Evaluation of remote results of treatment of children with long-bone fractures of the lower extremities

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Abstract


Background. Evaluation of the effectiveness of treatment of long-bone fractures of the lower extremities should be comprehensive and include both subjective and objective indicators. In the developed countires, it is standard to assess the quality of life related to children’s health after trauma. According to the Russian literature, such assessment has not been studied. The aim of our study was to assess the quality of life in children, with long-bone fractures of the lower extremities, and to compare the results with data from the Lower Extremity Functional Scale (LEFS) and assessment system according to N.B. Duysenov.

Materials and methods. We examined 70 patients (age range, 8–18 years) with long-bone fractures of the lower extremities. Forty patients had a history of tibia fracture, and 30 patients had a history of femoral fracture. We determined the severity of the fractures using pediatric comprehensive classification of long-bone fractures (PCCF). We assessed the quality of life of the children using the Pediatric Questionnaire for Quality of Life 
(PedsQLTM 4.0).

Results. Trauma had a significant impact on the quality of life in children. The children evaluated their quality of life after injury more objectively; on all scales, their scores had the highest correlation with LEFS and assessment system according to N.B Duysenov. In most cases, parents underestimated the mental and physical burden of their child’s condition after injury. The values for the “physical functioning” assessment in children with severe trauma was the lowest, and was not significantly different between parents and children. Parents who were aware of the severity of the injury gave their child more attention, which positively affected the child’s psychological and social functioning. Children with severe trauma had higher values on the emotional, social and role functioning scale, compared to children with minor 
injuries.

Conclusions. The results of all functional scales in the quality of life assessment, as assessed by the children themselves at different times after injury, had the highest correlation with LEFS and assessment system according to N.B. Duysenov. LEFS is the most informative for examining the consequences of fractures of different severity. There were no significant differences among the children with fractures of varying severity using the assessment system according to N.B. Duysenov.


Introduction

Accidental injuries are among the leading reasons for seeking medical treatment among the children of Russia [1, 2]. An increase in the severity of trauma and a rise in the rate of delayed consolidation of bone fragments have been noted [3].

According to various authors, fractures of the long tubular bones account for 53% to 65% of all musculoskeletal system injuries among children and adolescents [4, 5]. Fractures of the lower leg and femur among children are among the most frequent traumas of the musculoskeletal system [6] and require hospitalization [1].

The main task in the treatment of children with limb bone fractures and their consequences is the restoration or compensation of their functional state and improvement of the quality of life 
(QOL) [7].

Experts of the World Health Organization proposed assessing the results of surgical treatment by studying QOL [8]. The assessment of the health-related QOL (HRQOL) among children after trauma is included in healthcare standards abroad [9].

Among the general child questionnaires adopted in Russia, the questionnaire QOL PedsQLTM 4.0 [10] is particularly popular. It was recommended for use in healthy children and in patients, including those with orthopedic injuries.

Duisenov emphasized that the assessment of treatment efficacy in limb bone fractures should be complex, including the subjective signs and objective indicators (the results of special functional tests and motion tasks and of clinical and instrumental examinations), comprising the assessment of QOL, complaints, subjective assessment of the functional capabilities of a limb, accomplishment of special motion tasks, objective assessment of the functional capabilities of a limb, and assessment of the patient’s functional independence [7].

According to Pankov, the complex clinicoroentgenologic system for assessing treatment outcomes and the assessment of QOL with the MOS SF-36 questionnaire not only agree in substance but also complement each other in the qualitative and quantitative senses and more objectively permit the assessment of treatment outcomes at higher levels [11].

According to various authors, the recovery time of QOL indicators after lower extremity trauma is from 1 to 2 years or more, depending on the severity of damage, sample size, patient age, and the questionnaires used [12-14].

Goal of the study

The goal of the study was to assess QOL in patients after fracture of the long bones of the lower extremity and to compare the results with the data of the Lower Extremity Functional Scale (LEFS) and Duisenov’s assessment system.

Materials and methods

The studies were performed 1, 2, 3, and 4–5 years after trauma. Seventy patients were examined at ages ranging from 8 to 18 years. Forty patients had a medical history of lower leg fracture. Their mean age at the time of trauma was 11.15 ± 0.36 years, and their mean age at the time of examination was 13.7 ± 0.36 years. Thirty patients had a medical history of femur fracture. Their mean age at the time of trauma was 11.7 ± 0.43 years, and their mean age at the time of examination was 11.7 ± 0.43 years.

All patients willingly provided informed consent to participate in the study. The study was approved by the institutional review board of The Turner Scientific and Research Institute for Children Orthopedics, Saint Petersburg, Russian Federation (protocol 04.04.2013 No. 1/13).

To determine the severity of fractures, we used the pediatric comprehensive classification of long bone fractures (PCCF) specifically designed for pediatric population. Fractures are coded as diaphysis (D), metaphysis (M), and epiphysis (E). For assessment of the functional state of lower limbs, the LEFS [15] scale and the system of assessment of the functional state of lower limbs by their damage and its consequences by Duisenov [7], were used.

The pediatric questionnaire QOL PedsQLTM 4.0 was used to assess QOL. The Russian language version of the questionnaire consists of questions combined in four scales: “Physical functioning”; “Emotional functioning”; “Social functioning”; and “Role functioning”. The electronic Russian language version and the instructions for the scoring procedure were obtained by agreement with the head of the Scientific Research Department of the Multinational Center for Quality of Life Research (Saint Petersburg) at the site https://eprovide.mapi-trust.org directly from the developer.

For standardization of the results, in processing the data initially recorded in points, the points were converted to a relative value, the percentage of the maximum possible sum of points by the formula N (%) = (Nб × 100) : Maxб.

The methods of descriptive statistics included evaluation of the arithmetical mean (M) and the mean error of the mean value (m). Student’s t-test was applied to data with a continuous distribution. The critical level of significance for statistical hypotheses was taken to be 95% (р ≤ 0.05). To test the significance of relationships between indicators, Spearman’s correlation coefficient was calculated. The statistical significance of correlations was determined in accordance with the table of Spearman criteria of critical values (r) depending on sample size. Data were analyzed with the computer programs Statistica 6.0 and Excel 2003.

Study results

Regardless of the location of the fracture, both the children and their parents gave the lowest QOL estimate according to the scales “Physical functioning” (87.3%–82.2% for children and 72.5%–75.3% for parents), and “Role functioning” (87%–85% for children and 69.3%–70.5% for parents) (Table 1).

Table 1

Results of the assessment of QOL and functional state of lower extremities in children after fracture of the femur and the bones of the lower leg

Studied indicators

Max

(points)

Location of fracture

р-value

(Student’s t-test)

Femur (n = 30)

Lower leg

(n = 40)

PedsQL PARENTS block 1 
(“Physical functioning”)

(% of max)

800

87.3 ± 2.4*

82.2 ± 2.54*

> 0.05

(1.46)

PedsQL PARENTS block 2

(“Emotional functioning”)

(% of max)

500

94.7 ± 0.9*

90.5 ± 1.25*

≤ 0.05

(2.7)

PedsQL PARENTS block 3

(“Social functioning”)

(% of max)

500

93.0 ± 1.4*

94.7 ± 2.19*

> 0.05

(0.68)

PedsQL PARENTS block 4

(“Role functioning”)

(% of max)

500

87.0 ± 2.5*

85.0 ± 2.03*

> 0.05

(0.62)

TOTAL parents (% of max)

2300

90.7 ± 1.7*

87.5 ± 1.87*

> 0.05 (1.2)

PedsQL CHILDREN block 1

(“Physical functioning”)

(% of max)

800

72.5 ± 2.98

75.3 ± 2.34

> 0.05

(0.74)

PedsQL CHILDREN block 2

(“Emotional functioning”)

(% of max)

500

72.3 ± 3.64

76.5 ± 1.88

р > 0.05

(1.02)

PedsQL CHILDREN block 3

(“Social functioning”)

(% of max)

500

74.0 ± 4.55

89.5 ± 1.88

≤ 0.01

(3.15)

PedsQL CHILDREN block 4

(“Role functioning”)

(% of max)

500

69.3 ± 1.82

70.5 ± 3.13

> 0.05

(0.32)

TOTAL children (% of max)

2300

72.1 ± 2.2

77.6 ± 1.6

≤ 0.05 (2.02)

LEFS

(% of max)

80

85.7 ± 2.44

87.5 ± 1.68

> 0.05

(0.7)

According to Duisenov’s assessment system

(% of max)

25

94.5 ± 1.09

90.8 ± 3.13

> 0.05

(1.09)

Note: max, maximum possible number of points; *Significantly higher score than children’s estimate (р ≤ 0.01–0.001)

The assessment of QOL by children according to all scales was far below the assessment by their parents (р ≤ 0.01–0.001).

Compared with children with lower leg fractures, children with femur fractures assessed QOL as significantly lower according to the “Social functioning” scale (р ≤ 0.01) and as significantly higher according to the “Emotional functioning” scale (р ≤ 0.05). However, in general, according to the children’s assessment, QOL was higher after lower leg fracture than after femur fractures (Table 1).

Assessment by Duisenov’s system of the functional state of the lower extremities after fracture gave good results, with scores ranging from 94.5% to 90.8% of the maximum possible score. According to the LEFS scale, including the evaluation of difficulties related to the state of a lower extremity, the results were poorer, ranging from 85.7% to 87.5% of the maximum possible score (Table 1).

Follow-up periods for children with fractures of the femur and the lower leg were similar. Ten patients with femur fractures (44%) and 14 with lower extremity fractures (55.6%) were followed up for 1 year; eight patients with femur fractures (44.4%) and 10 with lower extremity fractures (55.6%) were followed up for 2 years; 10 patients with femur fractures (45.5%) and 12 with lower extremity fractures (54.5%) were followed up for 3 years; two patients with femur fractures (33.3%) and four with lower extremity fractures (66.7%) were followed up for 4–5 years. This allowed us to combine the patients with fractures of the long bones of the lower extremities (LBLE) into one group.

At 1 year after trauma, the lowest values of QOL in the parental and child forms of the questionnaire were noted according to the scale “Physical functioning” (84.1%–70.7%). Analysis of the results showed that parents in some cases underestimated the severity of the psychological and physical state of their children. Thus, according to the scales “Emotional functioning”, “Social functioning” and “Role functioning”, parents already recorded high scores 1 year after trauma, while the children themselves gave significantly lower estimates according to the scales. According to the scale “Physical functioning”, parents recorded lower scores, but not as low as the scores their children gave: 84.1% compared with 70.7% (р ≤ 0.05) (Table. 2).

Table 2

Results of assessment of QOL and functional state of lower extremities in children after fracture of the long bones at different follow-up times

Studied indicators

Max

(points)

Follow-up time (years)

1

n = 24

2

n = 18

3

n = 24

4–5

n = 6

PedsQL PARENTS block 1 (“Physical functioning”)

(% of max)

800

84.1 ± 4.06*

83.3 ± 3.13

86.9 ± 3.4

78.1 ± 10.4

PedsQL PARENTS block 2 (“Emotional functioning”)

(% of max)

500

97.3 ± 0.75*

93.3 ± 1.18*

88.75 ± 2.0*

85.0 ± 6.7

PedsQL PARENTS block 3 (“Social functioning”)

(% of max)

500

95.9 ± 1.5*

94.4 ± 0.88*

97.1 ± 1.25*

73.3 ± 11.7

PedsQL PARENTS block 4 (“Role functioning”)

(% of max)

500

92.7 ± 1.0*

72.2 ± 3.24*

92.5 ± 2.0*

75.0 ± 10

TOTAL parents

(% of max)

2300

91.4 ± 1.41*

85.9 ± 2.17*

90.8 ± 1.36*

77.9 ± 9.8

PedsQL CHILDREN block 1 (“Physical functioning”)

(% of max)

800

70.7 ± 3.75

76.4 ± 3.86

78.4 ± 2.9

62.5 ± 7.8

PedsQL CHILDREN block 2 (“Emotional functioning”)

(% of max)

500

75.9 ± 3.5

82.8 ± 2.35*

67.5 ± 3.7

75.0 ± 5.8

PedsQL CHILDREN block 3 (“Social functioning”)

(% of max)

500

77.7 ± 5.0

88.9 ± 1.76

84.5 ± 1.75

76.7 ± 10.0

PedsQL CHILDREN block 4 (“Role functioning”)

(% of max)

500

77.7 ± 2.25

62.2 ± 3.6

70.8 ± 2.0

61.7 ± 6.7

TOTAL children

(% of max)

2300

74.9 ± 2.88

77.4 ± 2.17

75.7 ± 2.07

68.12 ± 7.6

LEFS-scoring

(% of max)

80

86.8 ± 2.69

84.0 ± 3.16

89.6 ± 1.44

84.6 ± 5.0

According to Duisenov’s assessment system (% of max)

25

93.8 ± 1.2

84.9 ± 5.9

96.7 ± 0.8

92.0 ± 3.3

Note: max, maximum possible number of points; *Significantly higher score than children’s estimate (р ≤ 0.05–0.001)

At 2 years after trauma, the lowest values of QOL in the parental and child forms of the questionnaire were noted according to the scales “Physical functioning” (83.3% and 76.4%, respectively) and “Role functioning” (72.2% and 62.2%, respectively); the highest values of QOL were noted according to the scale “Social functioning” (94.4% and 88.9%, respectively). At 2 years after trauma, the assessment of QOL according to the scales of the psychological block by parents was also higher than the assessment by the children themselves (р ≤ 0.05–0.01). In the scale “Physical functioning”, the assessments of QOL by parents and children were not significantly different (р > 0.05).

At 3 years after trauma, both parents and children ranked “Social functioning” as highest (97.1% and 88.9%, respectively). Parents ranked “Physical functioning” as lowest (86.9%), and children ranked “Emotional functioning” as lowest (67.5%).

We could not assess QOL at 4–5 years after trauma because of the small number of subjects (six persons) and the large variation in the data.

LEFS scoring and the assessment of the functional state of an extremity by Duisenov showed an upward trend at 3 years after trauma to 89.6% and 96.7%, respectively (Table 2).

Because the severity of trauma had a definite impact on the functional state of a limb and self-assessment of QOL, all patients in accordance with PCCF were divided into three groups:

1) Severe trauma (32-D/5.2; 42-D/5.2; 42-D/4.2; 43-M/3.2; 42t-D/5.2): 20 patients;

2) Moderate trauma (41t-E/7; 31-E1.1; 32-D/4.1; 43t-M/3.1; 43-E/5.1; 43t-E/2.1; 32-D/4.1; 42-D/4.1): 20 patients;

3) Minor trauma (43-M/3.1; 41t-M/7; 42t-D/5.1; 32-D/5.1; 42-D/2.1; 42-D/5.1): 30 patients.

In severe trauma, the assessment of QOL according to the scale “Physical functioning” by parents and children was not significantly different (77.5% and 68.7%, respectively) and was the lowest in comparison both with other severe trauma scales and with the “Physical functioning” values in less severe traumas (р ≤ 0.05–0.01). In other scales in severe trauma, the assessment of QOL by parents was significantly higher than that by children themselves (р ≤ 0.001) (Table 3).

In moderate trauma, parents ranked QOL as lowest according to the scale “Role functioning” (85.0%) and as highest according to the scales “Emotional functioning” and “Social functioning” (93.5% and 93%, respectively). The children ranked QOL as lowest according to the scales “Emotional functioning” and “Physical functioning” (74.0% and 78.1%, respectively) and as highest according to the scale “Social functioning” (88.9%), as did the parents (see Table 3).

Table 3

Results of the assessment of QOL and functional state of lower extremities in children after fractures of different severity of the long bones of lower limbs

Studied indicators

Max

(points)

Severity of trauma

Severe

(n = 20)

Moderate

(n = 20)

Minor

(n = 30)

PedsQL PARENTS block 1

(“Physical functioning”) (% of max)

800

77.5 ± 3.5˚

90.0 ± 2.8*

85.4 ± 1.5*

PedsQL PARENTS block 2 
(“Emotional functioning”) (% of max)

500

96 ± 1.84*

93.5 ± 1.05*

87.3 ± 1.6*

PedsQL PARENTS block 3

(“Social functioning”) (% of max)

500

98.0 ± 0.26*

93.0 ± 1.58

93.3 ± 2.8*

PedsQL PARENTS block 4

(“Role functioning”) (% of max)

500

93.5 ± 1.84*

85.0 ± 2.89

80.7 ± 2.6*

TOTAL parents 4 blocks

(% of max)

2300

89.5 ± 1.49*

90.3 ± 1.95*

86.5 ± 2.4*

PedsQL CHILDREN block 1 
(“Physical functioning”) (% of max)

800

68.7 ± 2.95˚

78.1 ± 3.45

76.9 ± 2.6

PedsQL CHILDREN block 2 
(“Emotional functioning”) (% of max)

500

80.5 ± 2.63

74.0 ± 3.68

73.2 ± 2.4

PedsQL CHILDREN block 3

(“Social functioning”) (% of max)

500

87.5 ± 1.58

88.9 ± 2.11

80.7 ± 2.4

PedsQL CHILDREN block 4 
(“Role functioning”) (% of max)

500

77.5 ± 2.37

80.0 ± 2.37

66.1 ± 2.0

TOTAL children (4 blocks)

(% of max)

2300

77.28 ± 2.17

79.5 ± 3.0

72.5 ± 2.0

LEFS scoring

(% of max)

80

82.2 ± 2.1 ˚

88.3 ± 1.8

87.2 ± 1.45

According to Duisenov’s assessment system

(% of max)

25

94.8 ± 0.84

94.0 ± 1.26

89.3 ± 4.0

Note: max, maximum possible number of points; *Significantly higher score than children’s estimate (р ≤ 0.01–0.001); ˚Significantly lower score than that for fractures of other severity at р ≤ 005–0.01

Table 4

Results of correlation analysis of QOL indicators and functional assessment (n = 70)

Scale

LEFS scoring

Duisenov’s assessment system

r

р

r

р

PedsQL PARENTS block 1

(“Physical functioning”)

0.75

≤ 0.001

0.61

≤ 0.001

PedsQL PARENTS block 2

(“Emotional functioning”)

0.1

> 0.05

0.14

> 0.05

PedsQL PARENTS block 3

(“Social functioning”)

0.37

≤ 0.01

0.53

≤ 0.001

PedsQL PARENTS block 4

(“Role functioning”)

0.38

≤ 0.01

0.37

≤ 0.01

TOTAL PARENTS (4 blocks)

0.66

≤ 0.001

0.61

≤ 0.001

PedsQL CHILDREN block 1

(“Physical functioning”)

0.81

≤ 0.001

0.78

≤ 0.001

PedsQL CHILDREN block 2

(“Emotional functioning”)

0.28

≤ 0.05

0.47

≤ 0.001

PedsQL CHILDREN block 3

(“Social functioning”)

0.38

≤ 0.01

0.43

≤ 0.001

PedsQL CHILDREN block 4

(“Role functioning”)

0.41

≤ 0.001

0.41

≤ 0.001

TOTAL children (4 blocks)

0.72

≤ 0.001

0.77

≤ 0.001

According to Duisenov’s assessment system

0.81

≤ 0.001

Note: r, Spearman correlation coefficient; р, statistical significance in accordance with the table of the critical values of Spearman criteria

In minor trauma, parents ranked QOL as lowest according to the scales “Role functioning” and “Physical functioning” (80.7% and 85.4%, respectively), and children ranked QOL as lowest according to the scale “Role functioning” (66.1%). Parents’ assessment of children’s QOL according to all scales was higher than that of the children themselves (р ≤ 0.01–0.001).

In the LEFS scale, the lowest values (р ≤ 0.05 0.01) were noted in patients with more severe fractures.

Duisenov’s assessment system did not reveal significant differences between children with fractures of different severity (р > 0.05).

To find the correlation between the determined indicators of QOL and functional assessment in patients after LBLE fractures, we carried out a correlation analysis; the results are presented in Table 4.

High degrees of QOL correlation were found between the parents’ and the children’s assessment with the indicators of the functional scale LEFS and Duisenov’s assessment system.

High correlations with the LEFS functional scale were found in the QOL scale “Physical functioning” in both children’s and parents’ assessments; the correlation coefficient with the children’s assessment was higher, 0.81 vs. 0.75. The lowest correlation was in children’s assessment, or it was not detected at all (in parents’ assessment) according to the QOL scale “Emotional functioning”, 0.28 and 0.1, respectively. Thus, QOL according to children’s assessment correlated to a greater degree with the indicators of the LEFS functional scale (Table 4).

The highest correlations with Duisenov’s assessment system also were found in the QOL “Physical functioning” scale. As in the case of the LEFS scale, the highest correlation was noted with the children’s assessment, 0.78 vs. 0.61, and there was no correlation with the QOL “Emotional functioning” scale in the adults’ assessment.

A very high correlation of the LEFS scale with Duisenov’s assessment system was noted.

Discussion

We found that trauma had a long-term impact on QOL of children. The total value of QOL according to all scales in follow-up periods of 1–5 years varied slightly, from 74.9% to 77.4%, against the maximum possible value. At 1 year after trauma, the lowest QOL values in both the children’s and the parents’ forms of the questionnaire were noted according to the scale “Physical functioning”.

Parents in most cases underestimated the severity of the psychological and physical state of their children, especially their psychological state, after trauma. For example, 2 years after trauma, assessment of QOL by parents and children according to the “Physical functioning” scale was almost the same, but in other scales assessment of QOL by parents was significantly higher than that by the children themselves.

In severe trauma, assessment of QOL according to the scale “Physical functioning” by parents and children was not significantly different and was the lowest, at 77.5% ± 3.5% and 68.7% ± 2.95%, respectively, of the maximum possible value. Understanding the severity of the trauma forced parents to give close attention to their children, which positively affected the level of their psychological and social functioning. As a result, parents’ assessment of QOL in children with severe trauma according to scales of emotional, social, and role functioning was higher than that of QOL in those with minor traumas: 80.5% ± 2.63% vs. 73.2% ± 2.4%, 87.5% ± 1.58% vs. 80.7% ± 2.4%, and 77.5% ± 2.37% vs. 66.1% ± 2.0%, respectively.

The analysis of techniques of determination of the functional state of a lower extremity showed that in the LEFS scale, the lowest values were noted in patients with more severe fractures. Duisenov’s assessment system did not reveal significant differences between children with fractures of different severity. However, a high correlation was found between these techniques.

The highest correlations of the LEFS functional scale and Duisenov’s assessment system were found with the scale QOL “Physical functioning in the children’s assessment. The high correlations of assessment of QOL with the values of the LEFS scale and Duisenov’s assessment system proved the informative value in the assessment of the results of treatment in patients with LBLE.

Conclusions

The consequences of LBLE fractures have a long-term impact on QOL of children; changes are found at 3 years and more after trauma. Parents in most cases underestimate the severity of the psychological and physical state of their children after trauma, especially in children with minor LBLE fractures. Children assess their QOL after trauma more objectively; their assessment according to all scales has the highest correlation with the LEFS functional scale and Duisenov’s assessment system.

Information on funding and conflict of interest

The authors declare no evident and potential conflicts of interests related to the publication of the present paper. The study was conducted within the frame of the research work approved by I.I. Mechnikov North-Western State Medical University with the support from The Turner Scientific and Research Institute for Children Orthopedics, Saint Petersburg, Russian Federation

Aleksander A Patlatov

North-Western State Medical University n. a. I.I. Mechnikov

Author for correspondence.
Email: dr-pat@mail.ru
MD, PhD student of the chair of pediatric traumatology and orthopedics. North-Western State Medical University n. a. I.I. Mechnikov

Yury E Garkavenko

North-Western State Medical University n. a. I.I. Mechnikov; The Turner Scientific and Research Institute for Children’s Orthopedics

Email: yurijgarkavenko@mail.ru
MD, PhD, professor of the chair of pediatric traumatology and orthopedics. North-Western State Medical University n. a. I.I. Mechnikov, leading research associate of the department of bone pathology of The Turner Scientific and Research Institute for Children’s Orthopedics.

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