Skeletal versus skin traction before definitive management of pediatric femur fractures: a comparison of patient narcotic requirements

Skeletal Traction for Isolated Femur Fractures Does Not Reduce Opioid Consumption

OBJECTIVES

Isolated femoral shaft fractures can be treated preoperatively with skeletal traction (TXN) or maintenance of a position of comfort (COMF). The goal of this retrospective review was to determine whether preoperative opioid consumption differs significantly between these forms of treatment.

METHODS

DESIGN

Case-control retrospective study.

SETTING

Two academic Level 1 trauma centers.

PATIENT SELECTION CRITERIA

Patients presenting to the emergency department with isolated OTA/AO 32A-C femoral shaft fractures from 2017 to 2020.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was preoperative opioid consumption (morphine milligram equivalents) comparing patients treated with application of TXN or placed in a position of COMF.

RESULTS

Two hundred and twenty patients were studied (COMF n = 167, TXN n = 53). Multivariate regression analysis revealed significantly greater preoperative opioid consumption in the emergency department for the TXN group compared with COMF (2.6 more morphine milligram equivalents [confidence interval, 0.23-4.96], P = 0.031). There was no difference in preoperative opioid consumption between groups on the hospital floor ( P = 0.811) nor during the entire preoperative course ( P = 0.486). The total preoperative rate of opioid consumption (morphine milligram equivalents/hour) did not differ ( P = 0.825).

CONCLUSIONS

Patients with isolated femoral shaft fractures treated preoperatively with skeletal traction consumed more opioids in the emergency department compared with patients treated in a position of comfort, but no difference in opioid consumption was observed between groups for the entire preoperative course. A position of comfort may be considered as an acceptable alternative to skeletal traction for patients with isolated femur fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral fractures in the immature skeleton: Characterization, risk factors, and treatment options in a developing country

INTRODUCTION

Femur fracture is one of the most frequent reasons for admission to paediatric trauma units and has a bimodal incidence. The trauma mechanism varies according to the patient's age. Non-operative treatment continues to be performed, although surgical treatment has gained popularity in recent years. Paediatric orthopaedic traumatologists should always bear in mind the already known general principles of treatment. In this study, we aimed to provide a general characterization of femoral fractures, risk factors, and current definitive treatment methods in a developing Latin American country.

MATERIALS AND METHODS

This is an observational, analytical, retrospective study with a non-probabilistic sample of consecutive cases of skeletally immature patients with femoral fractures treated at a trauma hospital in Asunción, Paraguay, from January to December 2022. Patients with diseases fragile bones and femoral fractures were excluded. Demographic and clinical characteristics of the study population were analysed.

RESULTS

Traffic accidents were the most frequent cause of femoral fractures in our population. Femur fractures were more common in males. The femoral shaft was the most frequent fracture site. Age was one of the most important criteria for defining the treatment approach, considering non-operative management in children younger than 4 years.

CONCLUSIONS

Fracture of the femoral shaft in male patients is the most frequent presentation at our Institution. Summer vacations and traffic accidents are the main risk factors identified in Paraguayan children who suffer a femoral fracture. Non-operative treatment is preferred in children under 4 years of age, while surgical treatment is preferred in children aged 5 years and above. Paediatric orthopaedic traumatologists should be involved in parent education to promote children's safety, especially by increasing care and vigilance during school vacations and dangers related to traffic accidents.

A comparative evaluation of the efficacy between skeletal traction and skin traction in pre-operative management of femur shaft fractures in Korle Bu Teaching Hospital

OBJECTIVES

This study is to compare the outcomes of pre-operative skeletal and skin traction in adult femoral shaft fractures awaiting surgical fixation within two weeks of presentation to the Accident Center of Korle Bu Teaching Hospital.

METHODS

This study was a clinical trial on 86 recruited patients with closed femoral shaft fractures sustained within 24 hours of presentation grouped into 2 groups. Descriptive and inferential statistics comprising frequency, percentage, Chi-square, independent sample t-test and Mann-Whitney U test were used in analysing the data.

RESULTS

Of the total number of patients involved in the study, 74% (n=64) were males and 26% (n=22) were females with a mean age of 39.49 (SD ±15). There was no statistically significant difference in the mean visual analogue scale (VAS) pain assessment between the Skin traction group and Trans-tibia skeletal traction group after traction. With regards to complications, the difference between the Skin traction group and the Skeletal traction group was statistically significant (P=0.001). Moreover, the mean blood loss compared with the open type of reduction in the Transtibia skeletal traction group was significantly less than the Skin traction group (p=0.000).

CONCLUSION

This study has shown that both Skeletal traction and Skin traction were equally effective in controlling pre-operative pain in adult patients with femoral shaft fractures and does not affect intra-operative blood loss and post-operative management. Therefore, pre-operative Skin traction can be considered a useful and cost-effective method of maintaining alignment and pain relief in adult femoral shaft fractures.

FUNDING

Personal Funding.

[Application of delayed skin-stretching device in treatment of skin and soft tissue defects]

Objective

To summarize the effectiveness of delayed skin-stretching device in treatment of skin and soft tissue defects.

Methods

Between December 2014 and December 2016, 10 cases of skin and soft tissue defects were treated with delayed skin-stretching device. There were 6 males and 4 females with an average age of 53 years (range, 42-64 years). The skin and soft tissue defects were caused by acute trauma in 6 cases. The incision could not be closed directly after making incisions because of osseous fascia syndrome in 3 cases. The skin soft tissue defect caused after huge carbuncle incision and drainage in 1 case. The defect located at thigh in 4 cases, lower leg in 3 cases, upper arm in 2 cases, back in 1 case. The defect area ranged from 10 cm×4 cm to 22 cm×12 cm. Pinch test was performed on the wound margin, which confirmed that the wound could not be closed directly.

Results

Tension blisters were found in 3 cases during traction, and no complications such as impaired blood circulation or skin necrosis occurred in all cases. Skin defects closed directly after continuously stretching for 7-18 days. No skin graft or free flap repair was performed in all patients. The wound healed well after operation. All the 10 patients were followed up 5-8 months (mean, 6.5 months). There was no necrosis around the wound margin and the scar was linear. The sensation and function were not affected.

Conclusion

Delayed skin-stretching device is an effective method to treat skin and soft tissue defects, which has the advantages of simple operation, lower risk of operation, less complications, and reliable effectiveness.

The management of paediatric diaphyseal femoral fractures: a modern approach

The definitive treatment of paediatric femoral diaphyseal fractures remains controversial. Modalities of treatment vary mostly according to age, with fracture pattern and site having a lesser impact. Current evidence is reflective of this variation with most evidence cited by the American Academy of Orthopedic Surgeons being level 4 or 5. The authors present a review of the most up-to-date evidence relating to the treatment of these fractures in each age group. In an attempt to clarify the current trends, we have produced an algorithm for decision-making based on the experience from our own tertiary referral level 1 major trauma centre.

The Effect of Skin Traction on Preoperative Pain and Need for Analgesics in Patients With Intertrochanteric Fractures: A Randomized Clinical Trial

BACKGROUND

Preoperative skin traction is applied for many patients with hip fracture. However, the efficacy of this modality in pain relief is controversial.

OBJECTIVES

The aim of the current study was to investigate the effects of skin traction on pain in patients with intertrochanteric fractures.

PATIENTS AND METHODS

A total of 40 patients contributed in this randomized clinical trial. Patients were randomly allocated into two equal groups: the skin traction (3 kg) and control groups. The severity of pain was recorded at admission and 30 minutes, one, six, 12, and 24 hours after skin traction application utilizing a Visual Analogue Scale (VAS). In addition, the number of requests for analgesics was recorded. Finally, the mean severity of pain in each measurement and the mean number of analgesic requests were compared between the two groups.

RESULTS

The severity of pain was significantly decreased in skin traction group only at the end of the first day after traction application (2.7 ± 0.8 vs. 3.3 ± 0.9; P = 0.042), while there was no significant difference between the two groups in other pain measurements. The number of requests for analgesics was the same between the two groups.

CONCLUSIONS

Although skin traction had no effect on analgesic consumption, it significantly decreased the pain at the end of the first day. The application of skin traction in patients with intertrochanteric fractures is recommended.

J-splint use for temporizing management of pediatric femur fractures: a review of 18 cases

OBJECTIVES

Pediatric femoral fractures are common injuries encountered in the field and in emergency departments. Currently described temporizing management strategies include skeletal traction, skin traction, traction splinting, and posterior splinting, all of which are suboptimal in some instances. J-splinting femur fractures may be advantageous in temporizing management of pediatric femur fractures. The objective of this study was to evaluate the safety and effectiveness of J-splint use for temporizing management of pediatric femur fractures.

METHODS

This study used a retrospective review of 18 pediatric patients with femur fractures treated with J-splinting in the emergency department. Patient age, weight, and presplinting and postsplinting pain scale ratings were recorded, as well as presplint and postsplint anteroposterior and lateral radiographic fracture angulation. Pain before and after J-splinting was compared using a paired t test.

RESULTS

The mean age of this cohort was 5.4 years (range, 6 months-13 y), with a mean weight of 21.1 kg (range, 7.7-57 kg). In this cohort, there was a significant reduction in pain after reduction and splinting from a mean of 6 to a mean of 1 (P < 0.001). No significant difference in fracture alignment was noted after J-splinting. No complications were noted.

CONCLUSIONS

The J-splint is a reliable, simple, and rapidly applied splint that prevents many of the complications and downfalls of other described temporizing measures and helps to provide excellent pain management in the acute setting.

Diaphyseal femoral fractures below the age of six years: Results of plaster application and long term followup

BACKGROUND

In children less than 6 years, the treatment of femoral shaft fracture is often non surgical, using closed reduction and casting. The literature reports many experience about this type of trauma but none of these has a long term followup. We present a retrospective study on a group of femoral diaphyseal fractures treated nonsurgically in children up to 6 years of age, with a minimum of 10 year followup.

MATERIALS AND METHODS

48 cases (36 males/12 females) with femoral diaphyseal fractures treated between January 1988 and December 1998 were reviewed. Patients with fractures due to obstetrical trauma and pathologic fractures were excluded. The mean age of the patients was 3.3 ± 1.1 years (range 5 months-6 years). Right side was involved in 21 cases (44%), and left side in 27 cases (56%). In 34 cases (71%), closed reduction was performed and hip spica was applied with the hip and knee flexed to 45°. In 8 cases (17%), skeletal traction was applied to perform fracture reduction and the traction pin was embedded in plaster while in the remaining 6 cases (12%), the Delitala pressure apparatus was applied after casting.

RESULTS

All fractures healed in our study. There were no complications (infection or vascular nervous issues, axial deviations, consolidation delays, or pseudoarthrosis). In 13 cases (27%), followup examinations showed mean lengthening of 1.3 ± 0.75 (range 0.5-2.5 cm) of the fractured lower limb. All these patients were treated with skin traction before treatment and presented with 2.08 ± 0.28 cm mean initial femoral shortening. In 1 case (2%) with 2.5 cm lengthening, epiphysiodesis of the ipsilateral knee was performed. No patients showed prolonged difficulty with gait disorders.

CONCLUSION

On the basis of our results conservative treatment of femoral shaft fractures in children can be considered less invasive and safe procedure.

The safety of titanium elastic nailing in preschool femur fractures: a retrospective comparative study with spica cast

One hundred and four nonpathological fresh femur fractures not involving the neck or condyles in two groups of preschool children were retrospectively compared and followed up for a minimum of 3 years. Group I was treated by a spica cast and group II was treated by a titanium elastic nail (TEN). The mean age of the children was 4.5 years. TEN was statistically better in terms of union (P=0.000), shortening (P=0.016), sagittal angulation (P=0.018), coronal angulation (P=0.022), rotation (P=0.014), earlier weight bearing (P=0.000), and earlier return to nursery (P=0.000). However, both groups had a similar overgrowth rate and hospital stay time. TEN in preschool children is a safe choice but involves a scar, risk of infection, and the need for a second operation.

Femoral fractures in children

PURPOSE OF REVIEW

Femoral fractures in children are the commonest children's fracture requiring hospitalization. They consume disproportionate amounts of healthcare resource. Advances in operative management have resulted in improved clinical and health economic outcomes.

RECENT FINDINGS

This article describes 21st-century management of femoral fractures concentrating on recent advances. There is a clear trend to increased operative management in all femoral fractures with improved outcomes in the proximal femur and shaft. Crucially, advances in the treatment of both have led to a reduction in the rate of avascular necrosis of the femoral head.

SUMMARY

Units treating paediatric fractures need access to specialist surgeons and equipment to treat the full range of femoral fractures and improve outcomes.

Preoperative skeletal versus cutaneous traction for femoral shaft fractures treated within 24 hours

OBJECTIVES

To compare the advantages and disadvantages of preoperative cutaneous traction versus skeletal traction in adults with diaphyseal femur fractures amenable to fixation within 24 hours.

DESIGN

Randomized prospective trial.

SETTING

Level I trauma center in a major metropolitan area.

PATIENTS

Sixty-five patients with 66 femur fractures were prospectively enrolled and randomized to a traction group from July 2009 to July 2010.

MAIN OUTCOME MEASUREMENTS

Time of application for on call physicians/practitioners, pain relief after application of traction; time of reduction in the operating room theater, and evaluation of pain medication consumption before stabilization.

RESULTS

Thirty-seven patients received cutaneous femoral traction, whereas 29 patients received skeletal traction. There was a significant reduction in time of application for the cutaneous traction (24.30 ± 24.74 minutes) compared with skeletal traction (57.10 ± 33.60 minutes) (P ≤ 0.001). There was no statistically significant difference in visual analog scale (VAS) scores when compared with pretraction application pain assessment and posttraction pain assessment between the cutaneous and skeletal traction groups with a decrease in the VAS of (0.56 ± 3.73 and 0.54 ± 2.76), respectively (P = 0.99). There was no difference in pain medication requirements between groups (0.12 ± 0.17 mg/kg for cutaneous versus 0.09 ± 0.14 mg/kg for skeletal, P = 0.39). There was no significant difference in reduction time of the fracture (skin incision or opening reamer to guide wire passage) in the operating room between cutaneous traction versus skeletal traction (P = 0.59).

CONCLUSIONS

Use of cutaneous traction for diaphyseal femur fractures when compared with skeletal traction results in a statistically significant reduction in time of application to the on call practitioner with no complications or detrimental change in operative time and no difference in VAS pain scores or narcotic usage.

Temporizing management of pediatric femur fractures using J-splints

This article describes a novel splinting technique for the temporizing management of pediatric femur fractures. The J-splint is a reliable, simple, and rapidly applied splint that prevents many of the complications and pitfalls of other described temporizing measures, such as skeletal traction, skin traction, traction splinting, and posterior splinting. This technique of J-splinting femur fractures has low morbidity and provides many advantages in the temporizing management of pediatric femur fractures.

Clinical outcomes following invasive versus noninvasive preoperative stabilization of closed diaphyseal femur fractures

BACKGROUND

The use of invasive traction (INV-T) to stabilize femur fractures prior to fixation (open reduction and internal fixation, ORIF) remains controversial. Some centers have utilized noninvasive traction (NINV-T) or splinting preoperatively. It is possible that INV-T decreases hemorrhage. However, the use of INV-T in pediatric patients and for femoral neck fractures in adults is associated with worsened outcomes. We hypothesized that there is no difference in the need for transfusion between those who receive INV-T and NINV-T.

METHODS

A retrospective study was performed at two level I and one level II trauma center from January 2006 to December 2009. Patients ≥18 years with a closed diaphyseal femur fracture who underwent ORIF within 48 h of arrival were included. Patients were grouped by method of preoperative fracture stabilization. Primary endpoint was need for transfusion. A power analysis found that 94 patients were needed to detect a 25 % difference with 80 % power.

RESULTS

Fifty-six (22 %) received INV-T and 199 (78 %) received NINV-T stabilization. No significant differences were found between groups in terms of age, injury severity score, or ORIF method. There was no significant difference between the two groups in the hemoglobin value on arrival, preoperative hemoglobin value, or the difference between admission and preoperative hemoglobin values. We did not find a significant difference in the need for red blood cell transfusion between the two groups. There was no difference in length of stay or discharge destination.

CONCLUSION

INV-T is not associated with improved outcomes in adult patients with closed mid-shaft femoral fractures who are operated upon within 48 h of arrival.

Management of pediatric diaphyseal femur fractures

A variety of strategies are utilized for management of pediatric diaphyseal femur fractures, depending chiefly on the age of the patient. Other factors that can influence the selection of a technique-which range from skeletal traction with spica casting to immediate spica casting, flexible intramedullary nailing, rigid intramedullary rodding, or plate fixation-are weight, fracture severity, associated injuries, and underlying medical or musculoskeletal conditions. The available evidence regarding technique, outcomes, and complications of the aforementioned treatment options remains largely insufficient, and, at times, conflicting, which contributes to the challenges in management decisions. Considerable controversy has arisen over several topics, particularly the optimal treatment for patients aged 5 to 12 years and accepted standards of treatment. This review is designed to provide perspective for some of the most recent influential literature on pediatric diaphyseal femur fracture treatment in light of established evidence and evolving controversies.

[Randomised clinical trial on pain control in intertrochanteric fractures of the femur with and without skin traction]

AIM

To evaluate the level of pain control among patients with intertrochanteric fracture of the femur with and without the application of skin traction.

METHODS

A randomised, single centre, parallel, controlled and open, clinical trial performed in a hospital environment. The study subjects were patients with an intertrochanteric femur fracture seen in the Emergency Department. A non-probabilistic and consecutive sample of 40 patients (power 80% CI: 95%), was used. The patients were randomly assigned (1:1) to treatment with or without skin traction. The assignment was made by means of sealed envelopes. The principal variable of study was the evaluation of the pain at 48 hours after admission. Data was collected during February to October 2008 using an ad hoc questionnaire. Data was collected at baseline, 2 h, 24 h and 48 h after admission.

RESULTS

At 48 hours after admission, the mean baseline pain improved by 4.4 points (SD: 1.8) (P<.001), the differential effect of the level of pain between both study groups was 0.7 points of the VAS scale (95% CI, -0.7 to 0.6), while the effect of traction showed no statistically significant differences (P=.721). One patient was withdrawn due skin reaction to the traction adhesive.

CONCLUSIONS

The treatment with skin traction in the patients with intertrochanteric fracture of femur does not produce changes in the progression of the pain in comparison with the patients without skin traction.