Outcomes of diaphyseal femur fractures managed in children 10 years and younger at Charlotte Maxeke Johannesburg Academic Hospital

Abstract

Introduction: Paediatric femur fractures have a bimodal age presentation. Children under the age of six are generally treated with non-operative management, while those older than ten have been shown to do better with surgical fixation. The management of the intermediate age group of six to ten years remains controversial, with recent opinions tending to favour surgical fixation. At Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) a clearly defined stepwise protocol has been established, in which patients that do not meet defined indications for surgery are managed in skin traction until clinical and radiological signs of union are present, at which point, patients are discharged to weight-bear as tolerated. Methods: This study was a retrospective review with a prospective recall of paediatric orthopaedic patients aged 10 years and younger treated in skin traction for femur fractures at CMJAH from January 2016 to December 2018. X-ray parameters were assessed on the Picture Archiving and Communication System for patients who met the inclusion criteria. Patients were then followed up at a minimum of 24 months to assess outcomes according to Flynn’s criteria. Other variables assessed included length of hospital stay and rotational profiles. Results: One hundred and seventy-nine patients were admitted to the paediatric orthopaedic ward at CMJAH with femur fractures over this period. Sixty-nine patients met the inclusion criteria set out in the study, of which 31 were available for follow-up. Seventy-seven percent of patients were aged 5 years and younger and 52% of injuries occurred due to low velocity falls. In terms of complications, 3 patients were found to have a limb length discrepancy, none of which exceeded 1cm. Three patients were found to have radiological malunion of >5 degrees. One patient sustained a pressure sore which healed uneventfully, and no patients had any joint stiffness, pain or refracture. Twenty-four of the patients achieved excellent outcomes, with 6 satisfactory and 1 poor outcome. No patients reported any subjective concerns or complaints with the outcome. Time in traction showed a median of 25 days per patient, with increased length of traction having a significant correlation to advancing age. There was a median time to full weight-bearing of 6 weeks and a median of 8 weeks of school missed per child. Conclusion: The majority of patients with femur fractures treated non-operatively at CMJAH went on to excellent outcomes with no patient subjective complaints. These findings were comparable to similar studies reviewing surgical management. The findings in this study suggest that there is a role for promoting our protocol of treatment to surrounding regional and peripheral hospitals that do not have access to orthopaedic expertise to offload specialist hospitals.