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Where Do The Experts Go For Up-To-Date Guidelines on Pediatric Fractures?
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Posted on: 09/10/2009
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Orthopedic surgeons have to keep up with the latest research and trends in treatment for many, many problems, conditions, and diseases affecting the musculoskeletal system. Pediatric orthopedic surgeons face some problems not seen in the adult population. And often, pediatric problems like diaphyseal femur fractures (a break in the long shaft of the thigh bone) are only seen occasionally, making it even more difficult to know what to do to get the optimum results.
That's why the American Academy of Orthopaedic Surgeons (AAOS) has started researching and reviewing various topics with the purpose of developing clinical practice guidelines (CPGs). These guidelines help surgeons stay up with current evidence and provide the best treatment plan for each individual patient. The guidelines don't tell the doctor how to treat everyone. They are simply recommendations based on studies, expert opinion, and trends observed over the years.
The surgeon must still take many factors into consideration when developing a plan of care. The child's age, location and severity of the fracture, cause of the fracture (car accident, possible abuse, sports injury), family dynamics, and other social factors are all things that affect the decision-making process. Abuse is considered a possibility in any child under the age of five who has a fracture of this type. Sometimes the child's temperament and activity level are also important to weigh in on the decision whether to treat conservatively (nonoperatively) versus surgically.
Femoral fractures in children is an area where the research is lacking. The 14 guidelines provided in this article are based on the scientific data available at this time. But the author makes note of the fact that clearly, more and better research is needed in this area. Although there has been a trend toward surgical care instead of traction and prolonged casting, high-quality studies comparing the two approaches have not been done. The guidelines are strictly for children who are still growing.
The recommendations are broken down by age groups: 1) infants, 2) six months up to five years, 3) five to 11 years old, and 4) 11 years old up to skeletal maturity. Size of the child (including whether or not obesity is an issue) can make a difference if he or she falls outside the standard range for their age. Age compared with size is a variable the surgeon must take into consideration. To help the surgeon who consults the guidelines, the AAOS lists the level of evidence next to each of the 14 recommendations. That gives the surgeon an idea of how strong the evidence is to support the particular guideline of interest.
For example, Level I means the evidence comes from high-quality randomized and controlled trials. The higher the number, the lower the evidence until at Level IV and V, we are relying on the results of case series (several individual patients viewed one at a time) and expert opinion. Expert opinion may be the published opinion(s) of one or more surgeons with experience in this area. Sometimes, it's more the case of a panel of doctors discussing the problem and providing consensus (what they all agree on).
Treatment recommendations based on age makes sense because of the differences in level of skeletal maturity and muscular development from group-to-group. For example, the first recommendation is to consider abuse in any child younger than five years old, but especially any child three years old and younger. Another recommendation is that certain treatment approaches (e.g., Pavlik harness) can only be used with young children. Older children (13 and older) are better candidates for instrumentation using nails, pins, or metal plates. They have more skeletal maturity and strong enough bones to hold rigid supports of this type.
Some of the treatment recommendations are based on the severity of the injury. One of the recommendations deals with difficult cases that present with a wide separation of the two ends of the bone. Separation of more than two centimeters (half an inch) is more likely to require surgery to reduce the fracture (bring the ends of the bone back together). Otherwise, the risk of a leg length difference increases. The surgeon will still have to decide whether to use rigid or flexible nails/pins or locked versus unlocked plates. There just isn't enough evidence to support one over the other or to guide surgeons as to which patients would do better with one over the other. They are all treatment options available for consideration.
Likewise, there isn't a recommendation that says surgical implants should or shouldn't be removed once the leg is healed. This guideline really refers to children who have no symptoms related to the plates, pins, or screws. Those who are in pain from the fixation devices may require follow-up surgery. Symptoms are more likely to develop when the implants break, loosen, or migrate (move).
Some of the guidelines are given a status of inconclusive when the evidence is lacking, insufficient, or conflicting. Physical therapy to help improve function after diaphyseal femoral fractures in children makes good common sense, but there are no studies comparing children in one group who had physical therapy (PT) with another group who didn't have PT. Sometimes the ethics of conducting such research prevents it from taking place (i.e., withholding physical therapy from a child who might benefit is not acceptable, even for the sake of science).
In this summary, the full explanation for how each recommendation was determined is not included. The author suggests that any reader who is interested in the details and rationale for the guidelines can visit the AAOS website at www.aaosnow.org. For all areas where the evidence is weak or inconclusive, more research is needed. The current clinical guidelines may be changed or further clarified as a result of any new data that comes available over the next 10 years. For right now, the guidelines are meant to be used as one tool in making treatment decisions. They are not developed enough to be used as the only source of information regarding treatment.
Suggested topics for future study include answering the questions Can casting be delayed or must it be done right away for the six months old to six years old age group? At what age can flexible nailing be used inside the bone instead of the full spica (waist to toe) cast currently in use? What kind of instrumentation is best for the age group six years to skeletal maturity: flexible nail, rigid nail, or metal plate? When does the family situation enter into the decision? It would seem that family function does make a difference in their ability to care for a child who is laid up with a full spica cast for weeks to months. These are just a few of the suggested topics for future study.
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References:
Ernest L. Sink, MD. AAOS Releases First Pediatric Clinical Practice Guidelines. In AAOS Now. August 2009. Vol. No. 8. Pp. 1, 12-13.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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