Letters to the Editor 489
Letters to the Editor Journal of Pediatric Orthopaedics B 2014, 23:489–491
Are they overtreated? Yueju Liua,b and Yingze Zhanga,b, aDepartment of Orthopedic Center, Third Hospital of Hebei Medical University and bKey Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, People’s Republic of China Correspondence to Yingze Zhang, MD, Department of Orthopedic Center, Third Hospital of Hebei Medical University, No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, People’s Republic of China Tel: + 86 0311 8860 3682; fax: + 86 0311 8702 3626; e-mail: [email protected]
Karaman et al. [1] carried out a mid-term prospective study on 102 pediatric patients with long bone (the humerus, forearm, tibia, and femur) shaft fractures operated by elastic intramedullary nailing, and found that elastic intramedullary nailing is the best choice for diaphyseal fractures in children with skeletal immaturity compared with other surgical choices. However, we found that the patients are overtreated in this study, especially for forearm fractures. The author even performed an operation on a 5-year-old child with forearm shaft fractures, which is unheard of on the basis of our experience of nearly 200 pediatric shaft fractures and also rare in the English literature. Jones [2] pointed that ‘closed reduction still remains the gold standard for closed isolated pediatric forearm fractures’. Operative treatment of radial and ulnar shaft fractures is usually reserved for open fractures, those associated with compartment syndrome, floating elbow injuries, and fractures that develop unacceptable displacement during nonoperative management, and residual angulation after closed treatment is much better tolerated by younger children than older adolescents and adults because of the increased remodeling potential in the younger age group [3]. Bellemans [4] considered displaced oblique or comminuted midshaft forearm fractures in children older than 7 years of age to be an indication for elastic intramedullary nailing, which was accepted by most orthopedic doctors. In our clinical practice, we found that even significantly displaced forearm shaft fractures are usually manipulated in the emergency department using a conscious sedation protocol. Moreover, provided the child has at least 2 years of growth remaining, ∼ 20° of angulation in distal-third shaft fractures of the radius and ulna, 15° at the midshaft level, and 10° in the proximal third are accepted by most orthopedic doctors [5]. Thus, the indications for surgery in this study were severely magnified and X-ray exposure place children of only 5 years old in danger certainly, with long-term results we do not know. In addition, we, as doctors, should help parents 1060-152X © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
make the best decisions for their children, and we should not only accept their decision concerning surgery, in which they want the operation and we perform the operation
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2 3 4
5
Karaman I, Halici M, Kafadar IH, Guney A, Oner M, Gurbuz K, Karaman ZF. Mid-term results of the elastic intramedullary nailing in paediatric long bone shaft fractures: a prospective study of 102 cases. J Pediatr Orthop B 2014; 23:212–220. Jones K, Weiner DS. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop 1999; 19:811–815. Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. J Pediatr Orthop 1986; 6:306–310. Bellemans M, Lamoureux J. Indications for immediate percutaneous intramedullary nailing of complete diaphyseal forearm shaft fractures in children. Acta Orthop Belg 1995; 61 (Suppl 1):169–172. Younger AS, Tredwell SJ, Mackenzie WG, Orr JD, King PM, Tennant W. Accurate prediction of outcome after pediatric forearm fracture. J Pediatr Orthop 1994; 14:200–206.
Response to ‘Are they overtreated’ Ibrahim Karamana, Mehmet Halicia, Ibrahim H. Kafadara, Ahmet Guneya, Mithat Onera and Zehra F. Karamanb, aDepartment of Orthopaedics and Traumatology, Erciyes University Medical Faculty and bDepartment of Radiology, Training and Research Hospital, Kayseri, Turkey Correspondence to Ibrahim Karaman, MD, Orthopaedics and Traumatology Department, Gevher Nesibe Hospital, Erciyes University, Sok.Vakıf-Kınaş Apt. No. 4/18, Melikgazi 38039, Kayseri, Turkey Tel: + 90 352 2076666; fax: + 90 352 4377686; e-mail: [email protected]
Our results are in agreement with the literature as the author stated his concerns about the age limit for the indication of surgery in pediatric patients. We apply closed reduction and casting for patients younger than 10 years old [1]. Loss of reduction at follow-up or nonachievement of the required reduction is necessary for a surgical indication. The average age of the children in our study was older than 7 years and this is in agreement with the literature [1] and so we do not extend the indication of the surgery. When we reviewed the data of the patient that the author mentioned in particular, it was found that the patient had presented a day after the fracture had occurred; because of significant swelling at that time, closed reduction and casting could not be performed and so intramedullary nailing and splinting was performed. However, one limitation of our study was that we did not report detailed clinical information of this patient. Furthermore, we found that elastic intramedullary nails DOI: 10.1097/BPB.0000000000000080
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letters to the Editor Journal of Pediatric Orthopaedics B 2014, 23:489–491
Are they overtreated? Yueju Liua,b and Yingze Zhanga,b, aDepartment of Orthopedic Center, Third Hospital of Hebei Medical University and bKey Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, People’s Republic of China Correspondence to Yingze Zhang, MD, Department of Orthopedic Center, Third Hospital of Hebei Medical University, No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, People’s Republic of China Tel: + 86 0311 8860 3682; fax: + 86 0311 8702 3626; e-mail: [email protected]
Karaman et al. [1] carried out a mid-term prospective study on 102 pediatric patients with long bone (the humerus, forearm, tibia, and femur) shaft fractures operated by elastic intramedullary nailing, and found that elastic intramedullary nailing is the best choice for diaphyseal fractures in children with skeletal immaturity compared with other surgical choices. However, we found that the patients are overtreated in this study, especially for forearm fractures. The author even performed an operation on a 5-year-old child with forearm shaft fractures, which is unheard of on the basis of our experience of nearly 200 pediatric shaft fractures and also rare in the English literature. Jones [2] pointed that ‘closed reduction still remains the gold standard for closed isolated pediatric forearm fractures’. Operative treatment of radial and ulnar shaft fractures is usually reserved for open fractures, those associated with compartment syndrome, floating elbow injuries, and fractures that develop unacceptable displacement during nonoperative management, and residual angulation after closed treatment is much better tolerated by younger children than older adolescents and adults because of the increased remodeling potential in the younger age group [3]. Bellemans [4] considered displaced oblique or comminuted midshaft forearm fractures in children older than 7 years of age to be an indication for elastic intramedullary nailing, which was accepted by most orthopedic doctors. In our clinical practice, we found that even significantly displaced forearm shaft fractures are usually manipulated in the emergency department using a conscious sedation protocol. Moreover, provided the child has at least 2 years of growth remaining, ∼ 20° of angulation in distal-third shaft fractures of the radius and ulna, 15° at the midshaft level, and 10° in the proximal third are accepted by most orthopedic doctors [5]. Thus, the indications for surgery in this study were severely magnified and X-ray exposure place children of only 5 years old in danger certainly, with long-term results we do not know. In addition, we, as doctors, should help parents 1060-152X © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
make the best decisions for their children, and we should not only accept their decision concerning surgery, in which they want the operation and we perform the operation
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2 3 4
5
Karaman I, Halici M, Kafadar IH, Guney A, Oner M, Gurbuz K, Karaman ZF. Mid-term results of the elastic intramedullary nailing in paediatric long bone shaft fractures: a prospective study of 102 cases. J Pediatr Orthop B 2014; 23:212–220. Jones K, Weiner DS. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop 1999; 19:811–815. Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. J Pediatr Orthop 1986; 6:306–310. Bellemans M, Lamoureux J. Indications for immediate percutaneous intramedullary nailing of complete diaphyseal forearm shaft fractures in children. Acta Orthop Belg 1995; 61 (Suppl 1):169–172. Younger AS, Tredwell SJ, Mackenzie WG, Orr JD, King PM, Tennant W. Accurate prediction of outcome after pediatric forearm fracture. J Pediatr Orthop 1994; 14:200–206.
Response to ‘Are they overtreated’ Ibrahim Karamana, Mehmet Halicia, Ibrahim H. Kafadara, Ahmet Guneya, Mithat Onera and Zehra F. Karamanb, aDepartment of Orthopaedics and Traumatology, Erciyes University Medical Faculty and bDepartment of Radiology, Training and Research Hospital, Kayseri, Turkey Correspondence to Ibrahim Karaman, MD, Orthopaedics and Traumatology Department, Gevher Nesibe Hospital, Erciyes University, Sok.Vakıf-Kınaş Apt. No. 4/18, Melikgazi 38039, Kayseri, Turkey Tel: + 90 352 2076666; fax: + 90 352 4377686; e-mail: [email protected]
Our results are in agreement with the literature as the author stated his concerns about the age limit for the indication of surgery in pediatric patients. We apply closed reduction and casting for patients younger than 10 years old [1]. Loss of reduction at follow-up or nonachievement of the required reduction is necessary for a surgical indication. The average age of the children in our study was older than 7 years and this is in agreement with the literature [1] and so we do not extend the indication of the surgery. When we reviewed the data of the patient that the author mentioned in particular, it was found that the patient had presented a day after the fracture had occurred; because of significant swelling at that time, closed reduction and casting could not be performed and so intramedullary nailing and splinting was performed. However, one limitation of our study was that we did not report detailed clinical information of this patient. Furthermore, we found that elastic intramedullary nails DOI: 10.1097/BPB.0000000000000080
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
