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Saturday, February 16, 2002

To Operate or Not: Surgeons starting to factor in 'quality of life' in making treatment decisions for children's fractures

you were 15 and fractured your femur (thigh bone) in an accident, which would you prefer: (1) several weeks in the hospital in traction, followed by several months in a body cast; or (2) surgery, a few days in the hospital, and the rest of your recuperation at home and school in a wheelchair or on crutches?

Although the fracture would heal just as well either way, the first option would put a serious damper on your home and school life, while the second choice would keep you in circulation. It might even help you heal faster and your parents would not be making trips to the hospital every day to see you.

Ten years ago, in keeping with traditional thinking, most orthopaedic surgeons would have opted for the non-surgical alternative. Today, they would be more likely to recommend surgery.

This shift in thinking among orthopaedic surgeons parallels a changing definition of "positive outcome" within the specialty, James H. Beaty, MD, said at a media briefing on Wednesday.

We're no longer thinking just about how the bone heals," said Dr. Beaty, professor of orthopaedics at the University of Tennessee-Campbell Clinic in Memphis. "We're considering the pros and cons of various options, including shortening the time spent in the hospital, rehabilitation time, time out of school and impact on the family. And we're involving the family more in the decision-making process."

The weighing of "quality of life" factors such as these in treatment decisions for young patients arose from a reevaluation by orthopaedists during the past 10 years of a specific type of injury long associated with a lengthy hospitalization and recovery time-the femur fracture. "Our handling of femur fractures in children made us look very carefully at fractures that require long-term immobilization," Dr. Beaty said. "It made us begin to consider other options.

"Of course, decisions must be made injury by injury, but the driving force is keeping children out of the hospital as much as possible and allowing them to be mobile as soon as they can."

Although the divisions are not set in stone, orthopaedists generally divide children's fractures into three categories: (1) those that heal well only with surgery (e.g., hip fractures, growth plate fractures, fractures of the joint surface); (2) those that heal equally well with surgery or with immobilization (e.g., femur fractures); and (3) those for which surgery is not usually necessary (forearm fractures).

Despite the current inclination to recommend surgery more readily for some types of fractures in children, "the pendulum hasn't swung completely in this direction and made us want to operate on every fracture," Dr. Beaty added.

"The vast majority of fractures in children can be treated without surgery. But in the group of fractures that can be treated either way, we're beginning to zero in on differences in outcome between the two main options, and we've expanded our definition of outcome in making evaluations on a case-by-case basis."

The child's age also plays a role in treatment decisions, Dr. Beaty noted. A femur fracture that would take three months to heal in a teenager would heal in three to four weeks in a preschooler, so surgery would be recommended much less frequently for a younger child.

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Last modified 16/February/2002 by IS