I believe that the headline for the article on nightstick fractures (“Surgery better for nightstick fractures,” AAOS Now, February 2011) is misleading. A reader perusing the publication may be misled to believe that a definitive answer has been identified for the treatment of nightstick fractures.
The article reports on a retrospective review of a variety of nonsurgical treatments (long-arm cast, short-arm cast, brace, and sling) versus surgical treatment. The study authors readily admit the limitations of their work, with a significant population lost to follow-up.
In addition, the article notes that “clinical results and functional outcomes...were similar in both treatment groups and most patients achieved a full recovery.” Prior studies by Arsen M. Pankovich, MD, have demonstrated better outcomes in functional bracing versus a long-arm cast. The study authors elected to use radiographic criteria to define “malunion,” although it is unclear whether these malunions resulted in any cosmetic or functional problems. They also elected to convert to open reduction/internal fixation with 2 mm of secondary displacement, although generally others may not have used this criteria. Finally, they do not specifically define nonunion. Clearly, many authors have used a number of criteria to report nonunion and no standard criteria have ever been universally accepted.
Management of these injuries remains undefined and, as the study authors report, requires further investigation, prospectively comparing functional bracing and surgical treatment.
Paul E. Levin, MD