Session V Pediatrics

Outcome and Cost Analysis of Traction and Casting Compared to External Fixation in Isolated Femoral Shaft Fractures in Children

Paul Gregory, MD, and David Teague, MD

The Florida Orthopaedic Institute, Tampa, Florida and the University of Oklahoma, Department of Orthopaedics, Oklahoma City, Oklahoma

Purpose: To compare outcome and cost of two popular methods of treatment of femoral shaft fractures in pediatric patients with isolated injuries.

Methods: Between 1991 and 1996, 68 patients between the ages of 6 and 11 years of age were treated for a femoral shaft fracture at 2 major teaching hospitals. Twenty-three of these were eliminated from the study because they had associated significant other injuries which required surgery or prolonged hospital time or because they were treated with a method other than traction or external fixation. This left a group of 45 patients between the ages of 6 and 11 years with isolated femoral shaft fractures who were treated with traction followed by spica casting (n=25) or external fixation (n=20). The treatment modality was selected through discussion between the attending surgeon and the family. These groups were reviewed retrospectively for outcome including healing, function, and complications. Then, an in depth cost analysis was done to determine the relative expense of each treatment modality. Initially an attempt was made to simply compare charges as they appeared on the patients' bills. Because of gross inaccuracies encountered in several itemized bills, an alternative cost estimation was calculated. This was done by gathering all of the appropriate cost information for each patient and recalculating the total cost incurred.

Results: Of the 25 patients treated with traction and casting, 24 were followed until complete union. One patient never returned after discharge in the spica cast and could not be located. The average age of these patients was 92 months (72-125). Average follow-up was 12 months (2-28) postinjury. One patient had a refracture after cast removal which required another spica cast. Significant malunion (greater than 15 degrees) was seen in 11 patients; none was symptomatic. No significant residual stiffness was present at time of final review, and one leg length discrepancy greater than 1 cm was identified. Average length of hospitalization was 16.6 days. The average cost of inpatient care for this group of patients totaled $9,755. There was a noticeable difference between the cost incurred at the 2 institutions. This difference related mainly to the practice of placing the cast in the operating room at one institution, resulting in an increased cost of $2,666. Of the 20 patients treated with external fixation, all were followed until complete bony union. The average age of these patients was 99 months (76 -119). Average length of follow-up was 7 months (2-24). The only significant complication was that of a fracture through a pin site 4 days after fixator removal. This was related to a technical error in which a unicortical drill hole was made adjacent to a bicortical pin site. This patient was then treated with a spica cast and healed this second fracture uneventfully. A second patient did sustain a refracture while in a long leg cast after fixator removal. The cast, however, maintained anatomic alignment and was left in place until the fracture completely consolidated. Twelve of the patients were treated for pin tract infections while the external fixator was in place. These all resolved with oral antibiotics with no long term sequlae. Of the 20 patients followed until healing was complete, 19 healed with anatomic alignment on both anteroposterior and lateral radiographs. No residual stiffness or leg length discrepancy was noted at final follow-up. Average length of hospitalization was 3.5 days (1-6). The average cost of inpatient care in the patients treated with external fixation was $12,635. A large variation in cost was again noted between institutions. The difference with this treatment modality related to the cost of the external fixator used and to the habit of occasionally taking patients back to the operating room for fixator removal, if the more costly external fixator was used and the patient was taken back to the operating room for fixator removal, a cost increase of greater than $4,000 was noted.

Conclusion: Both traction followed by casting and external fixation can result in a good outcome for the patient. Traction and casting as a treatment modality is more commonly associated with malunion, whereas external fixation has a certain incidence of pin tract infections. Although external fixation is associated with a significantly shorter hospital stay, the average expense was greater for this modality compared with traction and casting. Several habits were identified which resulted in a significant increase in expense: placement of the cast in the operating room, use of a more expensive external fixator, and removal of the external fixator in the operating room. No significant clinical advantage seemed to be gained through these practices, but a significant increase in cost did occur.