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.

Non-operative Versus Operative Treatment for Blunt Pancreatic Trauma in Children

This week, as part of the Child Health Emergency Medicine Social Media Campaign, we are highlighting a Cochrane summary on non-operative versus operative treatment for blunt pancreatic trauma in children. This review was selected for the TREKK Evidence Repository on multiple trauma.

Key Messages:

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Related TREKK Resources:

Cochrane Summary:

Treatment of severe blunt pancreatic lesions in children

Background

Optimal treatment of severe blunt pancreatic trauma in children has long been debated, some doctors advocate operation while others prefer a conservative approach without operation as primary treatment. We conducted this systematic review to assess which strategy should be preferred. Blunt trauma to the pancreas typically occurs after crashes involving a bicycle handlebar, road traffic crashes or other types of injury that cause a blow to the upper abdomen.

Study characteristics

We searched medical databases for randomised (where two groups of children were randomly assigned to treatment or no treatment) clinical trials of children treated for blunt trauma to the pancreas by an operation or no operation. The children were aged 17 years or younger. The search was current to June 2013.

Key results

We found no randomised clinical trials investigating operative treatment compared with non-operative treatment of severe pancreatic injury in children, hence we have no firm evidence to support either operative treatment or non-operative treatment of severe pancreatic lesions in children. Although difficult because of the rarity and the acute nature of these lesions, we recommend that multicentre randomised clinical trials of good quality are conducted.

Authors’ Conclusions:

This review shows that strategies regarding non-operative versus operative treatment of severe blunt pancreatic trauma in children are not based on randomised clinical trials. We recommend that multi-centre trials evaluating non-operative versus operative treatment of paediatric pancreatic trauma are conducted to establish firm evidence in this field of medicine.

Check Out the Full Cochrane Systematic Review Below:

Haugaard, M.V., Wettergren, A., Hillinsø, J.G., Gluud, C., Penninga, L. (2014). Non-operative versus operative treatment for blunt pancreatic trauma in children. Cochrane Database Syst Rev, 2, CD009746. doi: 10.1002/14651858.CD009746.pub2

Take Home Message:

As described by the Cochrane review authors, evidence from randomised trials is needed to develop recommendations for the treatment of blunt pancreatic injuries in children. Check out the resources developed by TREKK for more information on what is currently known. Also follow us on Twitter @Cochrane_Child and @TREKKca for more information on this topic throughout the week.

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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.