Practice Patterns for Management of Pediatric Femur Fractures in Low- and Middle-Income Countries

Abstract

Background: Femoral shaft fractures in children are common in low and middle income countries. In high-income countries, patient age, fracture pattern, associated injuries, child/family socioeconomic status, and surgeon preference dictate fracture management. There is limited literature on treatment patterns for pediatric femur fractures in resource-limited settings. This study surveys surgeons from low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries regarding treatment patterns for pediatric femur fractures. Methods: Surgeons completed an electronic survey reporting surgeon demographics and treatment preference for pediatric femur fractures. Treatment preferences and indications for treatment were separated into 4 groups: infant (0 to 6 mo); toddler (7 mo to 4 y); child (5 to 12 y); adolescent (12 to 17 y). The survey was available in English, Spanish, and French. Analysis was completed with t test and χ2 test for continuous and categorical variables, respectively, and weighted Pearson correlation (P<0.05). Results: Survey respondents consisted of 413 surgeons from 83 countries (20 LIC, 33 LMIC, 30 UMIC). The majority of respondents were fellowship trained (83%) most commonly in pediatrics (26%) and trauma (43%). Most treated >10 pediatric femur fractures per year (68%). Respondents reported treating infant femur fractures nonoperatively using Pavlik harness (19%), spica cast (60%), or traction with delayed spica cast (14%). Decreasing socioeconomic status was associated with higher nonoperative treatment rate in toddlers, children, and adolescents. Respondents commonly utilize bed rest and traction for child femur fractures in LICs (63%) and LMICs (65%) compared with UMICs (35%) (UMIC vs. LMIC P<0.001; UMIC vs. LIC P<0.001). Surgeries in children more commonly involve open reduction with internal fixation (UMIC 19%, LMIC 33%, LIC 40%; P<0.05 between UMIC-LMIC and UMIC-LIC). Conclusion: This is one of the largest surveys describing treatment patterns for pediatric femur fractures in low and middle income countries. Differences are evident including lower operative treatment rate in younger children and lower intramedullary fixation rates in older children. Future studies should investigate the value of treatment options in resource-limited settings. Level of Evidence: Level II—prospective comparative study.

Elastic stable intramedullary nailing versus submuscular plating in pediatric diaphyseal femur fractures: a randomized controlled trial among children in South India

“…The cost in USA for operative fixation of a closed femoral shaft fracture has recently been estimated at 4500 USD. Healthcare costs, especially in LMICs where the cost is directly borne by the patient with minimal or nil health-insurance support, have an important bearing in choosing the implant for stabilizing pediatric diaphyseal femoral fractures in the 6-15 years age group [18][19][20][21][22]. With this background, a randomized controlled trial (RCT) was conducted to analyze our hypothesis that ESIN has less adverse events, better outcome and is cost-effective compared to SMP in pediatric femoral diaphyseal fractures.…”

Surveillance ultrasonography for conservative treatment of femoral shaft fractures in young children

“…Third, it was usually the grandparents taking care of the patients since the parents were working, thus assuming responsibility for the children’s care. Fourth, consistent with the trend seen in developing countries, conservative treatments such as skin traction are significantly cheaper than surgery [ 7 ]. Fifth, due to the humid weather in our region, spica casting leads to several skin problems.…”

“…In recent years, an increasing number of surgeons have tended to choose elastic stable intramedullary nail (ESIN) as the fixation material because of the mini-invasive method, short hospitalization, short time in bed, and lower cost associated with it [ 1 , 3 – 6 ]. However, some contraindications for ESIN in these children include multiple fractures and not isolated FSFs, excessive swelling in the thigh, and open fractures [ 7 ]. Complications associated with casting fixation include malunion of the fractures, such as angular or rotation deformity, skin compression, skin allergy caused by plaster, and the compartment syndrome, which cannot be diagnosed immediately and can lead to ischemic contracture [ 8 , 9 ].…”

Study to determine the Results of Femoral Shaft Fractures among Children managed with Immediate Hip Spica Cast

“…Femoral shaft fractures are the utmost communal pediatric injuries managed by an orthopaedic surgeon. Management is in luenced by trauma or multiple injuries, personality breakdowns, age, family problems and costs (Misaghi et al, 2020;Edwin et al, 2020;Curran et al, 2020). Spica cast ixation is an effective, safe and simple treatment for pediatric femoral shaft fractures.…”