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Comparison of Titanium Elastic Nails with Traction and a Spica Cast to Treat Femoral Fractures in Children
John M. Flynn, MD1; Lael M. Luedtke, MD2; Theodore J. Ganley, MD1; Judy Dawson, RN1; Richard S. Davidson, MD1; John P. Dormans, MD1; Malcolm L. Ecker, MD1; John R. Gregg, MD1; B. David Horn, MD1; Denis S. Drummond, MD1
1 Division of Orthopaedics, Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104-4399. E-mail address for J.M. Flynn: flynnj@email.chop.edu
2 Gillette Children's Hospital, 200 East University Avenue, St. Paul, MN 55101
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Division of Orthopaedics, Children's Hospital of Pennsylvania, and the Department of Orthopaedics, University of Pennsylvania, Philadelphia, Pennsylvania

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Apr 01;86(4):770-777
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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.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Charles T Mehlman, DO, MPH
    Posted on April 08, 2004
    Femoral Shaft Fractures in Children
    Cincinnati Children's Hospital Medical Center

    To the Editor:

    Flynn and his coauthors have presented an important prospective evaluation of their femoral shaft fracture patients and used a validated outcomes questionnaire (PODCI)to help gauge treatment effect. Their paper further establishes the effectiveness of an elastic stable intramedullary nailing approach to many of these fractures in this particular age group (6-16 y/o). It is gratifying to see that the excellent results that have been enjoyed by Jean-Paul Metaizeau (from Nancy, France)and others are now being replicated in large series at other centers (1,2).

    I do have three concerns regarding the overall message of the article. First, the authors have given us important information regarding certain milestones (walking independently etc), but they have not given us important details such as fracture pattern, degree of comminution, or patient weight. These data might help readers decide how similar their own patients are to those of Flynn et al. We have extensive experience with this nailing technique at our center and it is becoming clear that some of the older and heavier patients may not be best served by flexible nails (1). Luhman and coworkers have raised similar concerns about patient size(3).

    Second, certain complications such as pin site pain may have been overstated in the flexible nailing group, as it did not seem that the pin site pain that children with distal femoral traction pins experience (including pin site care) was tracked aggressively. Just like a traction pin is a temporary tool, elastic stable nails (aka Nancy Nails) are also temporary - as by design they are removed following adequate fracture healing(2).

    Third, the CHARGE DATA that Flynn et al have reported are of concern because they might mislead hospital administrators and/or policy makers to believe that the price tag of these two treatment approaches (traction & casting versus flexible nailing) is "a wash". To Flynn's credit, he acknowledged that charges are at times a rather poor proxy for costs. When we studied these same two treatments at our center, we found elastic stable intramedullary nailing to be a (approximately) $3,000.00 bargain per patient as compared to traction & casting(1). These cost savings were accompanied by equvalent or superior clincial outcomes, and earlier return to home and school environments make the Nancy Nail treatment approach very, very attractive indeed.


    1. Buechsenschuetz KE, Mehlman CT, Shaw KJ, et al. Femoral Shaft Fractures in Children: Traction and Casting Versus Elastic Stable Intramedullary Nailing. J Trauma 2002;53:914-921.

    2. Ligier JN, Metaizeau JP, Prevot J, et al. Elastic Stable Intramedullary Nailing of Femoral Shaft Fractures in Children. J Bone Joint Surg (Br) 1988;70-B:74-77.

    3. Luhmann SJ, Schootman M, Schoenecker PL, et al. Complications of Titanium Elastic Nails for Pediatric Femoral Shaft Fractures. J Pediatr Orthop 2003;23:443-447.

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