Page mackup-Final.qxd Original Article A Comparative Study Of Surgical Management Of Subtrochanteric Fractures In Children Sahu RL1, Gupta P2 Abstract: Introduction: Subtrochateric femoral fracture is a major cause of morbidity and mortality in patients with lower extremity injuries. There have been no studies that have specifically looked at the management of sub- trochanteric femoral fractures in skeletally immature adolescents. It was the purpose of this study to inves- tigate the treatment of this injury in this unique patient population. Methods: This study was conducted in the Department of Orthopaedic surgery in M. M. Medical College from July 2006 to November 2008. Thirty-four patients were recruited from Emergency and out patient department having closed sub- trochanteric femoral fracture. All patients were operated under general or spinal anesthesia. All patients were followed for twelve months. Results: All children achieved union in a mean time of 10 weeks (range from 6 - 16 weeks) depending on the type of long bone. Full weight bearing was possible in a mean time of 8.8 weeks. Mean duration of hospital stay was 9.8 days. The mean follow-up period was 28 months (17-48 months). Complications were recorded in 4 (11.77%) patients and included: two entry site skin irritations, one protrusion of the wires through the skin and one delayed union. The results were excellent in 97.06% and good in 2.97% patients. Conclusions: We conclude that Rigid and close interlocking nailing between the age of 9-16 years offered excellent fracture stability allowing early mobilization (early weight bearing) and joint motion in comparisons to the other groups and between the age of 6-8 years titanium elastic nail and bridging plate offered excellent result. Key wards: Subtrochanter, Fracture, Pediatric, Intramedullary. Introduction Femoral shaft fractures, including subtochanteric and supracondylar fractures, represent approximate- ly 1.6% of all bony injuries in children 1 . Paediatric subtrochanteric femoral fractures are rare and have received limited attention in the literature 2; 3 . The subtrochanteric femoral fracture in children is a spe- cial type which occurs 1 to 2 cm below the lesser trochanter. The proximal fragment tends to flex (ilio- psoas), abduct (abductor group) and rotate external- ly (short external rotators) 4 . The treatment of sub- trochanteric femoral fractures in children is contro- versial. Different treatment options have been used: skin traction, 90/90 skeletal traction, immediate spica casting, cast bracing, internal fixation and external fixation. Treatment choices are influenced by the child’s age and size and whether the femoral fracture is an isolated injury or part of a polytrauma. Economic concerns, the family’s ability to care for a child with a spica cast or external fixator, and the advantages and disadvantages of any operative pro- cedure are also important factors 1 . Indications for operative treatment include multiple trauma, head injury, open fracture, floating knee, vascular or neu- rological injuries, failure of conservative treatment, older child or adolescent and social indications 5 ,6, 7, 8 . Methods of internal fixation include; intramedullary nails, compression plating and external fixator 5, 7, 9, 10 . Methods: This prospective study was carried out at Orthopaedics department of M.M. Medical college from July 2006 to November 2008. It was approved by institutional medical ethics committee. A total of 34 patients with subtrochanteric femur fracture Bangladesh Journal of Medical Science Vol. 11 No. 03 July’12 178 1. Dr Ramji Lal Sahu MS, Associate Professor, Department of Orthopedics, SMS and RI, Sharda University., Greater Noida, U. P.,India 2. Dr Pratiksha gupta MD, Associate professor, PGIMSR,ESIC, Basaidarapur, New-Delhi, India Corresponds to: Dr Ramji Lal Sahu, House number 11284 Laj building,No 1, doriwalan new rohtak road,Karol bagh New, Email drrlsahu@gmail.com admitted to our institute were included in present study. A written informed consent was obtained from all the patients; they were explained about treatment plan, cost of operation, and hospital stay after sur- gery, and complications of anaesthesia. They were followed up after surgery, were clinically and radio- logically assessed for fracture healing, joint move- ments and implant failure. According to the criteria the results are graded as excellent when the fractures unites within 16 weeks without any complication, good when union occur within 24 weeks with treat- able complications like superfi cial infection and knee stiffness and poor when union occur before or after 24 weeks with one or more permanent compli- cations like infection (osteomyelitis), implant fail- ure, non-union, limb shortening and permanent knee stiffness. Delayed union was recorded when the fracture united between three to six months while nonunion was noted when union had not occurred after eight months of treatment Follow-up was done. Patients with closed subtrochanteric femoral fracture with age between 6-16 years and presented within a week of the injury and did not have any previous surgical treatment for the fracture was included in the study. Malnourished patients and those with open fractures, pathological fractures and fracture nonunion were excluded from the study. Examination of patients was done thoroughly at the time of admission to exclude other injuries. Patients were included when part of the fracture was within the inferior aspect of the lesser trochanter and 5 cm below it, Patients underwent skin traction till their operation. Anteroposterior and lateral radiographs were obtained from the hip to the knee. Fractures were classified according to Seinsheimer classifica- tion ( In type I there were 6 patients, in type II a-10 patients, in type II b- 8 patients, in type II c- 4 patients, in type III a-3 patients, in type III b-2 patients, in type IV-1 patient and in type V- 0 patient) (Table II). In all the patients surgical management of subtrochater of the femur was performed on seventh to fourteenth day after the injury. In patients who were not fit for surgery due to associated injuries to vital organs, were haemodynamically unstable or due to active infection at injury site, or were pyrexi- al delayed surgical management was performed when their over-all condition improved. All patients were operated under general or spinal anesthesia. First generation cephalosporin was administered at the time of induction of anesthesia as prophylaxis. Patients were laid supine on the fracture table with traction pin in condyles of fractured femur. The frac- ture was reduced by traction and manipulation under image intensifi cation. After preparing the femur in standard manner, internal fixation with implants were done. Rehabilitation such as touch down weight bearing was started on 2nd post-operative day and sutures were removed on 14th post-opera- tive day. These patients were assessed clinically and radio logically for union timing at nine months fol- lowing surgery. Patients were assessed for delayed union (more than 4-6 weeks postoperative) and non union (nine months following surgery). Stastical analysis was limited to calculation of percentage of patients who had unions, malunions, delayed unions, A Comparative Study Of Surgical Management Of Subtrochanteric Fractures In Children 179 Table I. Age and sex variations in study group (n=34) Age (years) Male R L Female R L Total 6-8 9-12 13-16 4 6 12 3 3 7 1 3 5 2 4 6 1 2 4 1 2 2 6 10 18 Total 22 13 9 12 7 5 34 Table I. Age and sex variations in study group (n=34) Age (years) Male R L Female R L Total 6-8 9-12 13-16 4 6 12 3 3 7 1 3 5 2 4 6 1 2 4 1 2 2 6 10 18 Total 22 13 9 12 7 5 34 Implant Group A Group B Group C Group D Group E Group F Group G Age (years) ESIN PFN ILN ENDERS DHS DCS LCDCP 6-8 9-12 13-16 1 2 2 0 2 3 0 2 3 1 2 2 1 2 3 1 1 3 1 2 3 Total 5 5 5 4 5 5 5 Table III: Implant used in subtrochanteric fractures (n=34), Elastic Stable Intra-medullary Nailing (ESIN),Proximal femoral nail (PFN), Interlocking nail (ILN), Dynamic hip screw (DHS), Dinamic condylar screw (DCS),Low contact dynamic compression screw (LCDCP). or non unions and Excellent, Good, and poor out- comes (Table IV). Ethical and legal procedure The protocol was approved by an ethics committee and thus meets the standards of the Declaration of Helsinki in its revised version of 1975 and amend- ments made to it in 1983, 1989 and 1996 (JAMA 1997; 277:925–6). Results: There were 22 (64.70%) male and 12 (35.29%) female patients (Table I). The mechanism of injury was road traffic accident in 80% of patients, fall from height 10% and industrial accident was 10%. Injury to left lower limb was seen in 41.18% and right lower limb in 58.82% of patients. The average hospital stay was 18 days. In group A, patients were having fracture according to seinsheimer classifica- tion, type I (6 fractures), type II A (10 fractures), type IIB (8 fractures), type IIC (4 fractures), type IIIA (3 fractures), type IIIB (2 fractures), type IV (1 fracture) and type V (0 fracture). These patients were divided into seven groups. Patients in A group were fixed with Elastic stable intramedullary nailing, group B with proximal femoral nailing, group C with interlocking nailing, group D with Enders nail- ing, group E with dynamic hip screws, group F with dynamic condylar screws and group G with low- contact dynamic compression plates (Table III) (FigureI-IV). In group A, complication of titaneum elastic nails was skin irritation at the nail entry site and in group D there was protrusions of the wires through the skin and malunion. In group B,C, E,F and G found no significant complication. Flexible nails are not suitable for proximal fractures and can withstand only 40% of the body weight and recom- mend starting of weight bearing to be delayed until the appearance of early callus formation at three to four weeks time following the fixation. In group B and C, between the age of 9-16 years, Rigid and close interlocking nailing on the other hand offered excellent fracture stability even in heavier adoles- cents especially those with a comminuted fracture pattern allowing early mobilization and joint motion in comparisons to the other groups. We placed the nails through the lateral aspect of the trochanter between the apophysis and the tip of the trochanter and avoid the piriformis fossa and the tip of the trochanter. No patient developed any significant complications such as alterations in the proximal femoral anatomy or a vascular necrosis. Physical therapy was started immediately if it was possible because of related injuries. Post-operatively, mean follow-up was 28 months (17 -48 months). No major complications were observed in relation to surgery. Complications as a result of the procedure were recorded in 4(11.77%) patients and included one patient (2.97%) were labeled as delayed union because of obvious gap at the fracture site in subse- quent radiographs (Table V). This was due to over distraction of fracture during operation, and was treated by bone graft, two entry site skin irritations; one protrusion of the wires through the skin although they had been buried during the procedure. This nail required removal 2–3 weeks prior to the planned date of removal. There was no instance of loss of reduction, or nail migration during the post-opera- tive period. No clinically significant deformities were ob-served. There were no cases of nonunion or mal-union. All patients achieved complete radi- ographic healing at a mean of 10 weeks (range from 6 -16 weeks).In a subjective measure of outcome at follow-up, 33(97.06%) of the patients were excellent and 1 (2.97%) good; no patients or parents reported their out-come as not satisfied (Table IV). At follow- up all patients went on to osseous union and regained a full range of movement after rehabilita- tion. Discussion Paediatric subtrochanteric femoral fractures present a special unstable type which receives no special attention in the literature 2, 3 . Patient’s age may be the most important single variable regarding pediatric femoral fracture treatment. The treatment for chil- dren between the ages 6-12 years is the most contro- versial. Treatment options include traction followed by hip spica cast, immediate spica casting, cast brac- ing, internal fixation and external fixation 11 . Traction Sahu RL, Gupta P 180 Out comes No Percentage Excellent Good Poor 33 1 0 97.06% 2.97% 0% Table IV: Out come of results of subtrochanteric fractures (n=34) Complications No 1 entry site skin irritations 2 protrusions of the wires through the ski n 3 delayed union 2 1 1 Table V: Complications (n=34) followed by hip spica cast is the method preferred by many surgeons for the treatment of children aged 6- 10 years 8 . Aronson et al 12 studied 54 children who had been treated in distal femoral 90/90 traction for an average of 24 days before being placed in a 1 1/2 hip spica cast. At an average follow-up of 4.3 years, all children were functionally normal and showed a symmetric range of motion of hip and knee. However, this method requires a relatively long hos- pitalization and accurate control of fracture align- ment with frequent radiographs and adjustment in traction as needed. 90/90 skeletal traction with post traction spica is not suitable in children weighing more than 45 kg or in children older than 10 years of age as it will be associated with an unacceptable high incidence of femoral shortening and malrota- tion 13, 14 . Immediate spica casting, popularized by Staheli and Sheridan 15 is indicated for isolated femoral shaft fractures in children under 6 years of age. Infante et al 16 expanded the indications for spica casts to children up to age 10 and up to 50 kg. Its pri- mary advantages are simplicity, low cost, and gener- ally good results. Ferguson and Nicol 17 conducted a prospective study of early spica casting in children less than 10 years of age. They found that age greater than 7 years was a variable predictive of a higher risk of failure of this technique to achieve satisfacto- ry alignment. Martinez et al 18 reported excessive shortening and angular deformity in 26 of 51 patients after immediate spica casting. Several stud- ies have documented superior results with internal fixation compared to non operative treatment 19, 20, 21 . According to Kregor et al 5 the indications for oper- ative fixation of paediatric femoral fractures were presence of associated closed head injury and/or multiple injuries, open fractures and failure of con- servative treatment. We applied the indications to include isolated paediatric subtrochanteric femoral fractures as we believe that it is difficult to maintain such fractures in an accepted position by non opera- tive means. Methods of internal fixation of paedi- atric subtrochanteric fractures include intramedullary nails, compression plating and exter- nal fixators 5, 7, 9, 10 . Awareness of the advantages and disadvantages of intramedullary nails, compression plates and external fixator and the skill to apply each method safely are requisites to the ideal management of such fractures 4 . Good results were reported with external fixators, but the rates of pin tract infection, refracture and loss of reduction are high 7, 11, 22, and 23. We preferred not to use the external fixator in the treatment of paediatric subtrochanteric femoral frac- tures as there is no sufficient room for application of the pins into the proximal femoral fragment. Flexible intramedullary nailing is nowadays the treatment of choice in paediatric femoral fractures. A Comparative Study Of Surgical Management Of Subtrochanteric Fractures In Children 181 Figure 1: Pre and post operative radiograph of sub- trochanter fracture of 5 years old child Treated with titanium elastic nail. Figure 2: Pre and post operative radiograph of sub- trochanter fracture of 15 years old child Treated with proximal femoral nail. Figure 3: Pre and post operative radiograph of sub- trochanter fracture of 16 years old child Treated with 95 0 dynamic condyler plate Figure 4: Pre and post operative radiograph of sub- trochanter fracture of 9 years old child Treated with low contact dynamic compression plate. Patients are able to partially weight bear early because a rod is a load-sharing device, there is rapid fracture healing and a low incidence of malunion and non union 6, 9, 19, 20, 24 . Disadvantages of intramedullary nailing are lack of rotational control, exposure to irradiation and backing out of implants 5. Fixation of subtrochanteric fractures in children using intramedullary nails need special experience and may be difficult to achieve. Plate fixation, despite the negative report of Ziv and Rang 25 , has been shown to work well in the paediatric age group 5, 10, 14, 26, 27 . The disadvantage of plating are the need for plate removal, poor cosmetic appearance of the scar, blood loss associated with exposure and reduc- tion of the fracture and reported higher degree of overgrowth induced by the plates compared with intramedullary fixation 25, 28 . On the other hand, patients treated with a plate require less assistance, can walk with crutches within ten days postopera- tively and return to school sooner than children treat- ed in 90/90 skeletal traction 21 . Ward et al 27 reported the use of a 4.5 mm AO dynamic compression plate for the treatment of femoral shaft fractures in 25 children, 6 to 16 years of age, 22 of whom had asso- ciated fractures or multisystem injury. The primary indication for this technique was simplification of nursing care and rehabilitation of children with an associated head injury or polytrauma. The average time to fracture union was 11 weeks. There were no infections and no angular deformities. Kregor et al 5 reported on 12 patients who had 15 femoral fractures treated with compression plating. All fractures healed at an average of 8 weeks. The mean healing time in our study was the same as that reported by Kregor et al 5 . Ziv and Rang 25 reported three deep infections among five children with head injuries and with femoral shaft fractures. They believed that infec-tions were related to the large number of tubes attached to these patients and their decreased resist- ance. Eren et al 26 reported one case of osteo- myelitis (2.1%) which occurred in a child with poly- trauma. In our study, we encountered no deep infec- tions. Many other reports documented no deep infec- tion with plate fixation 5, 10, and 27 . Flynn et al reported two deep infections (3%) with titanium elastic nails 9 . Extensive dissection and periosteal stripping during plate application may lead to overgrowth. Overgrowth was not a significant problem in the series of Kregor et al 5 , with an average increase in length of 0.9 cm (ranging between 0.3 and 1.4 cm), but Ward et al 27 reported several patients with considerable overgrowth (approximately 2.5 cm), and Hansen 29 reported overgrowth of 2.5 cm in a 12-year-old boy, suggesting that over- growth is possible in children over 10 years of age. Eren et al 26 reported a series of 40 children aged 4 to 10 years with significant lengthening on the operated side in 40% of patients, averaging 1.2 cm (range, 0.4-1.8 cm). In agreement with Kregor et al 5 , overgrowth was not a significant problem in our study. Scanograms revealed overgrowth of the injured femur with an average of 0.9 cm (range, 0.5 to 1.2 cm) in twelve patients (72.2%). Hardware failure is a possible complication with any implant. In the series of Ward et al 27 , there was one broken plate postoperatively in a boy who began full weight bear- ing a few days postoperatively. Fyodorov et al 10 reported hardware failure in 2 of 23 femoral frac- tures treated with dynamic compression plating. Hardware failure occurred at 6 weeks. One was treated with revision plating and the other with spica casting; both fractures healed uneventfully. No other complications were noted in their patients. In this study, implant failure did not occur in any patient. The need for hardware removal is controversial 26, 27 and30 . Refracture is rare distal to the plate or through screw holes and whether bone atrophy under the plate is caused by stress shielding or by avascularity of the cortex is unknown 1 and 31 . In the series of Ward et al 27 , there was a refracture through a screw hole in one of 15 patients who had the plate removed. They do not recommend plate removal in asymptomatic children. Eren et al 26 also reported one patient (out of 40 patients) who sustained a refracture 9 years after plate removal. This occurred with a minor trau- ma while he was playing basketball. On the other hand, Bransby- Zachary 30 recommended plate removal because they had five late fractures 20 to 60 months after internal fixation. In this study, we encountered no refracture or problems leaving the implants in place during the follow-up period. Conclusion: Subtrochanteric femoral fractures in children can be managed successfully in a variety of ways. Ultimately, many factors play a role in the choice of management, including the age and size of the child, fracture pattern, associated injuries and surgeon and family preferences. Operative management whether intramedullary or extramedullary devices both give better results because when operative treatment is undertaken, it should be by experienced surgeons using the technique with which they are most famil- iar. Children between the ages of 6 and 8 years are typically managed with TENs, but submuscular bridge plating is also an option, particularly for com- Sahu RL, Gupta P 182 minuted fractures. For children older than 8 years, rigid antegrade nails using a lateral trochanteric entry site have been successful and without reported major complications, although more studies are needed. In length-unstable fractures and in older, heavier patients, trochanteric entry nailing or plating is recommended. Traditional plating has excellent results reported in the literature, but involves a larg- er surgical approach and scar. References: 1. Kasser JR, Beaty JH. Femoral shaft fractures. In : Rockwood and Wilkins, Fractures in Children, 6th ed, Acta Orthopædica Belgica, Vol. 73 - 4 – 2007 490 M. EL-SAYED, M. ABULSAAD, M. EL- HADIDI, W. EL-ADL, M. EL-BATOUTY Beaty JH, Kasser JR (eds). 2006; Vol 3, pp 894-936, Lippincott Williams and Wilkins. 2. 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