Practice Patterns for Management of Pediatric Femur Fractures in Low- and Middle-Income Countries
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Published on: December 9, 2022
Patrick F Curran1, Patrick Albright2, John M Ibrahim2
1Department of Orthopaedic Surgery.
Insights
Pediatric femur fracture treatment varies globally, with lower-income countries favoring nonoperative methods like traction and casting over surgery. Socioeconomic status influences treatment choices for children and adolescents.
Area of Science:
- Orthopedic Surgery
- Pediatric Traumatology
- Global Health
Background:
- Femoral shaft fractures are common pediatric injuries, particularly in low and middle-income countries (LMICs).
- Treatment in high-income countries is influenced by patient age, fracture type, associated injuries, socioeconomic status, and surgeon preference.
- Limited data exists on pediatric femur fracture management strategies in resource-limited settings.
Purpose of the Study:
- To survey orthopedic surgeons globally regarding their treatment preferences and patterns for pediatric femur fractures.
- To identify variations in treatment based on country income level and patient age group.
- To understand the impact of socioeconomic factors on treatment decisions.
Main Methods:
- An electronic survey was distributed to surgeons across low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries.
- Surgeons reported demographics and treatment preferences for four age groups: infant (0-6 months), toddler (7 months-4 years), child (5-12 years), and adolescent (12-17 years).
- Data analysis included t-tests, chi-squared tests, and weighted Pearson correlation (P<0.05).
Main Results:
- 413 surgeons from 83 countries participated; most were fellowship-trained trauma or pediatric orthopedic surgeons treating >10 pediatric femur fractures annually.
- Infant fractures were predominantly treated nonoperatively (Pavlik harness, spica cast, or traction).
- Lower socioeconomic status correlated with increased nonoperative treatment for toddlers, children, and adolescents. LICs and LMICs utilized bed rest/traction more frequently for children (63-65%) compared to UMICs (35%). Operative rates, particularly open reduction internal fixation, were higher in LMICs (33%) and LICs (40%) than UMICs (19%).
Conclusions:
- This study represents one of the largest surveys on pediatric femur fracture treatment patterns in LMICs.
- Significant differences in treatment approaches were observed, including lower rates of operative intervention in younger children and reduced intramedullary fixation in older children in LMICs.
- Further research is needed to evaluate the efficacy and value of various treatment options in resource-limited environments.
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 χ 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.
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