Imagine a world where children with elbow fractures no longer need surgery, a notion that could redefine pediatric orthopedic treatment. Recent research conducted by teams in Liverpool and Oxford has revealed that surgical intervention for a frequently seen elbow fracture in young patients does not provide any advantages over non-surgical methods. This groundbreaking discovery could lead to major changes in treatment protocols and significant cost reductions for the National Health Service (NHS).
This research, published in The Lancet, stems from the largest randomised controlled trial of its kind, known as the SCIENCE study (Surgery or Cast for Injuries of the Epicondyle in Children's Elbows). This pivotal study sheds light on how best to treat children suffering from displaced medial epicondyle fractures of the elbow. Such injuries occur when a small piece of bone detaches from the inner elbow, often a result of strong muscles and tendons pulling it away during activities.
These fractures make up around 10% of all elbow injuries in children, predominantly affecting those aged between 10 and 12, typically following a fall during sports activities. Despite being a common occurrence, there remains a global discussion about whether surgical fixation is necessary, or if a simple cast or splint would suffice for natural healing.
Dan Perry, NIHR Research Professor in Children's Orthopaedics and Trauma Surgery at the University of Liverpool and Alder Hey Hospital, emphasized the importance of this research: "This is the first significant clinical trial focusing on children's orthopaedic surgery. Historically, treatment decisions for these types of injuries—and indeed most pediatric injuries—have not been grounded in solid scientific evidence.
"There has been a growing inclination to perform surgical repair on broken bones in children, despite a lack of substantial supporting data. We initiated the SCIENCE study to determine which treatment option was superior—surgical intervention or allowing the arm to heal with a plaster cast."
The SCIENCE study encompassed 334 children, ages seven to fifteen, from various hospitals in the UK, Australia, and New Zealand, all of whom had experienced a displaced medial epicondyle fracture. Participants were randomly assigned to two groups; one group received a cast for four weeks, while the other underwent surgery to address the fracture.
The main metric evaluated in the study was upper limb function after a year, assessed using the PROMIS Upper Extremity (UE) Score for Children. Additionally, both children and their parents reported on various aspects such as functional ability, pain levels, complications, school attendance, and overall health-related quality of life. Researchers also considered the financial impact on families and the NHS.
The results were telling: allowing the fracture to heal naturally in a plaster cast proved to be just as effective as surgical intervention, while eliminating the risks associated with surgery.
Before the trial commenced, families indicated that alleviating pain and restoring normal functionality were their top priorities. Remarkably, children whose fractures healed in a cast resumed their usual activities at the same pace as those who underwent surgery. Both groups experienced comparable pain levels and frequency of hospital visits, although the non-surgical group had slightly shorter absences from school.
Interestingly, one in seven children who had surgery required a second procedure, primarily to remove screws that were used to stabilize the fracture. In contrast, only one in 45 children treated with a cast needed an additional operation later for further healing assistance. Matt Costa, Professor of Trauma Surgery and lead investigator at the University of Oxford's Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, stated: "This study provides compelling evidence that surgery should no longer be the go-to option for displaced medial epicondyle fractures in children. This finding will spare many young patients from unnecessary surgical procedures and help save funds for the NHS."
The study received funding from the National Institute for Health and Care Research (NIHR) and enjoyed support from the NIHR Oxford Biomedical Research Centre (BRC).
This research opens the door to rethinking how we treat common pediatric injuries. But here's where it gets controversial: should we reevaluate other longstanding surgical practices in light of new evidence? What are your thoughts on this shift toward non-surgical solutions? We invite you to share your opinions in the comments!
