Management Protocol for Shaft Femur Fractures in Preschool Age Children: Do We Need to Rethink?
Venue: Journal of pediatric orthopedics

We read the article by Heffernan et al entitled "Treatment of femur fractures in young children: a multicenter comparison of flexible intramedullary nails to spica casting in young children aged 2 to 6 years" with great interest and congratulate authors for their diligent, comprehensive work on a less deciphered topic. There are certain pertinent queries and concerns that need to be addressed in this study. (1) The 2 study groups mentioned in the study cannot be compared and henceforth any conclusion drawn, because of grossly discrepant sample size, almost double the number in spica casting as compared with nailing group. (2) The patients in the spica casting group were significantly lost to follow up, had a shorter total follow up, and were younger as compared with the Titanium Elastic Nail (TEN) group, and hence chances of conclusion getting biased is significant. (3) The implant cost of TEN, 2 subsequent surgeries in the TEN group, associated anesthetic risks and complications thereof, the complications associated with wound healing, blood loss in surgery group, and risk of infections are important points deserving accountability and mention in the article but are surprisingly neglected and had gone unnoticed. (4) The TEN group has a significant dissatisfaction rate which needs further elucidation, reasoning, and clarifications and the surgeon's decision for selective implant removal also needs elaboration. (5) The long term follow up is missing in this retrospective study with no gross functional advantage of one over the other and hence recommendations of this study lack firm footing on conclusion and remarks. (6) The level of mobilization of TEN group needs mention along with its accompaniment with pain or not and the associated level of comfort. (7) This study mentions fall from standing height as the most common mode of injury. World Health Organization defines these fractures to be pathologic, whereas this subset of population are very clearly excluded in this study.2,3 (8) The time to fracture union and return to full activities was similar in both the groups. The return to full activities, even though average is smaller in the TEN group, the value of SD is wider and hence the outliers in the TEN group. This may be because of highly mismatched sample size between the 2  The recovery should be measured or parameter as per preinjury level. We also wish to know whether radiation exposure and its detrimental effects on physis, fertility were taken into consideration or otherwise. (10) We also wish to know any measures were adopted to eliminate surgeon bias as well as surgeon expertise bias and randomization during patient selection in this multicenter, retrospective study. (11) The 4 patients in the spica group required reoperation. The reason for reoperation has not been elaborated. (12) Neither there is detailed mention of fracture configuration and pattern, which is a significant, independent variable directly affecting clinic radiologic outcome nor a detailed mention of measures adopted to deal with comorbidities and other associated trauma. (13) The immediate as well as subsequent ambulation method and protocol in TEN group is missing and we are interested in knowing it as the same is mentioned in detail for the spica group. Considering the above queries we conclude that, although the treatment of shaft femur fractures with TEN in pediatric age group ranging 2 to 6 years appears attractive with added advantages of early mobilization and better psychosocial advantages to the family, the conclusion drawn in the present article needs to be considered cautiously. Hence the question remains management protocol for shaft femur fractures in preschool age children: do we need to rethink? A better quality randomized case control study is the need of the hour.