"We've shown that although both treatments usually have good outcomes, treatment with elastic nails allows children more rapid mobility and the ability to resume normal daily activities in half the time of the traditional traction and cast treatment," said Jack Flynn, M.D, pediatric orthopaedic surgeon at The Children's Hospital of Philadelphia and primary investigator of this study. The research team's study appeared in the April issue of the Journal of Bone and Joint Surgery.
Different than hardware nails, elastic nails are implanted flexible pins that are inserted into the broken bone to support the pieces while the bone heals. The nails are approximately 15 to 20 inches in length and about the width of a radio antenna. Often two nails are necessary for treatment of a fracture. Surgeons remove the nails after the fracture heals, typically six to nine months after surgery.
Since 1996, surgeons in the U.S. have implemented the use of elastic nails more frequently. This is the first prospective study to directly compare the technique to the traditional method of traction and casting. "This study compares the traditional gold standard in the treatment of femur fractures in a prospective way, head-to-head with the newer treatment method of using titanium elastic nails," said Dr. Flynn. "We were looking for a way to get children with femur fractures out of bed and moving as quickly and safely as possible."
The researchers studied 83 children, 6 to 16 years old, treated at The Children's Hospital of Philadelphia for a fractured femur - the long bone of the thigh. Thirty-five children were treated with traction and a body cast; 48 children were treated with elastic titanium nails. Researchers studied the children for a year following the fracture. All fractures healed and no child sustained a complication that was expected to cause permanent disability.
The study shows that at one year following the fracture, most children who received either treatment had an excellent outcome. The difference is that children who received the elastic nail treatment were able to get out of bed two days after surgery and were discharged from the hospital approximately four days after surgery. Within just a few weeks they were walking with crutches. The children treated with elastic nails missed about half the amount of school as those treated in casts.
Children treated with the traditional method undergo approximately three weeks of traction and then the application of a body cast, which is required for an additional three to five weeks. Casting requires a great commitment of parental involvement, as the child is unable to move on their own during this time. The body cast adds an additional twenty pounds to the child's weight. The study also shows that the elastic nails decrease the complication rate of the traditional casts.
"The elastic nail method makes the first six months of treatment much more livable for the child and the entire family," says Dr. Flynn. "The newer nail treatment has changed the way we are able to manage the care of these children and the families are very enthusiastic about this option."
Costs for both treatments are similar, but the overall totals were difficult to measure due to numerous factors. The researchers used hospital charges as a proxy for the entire cost of treatment. Other factors such as parents' time away from work to care for children, rehabilitation costs and well as the charges by varying insurance suppliers make obtaining accurate and complete cost information difficult to quantify.
Physicians were unable to randomize the treatment methods. Instead, the choice of treatment either with traction and application of a body cast or with elastic nails was based on the preference of the attending orthopaedic surgeon.
Elastic nail treatment is usually used in children above 6 years of age. Younger children are typically put in a body cast as their fractures heal much more quickly than older children and adults.
In 1996, titanium elastic nails were used by very few physicians in the U.S. as a treatment of femur fractures, but by the year 2000, the nails became a relatively common treatment option. Physicians from The Children's Hospital of Philadelphia were instrumental in showing the safety and efficacy of this new treatment model and are widely recognized within the orthopaedic community as innovators of this technique. Femur fractures are the most common major orthopaedic injury in children.
Children's Hospital sees approximately one child with a femur fracture each week for a total of approximately 40 to 50 each year. Children who range between 6 and 14 years old make up about two-thirds of that population.
Dr. Flynn's co-authors were: Lael M. Luedtke, M.D., of Gilette Children's Hospital, St. Paul, Minn.; and Theodore J. Ganley, M.D., Judy Dawson. R.N., Richard S. Davidson, M.D., John P. Dormans, M.D., Malcolm L. Ecker, M.D., John R. Gregg, M.D., B. David Horn, M.D., and Denis S. Drummond, M.D., all of the Division of Orthopaedics at The Children's Hospital of Philadelphia.
Founded in 1855 as the nation's first pediatric hospital, The Children's Hospital of Philadelphia is ranked in 2003 as the best pediatric hospital in the nation by U.S.News & World Report and Child magazines. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country, ranking second in National Institutes of Health funding among children's hospitals. In addition, its unique family-centered care and public service programs have brought the 430-bed hospital recognition as a leading advocate for children and adolescents from before birth through age 19. Children's Hospital operates the largest pediatric healthcare system in the U.S. with more than 40 locations in Pennsylvania, New Jersey and Delaware.