Hip fracture; an interruption that has consequences four months later. A qualitative study.

BACKGROUND: Effects following a hip fracture often lead to functional disabilities and increased dependence on others. Although persons sustaining a hip fracture constitute a heterogeneous group in Swedish health care, they tend to be treated as a homogenous one. AIM: The aim of this study was to reveal how previously healthy people, aged 65 years and older, described how they had adapted to daily life four months after a hip fracture. METHOD: The follow-up interviews were performed by the first author four months after the hip fracture. Data were analysed using conventional inductive content analysis. FINDINGS: The results from the interviews highlight that sustaining a hip fracture - even four months later - was seen by the participants as an interruption leading to lasting consequences for everyday life. The recovery process during this period was complex and consisted of both physical and psychological strain. Some were resigned, some strived in order to regain independence and some handled the situation by means of self-confidence and self-efficacy. CONCLUSION: Previous healthy and independently-living participants described, in different ways that the hip fracture was an interruption that still affected everyday life. The absence of psychological support may be one of the reasons for dependency after four months.

Older patients' perception of their own capacity to regain pre-fracture function after hip fracture surgery - an explorative qualitative study.

AIMS AND OBJECTIVES: To explore healthy older patients' perceptions of their own capacity to regain pre-fracture function in the acute phase following hip fracture surgery. BACKGROUND: The incidence of hip fractures is expected to increase. In Sweden, of the patients who sustain a hip fracture, 40 per cent are healthy and lived independently pre fracture. However, a hip fracture often results in declined functional outcomes for 40 per cent of these patients. DESIGN: The study had an explorative inductive qualitative design. METHODS: Semi-structured interviews (n = 30) were conducted two to five days after hip fracture surgery. Data were analysed using manifest inductive content analysis. RESULTS: As a description of patients' perception of their own capacity to regain pre-fracture function after a hip fracture, one main category emerged: To end up in a new situation with or without control. Patients expressed that they believed in recovery and thought nothing would be altered. However, since they had to adapt to the ward culture at the acute hospital, they became passive and became insecure about their future life situation. CONCLUSION: The attitudes of staff at the acute hospital can influence the outcome for hip fracture patients. Patients believe in recovery but do not receive psychological support to regain physical capacity.

Technique and considerations when using external fixation as a standard treatment of femoral fractures in children.

Femoral fractures in children can be treated effectively and with a low complication rate by using external fixation. However, as with most treatment modalities there is a learning curve to be considered. The aim of this paper is to report "tricks" and different considerations that we have learned to be of value based on experience gained during a prospective and consecutive study of 98 femoral fractures in children aged 3-15 years. Our experience is based on the use of a unilateral fixator with the option to apply axial dynamisation. Traction prior to operation is not needed if the child is operated on within 24h. During surgery a traction table will prevent significant malrotation and facilitate reduction prior to insertion of the pins. Four 4 or 5mm pins are sufficient for adequate stability in children. Transverse skin incisions are preferable for pin insertion as the scars become smaller and the soft tissue irritation during activity is less when compared with longitudinal incisions. Unrestricted weight-bearing can be allowed. A nihilistic approach to pin site care with daily showers is as effective as more aggressive treatment with local antiseptics. Pin infections can occur but are mild and can be treated locally or with a short period of antibiotics taken orally. Pin-loosening and deep infections are very uncommon. By using external fixation, malunion, overgrowth or delayed union can almost be avoided completely. Re-fractures are rare and occur only after significant trauma. Treatment time is relatively short. No physiotherapy or further protection of the leg is necessary during or after healing.

Surgical treatment of femoral fractures in children. Comparison between external fixation and elastic intramedullary nails: a review.

Femoral fractures represent about 2% of all fractures in childhood. Children with femoral fractures always need to be admitted to hospital and the use of resources is much higher than for other childhood fractures. During the past decade, there has been a trend towards surgical treatment of these fractures, one advantage being the shorter time required in hospital. Two common surgical treatment options are external fixation (EF) and elastic stable intramedullary nails (ESIN). Both methods have their advantages and disadvantages, and neither of them solves all of the problems. Used in a complementary manner, they are safe and reliable for the treatment of femoral fractures in children, and they give good long-term results and few serious complications.

A cost analysis of three methods of treating femoral shaft fractures in children: a comparison of traction in hospital, traction in hospital/home and external fixation.

INTRODUCTION: There is no consensus as to which is best treatment of femoral fractures in children. PATIENTS AND METHODS: We performed a cost analysis comparing three treatments of femoral shaft fractures in children aged 3-15 years at 3 hospitals during the same period (1993-2000). The analysis included total medical costs and costs for the care provider and were calculated from the time of injury up to 1 year. RESULTS: At hospital 1, treatment consisted of external fixation and early mobilization. At hospital 2, the treatment was skin or skeletal traction in hospital for 1-2 weeks, followed by home traction. At hospital 3, treatment was skin or skeletal traction in hospital until the fracture healed. RESULTS: The average total costs per patient were EUR 10,000 at hospital 1, EUR 23,000 at hospital 2, and EUR 38,000 at hospital 3. INTERPRETATION: The main factor for determining the cost of treatment was the number of days in hospital, which was lower in children treated with external fixation.

Muscle strength in children treated for displaced femoral fractures by external fixation: 31 patients compared with 31 matched controls.

In a prospective study (1993-2000), we measured the isokinetic strength of the quadriceps and hamstring muscles in 31 children aged 5-17 years, on average, 3 (1.5-5) years after treatment for a displaced femoral fracture by external fixation and early mobilization. A group of age-, sex- and weight-matched children without previous injury were used as controls. The hop-index test was used to assess the patient's confidence in the injured limb and was similar in the fractured and unfractured legs as well as in the patients and controls. We measured the peak torque output at 2 angular velocities (60 degrees/s and 180 degrees/s) in the hamstring and quadriceps muscles, using Cybex testing equipment. Torque to body weight ratios were used to compare muscle strength in patients and controls. We found no differences in muscle strength between patients and controls or in the distribution of which leg was stronger, equal or weaker in the patients or controls at any test speed. External fixation and early mobilization seem to prevent residual muscle weakness, which occurs with traction or a cast for femoral fractures in children.

External fixation of displaced femoral shaft fractures in children: a consecutive study of 98 fractures.

OBJECTIVE: To evaluate unilateral external fixation when applied as the standard treatment of children with displaced femoral shaft fractures. SETTING: Two county hospitals in central Sweden. DESIGN: A consecutive and prospective study including all children aged 3 to 15 years with displaced femoral fractures admitted to either of the two hospitals. Patients were followed clinically and radiographically until healing and at 1 year. RESULTS: A total of 96 children with 98 fractures were treated with the same kind of external fixator during the period 1993-2000. The mean age was 8.1 years (range 3-15 years). Average hospital stay was 8.7 days (median 7 days). Average time of external fixation was 61 days (range 37-127 days; median 56 days). Minor complications included pin track inflammation/infection in 36 of 98 (37%) fractures. In 18 of 36 fractures, a short treatment with oral antibiotics was given. Other minor complications were one heterotopic ossification, one patient with two rereductions, nine cases of clinically insignificant malunion (varus = valgus > 5 degrees or procurvatum > 10 degrees ), and one leg-length discrepancy greater than 2 cm. Major complications (6%) included two refractures, one through a pinhole and one at the fracture site, both after significant trauma. Three of the older children with transverse fractures after high-energy injury developed a bending due to premature removal of the fixator prior to healing and required corrective osteotomies. One boy had a third rereduction because of displacement after a fall. CONCLUSIONS: The use of external fixation as a standard treatment of uncomplicated displaced femoral shaft fractures in children gave satisfactory results. The surgical learning curve was short, and the advantages compared with nonsurgical treatment included shorter hospital stay, early mobilization, and fewer days out of school for the patient and out of work for the caregiver. We believe that the advantages far outweigh the complications, many of which can be avoided.

Radiological outcome after external fixation of 97 femoral shaft fractures in children.

The aim of this prospective, consecutive study was to assess overgrowth and malunion after anatomical reduction and external fixation of displaced femoral shaft fractures in children. Ninety-seven closed femoral fractures in 95 children aged 3-15 were fixed with a unilateral external fixator and followed with conventional radiographs and standardized orthograms for 1 year. To evaluate further overgrowth and remodelling a subgroup of 45 patients was also seen at 2 years. Parameters known to influence overgrowth and remodeling were recorded.Eighty-six percent of the femora had an angulation less than 10 degrees in varus/valgus or recurvatum at the time of healing. The remaining fractures remodeled nearly completely. Leg length discrepancy was on average 0.1cm at 1 year. The mean overgrowth was 0.3 cm at 1 year and 0.5 cm at 2 years. Overgrowth and remodeling was not correlated to whether the leg healed in a shortened or lengthened position, nor was it correlated to pin site infection or re-reduction.The overgrowth was far less than expected when compared with previous studies using traction. When external fixation is used in femoral fractures in children, we therefore, recommend fixing the fracture without shortening regardless of the age of the child, type of fracture, fracture level or injury.