title: Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children.
abstract: BACKGROUND
  Titanium elastic nails are commonly used to stabilize femoral fractures in school-aged children, but there have been few studies assessing the risks and benefits of this procedure compared with those of traditional traction and application of a spica cast. This prospective cohort study was designed to evaluate these two methods of treatment, with a specific focus on the first year after injury, the period when the treatment method should have the greatest impact.
  
  
  METHODS
  Eighty-three consecutive children, six to sixteen years of age, were studied prospectively. Factors that were analyzed included clinical and radiographic data, complications, hospital charges, and outcome data. Outcome and recovery were assessed both with the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collections Instrument, version 2.0, and according to a series of important recovery milestones including the time to walking with aids, time to independent walking, time absent from school, and time until full activity was allowed.
  
  
  RESULTS
  Thirty-five children (thirty-five fractures), with a mean age of 8.7 years, were treated with traction and application of a spica cast, and forty-eight children (forty-nine fractures), with a mean age of 10.2 years, were treated with titanium elastic nails. All fractures healed, and no child sustained a complication that was expected to cause permanent disability. At one year after the fracture, eighty of the children had acceptable alignment and no inequality between the lengths of the lower extremities. The remaining three children, who had an unsatisfactory result, had been treated with traction and a spica cast. Twelve patients (34%) treated with traction and a cast had a complication compared with ten patients (21%) treated with titanium elastic nails. Compared with the children treated with traction and a cast, those treated with titanium elastic nails had shorter hospitalization, walked with support sooner, walked independently sooner, and returned to school earlier. These differences were significant (p < 0.0001). We could detect no difference in total hospital charges between the two groups.
  
  
  CONCLUSIONS
  The results of this prospective study support the recent empiric observations and published results of retrospective series indicating that a child in whom a femoral fracture is treated with titanium elastic nails achieves recovery milestones significantly faster than a child treated with traction and a spica cast. Hospital charges for the two treatment methods are similar. The complication rate associated with nailing compares favorably with that associated with traction and application of a spica cast.
authors.affiliation: Division of Orthopaedics, Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104-4399, USA. flynnj@email.chop.edu
authors.forename: John M
authors.initials: JM
authors.lastname: Flynn
authors.forename: Lael M
authors.initials: LM
authors.lastname: Luedtke
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Ganley
authors.forename: Judy
authors.initials: J
authors.lastname: Dawson
authors.forename: Richard S
authors.initials: RS
authors.lastname: Davidson
authors.forename: John P
authors.initials: JP
authors.lastname: Dormans
authors.forename: Malcolm L
authors.initials: ML
authors.lastname: Ecker
authors.forename: John R
authors.initials: JR
authors.lastname: Gregg
authors.forename: B David
authors.initials: BD
authors.lastname: Horn
authors.forename: Denis S
authors.initials: DS
authors.lastname: Drummond
mesh_terms: D000293:Adolescent; D001672:Biocompatible Materials / Q000627:therapeutic use; D001858:Bone Nails; D002370:Casts, Surgical; D002648:Child; D005264:Femoral Fractures / Q000601:surgery* / Q000628:therapy*; D005593:Fracture Fixation, Internal / Q000295:instrumentation*; D006801:Humans; D011446:Prospective Studies; D020127:Recovery of Function; D014025:Titanium / Q000627:therapeutic use; D014143:Traction / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D001672:Biocompatible Materials; D014025:Titanium