Is There a “Best” Road to Rome?

These investigators selected a small subset of children, four and five-year-olds, in which to examine the efficacy of two treatments for femoral fractures: intramedullary nailing (IMN) versus reduction and immediate hip spica cast application. They concluded that the results at fracture-healing are the same after the two types of treatment but IMN has a higher complication rate.

A weakness of this study is the selection process for the type of treatment. Surgeons were allowed to choose according to their personal judgment with the approval of the family. Most surgeons, including the authors, tend to base their choice of IMN not on age per se but on the size of the child, the type of fracture, the amount of comminution, high-energy trauma, patient obesity, and association with other injuries or disabilities. The authors, to their credit, attempted to minimize some of this bias by including a cohort matched on the basis of age and weight, but numbers in this cohort were smaller than those in the total cohort and only one of the above parameters was used for matching. The fact that there was little difference between the two treatment groups in the matched cohort would seem to indicate that the surgeons were astute in choosing which children were best treated with IMN. However, a prospective review incorporating all indications for IMN is warranted to give us a better perspective of which children in this age group would be best treated with IMN and which would be best treated with closed reduction and a hip spica cast.

Another concern about this study is the lack of information about the family’s response to the treatment or the costs of each treatment modality. It would seem that many families would find caring for a child in a hip spica cast much more onerous than caring for one with a small wound at the knee or hip, but this needs to be determined with a quality-of-life measure such as the Pediatric Outcomes Data Collection Instrument (PODCI). We don’t know the impact of either treatment on the family after having read this paper. The same is true for the costs of each modality of treatment. Was the length of hospitalization comparable for the two methods of treatment? A prospective study is needed to answer the questions of both family-burden and cost differences between the two types of treatment for femoral fracture in this age group.

The mean duration of follow-up in this series was only thirty-two weeks (and follow-up was as short as five weeks), which is too short for us to know what the final limb-length discrepancy was or whether rotational malunion was an issue. However, clinically relevant rotational malunion seldom occurs after femoral IMN1. Hence, again, there is a need for a prospective study with longer follow-up.

Even though the elective removal of IMN is not classified as an “unplanned return to the operating room” in this study, it nevertheless is portrayed in the paper as an untoward event in the IMN treatment group. While removal is not always necessary, it often is recommended as the standard of care or insisted on by some families. As such it is debatable whether this is really a negative feature of IMN or is simply one aspect of the IMN agreed to before the procedure is performed. It should be noted that there were no untoward events related to the anesthesia.

The main take-away from this study, in my opinion, is that the radiographic results at the time of fracture-healing differ little between IMN and spica cast treatment in four to five-year-old children with a fractured femur. However, a prospective study is needed to ascertain the other parameters that predicate which treatment route is actually the most beneficial for the patient and family and in terms of the end result for the fractured femur. This may be the most important contribution of this study: clarifying the need for a prospective study to answer the many questions raised.

The authors are to be commended for opening the door for us to address this controversial issue of which type of fracture treatment is best for this age group. They now need to close that door by providing us with a prospective study incorporating the concerns and questions that their study has raised. We look forward to it.