Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame

Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame

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Contents lists available at ScienceDirect

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Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame L. Johnson∗, J. Messner, E.J. Igoe, P. Foster, P. Harwood Limb Reconstruction Unit and Leeds Major Trauma Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, United Kingdom

a r t i c l e

i n f o

Article history: Accepted 22 October 2019 Available online xxx Keywords: Paediatric tibial fractures Ilizarov frame Cast treatment Heath related quality of life Psychological functioning Post-traumatic stress Trauma

a b s t r a c t Purpose: To compare quality of life in children and adolescents with tibial fracture during treatment with either a definitive long-leg cast or Ilizarov frame. Methods: A prospective, longitudinal cohort study was undertaken. Patients aged between 5 and 17 years with tibial fractures treated definitively using a long-leg cast or Ilizarov frame were recruited at first follow-up. Health related quality of life was measured at each clinic appointment during treatment using the Pediatric Quality of Life Inventory (PedsQL) [1]; a validated measure of age-adjusted physical and psychosocial functioning. Psychological trauma symptoms were assessed using the Children’s Revised Impact of Events Scale (CRIES) [2]. Results were analysed based on time from injury (less than 30 days, 30 to 120 days). Data regarding injury and treatment was recorded from the clinical records. Statistical analysis was undertaken using a Kruksal–Wallis test with a Tukey–Kramer subgroup analysis. Results: Twenty-five patients from each group were included in the final analysis. Injuries were more severe in the frame patients based on the AO/OTA classification and number of open fractures. No statistically significant differences were detected in any of the outcome scores between treatment groups at either time point. A significant improvement was found in the child reported physical and total domains in both treatment groups based on time from application (<30 days vs. >30 days, frame: p < 0.0 0 01, cast: p = 0.003). There were no differences in the child reported psychosocial domain scores at any time point or between treatment groups. Parent reported scores only showed a significant physical improvement in the frame group (p < 0.0 0 01). CRIES scores for psychological trauma in the intrusion and avoidance domain improved significantly in the cast group between time points (p < 0.05), Multivariate analysis identified polytrauma, mechanism of injury and time from injury but not treatment modality (cast or frame) as significant predictors of quality of life scores (PedsQL) and severity of post-traumatic symptoms (CRIES). Conclusion: We found no difference in health-related quality of life during treatment between our patients treated for tibial fractures using a cast or an Ilizarov frame. © 2019 Elsevier Ltd. All rights reserved.

Introduction Fractures remain relatively common in children, occurring in about one third before the age of 17 [3]. Childhood fractures have significant impact on function, particularly in the early stages. This effect is greatest in those with lower limb injuries, including the tibia [4][5]. Various methods of treatment are advocated for tibial shaft fractures, including operative and non-operative techniques, and different modes of treatment have been associated with different effects on quality of life [6]. Increasing numbers of patients in



Corresponding author. E-mail address: [email protected] (L. Johnson).

our unit are being treated operatively, this is particularly applicable in patients with unstable, open, articular and physeal injuries. Circular external fixation has many potential advantages over other operative methods, including the potential for immediate weightbearing and functional rehabilitation, and has been associated with good clinical outcomes [7,8]. However, it is perceived by many as being a difficult treatment for patients and families and having significant impact on physical and social functioning. Conversely, cast treatment is often perceived as the least troublesome management option and therefore the most desirable. This may not always be the case however. For tibial fractures, immobilisation time can be lengthy and weightbearing is usually not permitted in the early stages, with children being dependent on crutches or wheelchairs.

https://doi.org/10.1016/j.injury.2019.10.077 0020-1383/© 2019 Elsevier Ltd. All rights reserved.

Please cite this article as: L. Johnson, J. Messner and E.J. Igoe et al., Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame, Injury, https://doi.org/10.1016/j.injury.2019.10.077

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This results in a cost of missed educational time, leading to approximately thirty per cent of children with tibial fractures having to repeat a year of school [9]. Trauma, including fractures in children, is associated with long term as well as short term impact on psychosocial functioning including post-traumatic stress disorder (PTSD) [10–12]. Previous work has linked the development of PTSD with health-related quality of life and it is unclear if this is a cause or an effect [13– 15]. There is a paucity of evidence regarding the effect of different treatment methods, particularly external fixation, on psychosocial functioning during the treatment phase. We therefore designed a study to investigate this in our patients. The aim of this study was to compare Health Related Quality of Life (HRQOL) and posttraumatic stress symptoms in a paediatric population receiving treatment for tibial fracture with either a cast or an Ilizarov frame. The null hypothesis is that there is no difference in function during treatment between patients treated using a frame or a cast for tibial fracture resultant on the mode of immobilisation alone. The main outcome measure was the Pediatric Quality of Life Inventory (PedsQL) [16]. The secondary outcome measure was the Children’s Revised Impact of Events Scale (CRIES) [2]. Methods A prospective, non-randomised, longitudinal study was designed to compare the PedsQL and CRIES scores in paediatric patients during treatment for tibial shaft fractures using either an Ilizarov frame or cast immobilisation. An opportunity sampling method of recruitment was used whereby eligible patients were identified during outpatients’ appointments by a member of the research team no involved in their clinical care. Patients aged between 5 and 17 with tibial fractures treated by either a definitive cast or circular external fixator were approached for potential inclusion. Patients in whom screw fixation of a metaphyseal segment had been undertaken with subsequent definitive immobilisation in a cast were also included in the cast group. Patients (and carers) in whom English was not their first language, and it was felt that this would impair their ability to complete the assessment questionnaires, were excluded. Informed consent was obtained. Data regarding injury and treatment were retrieved from the patients’ clinical records. Fractures were classified according to the Paediatric version of the AO/OTA classification. Clinical treatment Patients were treated according to established local clinical pathways. Indications for Ilizarov management were open injury, perceived or actual difficulty obtaining or maintaining reduction in a cast, patient choice and failure of cast immobilisation. Patients underwent initial cast immobilisation in the plaster room without sedation. Where satisfactory alignment was not obtained, a manipulation under general anaesthesia was undertaken and the cast applied in theatre. In those requiring screw fixation in addition to the cast application this was undertaken primarily under general anaesthetic. In the cast group, the use of above knee casts, conversion to Sarmiento patella tendon bearing casts and time to weightbearing was determined by the treating surgeon based upon the level of the fracture and perceived stability. All patients treated in Ilizarov frames were allowed unrestricted weightbearing and joint range of motion immediately post operatively. All patients received inpatient and outpatient physiotherapy during their period of immobilisation. Immobilisation was maintained until union was judged to have occurred based upon clinical (pain free weightbearing) and radiographic (bridging callus of at least 3 cortices on 2 views) findings.

Outcome measures The Pediatric Quality of Life Inventory Version 4.0 (PedsQL 4.0; [16]) was used to estimate health related quality of life. This uses 23 item parent proxy and child self-reports covering physical, emotional, social and school functioning. Three individual scores out of 100 are generated; physical functioning, psychosocial functioning, and overall quality of life, with 100 being best. Age adjusted versions were used for 5 to 7 years, 8 to 12 years, and for 13 to 18year olds. A score less than 70 has been recognised as an indicator for poor quality of life. This questionnaire is a validated measure and has been used previously in orthopaedic paediatrics [1,16,17]. The 13-item Children’s Revised Impact of Events Scale (CRIES13: [2]) was administered as a reliable and validated measure of PTSD symptoms in trauma patients [18]. This provides subscale scores of avoidance, intrusion and arousal. Indicators for a high risk of being diagnosed with PTSD were a score of 17 or above on the total scores from avoidance and intrusion; or an overall score of 30 or more across all subscales [2]. Questionnaires (the PedsQL and CRIES-13) were administered to the patients at each outpatient appointment that the patient attended. For analysis, results were divided by treatment type (Cast or Ilizarov frame) and time from application (30 days or less or more than 30 days). It was felt that these 2 time periods represented an early treatment phase whilst the patient was becoming used to living with the form of immobilisation and an established phase following this. Each recorded score was considered an individual event. This study was granted approval by our local audit and research and development teams as an observational service improvement project and was not felt to require independent ethical approval. Statistical analysis A sample size calculation was carried out to detect a clinically significant difference of 12 points on the PedsQL score [19] which equals one standard deviation in the population sample. This estimated that 21 participants for each treatment group would be required to detect as significant clinical difference on the PedsQL score between the two groups should this exist, with a power of detection of 90% and Alpha set at 5%. Study variables did not meet the assumptions for parametric analysis, either as they are not true scalar variables or because of their distribution. Continuous variables are therefore expressed as median, interquartile and absolute range. Statistical analysis was undertaken using Analyse-it software for Microsoft Excel (Version 4 – http://www.analyse-it.com). Differences between groups were examined using a Wilxocon–Mann–Witney or Kruksall–Wallis test as appropriate. Where more than 2 groups were present a Post Hoc Steel–Dwass–Critchlow–Fligner all pairs comparison was also used to identify which groups caused the observed effect. A Fishers Exact test was used to compare nominal variables between groups. Multiple linear regression analysis was undertaken with the different components of the PedsQL as the response variable. Age, gender, open injury, polytrauma, treatment group, time from treatment and injury mechanism were included as potential predictor variables. All predictors were included simultaneously in the model. Statistical significance was assumed at the p < 0.05 level. Results Participants A total of 50 children were recruited to the study. Details of their demographics, injury and treatment are found in Table 1.

Please cite this article as: L. Johnson, J. Messner and E.J. Igoe et al., Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame, Injury, https://doi.org/10.1016/j.injury.2019.10.077

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Table 1 Baseline patient and injury characteristics in the 2 groups. WMW – Wilxocon–Mann–Witney test. FE – Fishers exact test. Fracture location, physeal involvement and severity all according to the paediatric version of the AO / OTA classification. 41 – proximal metaphysis, 42 – disphyseal, 43 – distal metaphyseal. D – diaphyseal, M – metaphyseal, E – eipiphyseal.

N Gender Age Fracture location (41 / 42 / 43) Physeal Involvement – D M E Severity – 1 2 3 Open fracture Length of treatment (days) Total length of follow up (Months)

Cast

Frame

Analysis

25 7 female (26%) 11.6 (4–15) IQR 7–12 2 / 11 / 12 11 3 11 25 0 0 1 51 (30–126) IQR 45–75 6 (2–26) IQR 4–15

25 6 female (24%) 13.7 (7–17) IQR 11 – 14 1 / 18 / 6 16 6 3 10 0 15 7 99 (62–154) IQR 83–135 19 (4–25) IQR 15–23

n.s. WMW p = 0.002 n.s. Chisquared p = 0.039 Chisquared p<0.0001 FE p = 0.049 WMW p<0.0001 WMW p = 0.0006

Table 2 Physical and psychological scores for different groups at different time points. KW – Kruksall–Wallis test for significant patterns of difference between groups considering whole data. SDCF – Post Hoc Steel–Dwass–Critchlow–Fligner all pairs comparisons considering differences between treatment groups at each time point (no significant differences detected for any variable) and within treatment groups at each time point. Trauma in the CRIES score refers to the intrusion and avoidance domain. Outcome

Domain

Cast <30 days

Cast 30–120 days

Ilizarov <30 days

Ilizarov 30–120 days

Statistics

Parent PedsQL

Physical

25 (6–81) IQR 19–35 68 (45–90) IQR 60–83 57 (28–83) IQR 49–64

34 (19–81) IQR 25–49 73 (47–98) IQR 68–83 62 (37–90) IQR 54–73

25 (0–38)∗ IQR 9–32 78 (38–93) IQR 50–83 58∗ (18–66) IQR 39–66

52 (6–84)∗ IQR 34–66 82 (8–100) IQR 65–92 69∗ (8–94) IQR 53–80

KW p<0.0001 SDCF ∗ p<0.0001 KW p = 0.15 SDCF – n.s. KW p = 0.008 SDCF ∗ p = 0.02

25+ (3–56) IQR 19–31 66 (40–100) IQR 66–81 53+ (24–74) IQR 50–66

44+ (16–88) IQR 31–63 83 (45–93) IQR 67–90 67+ (35–74) IQR 60–78

30∗ (9–47) IQR 19–32 70 (48–95) IQR 59–85) 56∗ (30–71) IQR 45–63

53∗ (13–91) IQR 40–69 85 (18–100) IQR (68–90) 75∗ (21–93) IQR 60–80

KW p<0.0001 SDCF ∗ p<0.0001, + p-0.003 KW p = 0.04 SDCF – n.s. KW p<0.0001 SDCF ∗ p = 0.001, + p = 0.018

15 (0–23)∗ IQR 9–20 17 (0–36) IQR 8–29

6 (0–20)∗ IQR 1–8 6 (0–28) IQR 2–10

9 (0–36) IQR 3–21 16 (1–57) IQR 5–33

4 (0–38) IQR 0–12 8 (0–57) IQR 1–19

KW p = 0.03 SDCF ∗ p = 0.01 KW p = 0.06, SDCF n.s.

Psychosocial Total Child PedsQL

Physical Psychosocial Total

CRIES

Trauma Total

Patients in the frame group were significantly older, were significantly more likely to have suffered more complex (AO severity [20]) or open fractures, spent longer in hospital and had a longer period of overall follow up than those in the cast group. Four patients (16%) of the patients in the frame group had suffered multiple injuries, all the tibial fractures were isolated in the cast group. This difference did not reach statistical significance (Fisher exact p = 0.11). Three patients in the cast group had percutaneous screw fixation of a metaphyseal fracture, with the cast used to neutralise this. Ten patients, including these three, required general anaesthesia for cast application. Six patients (24%) in the cast group were treated in below knee splints from the outset. The median period of above knee immobilisation was 29 days (range 0 to 60 days, IQR 1.3 to 38). In five patients, all of whom had initial immobilisation with above knee splints, Sarmiento patellar bearing casts were used at conversion to below knee. All patients in the Ilizarov group were allowed immediate unrestricted weightbearing. In the cast group the median period the patients were instructed to remain non-weightbearing was 44 days (range 0 to 84 days, IQR 32 to 48 days). Overall time of immobilisation in either a cast or a frame was higher in the frame group. One patient from each group suffered a significant complication during the period of immobilisation. In the cast group this was a heel ulcer treated non-operatively by windowing the cast. In the frame group this was a deep vein thrombosis treated by 3 months of anti-coagulation. Neither of these patients suffered long term sequelae. Six patients in the frame groups

suffered at least one pin-site infection during treatment. All of these resolved with a course of oral antibiotics, again without sequelae. Quality of life and psychological scores The different domains of the PedsQL and CRIES scores for the different treatment groups at different time points are summarised in Table 2 and Figs. 1–3. Whilst significant improvements in scores were observed in both groups between those recorded at less than 30 days and more than 30 days, no significant differences in any measure were observed between treatment groups at any time point. Results from multiple linear regression analysis are shown in Table 3–5. For the child PedsQL responses, polytrauma (worse scores) and time from injury (improving scores the longer from injury the questionnaire was administered) were strongly significant predictors across all domains (Table 3). There was a weak association with injury mechanism. Open fractures were associated with worse psychosocial and total scores. For parent proxy responses, age (better scores with older children), open fracture (worse scores), polytrauma (worse scores) and time from injury were significant predictor variables (Table 4). Again, there were some associations with different injury mechanisms. Similar results were seen for the CRIES scores (Table 5) with a positive association between open injury and polytrauma and raised CRIES scores. There was a weak association with time from injury and

Please cite this article as: L. Johnson, J. Messner and E.J. Igoe et al., Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame, Injury, https://doi.org/10.1016/j.injury.2019.10.077

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Fig. 1. Box and whisker plots showing median, interquartile range and range for Child responses to physical (a) and social (b) PedsQL domains and total score (c). Wilcoxon Mann–Whitney test with Steel–Dwass–Critchlow–Fligner all pairs comparisons – ∗ significant differences between groups p < 0.05 or better (see Table 2).

lower CRIES scores and there was an association with some injury mechanisms. In no model for any outcome was treatment type (cast or frame) a significant predictor variable. Discussion The results of this study suggest that despite having more severe injuries, children treated in Ilizarov frames for tibial fractures

appear to report similar physical and psychosocial quality of life (indicated by the PedsQL scores) and posttraumatic stress symptoms (indicated by the CRIES scores) during treatment as those treated in a definitive cast. There is very little existing information regarding the effect of different treatment modalities on patients’ health related quality of life during treatment. Similarly, few studies have investigated both HRQOL and PTSD symptoms in paediatric orthopaedic patients.

Please cite this article as: L. Johnson, J. Messner and E.J. Igoe et al., Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame, Injury, https://doi.org/10.1016/j.injury.2019.10.077

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Fig. 2. Box and whisker plots showing median, interquartile range and range for Parent responses to physical (a) and social (b) PedsQL domains and total score (c). Wilcoxon Mann–Whitney test with Steel–Dwass–Critchlow–Fligner all pairs comparisons – ∗ significant differences between groups p < 0.05 or better (see Table 2).

Typically, studies have focused on the outcomes of patients post treatment [21]. Lim et al. explored HRQOL of children with severe lower limb trauma at least 12 months post-injury and looked at factors that may impact these outcomes [22]. Of these factors, gender and accident mechanism did not affect overall HRQOL scores. A recent study has investigated the impact of the Ilizarov frame treatment on HRQOL in paediatric and adolescents with complex tibial fractures using the PedsQL [8]. This study reported excellent

outcomes following treatment, with many young patients returning to function similar to that of a healthy population, although function during treatment was not investigated. This study did not compare outcomes with alternative treatment types. The findings from our study are however comparable, in that child reported total PedsQL scores improved during treatment in both groups to similar levels of that of a healthy population.

Please cite this article as: L. Johnson, J. Messner and E.J. Igoe et al., Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame, Injury, https://doi.org/10.1016/j.injury.2019.10.077

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Fig. 3. – Box and whisker plots showing median, interquartile range and range for CRIES score responses to trauma (intrusion and avoidance) (a) and total (b) domains. Wilcoxon Mann–Whitney test with Steel–Dwass–Critchlow–Fligner all pairs comparisons – ∗ significant differences between groups p < 0.05 or better (see Table 2). Table 3 Results of multiple linear regression analysis for child responses to physical, psychosocial and total PedsQOL domains. Parameter estimates reflect positive results for that variable being associated with higher scores and negative a lower score for the considered outcome. Results in bold indicate significant predictor variables for that model (p < 0.05 or better) with other variables held constant. R2 reflects predictive capacity of whole model, all models statistically significant predictors compared to null (p < 0.0 0 01). Physical

Psychosocial

Parameter

Estimate

95% CI

Age Gender: Female Open fracture Polytrauma Treatment: Frame Time from injury Mechanism:

0.19 −2.22 −3.27 −9.57 0.90 0.40 −13.63 6.29 −0.64 −6.14 13.37 0.74

−1.08 −6.60 −8.67 −18.30 −3.43 0.29 −33.44 −1.26 −13.17 −16.33 1.71 −6.64



Assault Fall Fall >2 m Ped vs car RTA Sport

0.465

to to to to to to to to to to to to

1.45 2.15 2.14 −0.84 5.22 0.51 6.17 13.85 11.89 4.05 25.04 8.13

p-value

Estimate

95% CI

0.77 0.32 0.23 0.03 0.68 <0.0001 0.17 0.10 0.92 0.23 0.03 0.84

1.17 −1.68 −5.97 −15.03 0.05 0.13 3.32 1.69 −9.86 −7.22 14.09 −2.01

0.06 −5.50 −10.71 −23.19 −3.72 0.03 −13.92 −4.88 −20.79 −16.18 3.57 −8.46

0.336

We have followed 50 patients throughout their treatment. Three quarters were male. This gender split appears to reflect recognised epidemiology in tibial fractures [23]. Frame patients were significantly older. Fracture location within the tibia did not vary significantly between groups. However, injuries in the frame group were significantly more severe as estimated by complexity component of the AO / OTA classification and the number of open fractures encountered. This is explained by our departmen-

Total

to to to to to to to to to to to to

2.27 2.14 −1.22 −6.88 3.82 0.22 20.56 8.27 1.06 1.73 24.60 4.43

p-value

Estimate

95% CI

0.04 0.38 0.01 0.0004 0.98 0.01 0.70 0.61 0.08 0.11 0.01 0.54

0.67 −1.82 −4.97 −14.23 0.55 0.23 −2.21 3.41 −6.74 −6.95 13.06 −0.56

−0.31 −5.21 −9.15 −21.00 −2.79 0.15 −17.55 −2.44 −16.45 −14.84 4.02 −6.28

p-value to to to to to to to to to to to to

1.65 1.57 −0.78 −7.47 3.90 0.31 13.13 9.26 2.96 0.93 22.09 5.15

0.18 0.29 0.02 <0.0001 0.74 <0.0001 0.78 0.25 0.17 0.08 0.01 0.85

0.441

tal approach to treat most open or complex fractures with circular frames. Treatment times varied according to the treatment modality, again likely a reflection of injury severity. Whilst these differences in injury severity might influence patient function during treatment between groups it is interesting that this is not reflection is the recorded scores between groups. Indeed, the multiple regression analyses consistently associated polytrauma and open fracture with worse reported scores whilst treatment group was

Please cite this article as: L. Johnson, J. Messner and E.J. Igoe et al., Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame, Injury, https://doi.org/10.1016/j.injury.2019.10.077

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Table 4 Results of multiple linear regression analysis for parent responses to physical, psychosocial and total PedsQOL domains. Parameter estimates reflect positive results for that variable being associated with higher scores and negative a lower score for the considered outcome. Results in bold indicate significant predictor variables for that model (p < 0.05 or better) with other variables held constant. R2 reflects predictive capacity of whole model, all models statistically significant predictors compared to null (p < 0.0 0 01). Physical

Psychosocial

Parameter

Estimate

95% CI

Age Gender: Female Open fracture Polytrauma Treatment: Frame Time from injury Mechanism:

1.99 −2.80 −8.39 −14.07 −2.47 0.39 −5.00 9.70 −8.37 1.23 10.77 −8.33

0.68 −7.29 −13.91 −23.09 −6.93 0.28 −25.18 1.76 −21.13 −9.17 −2.04 −15.98

Assault Fall Fall >2 m Ped vs car RTA Sport



to to to to to to to to to to to to

3.29 1.68 −2.87 −5.06 1.99 0.50 15.18 17.63 4.40 11.63 23.59 −0.68

p-value

Estimate

95% CI

0.003 0.22 0.003 0.003 0.27 <0.0001 0.62 0.02 0.20 0.81 0.10 0.03

2.43 −3.55 −6.13 −16.73 −1.95 0.12 8.31 7.06 −10.55 −10.15 13.02 −7.68

1.24 −7.63 −11.15 −24.93 −6.01 0.02 −10.05 −0.16 −22.16 −19.60 1.36 −14.64

0.5

Total

to to to to to to to to to to to to

3.61 0.53 −1.10 −8.53 2.10 0.22 26.66 14.27 1.05 −0.69 24.67 −0.73

p-value

Estimate

95% CI

0.0001 0.09 0.02 0.0001 0.34 0.02 0.37 0.06 0.07 0.04 0.03 0.03

2.19 −3.70 −7.20 −15.54 −2.12 0.23 3.64 8.10 −10.72 −6.02 12.95 −7.95

1.13 −7.35 −11.69 −22.88 −5.75 0.14 −12.80 1.64 −21.11 −14.49 2.51 −14.17

0.444

p-value to to to to to to to to to to to to

3.25 −0.04 −2.71 −8.20 1.51 0.31 20.07 14.56 −0.33 2.44 23.38 −1.72

<0.0001 0.05 0.002 <0.0001 0.25 <0.0001 0.66 0.01 0.04 0.16 0.02 0.01

0.504

Table 5 Results of multiple linear regression analysis for intrusion and avoidance and total CRIES domains. Parameter estimates reflect positive results for that variable being associated with higher scores and negative a lower score for the considered outcome. Results in bold indicate significant predictor variables for that model (p < 0.05 or better) with other variables held constant. R2 reflects predictive capacity of whole model, all models statistically significant predictors compared to null (p<0.0 0 01). Intrusion and Avoidance Parameter

Estimate

95% CI

Age Gender: Female Open fracture Polytrauma Treatment: Frame Time from injury Mechanism:

−0.48 1.86 4.53 9.35 −0.39 −0.07 −3.62 0.75 6.01 4.84 −10.84 2.86

−1.14 −0.46 1.68 4.81 −2.69 −0.13 −13.90 −3.21 −0.51 −0.45 −16.90 −1.05



Assault Fall Fall >2 m Ped vs car RTA Sport

to to to to to to to to to to to to

0.36

not a significant independent predictor variable in any of the models. This study has certain specific limitations which should be considered when interpreting the results. The groups are not matched in terms of age, injury severity or treatment duration. This is to be expected, as the indications for the respective treatments are different, but may influence the results when considering the effect of treatment modality. Recruiting non-consecutive patients introduces a potential risk of bias if treating clinicians unconsciously select patients they perceive to have coped particularly well with their treatment or had specific problems. For logistic reasons it was not possible to recruit consecutive patients, we protected against this risk of bias by using a member of the research team not involved in clinical care to recruit the patients. The measures were selfcompleted in a clinical environment and as such may be subject to reporting bias. It may be that patients and their parents in one of the groups inherently feel inclined to supply positive or negative responses. However, the use of the PedsQL is well-recognised as an appropriate, validated measure of HRQOL and has been used previously in orthopaedic trauma patients [5,21]. Previous research has suggested there is a predictive relationship between PTSD in children who have experienced trauma and HRQOL [13]. However, we were unable to investigate this relationship in this study due to the small sample size.

Total Cries

0.19 4.18 7.39 13.90 1.91 −0.02 6.68 4.71 12.54 10.13 −4.79 6.76

p-value

Estimate

95% CI

0.16 0.12 0.002 <0.0001 0.73 0.01 0.49 0.71 0.07 0.07 0.001 0.15

−0.59 3.66 4.64 16.18 0.46 −0.12 −9.06 0.75 9.98 7.22 −13.96 5.08

−1.56 0.29 0.49 9.58 −2.88 −0.20 −23.99 −4.99 0.50 −0.46 −22.76 −0.59

p-value to to to to to to to to to to to to

0.38 7.03 8.78 22.78 3.79 −0.03 5.87 6.50 19.46 14.90 −5.17 10.75

0.23 0.03 0.03 <0.0001 0.79 0.01 0.23 0.79 0.04 0.07 0.002 0.08

0.38

The PedsQL is one of the few paediatric HRQOL measures suitable for a wide age range, having good psychometric properties and covering over six chapters of the International Classification of Functioning, Disability and Health domains laid out by the World Health Organisation [24]. The PedsQL 4.0 has been demonstrated as being suitable for use in orthopaedic patients, with patients’ PedsQL 4.0 scores correlating with the patients’ Pediatric Outcomes Data Collection Instrument (PODCI) scores [25]. Furthermore, the PedsQL has been found to be an appropriate quality of life measure for children following a major trauma [24]. The PedsQL measures the four key dimensions of quality of life; physical, emotional, social, and school. This study focused on the physical and psychosocial domains, which includes emotional, social and schooling. Our raw data suggests that physical health related quality of life improved over time in the frame group (from median 30 to 53), both measured by parents and patients. This may be explained by improvements in pain and the patient adapting to life with the frame leading to improving mobility and engagement with usual activities. This improvement is less apparent in the cast patients, at least according to their parents, perhaps reflecting an ongoing perception that the cast is limiting mobility. Interestingly, the child’s scores do reflect an improvement over time in this group, with results almost mirroring those in the frame group. Psychosocially, both frame and cast patients recover to near “normal” levels between 30–120 days of treatment. This is in contrast with

Please cite this article as: L. Johnson, J. Messner and E.J. Igoe et al., Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame, Injury, https://doi.org/10.1016/j.injury.2019.10.077

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[m5G;November 5, 2019;16:58]

L. Johnson, J. Messner and E.J. Igoe et al. / Injury xxx (xxxx) xxx

previous qualitative research which suggests that adolescents consider external fixation as having an ongoing negative impact in this regard [26]. The PedsQL physical and psychosocial scores overall were comparable to that of previous studies which have used the PedsQL in a paediatric orthopaedic setting [5,8]. The Children’s Revised Impact of Events Scale (CRIES) is commonly used to screen for PTSD symptoms in children following injury [18]. Scores in the cast group improved significantly during treatment. Results from the frame group were much more varied and a similar improvement was not apparent. Whilst it is possible that this is due to the impact of the treatment modality, the contribution of more severe injuries in this group must also be considered. This hypothesis is supported by the results of the regression analysis. A validated cut-off threshold for significant risk of PTSD is a CRIES score of 30 or more [2]. Beyond 30 days into treatment, the majority of patients in the cast group returned scores well below this. Though overall a similar trend is observed among frame patients, approximately 1:4 patients remained at risk of posttraumatic stress symptoms according to the CRIES score, during their treatment in frame. Though only reaching statistical significance in the cast group, our findings do seem consistent with previous work suggesting that the proportion of children who exhibit posttraumatic stress symptoms following injury declines over time [27]. It is noteworthy greater variability was recorded in many of the scores for the frame group when compared to the cast group, particularly in the later phase of treatment. This may represent more extreme responses in patients with particularly severe injuries or having an especially adverse response to living with an Ilizarov fixator. Indeed, in every case the pattern is attributable to a very small number of extreme outliers. Nonetheless, it is important to consider individual responses to injury and treatment and provide social and psychological support as required. Our multivariable analysis has shown that the mode of immobilisation (cast or frame) does not significantly predict any of the response variables. Polytrauma and RTA as mechanism of injury seem to have to strongest impact on the physical and psychosocial domain in child self-reports, which is consistent with previous research [28]. The time from the injury plays an important part, as time during treatment progresses, physical and psychosocial scores improve. Interestingly parents do appear to consider their children’s HRQOL differently. Age, open fracture and sport as a mechanism of injury was found to significantly impact health-related quality of life observed in parent proxy reports during treatment (total scores). Parents also report a significant psycho-social impact when their children were hit by a car. Conclusions Despite suffering more severe injuries, according to the measures employed in this study, function and quality of life during treatment was similar in children treated with circular frames was similar to patients treated in casts. Although the treatment of tibial fractures is mainly based on the fracture configuration, location and associated soft tissue injury, the findings from this study may be helpful to clinicians in counselling patients and their families about the advantages and disadvantages of possible treatment options. A significant number of children in the frame group continued to return scores consistent with a high risk of PTSD. Whilst this appears related to factors other than the treatment modality itself it is important to be aware of this as patients may benefit from referral to clinical psychology services. Declaration of Competing Interest There are no conflicts of interest.

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Please cite this article as: L. Johnson, J. Messner and E.J. Igoe et al., Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame, Injury, https://doi.org/10.1016/j.injury.2019.10.077