Early reduction versus skin traction in the orthopaedic treatment of femoral shaft fractures in children under 6 years old

Abstract

Background Femoral shaft fractures occur very frequently in children, and their prognosis usually is good. Nonoperative treatment is the gold standard for children under 6 years because of the excellent bony union and the remodelling qualities. Purpose The aim of this study was to compare two orthopaedic therapeutic methods: skin traction versus immediate reduction. Materials and methods The study involved 35 children, divided into two groups: in group 1, treatment consisted of skin traction for 21 days followed by hip spica casting; in group 2, an immediate reduction with early hip spica casting was performed. The ranges of motion, the delay before weight bearing, the hospitalisation duration and the required amount of painkillers were recorded. We compared initial shortening, axial, sagittal and rotational alignment, and femoral length discrepancy. We calculated the injured femoral diaphysal overgrowth and correlated it to the fracture type and location and to the initial shortening. Economical variables were also studied. Results The mean overgrowth was 8.9 mm in group 1 and 8.5 mm in group 2. Three years after the trauma, length discrepancy was 4 mm in group 1 and 1 mm in group 2. Hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration and pain. The cost of treatment with skin traction was four times higher (24,472 euros) than that of immediate reduction (6,384 euros).Discussion Our results are in accordance with the literature. The femoral overgrowth was proportional to the initial shortening. Masculine gender, an oblique fracture and injury of the lower third of the femur were associated with the greatest femoral overgrowth. During the first year of follow-up, the femoral length discrepancy hardly varied after immediate reduction (4 mm), whereas the overgrowth reached 6 mm after skin traction. Overall, immediate hip spica casting leads to significant reductions in weightbearing delay, hospitalisation duration, complications and costs, while having similar clinical results as traction.

Outcome of non-operative management of femoral shaft fractures in children

“…[4,10,12,26,27] Seventy-seven percent of our study population were children of parents of low socio-economic status who could not afford operative management. It is therefore not surprising that the most common modality of treatment of paediatric femoral fractures in our setting was skin traction (87.7%) [ .…”

“…[4,5] The choice of management is influenced by age and size of the patient, location and site of the fracture (fracture personality), associated injuries or multiple trauma, social circumstances or family issues and cost. [6][7][8] The treatment options include non-operative management with home traction, [9,10] immediate spica cast application [11,12] or a short period of traction followed by spica cast [13,14] and operative management with external fixation, [15][16][17] flexible intramedullary nailing [18,19] and plate fixation. [20,21] We treat paediatric femoral fractures with skin traction only or a short period of skin traction followed by plaster of paris hip spica cast in our centre.…”

Outcome of Study of Immediate Hip Spica Application in Femoral Diaphyseal Fractures in Children

“…The duration of cast immobilisation ranged from 4 -6 weeks and average time of union was 50 days. D'Ollonne T et al 6 in their study showed that cast immobilisation duration was 76.8 days in skin traction group and 61.5 days in early hip spica group. Angulation was within acceptable range in all cases except in 1 case, where 25 o of angulation was in sagittal plane.…”

“…Average duration of hospital stay was 1.5 days in our study. D'Ollonne T et al 6 found that mean hospitalisation was 18.8 days in skin traction group and 2.8 days in early hip spica group. The duration of cast immobilisation ranged from 4 -6 weeks and average time of union was 50 days.…”

Four Weeks in a Single-Leg Weight-Bearing Hip Spica Cast is Sufficient Treatment for Isolated Femoral Shaft Fractures in Children Aged 1 to 3 Years

“…4 After the age of 6 months and up to 5 years old, the standard treatment is a hip spica cast. [5][6][7] Some surgeons use skin or skeletal traction [8][9][10] or external fixators 11 either alone or in conjunction with hip spica casting. Over age 5, surgical treatments are more commonly used, including flexible titanium elastic nails, [11][12][13][14] submuscular bridge plates, 15,16 and eventually as the child gets closer to skeletal maturity, lateral entry intramedullary nails.…”