Short-term outcomes of operative surgical treatment of femur diaphyseal fractures in children at Moi Teaching and Referral Hospital, Eldoret, Kenya

Abstract

Background: In the past three years at Moi Teaching and Referral Hospital (MTRH) an observation has been made that less patients with paediatric femur diaphyseal fractures are treated nonoperatively. The change from nonoperative to operative surgical treatment was seen in Europe and United States of America three decades ago. This study served to evaluate the operative surgical treatment outcomes of femur diaphyseal fracture in children. Objective: This study set out to characterize femur diaphyseal fractures in children operated at Moi Teaching and Referral Hospital, determine the operative surgical treatment techniques used and assess their short term outcomes. Methods: This was a cross sectional study, conducted at the paediatric orthopaedics clinic of MTRH after ethical clearance was obtained from IREC. Forty-three patients were identified and recruited 12 weeks after operative surgical management for their femur diaphyseal fractures and discharged from orthopaedics ward. Demographics of the patient, mechanism of injury and type of fracture, days to admission and days to surgery, operative surgical techniques, and the clinical outcomes including complications (knee stiffness, length discrepancy, and infection), the time to walk on crutches, and time to walk without support were recorded in a structured data collection form. Union was determined using clinical and radiological means. The Flynn criterion grading was determined for each patient at the same time. Data was entered into SPSS® version 23 for analysis and results presented in graphs, tables and figures. Results: There were forty-three patients seen at the clinic on the 12th week after their operative surgery and discharged from orthopaedics ward. Male to female ratio was 2.23:1. At the time of injury the mean age was 9 years (SD 2.9). Majority of the fractures were caused by a fall from height (46.5%) followed by road traffic accidents (32.5%). The fractures were simple (32- D/4.1) for majority of the patients (65.1%). Patients were admitted at a mean of 3.3 (SD 6.6) days after injury and had surgery done at a mean of 7.4 days (SD 4.9) after injury. However it took a mean of 10.7 (SD 7.6) days from injury to surgery. Dynamic compression plate (DCP) was used to treat 86% of the fractures. At 12 weeks knee stiffness was present in 8 (18.6%) of the patients, shortening of the femur in two. Deep infection occurred in one patient. Union and alignment were good at twelve weeks. However, two patients required reoperation due to loss of reduction before their twelfth week clinic checkup. Patients who scored satisfactory to excellent on Flynn criteria grading were 41 out of 43.Patients who scored poorly on the Flynn criteria grading were those who had open fractures and required external fixators and had deep infection at twelve weeks, 74% of patients were able to walk on crutches within 3 days after surgery and at 12 weeks 9 patients were still ambulating with crutches. Conclusions: Majority of the patients requiring surgery presented with type 32- D/4.1. The DCP was the main technique of fixation offered to the children, with surgery for femur fractures done within 8 days of their injury. At twelve weeks the majority of patients were able to ambulate without support but knee stiffness was encountered in some patients. The Flynn criteria grading were satisfactory to excellent for most of the patients at twelve weeks. Recommendations: Creating awareness on injury prevention should be encouraged. Use of DCP for simple femur fractures in children should be encouraged. Knee stiffness is a complication that surgeons should deliberately look for in the post-operative period following femur plating and take appropriate action, so as to improve the clinical short- term outcomes and Flynn criteria grading.