Rationale

Femur fractures are among the commonest fractures treated by the pediatric orthopedic surgeon, and over 70% of these involve the femoral shaft.¹,² Historical treatment included skeletal traction with or without casting, which was complicated by prolonged immobilization, traction injuries to nerves, and skin breakdown. Over the past 20 years, however, the standard of care has evolved to a systematic approach to the evaluation and treatment of pediatric femoral shaft fractures, with consideration given to both patient and injury characteristics, age, and fracture pattern.²

Clinical comment

In the young pediatric patient, tremendous remodeling potential exists and treatment modalities that are less invasive are generally preferred and have excellent outcomes.¹

Available literature and quality of the evidence

• Level I: 1 prospective, randomized controlled trial (RCT).³
  
• Level II: 1 prospective, randomized cohort study.⁴
  
• Level III: 1 prospective observational cohort study,⁵ 1 systematic review,⁶ and 4 retrospective cohort studies.⁷–¹⁰
  
• Level V: 2 consensus guidelines.¹,²

Findings

In a prospective case series of 14 patients with 16 femur fractures, Stannard et al. were the first to demonstrate the use of the Pavlik harness, demonstrating excellent outcomes.⁵ Treatment was initiated at <6 months of age, and all fractures united within five weeks without adverse events. Morris et al. later compared the efficacy of the Pavlik harness with traction and traditional spica casting in birth‐associated femoral fractures, studying eight femoral fractures retrospectively in 55 296 live births; all went on to heal without limb length discrepancy or angular deformity.⁷ A retrospective study in children <1 year of age with a femoral shaft fracture comparing 24 patients treated with Pavlik harness and 16 patients with traditional spica casting found similar results, with no differences in radiographic outcomes between the two groups.⁸ However, 38% of the patients treated with hip spica casting were noted to have skin complications from the casting. Despite excellent and equivalent fracture outcomes among these treatment modalities, potential advantages of the utilization of Pavlik harnesses in infants <6 months of age included ease of application without general anesthesia, ease of nursing care and hygiene, and ease of adjustment if the reduction was lost.⁵

Spica casting has generally been advocated for patients between six months and four years of age. Fracture patterns in this age group that are amenable to treatment with immediate spica casting include low‐energy mechanism fractures with up to 2 cm of shortening. Flynn et al. compared the efficacy of a walking spica cast (single leg spica with a hip band)¹¹ with traditional hip spica casting (bilateral leg spica).⁴ In this prospective cohort trial in 45 children 1–4.8 years old with low‐energy femoral shaft fractures, similar times to initial callus formation (traditional 2.4 weeks, 95% confidence interval [CI]: 2.1–2.7 weeks, vs walking 2.3 weeks, 95% CI: 1.7–2.8 weeks, p = 0.74) and mean time to fracture union (traditional 6.3 weeks, 95% CI: 5.9–6.6 weeks, vs spica 6.0 weeks, 95% CI: 5.7–6.3 weeks, p = 0.37) were observed. Two patients treated with traditional hip spica casts returned to the operating room for loss of fracture reduction, compared with one in the walking spica group (p = 1.0). Traditional hip spica casting was noted to place significantly more burden on family care, as assessed with Impact on Family Scale surveys (traditional 43.3, 95% CI: 38.5–48.0 vs walking 35.6, 95% CI: 28.7–42.4, p = 0.04) and a significant increase in the need for ambulance transportation (traditional 42% vs walking 0%, p = 0.001), costing an estimated $505 per trip with an additional $5 per mile at the time. Additionally, more patients with walking spica casts required wedge adjustments of the cast in clinic (traditional 4% vs walking 26%, p = 0.04). Both groups had similar malunion rates (traditional 8% vs walking 0%, p = 0.38).

Loss of reduction typically occurs in the first three weeks of care, secondary to decrease in swelling of the extremity, which can be corrected in the outpatient clinic setting with cast wedging. It has been recommended that patients with <2 cm of shortening have close surveillance during these first three weeks.²

Clinicians can use either single‐ or double‐leg hip spica casting. A prospective RCT of 52 patients between two and six years of age comparing immediate single‐ and double‐leg hip spica casting found similar clinical outcomes;³ however, patients with single‐leg hip spica casts were more likely to fit into their previous car seat (71% single vs 35% double, p = 0.01), were more comfortable sitting in a chair (as assessed by Visual Analog Scale; single 4.38 vs double 6.26, p = 0.032), and required the caregiver to take fewer days off of work (single 10.38 days vs double 19.00 days, p = 0.049); this study notably suffers from short follow‐up time and retrospective recall bias from survey instruments. Jaafar et al. in their retrospective chart review of 59 patients who underwent single‐leg hip spica casting and 35 patients who underwent double‐leg hip spica casting found that single‐leg casting resulted in shorter time to cast removal (4.1 weeks vs 5.3 weeks, p <0.0001), lower rates of clinically significant limb length discrepancies (1.7% vs 20%, p = 0.004), and lower rates of skin complications (10.2% vs 31.4%, p = 0.013).⁹ A systematic review corroborated these results.⁶

Some institutions have attempted to compare spica casting with other popular methods of fixation. Heffernan et al. performed a retrospective, multicenter chart review of 141 patients ages 2–6 years old treated with immediate spica casting and 74 treated with titanium elastic nails (TEN) and found that patients treated with TEN were more likely to have higher energy mechanisms of injury (26% vs 8%, p = 0.001), shorter time to unassisted ambulation (29 days vs 51 days, p <0.001), and similar times to radiographic union (45.1 days vs 44.1 days, p = 0.652); however, patients with hip spica casting were younger in this cohort (spica 3.2 years vs TEN 4.5 years, p <0.001),¹⁰ and would have fallen into the present treatment algorithm of spica casting.

Finally, a subset of patients <5 years of age with initial shortening up to 3 cm and a negative telescope test can be placed in a nonwalking/standard spica cast, with close, weekly follow‐up and cast adjustments as necessary.²

Resolution of clinical scenario

• Despite excellent and equivalent fracture outcomes with casting, Pavlik harnesses are recommended in infants <6 months of age due to ease of application without general anesthesia, ease of nursing care and hygiene, and ease of adjustment if the reduction is lost.
  
• In patients between six months and four years of age, given the lower costs, lesser family burden, decreased return to the operating room, and equivalent fracture outcomes, immediate walking spica casting offers a reliable clinical solution.
  
• Cast wedging may need to be performed during the first several weeks after casting.
  
• In patients with shortening up to 3 cm with a negative telescope test, a standard/nonwalking spica cast can be used.

Rationale

The pediatric patient between 4 and 11 years of age presents a difficult choice in fracture fixation; a wide variety of patient characteristics and fracture patterns exist. Moreover, the orthopedic surgeon has an array of options in the treatment toolbox, including titanium elastic nailing, external fixator placement, and submuscular plating. Regional implant use and surgeon comfort with specific implants also direct treatment considerations in this population.¹²

Related posts:

The Direct Anterior Approach Patient‐Specific Instrumentation in Total Knee Arthroplasty Management of Glenoid Bone Loss Distal Femur Fractures Periprosthetic Fractures: Knee Lisfranc Injuries

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