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Retrospective study of operative (Rush pin) versus conservative (Hip spica) management in treatment of diaphyseal femoral fractures in children

Background: Femoral fractures are common in children between 2 and 12 years of age and 75% of the lesions affect the femoral shaft. Traction followed by a plaster cast is universally accepted as conservative treatment. We compared primary hip spica with closed reduction and fixation with crossed Rush pins for diaphyseal femur fracture in children. The hypothesis was that Rush pin might provide better treatment with good clinical results in comparison with primary hip spica. Materials and Methods: Fifty children with femoral fractures were evaluated; 25 of them underwent conservative treatment using immediate hip spica (group A) and 25 were treated with crossed retrograde Rush pins (group B). The patients ages ranged from 3 to 15 years (mean of 9 years). Results: Mean duration of fracture union was 16 weeks in group A and 12 weeks in group B. Mean duration of weight bearing15 weeks in group A and 8 weeks in group B. Mean hospital stay was 5 days in group A and 9 days in group B. Mean follow up period in group A was 16 months and group B was 17 months. Complications such as angulation, shortening, infection were compared. Conclusions: Closed reduction and internal fixation with crossed Rush pins was superior in terms of early weight bearing and restoration of normal anatomy.


Introduction
Femoral shaft fractures are one of the most common fractures of lower extremity in children and the most commonly requiring hospitalization. Some degrees of angular deformity and some centimeters of shortening are acceptable in children according to age group because children have tremendous remodeling potential. Variety of methods are used for treatment of pediatric diaphyseal femur fractures including immediate spica casting, traction followed by spica casting, external fixators, internal fixation with intramedullary rod or flexible intreamedullary nailing, fixation with plates and screws. Choice of treatments depends upon age of children, anatomical site and fracture pattern. Traditionally, children below 6 years are treated with immediate hip spica and adolescent children are with operative methods [1][2][3] . External fixators are associated with increased chances of pin tract infection and refracture. Plate osteo-synthesis need extensive soft tissue stripping and resurgery for removal. Intramedullary rods increase chances of avascular necrosis of femoral head and damage to physis. 1, 2 Flexible intramedullary nailing has become an increasingly popular method of pediatric femoral fracture fixation [4,5] . Systemic reviews and various cohort studies have shown excellent clinical results with flexible intramedullary nails (Rush pins) for children and few studies have extended its indication to preschool going children also [2][3][4][5] . We present a comparative study between intramedullary Rush pins and immediate spica casting for pediatric diaphyseal femur fracture.
Materials and Methods 50 children (with age range 3-15 years) who presented between December 2012 and January 2014 with diaphyseal femur fracture were included in study. The informed consent was taken from parents. Twenty five were treated by hip spica cast (Group A) and twenty five by Rush pin sequentially (Group B).
Inclusion criteria for selection of patients were diaphyseal femoral fracture of age group 3-15 years, with or without comminution, multiple fractures, fractures in patients with polytrauma . Undisplaced fractures treated by traction and hip  spica, pathological fracture, open fracture, children with  neuromuscular disorders, irritable patients with head injury,  patients with pathological fracture, associated vascular injury  needing repair were excluded. Fracture pattern was classified according to AO classification type 32A. In group A fracture was reduced on the same or next day of presentation to hospital under fluoroscopy control one and half spica cast were applied under general anesthesia, traction after applying on fractured limb. Hip was flexed between 30° and 40°, while knee and ankle were kept in neutral position. X-ray was evaluated immediately after spica cast application. Criteria of acceptable reduction were based upon Kasser et al. [ Table 1]. [6] Children were admitted to hospital until parents learned how to take care of spica. Follow up was performed at 2nd weeks for evaluation of reduction and spica related complications. Radiological evaluation was performed at 6th weeks for evaluation of radiological union. If bridging callus was seen at three cortices, child was asked to bear weight with or without support according to pain tolerance. If callus was not evident long leg cast was applied for 4 more weeks. In group B, under general anesthesia, two small skin incisions were made on either side of distal metaphysis and two holes are made obliquely facing toward s medullary cavity with help of 4 mm awl, an inch proximal to growth plate. Two precontoured C-shaped Rush pins were passed retro gradely with fluoroscopy control until both tips reached just at distal fragment. Fracture was reduced closely with manual traction and Rush pins are pushed into medullary cavity of proximally diaphyseal fracture fragment under fluoroscopy control. Tips of the pins are targeted up to the level of neck and base of the greater trochanter. Care was taken that commercially made pre bent distal part of stainless steel Rush pin lied on cortical surface of the supracondylar region of the femur without soft tissue was impingement. Size of the Rush pins were measured as 40% of narrowest diameter of femur on anteroposterior (AP) and lateral view. Sizes of pins were selected below 2.5-3 mm. In initial 5 cases we applied posterior long leg plaster of Paris back slab. Thus we later discontinued and only knee immobilizer was applied postoperatively until sutures were removed on 2 weeks. As soon as pain was tolerable, hip and knee was mobilized and non-weight bearing ambulation was allowed. Weight bearing was permitted once bridging callus was evident on X-ray on three cortices. Followup was carried out at 6th, 12th week, 6th months, 1 year and 2 years for radiological and clinical evaluation. Rush pins were routinely removed after 1 year of surgery. Treatment cost was calculated as total amount paid to hospital which covered admission; investigation, operation and hospital.

Results
Age in both groups ranged from 3 to 15 years with mean age of 6.4 ± 3.46 years. Male to female ratio was 2.5:1 and 4:1 in group A and B respectively. Fracture pattern was classified according to AO classification which showed type 32A1 was the most common pattern of injury. Spiral or long oblique fractures or fracture with comminution more than two-third of diameter of bone were considered unstable. Fall related injury either from hill slope, tree, cliff or wall was most common mode of injury which comprises of 88% of injury in each group A and B. Anatomically, middle one third diaphyseal femur fracture was most common site of femur fracture in this study [  Table 3]. Increased hospital cost in group B can be attributed to longer hospital stay which ranges from 3 to 14 days as many patients in our teaching hospital come from far and remote distance from where it is not only expensive but also difficult for coming to hospital for removal of sutures. Hence, they preferred longer hospital stay until sutures were removed. The outcome was evaluated according to Flynn's grading.7 Table 4 shows individually and overall group B have superior outcome as compare to group A. 19/25 (76%) had excellent, 5/25 (20%) had satisfactory and 1/25 (4%) had poor result in children in group B as compare to 4/24 (17%) excellent, 11/24 (49%) satisfactory and 9/24 (44%) poor in group A (P = 0.000).The children were assessed for malunion both linear, rotational and limb length disparity. In group A, 3 patients had plaster sores at perineal area which recovered with dressing and antibiotics; 1 child had broken and loosened hip spica on 2nd week and needed reapplication of spica; 4 children had increased angular deformity or overlapping but within acceptable range on 2nd weeks of follow up. In group B, 2 children had complications related with long protruded Rush pin at entry site. One child presented with pin tract infection on the 7th day of surgery which recovered after trimming of protruded part; another child presented with bursitis after 1 year which recovered after removal of Rush pins. One patient had lost AP alignment on the 6th week follow up. In one child, penetration of posterior cortex of base of neck was identified in subsequent follow up. Rush pin was removed on 6th month and did not show any changes of avascular necrosis until 1½ years of follow up. Another patient had penetration of greater trochanter and he also had no limb length discrepancy.

Discussion
Staheli and Sheridan8 defined the ideal treatment of femoral shaft fractures in children as one that controls alignment and length, does not compress or elevate the extremity excessively, is comfortable for the child and convenient for the family and causes the least negative psychological impact possible. Immediate spica casting or skeletal traction and application of a cast is common method for treatment of diaphyseal femoral fractures in children and young adolescents and surgical intervention is indicated in open fractures, multitrauma, concomitant head injuries, burns and neuromuscular wounding. However, psychosocial and economic effects of spica cast immobilization on children and their families have been reported by Hughes et al. [9] and many studies advocate early fixation of femur fracture because complications inherent in conservative treatment, such as malunion and shortening, cast intolerance, financial factors and increased hospitalization can be decreased by surgery. Among operative methods, flexible intramedulary nail has been used increasingly due to its simplicity and characteristics of load sharing internal splint which maintains length and alignment of the limb until bridging callus is formed and spares the risk of damaging the physis or the blood supply to the capital femoral epiphysis with proper surgical technique. Torsional stability depends upon divergence of the rods in the proximal metaphysis and resistance to sagittal and coronal bending results from spreading of the pre bent rods through the diaphysis, size of the rod and material properties of the rod. Micro motion confirmed by elasticity of fixation promotes early callus formation. The Young modulus of stainless steel is nearly double that of titanium (approximately 200 GPa versus approximately 110 GPa), making it a much stiffer material with less elastic properties. Mahar et al. [10] in their study have reported regarding the material alloy for flexible nails, no conclusive evidence is provided in the literature that supports the superiority of titanium over steel. Differences between these two materials have been observed in laboratory tests and it is generally accepted that steel is stronger, yet less flexible. A study by Lee et al. [11] demonstrated that ender nail fixation of simulated femur fractures maintained fracture length and rotational control with weight bearing of up to 40% of body weight, even in presence of comminution whereas Fricka et al. [12] reported that the titanium implants provided greater stability in resisting torsional loading and axial compression in both transverse and comminuted fractures in biomechanical comparative study with stainless steel nails. Besides elastic property, retro gradely passed adequate size crossed Rush pins offer all the advantages of closed reduction technique and internal fixation with flexible intramedullary nails. Excellent clinical results using stainless steel flexible nails have been reported for both stable and unstable femur fracture in children.
Rathjen et al. [13] assume that the stiffer properties of a stainless steel implant should confer greater fracture stability, especially in the setting of an unstable fracture pattern. A study by Wall et al. [14] have demonstrated 118 patients with use of titanium elastic nails as compared with stainless steel elastic nails and noted the malunion rate was significantly higher in the titanium group (23.2%; thirteen of fifty-six) than in the stainless steel group (6.3%; three of forty-eight). The risk of malunion was nearly four times higher in the titanium group than in the stainless steel (Rush pin) group. Cramer et al., [15] prospectively evaluated 57 femoral shaft fractures in children treated with Ender rods, 21 of which were either spiral fractures or comminuted. Although, the results were not stratified according to fracture stability, the authors noted no clinically significant leg length discrepancy or malunion. Four patients did demonstrate radiographic angular deformities of <15° deviation at final followup. Another advantage of stainless steel nail would be readily availability and lesser cost. Lee et al., [16] in their study have reported that antegrade intramedullary Rush pin fixation for femoral shaft fracture in children older than 7 years is a simple and reliable alternative. A study by Simanovsky et al. [17] defined that the flexible intramedullary nails can be a safe treatment option in children aged 3-5 years for femoral shaft fracture. Treatments using nails for fixation have been indicated for patients between the ages of 4 and 17 years, although Bopst et al. [17] more recently reported an indication for children as young as 1.5 years of age and Simanovsky et al. [16] for those aged 3 years and over. This age group includes the phase at which these patients go to school and thus, independence during treatment is important for these patients. By reducing hospitalization time, children may return to school earlier, thereby avoiding social isolation and the need for extra care, such as the care needed to maintain hygiene when individuals are treated using casts [4,19,20] . Another advantage of Rush pin would be readily availability according to the size of pediatric femoral bone length, no need to cut and bend at the entry site of insertion. The available pre bent Rush pins are easily removable and less irritable soft-tissue. Pre bent stainless steel Rush pins are cheap, universally available and can be manufactured locally. This study had a prospective design and used a convenience sample, which were limitations of the study. The different characteristics of the two groups of patients were also a limitation. Nonetheless, this study points toward the important that femoral shaft fractures in children can be better treated with surgery.