Interventions for Treating Femoral Shaft Fractures in Children and Adolescents

This week, as part of the Child Health Emergency Medicine Social Media Campaign, we are highlighting a Cochrane summary on interventions for treating femoral shaft fractures in children and adolescents. This review was selected for the TREKK Evidence Repository on fractures.

Key Messages:

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Related TREKK Resources:

Cochrane Summary:

Different methods of treating fractures of the shaft of the thigh bone in children and adolescents

Although uncommon, fractures of the femoral shaft (thigh bone) in children may require prolonged treatment in hospital and sometimes surgery. This can cause significant discomfort and can disrupt the lives of the children and their familles. This review compared different methods of treating these fractures. Surgical treatment comprises different methods of fixing the broken bones, such as internally-placed nails, or pins incorporated into an external frame (external fixation). Non-surgical or conservative treatment usually involves different types of plaster casts with or without traction (where a pulling force is applied to the leg).

We searched for studies in the medical literature until August 2013. The review includes 10 randomised or quasi-randomised controlled trials that recruited 527 children. Four trials compared different surgical versus non-surgical treatments; three compared different methods of non-surgical treatment and three compared different methods of surgical treatment. Generally we are unsure about the results of these trials because some were at risk of bias, some results were contradictory and usually there was too little evidence to rule out chance findings. Most trials failed to report on self-assessed function or when children resumed their usual activities.

Comparing surgical versus non-surgical treatment

Low quality evidence (one trial, 101 children) showed children had similar function at two years after having surgery, involving external fixation, compared with those treated with a plaster cast. The other three trials did not report this outcome. There was moderate quality evidence (four trials, 264 children, aged 4 to 12 years, followed up for 3 to 24 months) that surgery reduced the risk of malunion (the leg is deformed) compared with non-surgical treatment. However, low quality evidence (four trials) indicated that there were more serious adverse events such as infections after surgery. There was low quality evidence (one trial, 101 children) of similar satisfaction levels in children and parents with surgery involving external fixation and plaster cast only. However, there was low quality evidence (one trial, 46 children) that more parents were satisfied with surgery involving an internal nail than with traction followed by a cast and that surgery reduced the time taken off from school.

Comparing various non-surgical treatments

Very low quality evidence means that we are very unsure if the rates of malunion differ or not between children treated with immediate plaster casts versus with traction followed by plaster cast (one trial, 42 children), or between children treated with traction followed by either a functional orthosis (a brace or cast that allows some movement) or a cast (one trial, 43 children). We are very unsure if either function or serious adverse events differ between young children (aged two to seven years) immobilised in single-leg versus double-leg casts (one trial, 52 children). However, single-leg casts appear to be easier to manage by parents and more comfortable for the child.

Comparing various surgical treatments

Very low quality evidence means that we are very unsure if the rates of malunion, serious adverse events, time to return to school or parental satisfaction actually differ in children whose fractures were fixed using internal nails or external fixation (one trial, 19 children). The same applies to the rates of serious adverse events and time to resume full weight-bearing in children treated with dynamic (less rigid) versus static external fixation (one trial, 52 children). Very low quality evidence (one trial, 47 children) means that we do not know if malunion, serious adverse events and time to resume weight-bearing actually differ between intramedullary nailing versus submuscular plating. However, there could be more difficulties in plate removal subsequently.

Conclusions

This review found insufficient evidence to determine if long-term function differs between surgical and conservative treatment of thigh bone fractures in children aged 4 to 12 years. It found surgery resulted in lower rates of malunion but increased the risk of serious adverse events, such as infections. It found internal nailing may speed up recovery.

The review found there was insufficient evidence from comparisons of different methods of non-surgical treatment to clearly show that any type of non-surgical treatment is better than any other. The same conclusion applies to comparisons of different methods of surgical treatment.

Authors’ Conclusions:

There is insufficient evidence to determine if long-term function differs between surgical and conservative treatment. Surgery results in lower rates of malunion in children aged 4 to 12 years, but may increase the risk of serious adverse events. Elastic stable intramedullary nailing may reduce recovery time.

There is insufficient evidence from comparisons of different methods of conservative treatment or of different methods of surgical treatment to draw conclusions on the relative effects of the treatments compared in the included trials.

Check Out the Full Cochrane Systematic Review Below:

Madhuri, V., Dutt, V., Gahukamble, A.D., Tharyan, P. (2014). Interventions for treating femoral shaft fractures in children and adolescents. Cochrane Database Syst Rev, 7, CD009076. doi: 10.1002/14651858.CD009076.pub2

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This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

Antibiotics for Preventing Infection in Open Limb Fractures

This week, as part of the Child Health Emergency Medicine Social Media Campaign, we are highlighting a Cochrane summary on antibiotics for preventing infection in open limb fractures. This review was selected for the TREKK Evidence Repository on fractures.

Key Messages:

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Related TREKK Resources:

Cochrane Summary:

Antibiotics for preventing infection in open limb fractures

Wound and bone infections are common complications following open fractures of the limbs. For more than 20 years in developed countries, the use of antibiotics has been a part of a standard management protocol that also includes washing the wound (irrigation), cleaning up the wound and fracture (surgical debridement), and stabilisation of the fracture, as required. This review, which included data from 1106 participants in eight trials, found that antibiotics are effective in decreasing the incidence of wound infections, as compared with no antibiotics or placebo. No studies reporting bone infection or long-term ill health (morbidity) were identified.

Authors’ Conclusions:

Antibiotics reduce the incidence of early infections in open fractures of the limbs. Further placebo controlled randomised trials are unlikely to be justified in middle and high income countries, except for open fractures of the fingers. Further research is necessary to the determine the avoidable burden of morbidity in countries where antibiotics are not used routinely in the management of open fractures.

Check Out the Full Cochrane Systematic Review Below:

Gosselin, R.A., Roberts, I., Gillespie, W.J. (2004). Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev, 1, CD003764. doi: 10.1002/14651858.CD003764.pub2

The Cochrane Bone, Joint and Muscle Trauma Group also recommends the following systematic reviews related to fractures in children:

Black, K.J., Bevan, C.A., Murphy, N.G., Howard, J.J. (2013). Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev, 12, CD009587. doi: 10.1002/14651858.CD009587.pub2

Yeung, D.E., Jia, X., Miller, C.A., Barker, S.L. (2016). Interventions for treating ankle fractures in children. Cochrane Database Syst Rev, 4, CD010836. doi: 10.1002/14651858.CD010836.pub2

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This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.