Treatment of Arm Fractures in Children: What’s the Evidence?

Every now and then it’s a good idea to step back and make sure we are on the right track with treatment of medical problems. And that’s exactly what these authors did in this study from Cincinnati Children’s Hospital. Using information presented at annual meetings of two orthopedic groups, they summarize current trends in treatment and evidence-based recommendations for management of these injuries.

Abstracts on the treatment of pediatric upper extremity fractures were reviewed from the Pediatric Orthopaedic Society of North America (POSNA) and the American Academy of Orthopaedic Surgeons (AAOS). The time period selected was from 1993 through 2012 (20 years).

Papers, posters, and abstracts were included with evidence from all Levels (I through IV). Level I and II were prospective, randomized controlled trials (RCT). Level III were case-control studies and retrospective comparative studies. Level IV was only case series.

Two pediatric orthopedic surgeons with special skill and training in the treatment of pediatric upper extremity fractures rated the treatment recommendations made in each publication as: 1) more aggressive, 2) less aggressive, or 3) neutral. More aggressive meant there were more diagnostic studies performed, more medications prescribed, surgery more often than conservative (nonoperative care), and faster time to surgery. Other criteria for a classification of more aggressive included treatment by a specialist and more invasive surgery (open incision, use of pins and plates).

What they found was a clinical trend toward more aggressive treatment despite research evidence that less aggressive treatment is just as effective. Large studies that compared operative versus nonoperative treatments concluded that less aggressive care is safe and effective. More aggressive treatment is not recommended. Case studies of individual patients with specific concerns were more likely to advise the use of more aggressive treatment.

Of all the bones in the upper extremity from the humerus (upper arm bone) down to the wrist, forearm fractures were the most likely to be treated surgically. Yet less than one-third of the studies favored operative care for forearm (shaft) fractures.

This study did not answer the question of why this trend (of more aggressive treatment despite evidence supporting a less aggressive approach) exists. The authors suggested several possible explanations. First, sometimes it just takes a while for research evidence to trickle down into clinical practice. Quality of studies has improved over time but many studies are still based on physician observation (not hard data). So, there can be a tendency to ignore recommendations based on Level III and IV evidence.

Some surgeons may take the more aggressive approach because of improved techniques and advancing technology making it easier to perform these procedures. It’s also possible that surgeons are influenced by advertising of newer surgical techniques. Patients may even be the source of pressure to be surgically aggressive if they believe “more is better”. And finally, other (as yet unknown) factors may be behind this trend. Procedures do pay more than conservative care. This notion suggests an economic reason behind surgeons’ choices.

In summary, the majority of comparative studies and case series recommend conservative (less aggressive) care for upper extremity fractures in children. Fewer diagnostic tests, less medicine, no surgery (or slower time to surgery) with less invasive surgical procedures is advised. The trend toward less aggressive care may occur naturally as research provides evidence to support this approach.

The authors recommend increased efforts to ensure quality and safety in the treatment of these pediatric injuries that are based on current evidence.