Expectations

These excerpts from two articles summarise the difficulties in deciding treatment on operative Vs non operative management of Paediatric fractures.

Hensingers article best describes the issues.

"Recently, I saw a patient with a juvenile Tillaux fracture. The fracture was only slightly displaced, and he had been placed in a nonweight-bearing cast and was returning a week later to make sure that the fragment hadn't displaced further. And it hadn't. The reduction met the usual 3-mm criteria (given the variations measuring 3 mm on an x-ray and the likelihood of it having been taken at a standard distance). I didn't think a CT scan was necessary. However, he was a very active young man and smirked when I said he should remain nonweight-bearing. His mother was very concerned that her son could have a long-term problem and asked that I give her a 100% guarantee that it was going to be all right. I said I couldn't guarantee anything but thought it would probably be okay, and I smiled.

The temptation was great to say, let's operate and fix it with a big screw. It is easy to do. The residents always enjoy a simple case at the end of the day and we will have a good time in the OR. There will be fewer clinic visits and I could say to Mom, “The x-ray of the big screw looks good.” Operating is cleaner, you schedule it, they call you when the OR is ready, and you perform. We all know it doesn't guarantee that it will be “100% all right,” but you can look Mom in the eye and say, “I did all that I could; the reduction is perfect and the x-rays are pretty.” And the mother can see that there is a big screw and the gap is gone and her maternal worries are relieved.

In the past, defending nonoperative treatment was seldom an issue. We could show bayonet apposition of a both-bones fracture of the forearm, say, “It will be okay,” and parents would believe us. Or a terrible fracture of the clavicle and say, “You won't be able to tell later on.” There are innumerable fractures of childhood that in the past orthopaedists have dismissed with a simple, “It will be okay.” Now we find such a comment is just not sufficient for the inquisitive parent or, for that matter, the primary care physician. There is more scepticism about whether we are telling them the truth, or whether we are just in a hurry or just being lazy. Patients (and families) are more distrustful of physicians in general, and particularly of physicians who come bearing less-than-perfect x-rays or who are unable to completely assuage the parents' concerns about the future. The media has endless stories about irreparable harm that has befallen patients at the hands of physicians who were too busy, unaware, out of date, or reluctant to recommend a treatment because of its cost. Stories are rampant of physicians who are rewarded for saving their health care plan money by avoiding expensive surgery or not referring to out-of-plan specialists. There are innumerable problems that have caused increasing doubt among ever-watchful parents.

Conversely, the doubtful parent surmises that a perfect reduction of the fracture has a greater propensity to ensure a good long-term outcome than bayonet apposition. It is intuitive: it “makes sense.” It doesn't give you a guarantee, but it comes close. At least it started out well. As a consequence, anatomic reduction has become an important goal in our management of childhood trauma. It is the paediatric orthopaedic equivalent to raising the bar in the high jump.

At the same time, operative fixation of fractures has become increasingly acceptable in the past 15 years. I believe surgical reduction has improved care. The children are out of the hospital faster and return more quickly to their premorbid state. They do better physiologically, muscle strength and joint range of motion are preserved, and rehabilitation is faster. However, there are still many fractures that will do well without a perfect reduction, and even simple surgical procedures carry significant risks.

Parents must share in the burden of choosing the best treatment for their child. If they are not comfortable with a less-than-perfect reduction, then options to improve the reduction should be considered, but coupled with a thorough discussion of short-term and long-term advantages and disadvantages.

Guidelines that define current acceptable standards seem to be a moving target. This informed involvement of patients and parents in the treatment choices, coupled with better results from surgical reduction, has moved orthopaedists to adopt more invasive solutions to fracture management. Today's standards may have shifted to accommodate patients and their expectation of a more predictable and positive outcome. This isn't all bad. Statements such as “close enough” or “it will be all right” no longer seem to fit in our society. I think we have moved closer to finding a balanced approach that weighs both risks with outcome."

Hensinger 2002

Wilkins described three factors why operative intervention is increasing. He described examples where it has been clearly beneficial but tempers this with examples emphasizing the healing and remodelling capacity of children

• First, a dramatic improvement in technology has allowed fractures to be treated with a minimum of soft-tissue trauma. Certainly in the 1950s, operative management meant extensive exposure of the fracture site. With the advent of image intensification, portable power drills, cannulated screws, and smaller, more flexible implants, fractures can now often be stabilized with a minimal amount of soft-tissue disruption.
• Second, because children's fractures heal and remodel rapidly, they are especially amenable to techniques using minimal or short-term internal fixation.
• Third, there are also many financial pressures to stabilize fractures surgically. In United States, more than two thirds of the families now have two wage earners. Having a child tied up in the hospital in traction places a lot of psychological and financial stresses on these families. Inpatient hospitalization has become very expensive. Children do better when they are mobile and in their own home environments.

WAVES OF TECHNOLOGY
The use of new surgical procedures appears in a series of waves. First, the procedure is proposed and tried in a few cases. If it shows promise, there is a rush by many surgeons to “jump on the bandwagon” and use the new procedure. Unfortunately, it is often widely used before the true indications have become well established.

References

Wilkins KE. Operative management of children's fractures: is it a sign of impetuousness or do the children really benefit? J Pediatr Orthop. 1998;18:1–3

Hensinger, Robert N. M.D.. Changing Expectations. Journal of Pediatric Orthopedics. 22(1):1, January/February 2002

Last updated 11/09/2015