Conservative management of closed femoral shaft fractures - is skeletal traction still justified or cost effective in a developing country like Tanzania?

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University of Dar es Salaam
Conservative Management of Closed Femoral Shaft Fractures Is Skeletal Traction Still Justified or Cost Effective in A Developing Country Like Tanzania? Closed femoral shaft fractures have always been a challenge to orthopaedic surgeons and traumatologists for many years. They account for high morbidity rates in trauma wards, prolonged hospitalization as well as affecting the productive age group of the society.In the developed world surgery is now the first option of treatment rather than conservative treatment. In the developing world however, owing to lack of both qualified personnel and funds to purchase modem implants, conservative treatment still remains the mainstay of treatment. The broad objective of this study was to determine medical and financial benefits of embarking on early surgery of femoral shaft fractures versus conservative treatment in the form of continuous skeletal traction. Specifically to determine lengths of hospitalization, early and late medical complications encountered as well as the cost incurred by both the patient and the hospital on both types of treatment. The study included patients admitted at Muhimbili Orthopaedic Institute with closed femoral shaft fractures during the period of August 2003 to July 2004 and of ages 11 to 72 years. There were 91 patients with closed femoral shaft fractures enrolled into the study, out of these 8 were lost to follow up and the remaining 83 were treated. 42 patients were managed by continuous skeletal traction and 41 by open reduction and internal fixation. Results The ages ranged from 11 to 72 years with median age 26 years. The age group 21-30 years accounted for 53 patients (63.8%) followed by age group 11-20 with 19 patients (22.9%) patients with age 40 years or above were least affected with 11 cases or (13.2%). 67(81%) were males and 16(19%) were females. The majority of injuries occurred within Dar es Salaam region affecting 72 patients (86.7%). The commonest mechanism of injury was Road Traffic Accidents being the cause of injury in 67 patients (80.7%) followed by industrial injuries 9(10.8%) least were sports injuries and assaults. The commonest sustained fracture was Transverse fracture type 32A3 by AO classification with 31 cases (37.3%) and there was no complex fracture type 32C3 in the study group. of 42 cases treated by conservative method 9(18.8%) had union, 1(2.4%) malunion and 31(75.6%) non union. One patient from this group died following complications from HIV/AIDS of 41 patients treated by open reduction and internal fixation 39(95.1%) had union, 1(2.4%) had non-union and 1(2.4%) had malunion following a loosened plate. There was no death in this group of those treated conservatively at 3 months follow up 10(23.8%) had severe knee joint stiffness 25(59.5%) had moderate and 7 (16.7%) had mild, while those treated by ORIF the complication was found on 2(4.9%), 17(41%) and 22(53.1%) respectively. At six months the joint function had improved for both groups with only case(2.4%) with severe residual knee stiffness from the conservatively treated and none from the ORIF group. Those treated by skeletal traction had significant longer hospital stays with mean stay of 58.33 days against 25.90 days for those treated by open reduction and internal fixation. The difference between the two means is 32.43, Kruskal-Wallis H chi- square 59.19 and P-value 0.00000 which is highly significant. Longer hospitalization meant more direct and indirect costs to the patient, longer sick leaves and more unproductive days for skeletal traction type of treatment. For the health facility longer hospitalization though not directly costing more per se its impact is in inefficient use of funds and increased workload. The former is compounded by the fact that the patient bears but only a fraction of real cost of treatment as the larger part of treatment is subsidized. Conclusions: 1.Road Traffic Accidents are the main cause of closed femoral shaft fractures. 2.Treatment by continuous skeletal traction is associated with more complications especially non-union and knee joint stiffness. 3.Treatment by skeletal traction leads to longer hospital stay and late ambulation of the patient. 4.Skeletal traction directly and indirectly costs more than surgical treatment. 5.Skeletal traction is inefficient in terms of utilization of funds by a health facility.
Available in print form, East Africana Collection, Dr. Wilbert Chagula Library, Class mark (THS EAF PL821 .T34.S34)
Conservative management, femoral shaft fractures, skeletal traction, cost effective, developing country, tanzania
Swaimd (varna), S p. M. (2005), Conservative management of closed femoral shaft fractures - is skeletal traction still justified or cost effective in a developing country like Tanzania?, Master dissertation, University of Dar es Salaam. Dar es Salaam