Immediate hip spica casting for femur fractures in pediatric patients. A review of 175 patients

Comparative Study Between Single-limb Versus One-and-a-Half Hip Spica Cast in Fracture Femur in Young Children

INTRODUCTION

Femoral fractures account for ∼1% to 2% of all pediatric bone injuries and are a common occurrence in children. The conservative approach, employing either a single or one-and-a-half spica casts, has been traditionally favored, yielding satisfactory outcomes in select cases. This study aims to compare both procedures regarding functional and radiologic outcomes, complications, and parents' satisfaction.

METHODS

In this randomized controlled trial, we enrolled 84 pediatric patients, aged between 2 and 6 years, presenting with femoral fractures. Participants were randomly allocated into 2 groups; one receiving single-limb spica cast fixation (n=42) and the other receiving one-and-a-half spica cast fixation (n=42). We assessed postprocedural functional and radiologic outcomes. Other evaluations focused on parental ease in maintaining hygiene for the casted child, the child's mobility capabilities including standing and crawling, and the incidence of skin complications.

RESULTS

No significant variance was observed between the 2 groups concerning the time to bone union, and the overall complication rates. Parental satisfaction was notably higher in the single-limb spica group, particularly regarding the ease of maintaining hygiene for the casted child and the child's mobility while encased in the cast (P<0.001). Furthermore, a significant correlation was identified between the one-and-a-half spica application and the increased occurrence of skin pressure ulcers (P<0.001).

CONCLUSION

Both single-limb and one-and-a-half spica cast applications demonstrated comparable results in functional and radiologic outcomes, as well as in complication rates. However, parents favored the single-limb method due to its facilitation of a more manageable lifestyle for both the child and their parents. These considerations suggest that the single-limb hip spica cast fixation may be preferable in managing pediatric femoral fractures.

LEVEL OF EVIDENCE

Level II.

Waterproof Hip Spica Casts for Pediatric Femur Fractures

BACKGROUND

Hip spica casting is the treatment of choice for femur fractures in children ages 6 months to 5 years. Traditional spica (TS) casting utilizes cotton padding that precludes patient bathing. Waterproof (WP) casting has inherent advantages, including clearance for bathing and improved family satisfaction. This study examines the safety and efficacy of WP hip spica casting for the treatment of pediatric femur fractures.

METHODS

This is a retrospective, matched cohort study of patients ≤5 years with a femur fracture treated with hip spica casting. Patients with WP casts were matched to patients with TS casts by age, sex, and fracture type. TS casts utilize a Goretex liner and cotton padding, while WP spicas utilize fully WP materials and can be completely submerged in water.

RESULTS

Fifty patients were included (25 WP, 25 TS) without differences between cohorts in age, weight, or sex. There were no differences in operative time, length of stay, or length of time in cast. Patient charges were significantly lower in the WP group ($230 vs. $301, P <0.001). At cast-off, coronal/sagittal alignment and shortening were similar, while 9 TS patients had minor skin and/or cast complications that required outpatient repair versus only 1 WP patient ( P <0.001).

CONCLUSIONS

In a matched comparison, WP spica casting significantly reduces skin and cast complications traditionally associated with cotton-based spica casting, with significantly lower charges for WP cast materials. Fracture healing rate, alignment, and shortening at cast-off are similar in WP versus TS casts. WP spica casting is safe and efficacious for pediatric femur fractures, with the inherent advantage of clearance for bathing.

LEVEL OF EVIDENCE

Level 3.

Can Paediatric Femoral Fracture Hip Spica Application be Done in the Outpatient Setting?

Introduction:

Hip spica casting is a standard treatment for children with femur fractures. This study compares the outcomes of spica cast application, in terms of quality of fracture reduction and hospital charges when performed in operating theatre versus outpatient clinics at a local institution.

Materials and Methods:

A total of 93 paediatric patients, aged between 2 months to 8 years, who underwent spica casting for an isolated femur fracture between January 2008 and March 2019, were identified retrospectively. They were separated into inpatient or outpatient cohort based on the location of spica cast application. Five patients with metaphyseal fractures and four with un-displaced fractures were excluded. There were 13 and 71 patients in the outpatient and inpatient cohort respectively who underwent spica casting for their diaphyseal and displaced femur fractures. Variables between cohorts were compared.

Results:

There were no significant differences in gender, fracture pattern, and mechanism of injury between cohorts. Spica casting as inpatients delayed the time from assessment to casting (23.55 ± 29.67h vs. 6.75 ± 4.27h, p<0.05), increased average hospital stay (41.2 ± 31.1h vs. 19.2 ± 15.0h, p<0.05) and average hospital charges (US$1857.14 vs US$775.49, p<0.05). Excluding the un-displaced fractures, there were no significant differences in the period of cast immobilisation and median follow-up length. Both cohorts had a similar proportion of unacceptable reduction and revision casting rate.

Conclusion:

Both cohorts presented similar spica casting outcomes of fracture reduction and follow-up period. With spica cast application in operating theatre reporting higher hospital charges and prolonged hospital stay, the outpatient clinic should always be considered for hip spica application.

Treatment of femoral fractures in children aged two to six

Aims

Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group.

Methods

Patients aged two to six years old with acute, non-pathological femur fractures were prospectively enrolled at one of three tertiary children’s hospitals. Either early closed reduction with spica cast application or flexible intramedullary nailing was accomplished under general anaesthesia. The treatment method was selected after discussion of the options by the surgeon with the family. Data were prospectively collected on patient demographics, fracture characteristics, complications, pain medication, and union. The Impact on Family Scale was obtained at the six-week follow-up visit. In all, 75 patients were included in the study: 39 in the spica group and 36 in the nailing group. The mean age of the spica group was 2.71 (2.0 to 6.9) years and the mean age of the nailing group was 3.16 (2.0 to 6.9) years.

Results

All fractures healed without evidence of malunion or more than 2.0 cm of shortening. The mean Impact on Family score was 70.2 for the spica group and 63.2 (55 to 99) for the nailing group, a statistically significant difference (p = 0.024) in a univariate analysis suggesting less impairment of the family in the intramedullary nailing group. There was no significant difference between pain medication requirements in the first 24 hours postoperatively. Two patients in the spica group and one patient in the intramedullary nailing group required additional treatment under anaesthesia.

Conclusion

Both early spica casting and intramedullary nailing were effective methods for treating femoral fractures in children two to six years of age. Intramedullary stabilization provides an option in this age group that may be advantageous in some social situations that depend on the child’s mobility. Fracture treatment should be individualized based on factors that extend beyond anatomical and biological factors. Cite this article: Bone Joint J 2020;102-B(8):1056–1061.

Early versus late hip spica casting for paediatric femoral shaft fractures

The purpose of our study was to evaluate the effectiveness of treating paediatric femoral shaft fractures by early (<48 h) versus late (>48 h) hip spica casting. A retrospective review of 44 patients with 44 femoral shaft fractures treated by either early or late hip spica application with at least 9-month follow-up was undertaken. Both groups were treated on an inpatient basis. The late hip spica group had skin traction applied before the application of a hip spica. The outcome measures involved both clinical [Pediatric Outcomes Questionnaire (POQ) and Activities Scale for Kids (ASK)] and radiological outcomes. Complications were noted. A total of 44 patients with a mean age of 33 months (range: 7-66 months) were evaluated. Overall, 20 patients underwent early and 24 had late hip spica casting. At follow-up, the ASK was similar amongst the two groups (44.2 vs. 44.8, P=0.8). However, the POQ was better in the early hip spica casting group (24.7 vs. 28.9, P=0.01). Length of hospital stay and duration of immobilization in the hip spica were significantly shorter in the early group (P<0.001). There were no differences in leg lengths, lateral distal femoral angles and medial proximal tibia angles between the fractured and nonfractured limbs in both groups. Early hip spica casting is a safe procedure for paediatric femoral shaft fractures and was associated with less time in hospital and hip spica with a better POQ score. However, early hip spica casting was associated with more hip spica changes and required wedging. At follow-up, radiological parameters were similar in both groups. Level of Evidence: III.

Financial Analysis of Closed Femur Fractures in 3- to 6-Year-Olds Treated With Immediate Spica Casting Versus Intramedullary Fixation

BACKGROUND

Health care in America continues to place more importance on providing value-based medicine. Medicare reimbursements are increasingly being tied to this and future policy changes are expected to reinforce these trends. Recent literature has shown pediatric femur fractures in preschool-age children have equivalent clinical and radiographic outcomes when treated with spica casting or flexible intramedullary nails (IMN). We compared hospital care statistics including charges for nonoperative versus operative treatment for closed femur fractures in 3- to 6-year-olds.

METHODS

An IRB-approved retrospective chart review was performed of 73 consecutive 3- to 6-year-olds treated at a regional level 1 pediatric hospital from January 1, 2009 to December 31, 2013 with an isolated, closed femoral shaft fracture. Exclusion criteria included open fractures, bilateral injury, and polytrauma. Immediate spica casting was performed in the Emergency Department or Anesthesia Procedure Unit versus IMN in the operating room.

RESULTS

A total of 41 patients were treated with spica casting and 32 patients were treated operatively with flexible IMNs; 3 patients failed nonoperative care. After analysis of final treatment groups, significant differences included age at injury: 3.7 years for cast versus 5.3 years for IMN (P<0.001), time to discharge 21 versus 41 hours (P<0.001), 3.2 versus 4.4 clinic visits (P<0.001), follow-up 3.5 versus 9.4 months (P<0.001). Orthopedic surgeon charges were $1500 for casted patients versus $5500 for IMN (P<0.001). Total hospital charges were $19,200 for cast versus $59,700 for IMN (P<0.001). No difference was found between clinic charges or number of radiographs between groups. In total, 76% of cast group were discharged <24 hours from admission versus 8.6% in operative group. In the operative group, 83% had implant removal with no statistically significant charge difference between those who had implant removal versus retention.

CONCLUSIONS

Treatment of pediatric femur fractures in 3- to 6-year-olds with IMN is associated with longer hospital stays, significantly greater hospital charges, longer follow-up and more clinic visits compared with spica casting. These findings are at odds with previous literature showing shorter hospital stays and decreased cost with nailing compared to traction and casting. This shows a clear difference between 2 treatments that yield similar clinical and radiographic outcomes.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Long leg splinting for pediatric femur fractures

Background

Pediatric femur fractures are frequently encountered injuries frequently treated with spica casting. Spica casting may, however, be expensive and burdensome to patients. A possible alternative is a long leg splint.

Methods

Patients aged 6 months to 5 years old who were treated for a femoral shaft fracture with a long leg splint extending above the waist were matched with a patient treated with a spica cast.

Results

At the time of healing, the alignment in the spica cast group was only significantly better than the alignment of the splint group with respect to coronal angulation.

Systematic review of spica casting for the treatment of paediatric diaphyseal femur fractures

PURPOSE

Paediatric femur fractures are commonly encountered and often successfully managed with spica casting. Despite spica casting's long history there is little formal guidance for optimal outcomes and no consolidation of existing literature. The purpose of this study is to review the available literature regarding the use of spica casting for the management of paediatric diaphyseal femur fractures.

METHODS

The PubMed database was queried for all research articles including the phrase "spica". A total of 788 abstracts were reviewed for relevance to the current study. Data was extracted from all available research studies which specified tolerance for fracture angulation or shortening in the cast. Additionally, all articles describing alternative materials, methods for spica application, and complications of spica casting were reviewed.

RESULTS

In all, 106 articles were found relevant to the management of diaphyseal femur fractures in the paediatric population. The aggregated, accepted fracture shortening decreased from 16 mm to 18 mm before age ten years to 12 mm to 14 mm after puberty. Aggregated, accepted angulation decreased from 14° to 16° varus/valgus and 18° to 22° pro/recurvatum before age two years, to 6° to 8° and 10° to 12° by puberty, respectively. The overall reported complication rate was 19.6%, with the most common complication being skin compromise in 8.2% of patients, followed by unacceptable angulation at the fracture site in 4.2% of patients and excessive limb shortening in 1.9% of patients.

CONCLUSION

This article reviews the available spica casting literature and compiles the available data. Spica casting offers a safe, effective means for definitive management of paediatric diaphyseal femur fractures. Future research identifying the rate and pattern of remodelling as it relates to angulation and shortening at various patient ages, particularly beyond the aforementioned norms, would be valuable to identify true biological tolerances versus accepted expert opinion.

LEVEL OF EVIDENCE LEVEL II

Review of level II evidence.

Outpatient Pediatric Orthopedic Surgery

Outpatient surgery refers to a surgical procedure that is performed without an overnight stay in a hospital. Outpatient surgery is associated with decreased individual and societal costs while achieving equivalent health outcomes and excellent patient satisfaction. Successful outpatient pediatric surgery is predicated on appropriate patient selection, adequate pain control, thorough preoperative education, and close clinical follow-up. Continuous research in quality, value, and patient safety are needed to ensure that this practice continues in as safe and efficient a manner as possible.

Preliminary Report-The Long Leg Cast With a Pelvic Band: A Novel Approach to Treatment of Pediatric Femur Fractures

OBJECTIVES

The aim of the study was to describe the long leg cast with a pelvic band (LLCPB), a novel alternative to spica casting for treating femur fractures in patients aged 6 months to 6 years which requires no casting above the waist, allows for hip flexion adjustments after it is applied, and does not require an operating room for placement.

METHODS

Seven children aged 7.9 months to 3.7 years with femur fractures treated with the LLCPB at a single institution were retrospectively studied. All children were casted in the emergency department under conscious sedation. Radiographic and subjective outcomes were recorded.

RESULTS

All 7 children achieved acceptable reduction of their fractures without the need for re-reduction or cast wedging. Five of the 7 children were discharged from the emergency department; 1 child required 1 night of hospitalization and another child required 2 nights of hospitalization. There were no complications. The cost of placing an LLCPB at our institution was $430.46. The cost of placing a spica cast in the operating room was $5427.54 to $6465.00.

CONCLUSIONS

The long leg cast with a pelvic band seems to be an acceptable treatment for children aged 8 months to 4 years with spiral femur fractures. This technique has significant advantages over traditional and modified spica casts including allowing for uninhibited toileting, weight bearing on the unaffected leg, adjustment of hip flexion at any point after placement, and easier access to the perineum, abdomen, and chest for hygienic and medical purposes. Furthermore, treatment with an LLCPB presents significant potential for cost savings.

V, RHH A, Khurana A. Current Concepts in Paediatric Femoral Shaft Fractures

Pediatric femoral shaft fractures account for less than 2% of all fractures in children. However, these are the most common pediatric fractures necessitating hospitalization and are associated with prolonged hospital stay, prolonged immobilization and impose a significant burden on the healthcare system as well as caregivers. In this paper, the authors present a comprehensive review of epidemiology, aetiology, classification and managemement options of pediatric femoral shaft fractures.

External fixation of pediatric femoral shaft fractures: a consecutive study based on 45 fractures

Forty-five displaced femur fractures in children were treated with unilateral external fixation as a standard treatment from March 2007 to March 2009 and the last follow-up was completed in May 2012. The average age of the children at presentation was 9.93 years. Patients were followed up till union, at 1 year, and at an average of 3.5 years after fixation. The fixator was removed at an average of 12.23 weeks. Twenty-one (47%) patients had a minor complication of pin-site infection. One patient had a major complication of refracture. Treatment of uncomplicated femur fractures using an external fixator in children yields satisfactory results. Our series had a longer duration of follow-up and fewer refractures compared with other series.

The safety of titanium elastic nailing in preschool femur fractures: a retrospective comparative study with spica cast

One hundred and four nonpathological fresh femur fractures not involving the neck or condyles in two groups of preschool children were retrospectively compared and followed up for a minimum of 3 years. Group I was treated by a spica cast and group II was treated by a titanium elastic nail (TEN). The mean age of the children was 4.5 years. TEN was statistically better in terms of union (P=0.000), shortening (P=0.016), sagittal angulation (P=0.018), coronal angulation (P=0.022), rotation (P=0.014), earlier weight bearing (P=0.000), and earlier return to nursery (P=0.000). However, both groups had a similar overgrowth rate and hospital stay time. TEN in preschool children is a safe choice but involves a scar, risk of infection, and the need for a second operation.

Which treatment option for paediatric femoral fractures in school-aged children: elastic nail or spica casting?

OBJECTIVE

Titanium elastic nails and immediate spica casts are treatment options for femoral fractures in school-aged children (6-12 years). This study aimed to compare the results of elastic nail and immediate spica cast methods for treating femoral fractures in school-aged children.

MATERIALS AND METHODS

A retrospective evaluation was made of patients who underwent immediate spica cast (20 patients) or titanium elastic nail (22 patients) for femoral fracture. Groups were compared in terms of clinical and radiographic union, duration of hospitalisation, range of knee motion, walking independently and complications. The mean age was 9.8 ± 1.3 years for the elastic nail group and 6.4 ± 1 for the cast group. The mean follow-up period was 12.6 ± 5.2 months for the elastic nail group and 14.3 ± 6 months for the cast group.

RESULTS

All fractures in both group were healed. Duration of hospitalisation was shorter (2.2/7.1) and range of knee motion was better (132°/129°) in the cast group. The duration for independent walking was shorter (49.2/79.8) in the nail group. These differences were significant (p < 0.001). Two superficial infections and two malalignment were detected in the nail group. Three superficial infections and four malalignment were detected in the cast group.

CONCLUSION

We detected that both treatment options were similar with regard to complications and results. Although the complications are similar in two treatment methods, complications of elastic nail are more challenging and may require new surgical procedure. If the elastic nail is selected, surgical complications should not be underestimated.

The treatment of low-energy femoral shaft fractures: a prospective study comparing the "walking spica" with the traditional spica cast

BACKGROUND

A single-leg, walking hip spica cast has been shown to be a safe and effective treatment for a low-energy femoral shaft fracture in young children. We designed a prospective cohort trial comparing walking and traditional hip spica casting to determine whether a walking hip spica cast was superior to a traditional hip spica cast following a low-energy femoral shaft fracture in children one to six years old.

METHODS

We studied forty-five consecutive low-energy femoral shaft fractures during a three-year period in children one to six years old. Three surgeons treated their patients with a walking hip spica cast, and three other surgeons treated their patients with a traditional spica cast. Complications and subsequent interventions were recorded prospectively. Caregivers were asked to complete the validated Impact on Family Scale as well as a ten-item questionnaire developed by the authors at the time of cast removal.

RESULTS

Forty-five patients with a low-energy fracture were enrolled in the study. Nineteen patients were treated with a walking hip spica cast and twenty-six, with a traditional hip spica cast. The two cohorts were similar with respect to age, length of hospital stay, time to initial callus formation, and time to fracture union. Two children treated with a traditional hip spica cast and no children in the walking hip spica group returned to the operating room for the treatment of spontaneous loss of fracture reduction. Five of the nineteen children treated with a walking hip spica cast and one of the twenty-six treated with a traditional hip spica cast required wedge adjustment of the cast in the clinic to treat fracture malalignment (p = 0.04). One patient treated with a walking hip spica cast required repeat reduction in the operating room because of overcorrection during wedge adjustment. The malunion rate did not differ significantly between the groups (three of twenty-six in the traditional hip spica group compared with none of nineteen in the walking hip spica group). All patients treated with a walking hip spica cast were able to crawl in the cast, and 71% (twelve of seventeen) were able to walk. Use of the traditional hip spica cast resulted in a significantly greater care burden for the family as measured with use of the Impact on Family Scale (43.3 for the traditional hip spica group compared with 35.6 for the walking hip spica group, p = 0.04). Insurance-funded ambulance transportation was needed for eleven of the twenty-six patients treated with a traditional hip spica cast compared with none of the nineteen patients treated with a walking hip spica cast (p = 0.001).

CONCLUSIONS

The walking hip spica cast and the traditional hip spica cast resulted in similar orthopaedic outcomes, and the walking hip spica cast resulted in a lower care burden for the family. Surgeons and families should be aware that use of a walking hip spica cast rather than a traditional hip spica cast may be associated with a greater likelihood that wedge adjustment of the cast will be necessary to treat fracture malalignment.

Incidence of skin complications and associated charges in children treated with hip spica casts for femur fractures

BACKGROUND

Spica cast immobilization remains the treatment of choice for femur fractures in children aged 6 months to 6 years. The incidence of skin complications and their associated charges have not been well described. This study's purposes were to: (1) determine the rate of skin complications in children treated with spica casts for femur fractures, (2) identify predictors, and (3) calculate the charges associated with skin complications.

METHODS

Health records for all patients treated with immediate spica casting for a femur fracture at a major tertiary-care children's hospital from 2003 to 2009 were reviewed and relevant data were abstracted. Descriptive statistics and univariate and multiple logistic regression analyses were used to compare children with and without skin complications and to identify predictors of skin complications. The total charges for skin complications leading to a cast change and early bivalving and lining were calculated.

RESULTS

Of the 300 spica cast applications in 297 patients, 77 subjects (28%) had skin complications. Twenty-four (31%) of these 77 patients underwent a cast change in the operating room, 34 (44%) required early bivalving and lining and 19 (25%) required cast trimming and/or skin care. Predictors of skin complications included: child abuse as mechanism of injury, younger age, and cast time more than 40 days. Sex, weight, fracture location, and total number of clinic visits were not statistically significant predictors of skin complications. The median charge for patients who required cast changes for skin complications was $12,719 ($8632 to $53,768), whereas the median charge for bivalving and lining was $416.51 ($403.32 to $449.00).

CONCLUSIONS

Spica cast treatment is associated with numerous skin complications and additional charges. Victims of child abuse may benefit from additional clinical oversight. Future research needs to investigate patient education and casting interventions that reduce skin complications.

LEVEL OF EVIDENCE

Prognostic Level III-case-control study with patient identified based on outcome-skin complications versus no skin complications.

Immediate spica casting of pediatric femoral fractures in the operating room versus the emergency department: comparison of reduction, complications, and hospital charges

BACKGROUND

Immediate spica casting for pediatric femur fractures is well described as a standard treatment in the literature. The purpose of this study is to evaluate the application of a spica cast in the emergency department (ED) versus the operating room (OR) with regard to quality of reduction, complications, and hospital charges at an academic institution.

METHODS

An institutional review board-approved retrospective review identified 100 children aged 6 months to 5 years between January 2003 and October 2008 with an isolated femur fracture treated with a hip spica cast. Patients were compared based on the setting of spica cast application.

RESULTS

There were 79 patients in the ED cohort and 21 patients in the OR cohort. There were no significant differences in age, weight, sex, fracture pattern, prereduction shortening, injury mechanism, duration of spica treatment, time to heal, or length of follow-up between cohorts. There were no significant differences in the rate of loss of reduction requiring revision casting or operative treatment (6.3% vs. 4.8%), the need for cast wedging (8.9% vs. 14.3%), or minor skin breakdown (12.7% vs. 14.3%). There were no sedation or anesthetic complications in either group. There were no significant differences in the quality of reduction or the rate of complications between the 2 groups. Spica casting in the OR delayed the time from presentation to cast placement as compared with the ED cohort (11.5 h vs. 3.8 h, P<0.0001) and lengthened the hospital stay (30.5 h vs. 16.9 h, P=0.0002). The average hospital charges of spica cast application in the OR was 3 times higher than the cost of casting in the ED ($15,983 vs. $5150, P<0.0001).

CONCLUSIONS

Immediate spica casting in the ED and OR provide similar results in terms of reduction and complications. With the significantly higher hospital charges for spica casting in the OR, alternative settings should be considered.

LEVEL OF EVIDENCE

III--Retrospective comparative study.

Early reduction versus skin traction in the orthopaedic treatment of femoral shaft fractures in children under 6 years old

BACKGROUND

Femoral shaft fractures occur very frequently in children, and their prognosis usually is good. Nonoperative treatment is the gold standard for children under 6 years because of the excellent bony union and the remodelling qualities.

PURPOSE

The aim of this study was to compare two orthopaedic therapeutic methods: skin traction versus immediate reduction.

MATERIALS AND METHODS

The study involved 35 children, divided into two groups: in group 1, treatment consisted of skin traction for 21 days followed by hip spica casting; in group 2, an immediate reduction with early hip spica casting was performed. The ranges of motion, the delay before weight bearing, the hospitalisation duration and the required amount of painkillers were recorded. We compared initial shortening, axial, sagittal and rotational alignment, and femoral length discrepancy. We calculated the injured femoral diaphysal overgrowth and correlated it to the fracture type and location and to the initial shortening. Economical variables were also studied.

RESULTS

The mean overgrowth was 8.9 mm in group 1 and 8.5 mm in group 2. Three years after the trauma, length discrepancy was 4 mm in group 1 and 1 mm in group 2. Hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration and pain. The cost of treatment with skin traction was four times higher (24,472 euros) than that of immediate reduction (6,384 euros).

DISCUSSION

Our results are in accordance with the literature. The femoral overgrowth was proportional to the initial shortening. Masculine gender, an oblique fracture and injury of the lower third of the femur were associated with the greatest femoral overgrowth. During the first year of follow-up, the femoral length discrepancy hardly varied after immediate reduction (4 mm), whereas the overgrowth reached 6 mm after skin traction. Overall, immediate hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration, complications and costs, while having similar clinical results as traction.

Immediate incorporated hip spica casting in pediatric femoral fractures: comparison of efficacy between normal and high-risk groups

BACKGROUND

Immediate hip spica casting is the most commonly used method for the treatment of pediatric femoral fractures. The main disadvantage of the method is the unacceptable shortening (>25 mm), which may occur during the treatment. Buehler et al described the so-called telescope test to identify the cases with a relatively high risk of unacceptable shortening. On the basis of this test, patients with an overriding of the fracture ends of more than 30 mm have a 20.4 times higher risk of unacceptable shortening compared with those with an overriding of less than 30 mm. This relatively higher risk of unacceptable shortening may be avoided by a hip spica cast, which is incorporated to a distal femoral traction pin.

METHODS

The study consists of 47 (26 boys and 21 girls) patients. Mean age was 40.3 months (range, 18 months to 6 years). Patients were divided into 2 groups according to the telescope test. Group 1 included patients with telescope test results of more than 30 mm. Group 2 included patients with telescope test results of 30 mm or less. All patients were treated with a hip spica cast, which is incorporated to a distal femoral traction pin within 8 hours of the initial trauma. During cast treatment, patients were followed up by weekly x-ray controls for the first month. Patients were assessed for unacceptable shortening and misalignment.

RESULTS

Mean (SD) shortening during cast treatment was 2.9 (5.1) mm on the treated site. Shortening was detected in 16 patients (88.9%) in group 1 and in 7 patients (24.1%) in group 2. A significantly higher number (P < 0.001) of patients developed shortening in group 1. However, unacceptable shortening (>25 mm) did not develop in any patient in both groups. There was no significant frontal plane malalignment in both groups (P > 0.05). Sagittal plane malalignment was significantly higher in group 1 (P < 0.05).

CONCLUSIONS

Hip spica cast, which is incorporated to a distal femoral traction pin, avoids unacceptable shortening and frontal plane malalignment in pediatric femoral fractures, which even have a relatively high risk of unacceptable shortening based on the so-called telescope test. However, the technique cannot avoid sagittal malalignment.

Flexible interlocked nailing of pediatric femoral fractures: experience with a new flexible interlocking intramedullary nail compared with other fixation procedures

BACKGROUND

The optimal treatment of femoral shaft fractures in older children and adolescents remains controversial. We hypothesized that fixation with a flexible interlocking intramedullary nail (FIIN) reduces perioperative complications and improves outcomes, including leg-length discrepancy, time to healing, and time to weight bearing compared with other fixation procedures (OFPs) including standard elastic nail implants.

METHODS

Using a retrospective cohort study design, we reviewed medical records and radiographs of children, 7 to 18 years of age, with femoral shaft fractures requiring open treatment between July 1, 1998, and June 30, 2003. Patients selected for the study had unilateral fracture sites proximal to the supracondylar region and distal to the lesser trochanter, presence of open femoral growth plates, and open surgical treatment. Analyses compared inpatient measures and patient outcomes between FIIN and OFP groups.

RESULTS

Of the 160 patients eligible for inclusion, 23 were lost to follow-up. The remaining 137 patients had a mean follow-up of 396.3 days (SD, 320.4 days), with 58 receiving FIIN fixation and 79 OFP. Although the difference was not statistically significant, complications occurred in 19.0% of patients in the FIIN group and 30.4% in the OFP group. Trochanteric heterotopic ossification was the most common complication (13.8%) noted in the FIIN group and superficial infection (12.8%) in the OFP group. The FIIN group experienced less blood loss (P = 0.042) and shorter time to weight bearing (P = 0.001) without disturbance of proximal femoral geometry or avascular necrosis of the femoral head. In children weighing less than 45.5 kg (100 lb), complications were less common with FIIN (3.6%) compared with OFP (24.4%). A subgroup of patients less than 45.5 kg (100 lb) with standard elastic nail implants (n = 24) had 8.1 times the complications of patients with FIIN.

CONCLUSIONS

Older children and adolescents with femoral shaft fractures treated with a FIIN showed improved outcomes compared with patients treated with OFP.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Skin traction in hip spica casting for femoral fractures in children

BACKGROUND

The purpose of this study was to evaluate the skin traction in hip spica casting when applied as the standard treatment for children with femoral shaft fractures.

METHODS

A total of 207 patients with femoral fractures were treated with this method. The average age was 4.7 years. After the application of skin traction, the fracture of the femur was reduced and was placed in a hip spica cast. Traction was continued in the cast.

RESULTS

All fractures united within 4-8 weeks. No significant residual angular deformities were seen in any of the children. The only complication was refracture in two children who fell after removal of the cast. None of the children required external shoe lifts, epiphysiodesis, antibiotics, irrigation, or débridement.

CONCLUSIONS

Skin traction and a well-molded hip spica cast is a safe, reliable treatment option for isolated, closed femoral fractures in children 2-7 years of age.

Traction and spica casting for closed femoral shaft fractures in children

PURPOSE

To evaluate the treatment outcome of skin traction followed by spica casting for closed femoral shaft fractures in children.

METHODS

Between September 1997 and December 2001 inclusive, outcomes of 63 children aged one month to 15 (mean, 5.3) years with closed femoral shaft fractures managed with skin traction and spica casting were reviewed. Depending on age, patients were kept in traction from 2 to 15 (median, 9) days, then in spica casts for 2 to 8 (median, 5) weeks.

RESULTS

Bony union took 3 to 12 (median, 6) weeks. There were no malunion, nonunion, or rotational deformities. Nor were there any significant limb length discrepancies, pressure sores, or nerve palsies. On no occasion was a spica cast removed and reapplied for loss of fracture reduction. At final follow-up, limb length discrepancy was noted in 14 (22%) of the patients, but none had a discrepancy of greater than 1.5 cm or a short-legged gait.

CONCLUSION

Skin traction followed by spica casting for closed femoral shaft fractures in children is safe, cost-effective and associated with a low complication rate. It is effective in children below 5 years of age and no less effective in older children, except in instances of open fracture, multiple fractures, or older children with large statures, which conditions render them intolerant to spica casts.

Volkmann contracture and compartment syndromes after femur fractures in children treated with 90/90 spica casts

Nine pediatric patients (mean age 3.5 yrs) with low energy femur fractures were treated with 90/90 spica casts and developed leg compartment syndromes, Volkmann contracture, and ankle skin loss. These cases are detailed and a proposed mechanism leading to this devastating complication is explained. The authors believe the technique of an initial below knee cast, and then using that cast for applying traction while immobilizing the child in the 90/90 spica is potentially dangerous. Alternative spica application methods are advocated.

Immediate single-leg spica cast for pediatric femoral diaphysis fractures

PURPOSE

Immediate spica cast application is the standard of care for young children with isolated femur fractures. We evaluated the outcomes and function of children treated with single-leg spica casts.

METHODS

We performed a retrospective review of 45 children treated with single-leg spica casts. Demographic data, mechanism of injury, hospitalization time, time in cast, and complications were collected by chart review. Children returned for a physical examination and radiographs. Subjects completed a questionnaire about the child's functional level and the Activities Scale for Kids.

RESULTS

There were 33 boys and 12 girls. The average age was 3.3 (9 months to 9 years). The mechanism of injury was a fall in 71%. The mean hospitalization was 1 day (0-4 days) and the mean time to union was 6 weeks (4-9 weeks). Ninety-five percent of the patients crawled in the cast, 90% pulled to stand, 81% cruised, and 62% walked either independently or with assistive devices. One half of the patients in school or daycare returned while in the cast. Two children failed because of unacceptable shortening. Two children required repeat reductions under anesthesia due to unacceptable alignment. Five casts broke at the hip joint. At final review, there was 1 rotational malunion. There were no radiographic malunions. The median Activities Scale for Kids score was 95 of 100 possible points.

CONCLUSIONS

The single-leg spica can safely, effectively manage low-energy femur fractures in young children.

SIGNIFICANCE

The single-leg spica may address some of the social concerns associated with the use of a spica cast for simple femur fractures.

Broken Bones

Lower extremity injuries and fractures occur frequently in young children and adolescents. Nurses are often one of the first healthcare providers to assess a child with an injury or fracture. Although basic fracture care and principles can be applied, nurses caring for these young patients must have a good understanding of normal bone growth and development as well as common mechanisms of injury and fracture patterns seen in children. Similar to many of the injuries in the upper extremity, fractures in the lower extremity in children often can be treated nonoperatively with closed reduction and casting. However, this article will also review several lower extremity fractures that frequently require surgical intervention to obtain a precise anatomical reduction. Common mechanisms of injury, fracture patterns, and current management techniques will be discussed. Teaching strategies and guidelines that will enable nurses and nurse practitioners to confidently educate parents, families, and other providers caring for these young patients will be reviewed.

Comparison of compression plate and flexible intramedullary nail fixation in pediatric femoral shaft fractures

The purpose of this study was to compare the results of compression plating and flexible intramedullary nailing for pediatric femoral shaft fractures. Thirty-eight consecutive patients with 40 femoral shaft fractures were evaluated. Twenty-two femoral segments were treated with a compression plate and 18 femoral segments were treated with flexible intramedullary nailing. The time to healing, operation time and complications were evaluated. The average operation time was statistically significantly shorter in the nailing group (P=0.039). Four implant failures occurred in the compression plate group whereas one non-union was observed in the flexible nailing group. Flexible intramedullary nailing seems to provide a high union rate with a shorter operation time when compared with plate fixation.

Treatment options in pediatric femoral shaft fractures

Fracture of the femur in a pediatric patient presents special problems, and a variety of treatment options. Child abuse and neglect should be considered and evaluated. Fractures in infants (0-18 months) may be treated successfully in a Pavlik Harness. Spica casting is safe and effective in children up to about 6 years or 100 pounds, although complications can occur and careful attention to technique is important. Surgical treatment is superior in most older or larger children or adolescents, and in cases of multiple trauma, soft tissue injury, obesity or head injury. External fixation is minimally invasive, but carries a risk of malunion and refracture. Rigid antegrade intramedully nailing is possible in adolescents of acceptable size, but has a risk of avascular necrosis. Flexible nailing is minimally invasive and well suited to fractures of the central 2/3 of the diaphysis. In comminuted fractures, it may require supplemental external support. Plate fixation is stable and addresses the entire length of the femur. Soft tissue concerns due to surgical exposure can be minimized by the use of submuscular placement technique.

The locked flexible intramedullary humerus nail in pediatric femur and tibia shaft fractures: a feasibility study

There are several options for the treatment of long bone fractures in skeletally immature patients. Surgeon experience, type of fracture, and the possibility of damage to the physeal area dictate individual fracture management patterns. Notably, nail devices have not gained popularity in this patient group. Intramedullary locking nails have become the standard of care in adult patients due to decreased morbidity and mortality. A novel nail has been developed for humeral shaft fractures that uses a lateral starting position to avoid damage to the rotator cuff in humeral fracture fixation. This is possible because of the nail's transient flexibility during insertion. This study illustrates that it is feasible to insert this type of nail through multiple entry portals for both tibial and femoral fracture fixation, without damaging the physeal blood supply or growth areas.

Gait patterns after fracture of the femoral shaft in children, managed by external fixation or early hip spica cast

The authors prospectively studied three-dimensional kinematics and kinetics of gait in children recovering from a closed, isolated, nonpathologic fracture of the femoral diaphysis, who had been randomly assigned to management by monolateral external fixation or early hip spica casting. The aims were to investigate the gait patterns soon after injury and at 2 years after injury. Children treated with external fixation, walking with the external fixator in situ, demonstrated asymmetric gait abnormalities in all three anatomic planes affecting the trunk, pelvis, hip, knee, and ankle. This appears to be a strategy to minimize movement and pain at the fixator pin sites. The gait pattern normalized rapidly after removal of the external fixator with few kinematic or kinetic abnormalities and no clinically significant disturbances of gait at 2 years after injury. In contrast, children in the early hip spica cast group developed a "crouch gait" pattern in the sagittal plane, most likely due to weakness. They also had abnormal coronal plane kinematics related to shortening of the injured side. Gait patterns improved, but at 2 years there were some persistent gait deviations, probably related to residual limb length discrepancy.

Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children

OBJECTIVES

To evaluate the clinical results of intramedullary nailing of femoral shaft fractures using a rigid intramedullary nail placed through the lateral aspect of the greater trochanter in older children and adolescents.

DESIGN

A retrospective study was carried out evaluating all skeletally immature patients with femoral shaft fractures treated using a modified rigid humeral intramedullary nail.

PATIENTS/PARTICIPANTS

Fifteen children and adolescents with displaced femoral diaphyseal fractures and open physes.

INTERVENTION

Femoral shaft fractures in children and adolescents were stabilized using a modified humeral intramedullary nail placed through the lateral aspect of the greater trochanter.

MAIN OUTCOME MEASUREMENTS

Patients were evaluated to determine time to union, final fracture alignment, hospital stay, complications, clinical outcome, and proximal femoral changes including avascular necrosis or proximal femoral valgus with femoral neck narrowing.

RESULTS

Fifteen patients were followed for a minimum of 1 year (range 70-157 weeks). The average age of the patients was 12 years and 5 months (range 8 years and 2 months-17 years and 1 month). All fractures healed at a mean of 7 weeks (range 5-14 weeks) after fracture. The average hospital stay for patients with isolated femur fractures (8/15) was 2.8 days (range 1-5 days). At an average follow-up of 141 weeks (range 70-326 weeks), no patient had developed avascular necrosis, femoral neck valgus, femoral neck narrowing, or other complications.

CONCLUSIONS

The technique of intramedullary nailing in children through the lateral aspect of the greater trochanter seems to be safe, effective, and well tolerated by patients.

A new technique for creating an abdominal window in a hip spica cast

Opening an abdominal window in a hip spica type of cast can be a troubling maneuver for both orthopaedic surgeon and patient. We present a simple device to create an abdominal window more easily.