The study by Ramo et al. in the February 17, 2016 JBJS examines the evolution toward more aggressive operative treatment of children with isolated femoral fractures. This movement started 30 years ago, initially with the notion that adolescents should be treated as adults, with preferential intramedullary (IM) nail fixation. Concerns regarding damage to the femoral-head arterial supply led to the development of nails that could be started at the trochanteric region.
In the five- to twelve-year-old group, the options that have been documented as safe and effective include flexible nailing, plating, and external fixation, each with its own set of advantages and downsides. Fractures in kids ages four and five have generally been treated by spica cast management. However, parental concerns over cast care, more frequent radiographs, and the negative impact on family life have influenced many centers to move toward IM fixation even in this “preschool” age group.
The Ramo et al. study has all the limitations of a retrospective study, but it strongly suggests that in four- and five-year-olds, the radiographic outcomes of nailing and casting are equivalent after a mean follow-up of 32 weeks. These findings will provide some information for a shared decision-making discussion with parents, but as with many topics in pediatric fracture management, the clinical questions raised by this study beg for a prospective, controlled, multicenter trial. I agree with commentator Merv Letts, who points out that the Ramo et al. study raises important and complex clinical and family-environment issues that we need to grapple with as an orthopaedic community, but that more definitive answers will come only with prospective research and longer follow-up periods.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Because of the remarkable ability of children of this age to remodel bone damage, the simple radiographic evaluation does not tell the true story of this injury. How much leg length difference or rotational deformity was present. In addition is 6 or more weeks in a spica cast preferable, from the patient’s and parents perspective, to the ability of the child to be ambulatory for much of that time if the fracture is stabilized surgically?
I am now 80 years old. I worked in UK and came back to India to work as a associate professor at the Calcutta Medical College for about fifteen years. I have never operated on a child below 10 years of age with a fracture femur. I have no regret. Mr J Craw, my teacher, presented a copy of Walter Putnam Blount’s book Fractures in Children to me in the year 1964. The bottom line is: Do not treat the Xrays; treat the child. Nature is a wonderful healer. Wait patiently for the remodeling.
As my Peds Ortho Professor once said, most children (unfortunately) come with a parent who must also be ‘treated’. If one treats children’s injuries, one must treat all parties optimally for the long term and treat the short term problems (especially the minor and social ones) appropriately. Permanent scars, operations, and metal implants which may need another operation for removal have their own anxieties, complications and long term memories. Short term convenience is indeed short term.
Cast care is a skill, just as surgical care, that requires learning and experience. Its long term benefits and minimal complications when properly done should not be dismissed for short term convenience by the ‘modern surgeon’.
A child is not a small adult and should not be treated as one. The properly skilled Pediatric Orthopedist should prefer casting a young child unless the psycho/social situation makes it untenable.
Not addressed was the ‘drift’ from the legitimate problem of how to treat the maturing adolescent.