64°, 5.41±2.36°, 6.02±1.32°, 0.52±0.11 cm, 6.71±2.28 weeks, 4.66±1.81 weeks, 6.39±3.96 weeks, 7.43±0.99 weeks.

Conclusion: Titanium elastic nailing is the treatment of choice for femoral shaft fracture between ages 5 to 15 years. Titanium elastic nailing reduces the malunion, shortening of length and enhances the union, early recovery and return to school.

Key Words: Hip Spica casting, Pediatric femur fracture, Titanium elastic nailing, Union, Coronal angulation.

Citation of article: Buzdar MI, Ahmad Z, Haider MI, Ishfaq M. Comparison of Treatment of Fracture Shaft of Femur in Children with Titanium Elastic Nail VS Hip Spica Casting. Med Forum 2020;31(8):50-53.

 

 

INTRODUCTION

Among pediatric injuries and fractures femoral shaft fractures are the most common fractures treated by orthopedic surgeon1. These fractures result by high traumatic incidents, most common cause of these injuries are high energy trauma2. Multiple treatment options are available for its management like hip Spica casting with and without traction and closed reduction, other options include Intramedullary gadejets, plates and fixations3,4.

Most of children age less than 6 years can effectively managed with Spica casting and skeletally mature children/teenagers are so best managed with nailing technique (antigrade inter looked)5.

 

 

1. Department of Orthopedics, QAMC/BV Hospital Bahawalpur.

2. Department of Orthopedics, Nishtar Medical University and Hospital, Multan.

 

 

Correspondence: Dr. Muhammad Iqbal Buzdar, Senior Registrar Orthopedic BV hospital, Bahawalpur.

Contact No: 0332-6376865

Email: drmiqbalbuzdar@gmail.com

 

 

Received:    April, 2020

Accepted:    May, 2020

Printed:        August, 2020

 

 

Among these all options best and effective technique for 6-16 years of age is still under debate6. Few years before this age group was managed with Spica casting after some time of traction application but this method of treatment have multiple complications like social, psychological, economics7.

Spica casting is a non-invasive procedure which not required time for wound healing and no risk of wound infection that why this procedure was recommended for children in previous years8. Latest technique of TEN and is property of non-infectious material replace the spica casting method9. From last two decade advantages of internal fixation and mobilization were highlighted day by day. External fixation and intramedullary nailing is a normal technique among surgical management0. This study was conducted to make the recognition about valid treatment of Pediatric femoral fracture like titanium elastic nailing or else.

MATERIALS AND METHODS

This study was started after ethical approval from board of hospital at orthopedic department of QAMC/BV hospital Bahawalpur. Study was completed in one-year duration from 2nd January 2019 to 1st January 2020. Patients were explained about purpose of study and written consent was obtained. Twenty patients of age
5-15 years were related for study and included, gastilo type I compound fracture of femoral shaft were included. Patients were divided into two groups (group TEN and group Spica) by lottery method. Patients in group TEN were treated with retrograde elastic nailing (equal sized titanium nails). Patients in group Spica were treated with Spica casting. Patients of age more than 15 years and segmental and communated fracture were excluded from study. Pathological fractures were also excluded. Standard method of elastic nailing was used and ends of nail were not bent. Fractures of instability and doubtful were done with long leg walking cast after one month of management. Stable fractures were fixed with support of Plaster of Paris Thigh corest. Some exercises for quadriceps strengthening were advised with non-weight bearing. In Spica group under general anesthesia one and half hip Spica was applied 20-30-degree flexion was given at hip and 10-15 degree at limb on external rotation. Full weight bearing was started after 1-2 weeks of casting and Spica casting was continued till union.

Collected data like age, gender, pattern of fracture, type of surgery, detail of fracture union rehabilitation milestones and complications were noted on SPSS version 23. Mean and standard deviation was calculated for numerical variables. Frequencies (percentages) were calculated for categorical data. Student t test and chi square test were applied to see association among variables. P value less than or equal to 0.05 was considered as significant.

RESULTS

Fifty patients were included in this study, both gender. The patients were divided into two groups i.e. TEN n=25 (50%) and Spica n=25 (50%). There were n=16 (64%) males and n=9 (36%) females, in TEN Group. While, in Spica, there were n=13 (52%) males and n=12 (48%) females. The mean age of Group TEN and Group Spica was 13.71±3.86 years and 12.36±2.78 years, respectively. (Table. 1).

Table No.1: Demographic characteristics of both the groups

Variable

Ten

n=25 (50%)

Spica

n=25 (50%)

P-value

Age (years)

13.71±3.86

12.36±2.78

0.274

Gender

Male

n=16 (64%)

n=13 (52%)

0.639

Female

n=9 (36%)

n=12 (48%)

The mean coronal plane angulation, sagittal plane angulation, rotational malalignment, LLD at 1 year follow-up, union, non-weight-bearing, full
weight-bearing and schooling lost, of TEN Group was 2.76
±1.64°, 5.41±2.36°, 6.02±1.32°, 0.52±0.11 cm, 6.71±2.28 weeks, 4.66±1.81 weeks, 6.39±3.96 weeks, 7.43±0.99 weeks, respectively. While, the mean coronal plane angulation, sagittal plane angulation, rotational malalignment, LLD at 1 year follow-up, union, non-weight-bearing, full weight-bearing and schooling lost, of Spica Group was 10.21±2.55, 7.91±2.29, 14.22±3.37, 1.47±0.32 cm, 8.99±1.26 weeks, 8.01±3.02 weeks, 11.32±2.82 weeks and 14.32±3.18 weeks, respectively. (Table. 2).

Table No.2: Outcome comparison of both the groups

Variable

Ten

n=25 (50%)

Spica

n=25 (50%)

P-value

Coronal plane angulation (°)

2.76±1.64

10.21±2.55

0.000

Sagittal plane angulation (°)

5.41±2.36

7.91±2.29

0.028

Rotational malalignment (°)

6.02±1.32

14.22±3.37

0.000

LLD at 1 year follow-up (cm)

0.52±0.11

1.47±0.32

0.000

Union (weeks)

6.71±2.28

8.99±1.26

0.013

Non-weight-bearing (weeks)

4.66±1.81

8.01±3.02

0.008

Full weight-bearing (weeks)

6.39±3.96

11.32±2.82

0.005

Schooling lost (weeks)

7.43±0.99

14.32±3.18

0.000

DISCUSSION

Femoral fractures are common in children and treated with Spica casting and traction after Spica casting. This procedure also resulted in number of complications. In a study Mastinez et al11 reported joint stiffness, malunion and delay in functional outcome. In another study conducted by Thomspson et al12 reported that complications occurred in both groups but Spica group have higher complications. Our study also reported similar findings that Spica group have higher complications rate as compared to titanium elastic nailing.

In a study conducted by Saseendar et al13 reported that higher coronal plane angulation was present in Spica casting group, rotational malaligament and limb length discrepancy also higher in Spica casting. Similar finding was reported in a study by Flynn et al14. Another study was conducted by Pollak et al15 in 1994 and reported higher incidence of loss of reduction and malunion in Spica casting group.

I in angulation following titanium nailing is due to miss match of nails and loss of diameter at fracture site. This finding was reported by Saikia et al16 and Navayanan et al17. Both of these studies recommended that protocols and standards of procedure must be followed.

Lee et al18 reported higher incidence of shortening and angulation that unacceptable is high in Spica casting group as compared elastic nailing treatment modality. Another study by Singh et al19 also reported similar findings angulation shortening is an undesired complication. His study compared these results with elastic nailing in which group this complication is less found.

All actions before concluded that early union and weight bearing is the key to early recovery to routine work and school. Similar milestones were recognized by Griesberg et al20. Hedin et al21 also conducted a study and reported that Spica casting have greater complications rate as compared to elastic nailing technique, malaligament and angulation miss match are two main outcomes that are essential to identify in both techniques.

CONCLUSION

This study reveals that Titanium elastic nailing is the treatment of choice for femoral shaft fracture between ages 5 to 15 years. Titanium elastic nailing reduces the malunion, shortening of length and enhances the union, early recovery and return to school.

Author’s Contribution

Concept & Design of Study:

Muhammad Iqbal Buzdar

Drafting:

Zulfiqar Ahmad, Muhammad Imran Haider

Data Analysis:

Muhammad Ishfaq

Revisiting Critically:

Muhammad Iqbal Buzdar, Zulfiqar Ahmad

Final Approval of version:

Muhammad Iqbal  Buzdar

Conflict of Interest: The study has no conflict of interest to declare by any author.

REFERENCES

1.      Imam MA, Negida AS, Elgebaly A, et al. Titanium Elastic Nails Versus Spica Cast in Pediatric Femoral Shaft Fractures: A Systematic Review and Meta-analysis of 1012 Patients. Arch Bone Jt Surg 2018;6(3):176–188.

2.      Andalib A, Sheikhbahaei E, Andalib Z, Tahririan MA. Effectiveness of minimally invasive plate osteosynthesis (MIPO) on comminuted tibial or femoral fractures. Arch Bone Jt Surg 2017; 5(5):290–5.

3.      DerSimonian R, Laird N. Meta-analysis in clinical trials revisited. Contemporary clinical trials 2015; 45(Pt A):139–45.

 

 

4.      Kumar A, Kumari A. Evaluation of outcome of titanium elastic nailing (TEN) versus hip spica cast in the treatment of femoral shaft fractures in children. Int J Orthopaedics Sci 2018;4(4):
149-154.

5.      Khaffaf RMN, Altaweel AH. Comparative Study between the Elastic Nail versus Hip Spica Cast in Early Treatment of Pediatric Femoral Shaft Fractures. Open J Orthopedics 2016; 6:259-267.

6.      Chandra Sekhar R et al. Femoral Shaft Fractures in Children: A Comparative Study in Treatment with Spica and Tens. IOSR J Dental and Med Sci (IOSR-JDMS) 2017; 16(6)I:11-14.

7.      Verma DP, et al. Comparative study of titanium elastic nailing versus hip spica in treatment of femoral shaft fractures in children Int J Res Orthop 2016;2(3):155-158.

8.      Imam MA, Negida AS, Elgebaly A, et al. Titanium Elastic Nails Versus Spica Cast in Pediatric Femoral Shaft Fractures: A Systematic Review and Meta-analysis of 1012 Patients. Arch Bone Jt Surg 2018;6(3):176–188.

9.      Ansari MAQ, Farhan MM. Closed diaphyseal fractures of femur in children treated by hip spica: early result of a clinical study results of a clinical study. International Journal of Research in Orthopaedics Ansari MAQ et al. Int J Res Orthop 2018;4(1):22-26.

10.  Sugi M, Cole WG. Early plaster treatment for fractures of the femoral shaft in childhood. J Bone Joint Surg Br 1987;69:743-5.

11.  Martinez AG, Carroll NC, Sarwark JF, Dias LS, Kelikian AS, Sisson GA Jr. Femoral shaft fractures in children treated with early spica cast. J Pediatr Orthop 1991;11:712–16.

12.  Thompson JD, Buehler KC, Sponseller PD, Gray DW, Black BE, Buckley SL, Griffin PP. Shortening in femoral shaft fractures in children treated with spica cast. Clin Orthop Relat Res 1997;338:74–78.

13.  Saseennder S. Treatment of femoral fractures in children: is titanium elastic nailing an improvement over hip spica casting? J Child Orthop 20104:
245–51.

14.  Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4–8.

15.  Pollak AN, Cooperman DR, Thompson GH. Spica cast treatment of femoral shaft fractures in children—the prognostic value of the mechanism of injury. J Trauma 1994;37:223–229.

 

 

 

16.  Saikia KC, Bhuyan SK, Bhattacharya TD, Saikia SP. Titanium elastic nailing in femoral diaphyseal fractures of children in 6–16 years of age. Indian J Orthop 2007;41:381–385.

17.  Narayanan UG, Hyman JE, Wainwright AM, Rang M, Alman BA. Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them. J Pediatr Orthop 2004;24:363–369.

18.  Lee SS, Mahar AT, Newton PO. Ender nail fixation of pediatric femur fractures: a biomechanical analysis. J Pediatr Orthop 2001; 21:442–445.

19.  Singh R, Sharma SC, Magu NK, Singla A. Titanium elastic nailing in pediatric femoral diaphyseal fractures. Ind J Orthop 2006;40:29–34.

20.  Greisberg J, Bliss MJ, Eberson CP, Solga P, d’Amato C. Social and economic benefits of flexible intramedullary nails in the treatment of pediatric femoral shaft fractures. Orthopedics 25:1067–1070.

21.  Hedin H. Surgical treatment of femoral fractures in children. Comparison between external fixation and elastic intramedullary nails: a review. Acta Orthop Scand 2004;75:231–240.