REVIEW QUESTION What are the benefits and harms of treatments for femoral shaft fractures in children and adolescents?

Nursing Implications

Femoral shaft fractures in children are relatively uncommon but are considered a serious orthopaedic injury that can cause considerable disruption to the life of a child and their carer(s) and potentially a long-term physical disability, depending on the treatment. Such fractures can be treated conservatively using techniques such as limb casting, usually involving a long period of immobilization, or alternatively can be managed surgically, which has the potential to disrupt subsequent bone growth. Currently, treatment decisions are based on professional consideration of the child's age, size, and weight; the nature of the injury, fracture pattern, and stability. A systematic review was undertaken to evaluate current evidence regarding femoral shaft fracture interventions to assess the benefits and potential detriment caused by the various treatments available.

Study Characteristics

This was a Cochrane systematic review with meta-analyses synthesizing evidence from randomized and quasi-randomized controlled trials of children and adolescents younger than 18 years, with fractured shaft of femur. Studies that reviewed surgical interventions such as intramedullary nailing or external fixation or conservative treatments, for example, Pavlik harness or Bryant's traction, were included in this review. The primary review outcomes were (1) function (as measured by the PODCI [Pediatric Outcomes Data Collection Instrument], POSNA [Pediatric Orthopaedics Society of North America], or RANDscales); (2) unacceptable malunion such as leg length discrepancy or limp; and (3) serious adverse events, for example, nonunion or deep infections. Time to return to usual activities, child/parent satisfaction, and resource use were considered as secondary outcomes. Outcome data were gathered of short-term (up to 3 months) and long-term effects (more than 3 months or over 1 year, where possible).

Summary of Key Evidence

Surgical Interventions

Three trials assessed the effect of different surgical interventions. One very low-quality trial involving n = 19 children suggests that malunion rates, serious adverse events, time to return to school, or parent satisfaction may not differ between elastic stable intramedullary nailing or external fixation. Rates of serious adverse events and time to resume full weight-bearing may not differ in children treated with dynamic versus static external fixation (one trial, n = 52). Based on very low-quality evidence from one trial (n = 47 children) comparing intramedullary nailing versus submuscular plating, it is uncertain if there is no difference in malunion, serious adverse events, or time to weight-bearing rates.

Conservative Interventions

Three trials evaluated the effect of different conservative treatments. Very low-quality evidence from one study may suggest hip spica versus "traction followed by spica" in (n = 42) 3- to 10-year-olds, have different malunion rates at 6-8 weeks (risk ratio [RR] = 4.0, 95% confidence interval [CI]: 0.5-32.9). Low-quality evidence in one trial of n = 43 children aged 5-10 years suggests that malunion may be similar in "traction followed by functional orthosis" versus "traction followed by spica cast" (RR = 0.98, 95% CI: 0.46-2.12). Very low-quality evidence from one study (n = 52 children aged 2-7 years) means that it is unclear whether neither function nor adverse outcomes differ with single-leg or double-leg spica cast usage; nonetheless, single-leg casts were deemed easier to manage by parents and more comfortable by children.

Surgical Versus Conservative Treatment

Four trials (n = 264 children aged 4-12 years) were reviewed that compared (i) external fixation with immediate hip spica cast, (ii) "intramedullary pin fixation and spica cast" against "skeletal traction and spica cast," (iii) elastic stable intramedullary nail versus traction and spica cast, and (iv) elastic stable intramedullary nailing against skeletal traction spica casting. Only the "nailing versus spica cast" trial measured "function" and this study found little difference between the treatments 2 years following the injury (low-quality evidence). Moderate evidence from all four studies indicated that surgery reduces malunion (RR = 0.29, 95% CI: 0.15-0.59; n = 264) 4-24 months following treatment. These studies produced low-quality evidence that surgery increases the risk of serious adverse events such as infection (RR = 2.39, 95% CI: 1.10-5.17; n = 264). The "external fixation versus cast" study (n = 101 children) identified similar levels of child satisfaction for the two interventions, but more parents (n = 46) were satisfied with intramedullary nailing than traction.

Best Practice Recommendations

Surgery seems to result in lower rates of malunion in children aged 3-12 years in comparison to some conservative treatments, but surgery may also increase the risk of serious adverse events. There is currently insufficient evidence about the different impact of conservative or surgical treatments for femoral shaft breakages in children to make a conclusive decision. Further research is required, especially regarding long-term function and cost outcomes.

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