Версия для печати Yunusov D. I., Malievsky V.A., Mironov P. I

QUALITY OF LIFE AS A TOOL FOR EVALUATION OF REMOTE RESULTS OF TREATMENT OF FRACTURES OF LONG BONES IN CHILDREN WITH ASSOCIATED INJURY.

Bashkir State Medical University, Ufa, Russia

In the domestic traumatology, restoration of anatomical integrity of the bone after fractures allows estimating the treatment outcomes as good or even excellent, despite of presence of different residual events causing the changes in physical and social activity of the human. However such estimation of efficiency of the treatment methods is insufficient and low effective at the present time [1]. The modern requirements for quality of curative and preventive measures determine the necessity for searching more efficient medical technologies and the criteria of efficiency [2, 3].
During the recent decade, some data shows that estimating the life quality can be and universal, informative tool for estimating efficiency of medical care system in diseases and injuries [4, 6, 7]. In pediatrics, the term life quality means the integral patterns of physical, psychological and social functions of the child on the basis of subjective perception of the child and his/her parents [5]. Many clinicians have the uniform opinion that life quality monitoring in pediatrics can identify the efficiency of preventive, medical and rehabilitation programs, but also allows developing the recommendations for improving the system of medicosocial care for children [8, 9].
The study objective – to study the quality of life in children undergoing surgical treatment regarding the associated injury with damage of the long bones on the basis of Child Health Questionnaire.

MATERIALS AND METHODS

The study was retrospective, controlled and single-center. The inclusion criteria were the age> 1 and < 14, the associated injury with presence of diaphysis fractures. The exclusion criteria were severe traumatic brain injury (Glasgow Coma Scale < 9), chronic diseases in the phase of sub- and decompensation. 130 children corresponded to the inclusion and exclusion criteria. The children were treated in in the traumatology and orthopedics unit of Bashkir Republican Pediatric Clinical Hospital in 2010-2015.
There were 71 boys (54.6 %) and 59 girls (45.4 %). The mean age was 9.4 ± 3.9. The causes of the injuries were road traffic accidents – 103 patients (79.2 %), catatrauma – 22 patients (16.9 %), other injuries – 5 (3.9 %). In most cases, the children were transported by ambulance (112 cases, 86.2 %). The incidental cars were in 18 cases (13.8 %).
At the moment of admission, traumatic shock was diagnosed in 75.4 % (98): degree 1 – 48 % (47), degree 2 – 44.9 % (44), degree 3 – 7.1 % (7).
The mean ISS was 23.1 ± 6.5 (the median – 21). 564 injuries were in 130 children (on average, 4.3 per 1 patient). 269 children had the fractures of the extremities and the body bones, 114 children – traumatic brain injury, 27 – damages of internal organs (hemopneumothorax – 5, contusion of internal organs – 27), 56 wounds, 26 soft tissue contusions.
The patients were distributed into two groups according to the types of treatment of fractures with displaced fragments. The main group included 64 children who received the treatment of locomotor system injuries according to damage control concept.
In this group of the children, temporary immobilization of fractures of the extremities with displaced fragments and immobilization for unstable damages of pelvic bones were realized by means of the external fixing devices. This group of the patients received the final surgical treatment of fractures after sanitary aviation transfer at the stage of specialized care. The patients received 26 procedures of opened plate fixation. Flexible titanium nails (TEN) were used in 19 cases, fracture fixation with MIPO – in 10 cases, osteosynthesis with K-wire – in 19 cases.
The control group included 66 patients treated with the common techniques: closed reposition with plaster application – 17, skeletal traction with subsequent long term immobilization – 14, opened fixation with K-wire – 24, external osteosynthesis with plates – 18. The fractures without displacement were treated with plaster splints in both groups.
During estimation of life quality, 78 healthy children with similar demographic values were additionally examined (n = 130).
The efficiency of the results of the surgical treatment of fractures was performed according to the recommendations by J.M. Flynn et al [10] 12 months after hospital discharge (the table 1).

Table 1. Criteria for estimating functional outcomes of surgical treatment according to J.M. Flynn

Criteria	Result
	Excellent	Satisfactory	Poor
Disproportion of extremity length in relation to a healthy one, cm	<1	<2	>2
Angle deformation, degrees	<5	5–10	>10
Pain	No	No	Yes
Complications	No	Minor	Serious complications and/or ongoing bleeding

The parental version of Child Health Questionnaire (CHQ) was used for estimating the life quality and health [11]. We used the Russian version of PF-50 Child Health Questionnaire, which is the tool confirmed by the International Center of Life Quality Research and is recommended for scientific studies of life quality in children [12]. The study was conducted in 24-36 months after hospital discharge.
CHQ allows estimating the different spheres of child’s daily life with the following parameters: general estimation of health, physical activity, role of emotional and behavior problems in life activity limitation, role of physical problems in life activity limitation, pain/discomfort, behavior, mental health, self-estimation, general estimation of health, changes in health state, emotional influence on parents, limitation of parents’ free time, family activity, family solidarity. The amount of scores is calculated with 100-point system. The higher score is, the higher life quality is.
The study was conducted on the basis of the informed consent from parents, in concordance with “The Rules for Clinical Practice in the Russian Federation” confirmed by the Order of Health Ministry of the Russian Federation, June 19, 2003, No. 266. The study program was approved by the ethical committee of Republican Pediatric Clinical Hospital on the basis of the principles of Helsinki World Medical Declare 2000.
The statistical analysis was performed with Windows 7 and Statistica 6.0. The quantitative data was presented as the mean arithmetic (M) and standard deviation (SD). The non-parametric statistical methods were used for the analysis of the results. The reliability of the intergroup quantitative values was estimated with Mann-Whitney test. P value < 0.05 was statistically significant.   

RESULTS AND DISCUSSION

The estimation of the functional outcomes of the treatment of diaphysis fractures was performed with Flynn (the table 2). It showed the excellent results of surgical treatment in most children of the main group, whereas the control group demonstrated the satisfactory outcomes.

Table 2. Functional outcomes of treatment of fractures in studied children according to Flynn

Results	Excellent	Satisfactory	Poor
Main group, n = 64	57 (89.0 %)	7 (11.0 %)	-
Control group, n = 66	13 (19.7 %)	51 (77.3 %)	2 (3.0 %)

The table 3 shows the summary data of CHQ. All included children showed the reliable decrease in the analyzed values of life quality in comparison with the healthy children (p < 0.001). The intergroup comparative analysis did not identify any reliable differences between the children who had been operated with use of various techniques. The analysis included the following parameters of the questionnaire: behavior (B), self-estimation (SE), general perception of health (GPH) and emotional influence on parents (EIP).

Table 3. Estimation of life quality in studied children according to Child Health Questionnaire

Sections of CHQ	Healthy (0) n =78, points	Main group (1) n = 64, points	Control group (2) n = 66, points	P
Physical activity, (PA)	98.0 ± 0.3	75.3 ± 25.9	65.2 ± 26.2	р1-2 = 0.013
				р0-1 < 0.001
				р0-2 < 0.001
Role of emotional problems in limited life activity, (REP)	96.3 ± 0.6	83.7 ± 22.9	65.6 ± 30.7	р1-2 = 0.012
				р0-1 < 0.001
				р0-2 < 0.001
Role of physical problems in limited life activity, (RF)	98.9 ± 0.1	81.8 ± 28.6	63.2 ± 29.7	р1-2 = 0.00007
				р0-1 < 0.001
				р0-2 < 0.001
Pain/Discomfort (P)	94.1 ± 1.1	74.4 ± 25.1	60.3 ± 28.5	р1-2 = 0.0037
				р0-1 < 0.001
				р0-2 < 0.001
Behavior, (B)	74.5 ± 0.8	69.4 ± 15.8	68.5 ± 16.3	р1-2 => 0.05
				р0-1 < 0.001
				р0-2 < 0.001
Mental health, (MH)	77.8 ± 0.9	76.4 ± 16.7	66.1 ± 16.6	р1-2 = 0.0001
				р0-1 < 0.001
				р0-2 < 0.001
Self-assessment, (SA)	75.3 ± 0.5	71.6 ± 19.8	69.1 ± 14.4	р1-2 => 0.05
				р0-1 < 0.001
				р0-2 < 0.001
Overall comprehension of health, (OCH)	65.6 ± 0.9	52.5 ± 13.7	50.6 ± 15.6	р1-2 => 0.05
				р0-1 < 0.001
				р0-2 < 0.001
Emonional influence on parents, (EIP)	70.9 ± 2.1	61.9 ± 29.7	57.8 ± 25.6	р1-2 => 0.05
				р0-1 < 0.001
				р0-2 < 0.001
Free time limitation, (FTL)	88.9 ± 0.9	73.9 ± 24.6	61.6 ± 27.6	р1-2 = 0.009
				р0-1 < 0.001
				р0-2 < 0.001
Changes in health condition (Estimation of true condition)	55.0 ± 2.6	36.4 ± 9.4	31.5 ± 8.5	р1-2 = 0.012
				р0-1 < 0.001
				р0-2 < 0.001
Family unity (FU)	88.0 ± 5.9	67.1 ± 13.9	60.7 ± 12.4	р1-2 = 0.022
				р0-1 < 0.001
				р0-2 < 0.001

At the same time, many parameters of CHQ showed worse results in the control group as compared with the study group.
The statistically significant differences were physical activity limitations (p = 0.013), limitations in daily activity, learning performance and playing with friends that were conditioned by limited physical capability, as well as emotional state and decreased physical activity motivation (p < 0.012).
The statistically significant (p < 0.041) differences in the index “Pain/Discomfort” testified more frequent and more intense pain feelings. One can suppose that discomfort feeling and pain could lead to the psychoemotional disorders (anxiety, depression, depressed state) causing the limited physical activity in the control group children.
Lower values of the parameter “Mental Health”, which reflects the child’s emotional status (p = 0.009) testified the presence of tearfulness, lowliness feeling, bad mood, disappointment and frustration.
The results of the questionnaire survey for the parents of the control group children showed the influence of the child’s disease on “Limitation of free time of parents” (p < 0.011) and limited amount of family entertainment, cancellation of change of parents’ plans, appearance of disagreement or family conflicts that were confirmed by the lower values of “Family solidarity” that testified that the child’s disease had caused the limitation of family entertainment and disagreement and conflicts in the family.
Our study of life quality with use of CHQ found the lower values in most items of the score describing the child’s physical activity, psychoemotional response, the feature of family functioning. It testified the lower life quality in the patients who had experienced the severe associated injury as compared to the healthy children.
It is known that trauma consequences influences on life quality of children within long time, even with other results of functional estimation of trauma outcomes [13].
Moreover, the mismatch between the functional estimation of extremity fractures and the level of social and home adaptation of the child was identified in the previous study by B.J. Gabbeetal, 2011 [14]. The necessity and appropriateness of use of the pediatric life quality questionnaires in estimation of outcomes of traumatic injuries in children were noted in the studies by A.L. Winhrop et al [15]. It corresponds to the data by L. Ewing-Cobbs and coauthors [16] and A.A. Palatov [17].
Therefore, the estimation of life quality can be the informative tool for assessment of long term results and consequences of pediatric injury.

CONCLUSION

1. Our study of life quality with use of CHQ showed the lower life quality in the long term postsurgical period in children with severe associated injury as compared to healthy children.
2. The use of the modern methods for fixation of diaphysis fractures in children with associated injury gives the better functional outcomes of treatment and higher life quality in the long term postsurgical period.
3. The study of life quality is an informative tool for estimating long term outcomes and consequences of associated injury, because it negatively influences on life quality and causes the significant limitations of physical activity and interpersonal communication between the child, school peers and family members.

Information about financing and conflict of interests:
The study was conducted without sponsorship.
The authors declare the absence of clear and potential conflicts of interests relating to the publication of this article.

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