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FEMORAL SHAFT FRACTURES: MECHANISMS, PATTERNS AND ASSOCIATED INJURIES IN MAKURDI, NIGERIA.

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Yongu T. Williams; FWACS, Elachi C. Itodo; FWACS, Mue D. Daniel; FWACS,
Kortor N. Joseph; FMCS, Atokolo  Stephen; MBBS

Department of surgery, College  of  Health  Sciences, Benue  State  University  Teaching  Hospital  and
Benue  State  University  Teaching  Hospital  Makurdi.

ABSTRACT
Context: The femur is the strongest and longest bone in the body but is frequently fractured in high energy trauma. Femoral shaft fractures are commonly associated with multiple system injury which may be missed during initial assessment.
Methods: A four year retrospective   study was conducted at Benue State University Teaching Hospital. The data was ob¬tained from records of all the patients with femoral shaft fractures that were admitted and treated in the hospital. These included demographic characteristics, mechanism of fracture, associated injuries, radiological findings. and treatment options. Descriptive statistics done using the Statistical Package for Social Sciences version 16.0  (SPSS Inc. Chicago, IL).
Results: There were 83 patients with femoral shaft fractures with  mean age of 32.75±1.5 years. The age range was 3 -80 years. There were 52 males and 21 females giving a  male to female ratio of  1.7:1 .Thirty of them (36.1%) presented  within 1 hour (Golden hour). There were 62(72.7%) closed fractures while open fractures accounted for 21(27.3%). The most common cause of femoral shaft  fracture was motor vehicular/motorcycle collision 28(33.7%).The most frequent fracture pattern observed was comminuted fracture accounting for 21(32.5%).There were 26 associated injuries occurring a total of 81 times in 52 patients.. Head injury accounted for 27(33.7%) of the associated injuries .Plate and screws, interlocking nail  and external fixation were used for treatment.

Conclusion: Femoral shaft fractures are common and mostly result from  motor vehicular/motorcycle crashes among young people in Makurdi. These fractures are often associated with multiple system injuries including the head and limbs.

Keywords: Femoral Shaft, Fracture, Mechanisms, Associated Injuries

INTRODUCTION
The femur is the strongest, longest, and heaviest bone in the body and is essential for normal ambulation.1,2 The shaft of the femur begins at the top of the femoral isthmus and extends to the distal metadiaphyseal junction, an indistinct transitional zone contiguous with the supracondylar region. Femoral shaft fractures are frequently  due to  high-energy trauma  and for this reason, they are  a threat  to  life itself. They also  account for important handicaps, and are usually associated with multiple injuries.1-4 The   complications  frequently encountered in the management of this fracture  are  malunion, limb  shortening, poor alignment and knee stiffness.5
Femoral shaft fracture patterns vary according to the direction of the force applied and the quantity of force absorbed. A perpendicular force results in a transverse fracture pattern, an axial force may injure the hip or knee, and rotational forces may cause spiral or oblique fracture patterns. The amount of comminution present increases with increasing amounts of force.1,2,4
The incidence of femoral shaft fractures  ranges from 9.9 to 12 for every 100,000 persons/year ;sixty  percent   occur in men and 40% in women.5 The average age is 25, with a maximum incidence peak among 15 and 24 years of age.1-4 The cause in the majority of cases is high-energy trauma, mainly traffic crashes (80-90%).4 The considerable energy required to cause many of these fractures often also provoke injuries in other structures especially in the ipsilateral hip and knee and  may  go undiagnosed.1-4 Concomitant injuries may also occur in other parts of the body like the head, abdomen, chest, pelvis, spine and the  contralateral limb.
Several classifications exist for diaphyseal shaft fractures. The AO classification defines 27 diaphyseal femo­ral fracture patterns based on the location of the fracture (proximal, mid-shaft or distal), its anatomy (transverse or oblique) and the degree of comminution, does not have implications on therapy or prognosis.5 However, the Winquist et al classification, based on de­gree of comminution, has therapeutic implications.4,5 Four types are defined: type I, with non-existent or mini­mal comminution; type II, with comminution of less than 50% of the circumference of the femoral shaft; type III, with comminution affecting 50-100% of the circumfer­ence of both major fragments; and type IV, with circum­ferential shaft comminution and no contact between the cortical parts of the larger fragments after reduction.6-10 The minimally comminuted (Types I and II) usually resist shortening and malrotation  and  can be  successfully stabilized with a non-locking intramedullary nail. Types III and IV require a distal and proximal locking nail to maintain length and guarantee rotational stability. Open fractures are classified using the Gustilo and Anderson classification.
This study was conducted to identify the causes of femoral shaft fractures in our region, determine the fracture patterns and the associated injuries. This will provide a basis for stakeholders in trauma care to formulate and implement policies that will lead to both prevention and early identification and appropriate treatment of this challenging fracture and its associated injuries.

METHODS
A four year (September 2012 and August 2016)  retrospective study was conducted at Benue State University Teaching Hospital Makurdi (BSUTH). Permission for the study was obtained from the  Health Research Ethics committee of the Hospital. The data was ob­tained by reviewing the records of all the patients with femoral shaft fractures. This included demographic data, cause of fracture (including details of mechanism; motorcycle/motorcycle collision, motorcycle/motor vehicular collision, motorcycle/pedestrian collision and motor vehicular/pedestrian collision), falls, gunshot injuries and osteoporosis. The time of presentation (within one hour, within 6hours), fracture type (open or closed) and pattern were documented. Associated injuries (Other injuries with an Abbreviated Injury Scale of 2 or higher at another level of ipsilateral limb or contralateral limb as well as head injury, chest injury, spinal and abdominal injury) were also documented. The fractures in this study were defined radiographically according to fracture pattern as transverse, oblique, spiral, segmental or comminuted.
Exclusion criteria included peripros­thetic fractures and patient not admitted to the hospital.
Our modalities for managing femoral fractures depends on the age, the etiology, fracture orientation, bone quality and concurrent soft tissue injuries. Other considerations include the surgeon’s preference, available resources and patient’s choice. These modalities include conservative management(especially in the paediatric age group), open reduction and internal fixation (using interlocking nailing or plates and screws) and external fixation for some open fractures after debridement. Follow-up activities for the patients include physiotherapy, early mobilization, medical therapy and out-patient visits until fracture consolidation. Implant removal can then be planned subsequently if it is considered necessary.
Descriptive statistics of the samples was done using the Statistical Package for Social Sciences version 16.0 (SPSS Inc. Chicago, IL).

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RESULTS
There were 83 patients with femoral shaft fractures with mean age of 32.75±1.5 years. The age range was 3 -80 years (Table 1). There were 52 males and 21 females giving a male to female ratio of 1.7:1. Thirty of them (36.1%) presented within 1 hour (Golden hour) while 60(72.3%) presented within 6 hours. Their occupations were civil servants 15(18.1%), students 13(15.7%), Business 13(15.7%), farmers 10(12.0%), pupil 11(13.3%), motorcyclists 7(8.4%), others 14(16.8%). There were 62(72.7) closed fractures while open fractures accounted for 21(27.3). Road traffic crash was significantly associated with open femoral shaft fractures (OR=2.54;95% confidence interval 0.29-22.00; z =0.84; p=0.39). The most common cause of femoral shaft fracture was motorcycle/motor vehicular collision 28(33.7%). The motorcycle was involved in 50(60.2%) of femoral shaft fractures (Table 2). The most frequent fracture pattern observed was comminuted fracture accounting for 27(32.53%) (table 3). There was only one gunshot injury (Figure 1). There were 26 associated injuries occurring a total of 81 times in 52(62.6%) patients (Table4).Thirty one (37.2%) patients did not have associated injuries. Ten (12%) of the associated injuries were missed during initial assessment   but were identified and treated before discharge from the hospital. Head injury accounted for 27(33.7%) of the associated injuries (Table 4). Among those with associated head injury, the cause of femoral shaft fracture was  motorcycle/motor vehicular collision 12(44.4%), motor vehicular crash 7(25.9%), motorcycle/motorcycle collision 5(18.5%), motorcycle/pedestrian collision 2(7.4%) and motor vehicular/pedestrian collision 1(3.7%). None of the motorcyclists in this study wore a helmet. The incidence of femoral fractures rose from 2(2.4%) in 2012 to 30(36.1%) in 2016 (Figure2). Plate and screws were used in 11(13.2%) patients, interlocking nail in 7(8.4%), external fixation in 3(3.6%) and skeletal traction in 3(3.6%). Six (7.2%) patients died and the remaining 53(63.8%) of the patients discharged themselves against medical advice after resuscitation.

DISCUSSION
This study shows that the most vulnerable age group for femoral fractures in Makurdi, Nigeria is the young population within the age group of 21-40 years. This agrees   with other studies   in Nigeria11-15 but lower than the  average age of 51.9 years documented in Spain.16 The mechanisms involved in femoral shaft fractures  predominantly involve high energy transfer with road traffic crash alone accounting for 90.3%. Motor vehicular crashes either isolated or collisions with other motor vehicles or motorcycles or pedestrians were found to account for 63.8% of the fractures. Of particular note is the finding that motor vehicular/motorcycle collision was both commonest cause of the femoral shaft fractures and also the mechanism most associated with head injury. Other studies have implicated motor vehicular and motorcycle crashes as well but the details of the collisions were not emphasized.11-16 This knowledge will be important in planning preventive strategies. These injuries occur because the body parts of the victims at the time of impact are vulnerable to injury from direct contact with motor vehicle or thrown off the motorcycle and land on the tar road. The femoral shaft commonly fractures because it is the most vulnerable part of the femur that receives most of the impact when there is trauma to the thigh due to its length.11,17 These fractures have also been known to be associated multiple system injuries.11,12,17,18 Some states in Nigeria including Lagos and Kano  have banned the use of motorcycles in the urban areas mainly because of security reasons. However, if comparative studies are done on the incidence of femoral fractures in these states before and after the ban, there may be statistical justification for opting for the use of tricycles as alternatives to motorcycles in commuting passengers in the urban areas.
Road traffic crashes are on the increase partly due to poor road infrastructure, ignorance of road safety guidelines and reckless disregard to traffic rules.19 None of the motorcyclist in our study wore a helmet. There is also a weak attempt at enforcement of the use of this protective device by law enforcement agents in our region of the country.20 Generally speaking, Nigeria has a peculiar transport challenge. Commercial motorcycles are a common means of   commuting passengers in rural, semi urban and some urban areas. The ease with which drivers’ licenses are obtained as well as  the recklessness and speed used by some of these cyclists have contributed to an increase in road traffic crashes11,19 and consequently femoral shaft fractures. Only one third (36.1%) of the patients in our study presented within the ‘Golden hour’ to the hospital. This ‘Golden Hour’ of accident, which is the first one hour after injury during which treatment intervention is believed to have the best outcome is not well observed by  patients in some parts of Nigeria. A study on trauma in Ife documented 18.6% 21presenting within the Golden hour while in Cape town South Africa, the average time between accident and presentation to hospital  was  found to be 27.55 minutes in six regions.22 This delay may be due to the relatively weak emergency response services in some parts of Nigeria.19 Most times patients are transported by bystanders, relatives and friends in inappropriate vehicles instead of ambulances manned by emergency response personnel.l6,22 More needs to be done by stakeholders in this regard to improve outcome of femoral fractures and other accident victims.
The most frequent fracture pattern observed in this study was comminuted fractures which accounted for 32.53%. This is in contradistinction to the findings documented in spain16 and Pakistan23 where transverse and spiral patterns were more common. This shows that relatively higher motor vehicular collisions in our study have led to higher energy transfers to the femur producing the predominant comminuted fracture pattern observed. Comminuted fractures pose a great challenge to the surgeon during fixation because of the tendency towards compromising length in order to achieve union especially for Winquist type III and IV fractures. Closed interlocking femoral nailing is usually the best option compared to plating because of preservation of the periosteal blood supply which facilitates healing.12,16,23 Unreamed intramedullary nailing is preferable in the more comminuted fractures. These nails are solid and are usually made of titanium alloys. However because of logistic challenges in the developing world, the less desirable option of plating may be used.
Most of the patients in our study had associated injuries. Other studies have also documented high incidences of associated injuries involving the head, upper and lower limbs, abdomen, contralateral limb and pelvis.11,16,24 These findings are similar to ours. We also observed that open femoral shaft fractures were more associated with road traffic crashes. This is understandable because of the high energy injuries. Some of the associated injuries were missed initially but identified and treated before the patients were discharged. Some of the missed injuries included pelvic ramus fracture, lateral collateral ligament injury, fracture of the second rib, scapula fracture, diaphragmatic rupture and sacroiliac joint dislocation in a concomitantly spinal injured patient. These injuries were initially missed because the patients were multiply injured and had more life threatening injuries that engaged the attention of the attending physicians. In another study, missed associated injuries were documented in 25.8% of the patients with some noticed in the outpatient department after discharge from initial admission.16 We recorded only 12.8% which is a relatively lower percentage probably due to our smaller sample size. This calls for a thorough and deliberate search for these associated   injuries by Orthopaedic and trauma surgeons in order to offer a holistic care to these patients.
Majority of the patients 63.2% in our series discharged themselves against medical advice (DAMA) after resuscitation despite the fact that 72.3% of them presented within six hours of injury. A study conducted to find out why trauma victims with orthopaedic injuries discharged themselves against medical advice showed that 36.6% is due to hospital cost while another 36% prefer traditional bone setting.25 The few patients that were willing to document reasons for their actions in our study mentioned lack of funds for further orthodox care  and  proximity to their families. The 2006 United Nations Human Development Index puts Nigeria at 159 out of 177 countries with 70.8% of their population living on less than one dollar a day and 92.4% on less than two dollars a day. Nigeria has officially been declared to be in recession by the National Bureau of statistics third quarter report since October 2016. This may be one of the reasons most patients in our study found it difficult to continue orthodox treatment in our hospital. Government could alleviate this predicament by ensuring Universal coverage of National Health Insurance Scheme as a means of subsidizing cost of care.
In conclusion, femoral shaft fractures are common and mostly result from motor vehicular and motorcycle crashes among young people in Makurdi, Nigeria. These fractures are often associated with multiple system injuries including the head, limbs, chest, abdomen, pelvis and spine.

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