Elastic robust intramedullary nailing for forearm fracture in children

BACKGROUND: Forearm fractures are the most common fractures in children (23% of all fractures). Basically there are two treatment options available for diaphyseal forearm fractures in children: closed reduction with cast immobilisation (conservative therapy) and the elastic stable intramedullary nailing (ESIN). Treatment decision is influenced by the doctor's estimation of fracture instability. Stable fractures can be treated conservatively whereas instable forearm shaft fractures can be treated according the following three treatment strategies: 1. conservative therapy in an outpatient setting; 2. conservative therapy in the operating room in attendance to change to ESIN in case that no stabilisation can be achieved with cast immobilisation; 3. immediate treatment with ESIN in the operating room. OBJECTIVES: Aim of this Health Technology Assessment (HTA) report is to assess and report the published evidence concerning effectiveness and cost-effectiveness of ESIN as a treatment option for diaphyseal forearm fractures in children and to identify future research need. Important parameters for the assessment of effectiveness are objective parameters (axis deviation, losses of motion, and numbers of reductions in case of redislocations) and subjective parameters (pain or impairment in quality of life). Furthermore, a health economic evaluation shall be done which refers to the costs of the different therapy strategies. METHODS: An extensive, systematic literature search in medical, economic, and HTA literature databases was performed. Relevant data were extracted and synthesised. RESULTS: Three cohort studies and seven case series have been identified. Controlled clinical studies, systematic reviews and/or HTA reports that gave evidence to answer the own study question have not been found. The identified studies partly differed in respect of defined indication for ESIN, study population and treatment strategies. For that reason comparability of results was limited. In the majority of cases the publications reported a successful consolidation of fractures treated with ESIN. The cohort studies reported no differences in mobility after treatment with ESIN compared to patients who were treated conservatively. No publications that argue health economic aspects of the ESIN in children could be identified in the literature search. A cost data assessment conducted by the authors of this report showed that ESIN is associated with higher costs compared to the other treatment strategies (without considering long term costs due to reduction in case of redisplacement). CONCLUSIONS: Little evidence for a dominance of ESIN in treating forearm shaft fractures of children compared to conservative therapy could be found. Accomplishment of ESIN without complications causes more costs than conservative therapy both in outpatient and in inpatient setting. However, if fracture stabilisation cannot be achieved by conservative therapy, further interventions will be necessary. They will result in a burden for the patients and higher costs.