Commentary & Perspective

Commentary & Perspective on
"Operative Treatment of Tibial Fractures in Children: Are Elastic Stable Intramedullary Nails an Improvement Over External Fixation?"
by Erik N. Kubiak, MD, et al.

Commentary & Perspective by
John M. Flynn, MD*,
Children's Hospital Philadelphia, Philadelphia, Pennsylvania

The study by Kubiak et al. is an important contribution to the literature regarding pediatric orthopaedic trauma. The authors retrospectively reviewed the trauma registries of three institutions within their hospital system and identified skeletally immature patients who had undergone operative treatment of a tibial fracture and who had been managed with either titanium elastic nailing or external fixation between April 1997 and June 2004. They identified thirty-one patients, sixteen of whom had been managed with titanium elastic nailing and fifteen of whom had been managed with external fixation. The reader should be aware of several important strengths and weaknesses of this study.

The strength of this study includes the detailed information about each patient, the greater than two-year follow-up, and the use of a validated outcome tool. As anyone who has performed retrospective pediatric trauma studies knows, the authors had to work very hard to obtain a two-year follow-up for every patient in their series. The authors should be commended for performing telephone interviews for the few patients that would not come back for a final physical examination and radiographic evaluation. With this longer follow-up and the use of a validated outcome tool, the authors give us some reliable and important information about the extent of the disability that can occur after these injuries. In particular, the finding that the external fixation group had such low scores two years after injury suggests that the disability following a severe pediatric tibial fracture is much greater than is commonly recognized.

The main weakness of the paper is its retrospective design, but, as the authors point out, very few pediatric tibial fractures require operative intervention, so the population available for this type of study is always going to be fairly small. This makes a single-center prospective study very difficult to perform, as it would take probably a decade to accumulate a sufficient number of patients at any individual institution. Additionally, a prospective multicenter study invites its own set of challenges.

The weakness of this particular retrospective study is that the two groups may not have been similar. The external fixation group had a higher percentage of open fractures. Such injuries are known to be associated with delayed union and increased pain and problems overall. It is possible that some of the surgeons involved were more likely to treat the more difficult fractures with external fixation, which may have biased the results to indicate that the external fixation group had a worse outcome. The authors did their best to show that the two groups were similar, but this was impossible to do given the small numbers available.

Nevertheless, the results of this study strongly support the use of titanium elastic nails over external fixation for a difficult, unstable pediatric tibial fracture. Historically, titanium elastic nailing was rapidly adopted as the method of choice for pediatric femoral fractures because it permitted a child with a femoral fracture to be mobilized soon after surgery rather than being confined to bed and to a wheelchair for two to three months, as was usual after the so-called "conservative" alternative of traction and spica casting. The situation with tibial fractures is very different, however. Children can be mobilized immediately with a tibial fracture whether treated with a cast, external fixation, or titanium nailing. Only the most severe fractures (those associated with substantial instability or soft-tissue injury) require operative management. In this study, the authors show fairly convincingly that titanium elastic nailing is the operative treatment of choice for the rare pediatric tibial fracture that requires stabilization.

It is very important, however, that readers do not misinterpret this study as suggesting that titanium elastic nailing should be used as the treatment for most pediatric tibial fractures. Most pediatric tibial fractures can and should be managed with cast immobilization as it is a successful treatment and still allows mobilization of the child. Finally, the authors' finding of persistent disability, as measured on the Pediatric Outcomes Data Collection Instrument (PODCI) outcome form at two years, warrants further study, given the conventional wisdom that the vast majority of children are "back to normal" within a year after fracture. These results are different from those reported for femoral fractures and may suggest that pediatric tibial fractures are more disabling in children than was previous suspected.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

Copyright © 2005 by the The Journal of Bone and Joint Surgery, Inc.