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New Clinical Practice Guidelines for Leg Fractures in Children
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Posted on: 11/30/1999
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Children who break a leg don't always have a specialized children's hospital to go to for the latest in care. Orthopedic surgeons around the country treating pediatric diaphyseal femur fractures aren't always pediatric specialists or if they are, they don't see 100s of these cases each year.
In order to help all orthopedic surgeons follow the best evidence in treating these traumatic injuries, the American Academy of Orthopaedic Surgeons (AAOS) has published this list of 14 clinical practice guidelines. They are specific to children from infancy to skeletal maturity who have broken the shaft of the femur (long bone of the thigh). That's what pediatric diaphyseal femur fractures refers to.
A group of 16 pediatric experts worked together to review all published studies from 1996 through 2008 dealing with the treatment of diaphyseal femur fractures in four age groups. The ages were divided into 1) infants, 2) children from six months up to five years, 3) children five to 11 years, and 4) ages 11 to skeletal maturity. Skeletal maturity means the bones have stopped growing. This is determined by X-rays of the bones. Pediatric orthopedic surgeons from children's clinics and hospitals all over the country (Texas, Ohio, Colorado, New York, Boston, Seattle, St. Louis, Illinois, and more!) participated in this project.
In the course of reviewing treatment results and recommendations, they noticed a trend over the past 10 years. Treatment seems to have shifted away from conservative (nonoperative) care more toward surgical intervention to stabilize the leg. Nonsurgical options include Pavlik harness for infants, and traction or casting in a waist-high cast called a hip spica cast for all other ages. Surgery can include placing a nail (long metal rod) down through the bone, and/or special submuscular plating. Different types of nails can be used. Some are rigid, others are more flexible. Pain management may be required no matter what type of treatment is used.
The specific treatment plan selected depends on many factors such as the child's age, type of fracture (severity, location, displaced versus nondisplaced), and the family's social and economic situation. Surgeons are encouraged to follow these guidelines but within the context of all other factors present. All decisions are made together by the family and physician with the patient's best interests in mind.
Each of the guidelines was graded according to the level of evidence available from Grade A Level I recommendations to Grade B Level II or III suggestions, and grade C Level IV or V options. The first recommendation is always to evaluate young children for potential child abuse. Age less than three years of age and not yet walking are two big red flags for child abuse when the diagnosis is diaphyseal femur fracture. Infants up to age six months can be treated with a special harness called a Pavlik harness. The harness holds the hips and knees in a flexed position and abducted (knees apart) position. It works best for younger infants. A spica cast is also an option but there can be some problems with skin rashes and sores under the cast. Either treatment option yields an equally good bone healing response.
Other recommendations center around children with shortening of the femur as a result of the fracture. Traction to pull the bone back into a normal position followed by spica casting is recommended depending on whether the bone ends have separated apart more than two centimeters. Sometimes children can be put in a spica cast without the traction. There are no studies comparing these two forms of treatment to tell us if one is better than the other. Likewise, there are no studies comparing one treatment over the other based on age or body weight. Those are wide open areas for future research.
X-rays should be repeated during treatment to follow the bone's progress in healing. If the surgeon sees that the bones are shifting too close together, too far apart, or rotating too much, then the treatment plan might have to be changed. The goal is to avoid a significant leg length difference (one leg shorter or longer than the other). But the problem is no one knows how much of a shift is too much. And with any bone fracture, there can be an overproduction of bone as the body strengthens the break and later remodels that overgrowth. This phenomenon is more dramatic in children than in adults and hard to predict the final outcome.
Surgeons have a choice between flexible versus rigid rods (nails) depending on the age of the child. Younger children who have not yet finished growing are better candidates for the flexible nails. There are fewer issues with complications, the children leave the hospital and get back to school faster, and with shorter hospital stays (compared with traction and casting), the costs are less. With a more flexible (less rigid) support system, there is always the concern that children who weigh more may have problems. But there haven't been any studies to investigate this yet.
Older and heavier children are more likely to need a rigid (rod or nail) stabilization system. Additional metal plates and screws and/or external fixation (rods placed outside the leg attached with pins) may be considered in this group as well. Of course, the use of any of these surgical implants begs the question: should they be removed after the fracture is healed? There is a risk for the bone to break again without the stabilization system. Routine removal isn't usually practiced but again, there's not enough evidence for the committee to recommend for or against implant removal.
What about physical therapy? Can these children benefit from a rehab program to recover strength and function? No one has studied this yet. Next question: what's the best way to control pain levels? Sometimes when placing the pins, plates, or screws in place, a nerve can get pinched or poked causing distracting and even disabling pain. Only one study has addressed this issue. The use of a nerve block was very effective in reducing pain for patients who fall into this category.
And finally, of concern to any parent who has had to take care of a child in a spica cast, is there some way to protect the child's skin from chafing and scratching caused by the cast? Waterproof cast liners have been developed for this purpose but they have only been used with children in spica casts for reasons other than a femur fracture. The liners do work in those cases, so perhaps they could be tried with femoral fractures as well.
That pretty much sums it up for best practice and clinical practice guidelines in the treatment of pediatric diaphyseal femur fractures. The committee concludes there's plenty of room for future research and study around this topic. The quality of currently available studies is not sufficient to make strong recommendations. At this point, the guidelines are more suggestion than recommendation. The American Academy of Orthopaedic Surgeons will review these again in another five years. By then, other studies will be published and new technology may change current treatment approaches.
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References:
Mininder S. Kocher, MD, MPH, et al. Treatment of Pediatric Diaphyseal Femur Fractures. In Journal of the American Academy of Orthopaedic Surgeons. November 2009. Vol. 17. No. 11. Pp. 718-725.
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