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