PubMed2003
PURPOSE OF THE STUDY: Conservative therapy is the method of choice for treating femoral fractures in younger children all over the world. At the Department of Orthopedic Surgery of the Second Faculty of Medicine, Charles University in Prague, this approach has had a long tradition and has only partly been replaced by other, more recent methods. It is not always necessary to abandon well-established and reliable techniques because of new achievements and this is demonstrated by the results of our study. MATERIAL: In a period of 22 years, 112 boys and 97 girls were treated by Bryant's traction and 62 boys and 46 girls by Weber's traction. The former was used in children younger than 5 years, weighing less than 20 kg. The latter was applied in patients between 5 and 10 years of age whose body mass was between 20 to 35 kg. METHODS: Bryant's traction, used in the younger age category, offered the advantage of easy application without total anesthesia. Both legs were suspended in an apparatus that keeps the patient's pelvis slightly elevated above the bed level. Counter traction was provided by the weight of the suspended pelvis. In Weber's traction, used in children aged 5 to 10 years, a Kirschner's wire was inserted in the distal metaphysis of each femur in the frontal plane. The ends of each wire were attached to a metal U-shaped spreader. This apparatus holds the legs at right angles both in the knees and hips. Each patient was examined by X-ray at 1 week to check the correction of displacement and at 3 weeks to check callus development. All the patients were immobilized in a plaster cast spica for a period of 6 to 8 weeks after injury and each child was also shortly hospitalized for cast removal and early physical therapy. RESULTS: Fractures in the middle of the diaphysis with an oblique fracture line were most frequent. These and long spiral fractures responded well to these two methods in almost all cases. In transverse fractures, which are less common, when an angular dislocation persisted it was tolerated owing to the subsequent remodelation. The most serious complication was a shortening of the leg involved, which often occurred with the use of Bryant's traction. The shortening was found in 80% of the patients shortly after the fracture had healed. A low body mass of the child was generally responsible for failure to stretch the femur to its full length. In children treated by Weber's traction, the shortening was observed in 55% immediately after fracture healing. On examination at 1 and 3 weeks, its presence was markedly lower, occurring in 25% and 17% of the children, respectively. Lengthening was found only occasionally on examination in adolescence or adulthood, but this may have been due to other causes. Excessive movement of the child in bed, usually when the parents came to visit, sometimes interfered with good correction of the displacement. DISCUSSION: Bryant's traction was used in our department for conservative treatment even in very young children. The plaster cast spica was applied primarily to non-displaced fractures. Pavlík's harness, recommended by Rockwood and Stannard, was used in pediatric injuries only occasionally. When conservative treatment was indicated in older children, Weber's traction was applied. The Göteborg traction described by Havránek was not used. The shortening of the leg treated was the most frequent complication, but our results were not in agreement with the data reported by Stahelim, who described a greater and more frequent shortening in children older than our patients. In our study, younger children suffered from leg shortening more often, as was also reported by Náhoda and Stryhal. The subsequent lengthening was found only occasionally; the average values of 2.6 cm and 2.3 cm in younger and older children, respectively, as reported by Náhoda and Stryhal, were not recorded. When lengthening was observed, its value was always lower. A 30 degrees rotational deviation, observed by Verbeek in one third of his patients, was not seen in our children. Pseudoarthrosis or infection were absent in our population and a literature search showed that, when treated conservatively, femoral fractures were not associated with these complications. CONCLUSIONS: Well-established methods of conservative treatment of femoral fractures in children were evaluated with the objective to advocate their importance for today's orthopedic surgery. Although the children treated by these methods are confined to bed for a longer period than when more recent techniques are used, they may avoid many of the complications that accompany these new approaches.