Background: Titanium elastic nails are commonly used to stabilize
femoral fractures in school-aged children, but there have been few studies
assessing the risks and benefits of this procedure compared with those of
traditional traction and application of a spica cast. This prospective cohort
study was designed to evaluate these two methods of treatment, with a specific
focus on the first year after injury, the period when the treatment method
should have the greatest impact.
Methods: Eighty-three consecutive children, six to sixteen years of
age, were studied prospectively. Factors that were analyzed included clinical
and radiographic data, complications, hospital charges, and outcome data.
Outcome and recovery were assessed both with the American Academy of
Orthopaedic Surgeons Pediatric Outcomes Data Collections Instrument, version
2.0, and according to a series of important recovery milestones including the
time to walking with aids, time to independent walking, time absent from
school, and time until full activity was allowed.
Results: Thirty-five children (thirty-five fractures), with a mean
age of 8.7 years, were treated with traction and application of a spica cast,
and forty-eight children (forty-nine fractures), with a mean age of 10.2
years, were treated with titanium elastic nails. All fractures healed, and no
child sustained a complication that was expected to cause permanent
disability. At one year after the fracture, eighty of the children had
acceptable alignment and no inequality between the lengths of the lower
extremities. The remaining three children, who had an unsatisfactory result,
had been treated with traction and a spica cast. Twelve patients (34%) treated
with traction and a cast had a complication compared with ten patients (21%)
treated with titanium elastic nails. Compared with the children treated with
traction and a cast, those treated with titanium elastic nails had shorter
hospitalization, walked with support sooner, walked independently sooner, and
returned to school earlier. These differences were significant (p <
0.0001). We could detect no difference in total hospital charges between the
two groups.
Conclusions: The results of this prospective study support the
recent empiric observations and published results of retrospective series
indicating that a child in whom a femoral fracture is treated with titanium
elastic nails achieves recovery milestones significantly faster than a child
treated with traction and a spica cast. Hospital charges for the two treatment
methods are similar. The complication rate associated with nailing compares
favorably with that associated with traction and application of a spica
cast.
Level of Evidence: Therapeutic study, Level II-1
(prospective cohort study). See Instructions to Authors for a complete
description of levels of evidence.