|Year : 2014 | Volume
| Issue : 2 | Page : 60-64
Cast splintage: An alternative to internal fixation for the treatment of metastatic diaphyseal femoral fractures secondary to carcinoma of the prostate in developing countries
Chima C Ihegihu1, Ebere Y Ihegihu2, Nzube O Chukwujama3
1 Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
2 Department of Physiotherapy, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
3 Department of Surgery, Federal Medical Center, Owerri, Imo State, Nigeria
|Date of Acceptance||10-Oct-2014|
|Date of Web Publication||21-Jan-2015|
Chima C Ihegihu
Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State
Source of Support: None, Conflict of Interest: None
Carcinoma of the prostate is the most common malignant tumor in men over 65 years of age, and the prostate is the most common site of origin for skeletal metastases. The femur is the long bone most commonly affected by metastatic prostate disease resulting in pathologic fractures. Internal fixation with the proper constructs is the standard treatment for metastatic diaphyseal femoral fractures secondary to carcinoma of the prostate in well-equipped hospitals in developed countries. In developing countries such as ours where many of the hospitals are ill-equipped, and these constructs are hardly available, cast splintage is a viable alternative to being considered. It is efficacious as demonstrated in this case report of a patient with bilateral metastatic diaphyseal femoral fractures treated with bilateral high above knee full casts. Casting materials are cheap, readily available, and affordable, and patients are discharged home early.
Keywords: Carcinoma of the prostate, cast splintage, diaphyseal femoral fractures, internal fixation
|How to cite this article:|
Ihegihu CC, Ihegihu EY, Chukwujama NO. Cast splintage: An alternative to internal fixation for the treatment of metastatic diaphyseal femoral fractures secondary to carcinoma of the prostate in developing countries. Niger J Surg Sci 2014;24:60-4
|How to cite this URL:|
Ihegihu CC, Ihegihu EY, Chukwujama NO. Cast splintage: An alternative to internal fixation for the treatment of metastatic diaphyseal femoral fractures secondary to carcinoma of the prostate in developing countries. Niger J Surg Sci [serial online] 2014 [cited 2022 Aug 15];24:60-4. Available from: https://www.njssjournal.org/text.asp?2014/24/2/60/149606
| Introduction|| |
Carcinoma of the prostate is the most common malignant tumor in men over 65 years of age, and the prostate is the most common site of origin for skeletal metastases.  The femur is the long bone most commonly affected by metastatic prostate disease resulting in pathologic fractures.  These fractures are associated with a reduction in survival, poor prognosis and increased healthcare costs. The bony metastases are characterized by both osteoblastic and osteoclastic activities, but the relative amount of osteoblastic activity exceeds that of the osteoclasts, and bone formation is the net result; however the sclerotic bone becomes increasingly brittle and prone to fractures. 
The goals of treatment in metastatic diaphyseal femoral fractures are to relieve pain, stabilize the fractures, allow for early weight bearing and provide an intervention that will last the patient's entire life span.  The standard practice is internal fixation with constructs that provide stability and allow early weight bearing though different tools exist for determining whether particular fractures or selected patients will benefit from surgery.  Metastatic mid-diaphyseal femoral fractures are surgically treated with large diameter intramedullary nails, plates and screws with or without tumor resection, polymethyl methacrylate (PMMA) bone cement augmentation and bone grafting. Arthroplasty is done for proximal diaphyseal femoral fractures while fixed angle devices with locked screws and augmentation with PMMA or endoprosthetic replacement are used for treating distal diaphyseal femoral fractures. Failure rate for surgical stabilization of diaphyseal metastatic prostate fractures in well-developed properly equipped centers with adequate facilities is about 10.3%.  The failures are as a result of immediate failures, tumor progression, nonunions, skin necrosis and stress fractures of the bones.
In many hospitals in Nigeria and other developing countries, the facilities to implement this standard practice are hardly available, so sometimes orthopedic surgeons resort to other methods of stabilization such as cast splintage and traction. Casting involves circumferential application of plaster of Paris, polyester or fiberglass to an extremity to immobilize the joints proximal and distal to the fracture site. Cast splintage provides incomplete immobilization of the fractured fragments but prevents displacement to allow healing. Restriction of movement also promotes soft tissue healing, and unaffected parts can be moved freely. Patients can go home soon after application of the cast. However, the fracture may mal-unite, and joints encased in casts cannot move and are liable to stiffen.  Casting is efficacious as demonstrated in this case report. Casting materials are cheap, available and affordable hence cast splintage provides a viable alternative to the standard operative treatment in metastatic diaphyseal femoral fractures secondary to carcinoma of the prostate (CAP) when there is institutional incapability to provide standard fixation as is the case in many hospitals in the developing countries.
| Case report|| |
A 65-year-old man presented with a history of a sudden fall while standing and subsequent inability to stand or walk of 1-day duration. Prior to the fall, there was a history of pain in both thighs of several months duration which was progressive and unremitting, relieved temporarily by taking some analgesics purchased from patent medicine stores. There was no associated obvious swelling but walked progressively became difficult. There was no history of trauma, paraesthesia, numbness or urinary symptoms. After the fall, the pains increased in intensity, and the thighs became swollen and deformed.
On examination, the patient was pale, in pains but the vital signs were normal. The thighs were swollen; tender, deformed, and abnormal mobility was elicited in both thighs. There were no neurovascular deficits and no clinical evidence suggestive of a fracture in any other part of the body. No abnormalities were clinically detected in the other systems. On digital rectal examination, the patient had good anal hygiene and normal sphincteric tone. The prostate was mild to moderately enlarged, hard in consistency and nodular. Rectal mucosa was free. We made a provisional diagnosis of bilateral pathological diaphyseal femoral fractures? Secondary to metastatic carcinoma of the prostate.
The patient was sent for investigations and the results were as follows: packed cell volume - 0.27, abdominal scan showed normal abdominal organs, prostate profile/transrectal scan revealed an enlarged prostate measuring 72.2 mm × 64.7 mm × 71.0 mm, volume - 173.68 cm 3 (≤20 cm 3 normal volume), weight 173 g, irregular, heterogeneous glandular echo texture, continuous capsular echo pattern, significant postvoidal urine, normal kidneys and bladder, conclusion/impression: Benign prostatic hyperplasia. Total prostate-specific antigen (PSA) - 128 ng/ml, free PSA - 12 ng/ml, percentage free PSA - 9.4%, comment: Result is consistent with carcinoma of the prostate (CAP). Liver function tests, serum electrolytes, urea, and creatinine, urinalysis, total white blood cell count were essentially normal.
Plain radiographs of the femurs showed displaced diaphyseal fractures of both femurs [Figure 1] and [Figure 2]. Plain chest radiograph showed no secondary deposit. Tru-cut biopsy of the prostate confirmed Adenocarcinoma (Gleason's Grade IV score VII) of the prostate gland. Computerized tomography, magnetic resonance imaging and bone scan were not done.
|Figure 1: Plain radiograph (anterior-posterior view) of diaphyseal fracture of the right femur|
Click here to view
|Figure 2: Plain radiograph (anterior-posterior view) of diaphyseal fracture of the left femur|
Click here to view
The patient was transfused two units of blood and commenced on medication that included nonsteroidal anti-inflammatory drugs and analgesics. The fractures were manipulated in theatre under anaesthesia, and full bilateral high above knee casts were applied using polyester material. Check plain radiographs showed satisfactory reduction. The patient was taught the following exercises by the physiotherapist: Strengthening exercises of the upper limb muscles, breathing exercises, isometric exercises of the quadriceps, hamstrings and glutei muscles and active range of motion exercises of the joints of the toes and hips; and discharged in a wheel chair after 3 days admission. He was readmitted 2 weeks later when the biopsy result confirmed Adenocarcinoma of the prostate for simple bilateral orchidectomy and discharged after 2 days. He was seen at the outpatient clinic for follow-up.
Check plain radiographs done after 14 weeks of cast splintage showed exuberant consolidated callus bridging the fracture sites [Figure 3] and [Figure 4]. Clinically, no tenderness or abnormal mobility was elicited at the fracture sites. There was stiffness of the knees (range of motion 0°-10° in both knees) and ankle joints. The physiotherapist commenced the patient on a graduated intensive passive and active range of motion exercises of the lower limb joints, exercises to strengthen the muscles and wheelchair training. We have continued to mobilize the patient in a wheelchair hoping to graduate possibly to a walking frame mindful of the risk of new fractures from recurrences or metastatic lesions in other parts of the lower limbs.
|Figure 3: Plain radiograph (anterior-posterior view) of united diaphyseal fracture of the right femur|
Click here to view
|Figure 4: Plain radiograph (anterior-posterior view) of united diaphyseal fracture of the left femur|
Click here to view
| Discussion|| |
Approximately 70% of the patients with advanced cancer of the prostate can be expected to develop skeletal metastases  and decision making regarding treatment is influenced by factors such as expected duration of survival, overall medical condition and rehabilitation potential. The ultimate goal is to relieve pain and improve function for the maximum amount of time. Operative treatment is generally recommended for displaced diaphyseal femoral fractures in prostate cancer patients using generally accepted criteria. Operative treatment produces better functional results.  Patients with a short life expectancy may not benefit from surgery due to rapid deterioration of health and difficulties in managing the postoperative rehabilitation. Some authors have argued that a postoperative lifespan of at least 2 months is required for surgery to be beneficial in extremity metastases.  However, this has been highly debated, and the decision to offer surgery remains patient-specific.
Pathological fractures, visceral metastases, low hemoglobin level, number of skeletal metastases, are independent negative prognostic factors for postoperative survival.  In a survival data on patients with prostate cancer in a large population-based cohort study, 1-year survival was 87% in patients without skeletal metastasis and 47% in those with skeletal metastasis.  Younger patients and patients with a solitary bone metastasis (as compared to multiple metastases) had better survival.  The overall failure rate for operative treatment of skeletal metastases in prostate cancer alone was about 10.3%,  whereas the survival rate was 0.3 at 1-year after surgery. 
Internal fixation methods that require bone healing, porous ingrowths, and bone grafting are generally avoided in the treatment of metastatic fractures because of limitations in activity that these constructs initially require for appropriate healing to occur. Immediate stability constructs required for fixation in these patients are not readily available in many hospitals in Nigeria and other developing countries hence the need for alternative methods of treatment. Inability to achieve adequate fixation by using improper constructs is likely to lead to unwanted problems such as frequent reoperations, revision surgeries and increased morbidity. Complications of surgery such as severe bleeding, infection and risk of dissemination  with a consequent reduction in longevity makes surgery a formidable option of treatment. Cost of surgery is another issue in developing countries where majority lives below the poverty level making a cheaper viable alternative option of treatment a welcome choice.
Lack of institutional capabilities to offer adequate fixation makes cast splintage a viable alternative. Cast splintage of fractures has been used for millennia, but in the last 50-60 years, there has been an increased interest in operative fracture fixation in many specialized trauma hospitals in developed countries around the world. However, these specialized hospitals do not reflect fracture treatment in many hospitals in the developing countries, and Cast splintage remains the most widely used method of fracture treatment.  Cast splintage is cheap, easily affordable and patients are discharged home early. With cast splintage, we achieved pain relief, fracture healing and early mobilization of the patient in a wheel chair. We could have used a double hip spica to provide better stabilization of the fractures in this patient, but we considered that it would be impossible to mobilize the patient in a wheel chair, that complications may be more and nursing care more challenging.
Casting, if properly applied, is very safe, although the frequent need to include adjacent joints may cause stiffness. This can be minimized by the use of hinged braces.  Angulation may be controlled by a well-applied cast; it may, however, be difficult to control rotation and shortening. Cast splintage should be considered in hospitals when: (1) the attending surgeon does not possess the skill to carry out such formidable operations; (2) the facilities (instrumentation and implants) are not available; (3) the fracture character is complex and the investigating imaging modality to fully characterize the fracture is not available (computed tomography, magnetic resonance imaging or bone scan to detect occult lesions); (4) the patient is not able to afford the cost of surgery due to financial constraints; (5) there is inadequate bone stock and (6) in advanced disease where the prognosis is poor with short life expectancy or presence of other co-morbid medical conditions that contraindicate surgery.
Complications of cast splintage include tight cast, pressure sores, skin abrasion, laceration, loose cast, neurologic injury, ischemia, muscle atrophy, compartment syndrome and complex regional pain syndrome.  These complications are easily manageable. Because cast splintage does not provide as much stabilization of the fracture as internal fixation, the incidence of mal-union is higher. The use of cast is generally continued until the fracture is consolidated. Patients who are placed in casts require careful monitoring to ensure proper recovery, and with physiotherapy, most patients do not develop residual long term complications.
| Conclusion|| |
Operative treatment of metastatic diaphyseal femoral fractures is the gold standard and is almost always justified unless the patient has reached a terminal stage and death is imminent. This should be the case if adequate facilities and know-how exist for safe surgical care. If appropriate operating facilities and instrumentation do not exist as is the case in many hospitals in the developing countries, cast splintage becomes a viable alternative.
| References|| |
Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res 2006;12:6243s-9.
Hage WD, Aboulafia AJ, Aboulafia DM. Incidence, location, and diagnostic evaluation of metastatic bone disease. Orthop Clin North Am 2000;31:515-28, vii.
Keller ET, Brown J. Prostate cancer bone metastases promote both osteolytic and osteoblastic activity. J Cell Biochem 2004;91:718-29.
Böhm P, Huber J. The surgical treatment of bony metastases of the spine and limbs. J Bone Joint Surg Br 2002;84:521-9.
Mac Niocaill RF, Quinlan JF, Stapleton RD, Hurson B, Dudeney S, O'Toole GC. Inter-and intra-observer variability associated with the use of the Mirels' scoring system for metastatic bone lesions. Int Orthop 2011;35:83-6.
Wedin R, Bauer HC. Surgical treatment of skeletal metastatic lesions of the proximal femur: Endoprosthesis or reconstruction nail? J Bone Joint Surg Br 2005;87:1653-7.
Simon RR, Sherman SC, Koenigsknecht SJ. General principles. In: Simon RR, Sherman SC, Koenigsknecht SJ, editors. Emergency Orthopedics: The Extremities. 5 th
ed. New York: McGraw-Hill; 2007. p. 1-29.
Coleman RE. Metastatic bone disease: Clinical features, pathophysiology and treatment strategies. Cancer Treat Rev 2001;27:165-76.
Wallny T, Sagebiel C, Westerman K, Wagner UA, Reimer M. Comparative results of bracing and interlocking nailing in the treatment of humeral shaft fractures. Int Orthop 1997;21:374-9.
Harrington KD, Sim FH, Enis JE, Johnston JO, Diok HM, Gristina AG. Methylmethacrylate as an adjunct in internal fixation of pathological fractures. Experience with three hundred and seventy-five cases. J Bone Joint Surg Am 1976;58:1047-55.
Weiss RJ, Forsberg JA, Wedin R. Surgery of skeletal metastases in 306 patients with prostate cancer. Acta Orthop 2012;83:74-9.
Nørgaard M, Jensen AØ, Jacobsen JB, Cetin K, Fryzek JP, Sørensen HT. Skeletal related events, bone metastasis and survival of prostate cancer: a population based cohort study in Denmark (1999 to 2007). J Urol 2010;184:162-7.
Utzschneider S, Weber P, Fottner A, Wegener B, Jansson V, Dürr HR. Prognosis-adapted surgical management of bone metastases. Orthopade 2009;38:308, 310-2, 314.
Wedin R, Bauer HC, Wersäll P. Failures after operation for skeletal metastatic lesions of long bones. Clin Orthop 1999;128-39.
Cipriano CA, Arvanitis LD, Virkus WW. Use of the reamer-irrigator-aspirator may reduce tumor dissemination during intramedullary fixation of malignancies. Orthopedics 2012;35:e48-52.
Court-Brown CM, Aitken S, Hamilton TW, Rennie L, Caesar B. Nonoperative fracture treatment in the modern era. J Trauma 2010;69:699-707.
Sarmiento A, Latta LL. Closed Functional Treatment of Fracture Bracing. Berlin Heidelberg New York: Springer-Verlag; 1995.
Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physician 2009;79:16-22.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]