Treatment of femoral shaft fractures in children by early spica casting

Eighty-five children with femoral shaft fractures were studied prospectively to determine the benefits of early application of a single-hip spica cast. They were compared with 85 children with similar fractures treated by skin traction for 4 weeks followed by a spica cast for 2 weeks. The study revealed that femoral shaft fractures in children can be treated in a single-hip spica cast with results comparable to those achieved by traction. The additional advantages were substantial savings in cost, early reunion of child with parents and increased availability of beds.     

Close reduction and intramedullary flexible titanium nails fixation of femoral shaft fractures in children under 5 years of age

We retrospectively reviewed 13 cases of diaphyseal femoral fractures treated with close reduction and intramedullary flexible titanium nails, in children aged 3-5 years. The mean follow-up time was 11.5 months (range 3-29). No cases of nonunion or malunion were noted. Minor complications were observed in two children. Loss of initially restored femoral lengthening had occurred in one child, with nail protrusion and related focal cellulites. Mild postoperative leg-length discrepancy occurred in another child. The healed fractures usually exhibited abundant callus, which allowed an early ambulation. Although the operative approach to simple diaphyseal fractures of the femur at such a young age is not routinely recommended, it can be a valuable option as an initial treatment, or when a conventional treatment with a spica cast has failed. In our group of patients, the parents chose this type of treatment as an alternative to the conventional spica cast.     

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.     

Treatment of complicated pediatric femoral fractures with titanium elastic nail

Nonunion and major complications are not very common in pediatric fractures. No commonly accepted methods exist for the treatment of these fractures. In this study, treatment of complicated pediatric femoral fractures with titanium elastic nails was evaluated. Five girls and four boys with nine femoral fractures constituted the group. The mean age of the patients was 8.7 (5-11) years and the mean follow-up was 46.6 (24-84) months. Five of them had implant failure and nonunion, two of them had loss of position in the external fixator, one of them had incomplete union and loss of position in the external fixator and the other had femoral fracture in the lengthening segment of the femur and had loss of position and incomplete union in the spica cast. All the patients were treated with a closed or open reduction of the fracture, debridement if treated with open method and fixation of the fracture with titanium elastic nails. Complete union was achieved in all the patients within the 6-9 months. No neurovascular injury or infection was reported in the group. The result of the treatment showed that fixation of complicated pediatric femoral fractures with intramedullary titanium elastic nails is a good option.     

Stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails (a technique paper).

The indications for surgical stabilization of a pediatric diaphyseal femur fracture are expanding. Children with multiple system injuries, a head injury, and/or multiple fractures have fewer local and distant complications if the femur fracture is treated operatively. Other indications include a pathological fracture in osteoporotic bone, a fracture in a child with a preexisting condition that prevents the application of a spica cast, a child older than 10 years of age, or a child less than 10 years of age who cannot be kept adequately aligned using conventional (traction/casting) methods of fracture management. Here we describe a technique of stabilizing pediatric diaphyseal femur fractures using flexible intramedullary nails (Ender). This technique can be used in children of all ages and with all patterns of diaphyseal fractures.     

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.     

Management of pediatric femoral shaft fractures

Femoral shaft fractures are the most common major pediatric injuries managed by the orthopaedic surgeon. Management is influenced by associated injuries or multiple trauma, fracture personality, age, family issues, and cost. In addition, child abuse should be considered in a young child with a femoral fracture. Nonsurgical management, usually with early spica cast application, is preferred in younger children. Surgery is common for the school-age child and for patients with high-energy trauma. In the older child, traction followed by casting, external fixation, flexible intramedullary nails, and plate fixation have specific indications. The skeletally mature teenager is treated with rigid intramedullary fixation. Potential complications of treatment include shortening, angular and rotational deformity, delayed union, nonunion, compartment syndrome, overgrowth, infection, skin problems, and scarring. Risks of surgical management include refracture after external fixator or plate removal, osteonecrosis after rigid antegrade intramedullary nail fixation, and soft-tissue irritation caused by the ends of flexible nails.     

The treatment of femoral shaft fractures in children: a systematic overview and critical appraisal of the literature.

OBJECTIVE: Through a critical systematic overview of the literature on the treatment of pediatric femoral shaft fractures to determine if any method of treatment can be recommended over others. DATA SOURCES: A MEDLINE search was performed for all cohort and randomized clinical trials for the years 1966 to 1996. STUDY SELECTION: Of 1217 identified articles, 15 cohort studies (where 2 or more treatments were compared in the same study) reported the treatment of children with femoral fractures. DATA EXTRACTION: Information was abstracted and articles rated for quality blind to author, institution and journal. DATA SYNTHESIS: Children having early application of a hip spica cast had an average hospital stay of 11 days (range from 5 to 29 days), average charges of $5784 (range from $590 to $11,800), average rates of limb-length discrepancy (greater than 2 cm) of 3% (range from 0 to 25%), angulatory malunion rates (greater than 10 degrees) of 8% (range from 0 to 19%), and rotational malunion rates (greater than 10 degrees) of 13% (range from 0 to 5%). The costs and malunion rates of early application of a hip spica cast were lower than for traction. Internal fixation (including intramedullary nails) had low angulatory malunion rates compared with early application of a hip spica cast but higher over-lengthening rates (greater than 2 cm) of 25% (range from 5% to 100%) and mean rotational malunion rates (greater than 10 degrees) of 25% (range from 11% to 32%). CONCLUSION: Early application of a hip spica cast had lower costs and malunion rates than traction.     

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.     

Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications

Titanium elastic nailing is used instead of traction and casting in many European centers, but limited availability has prevented widespread use in North America. Before a planned general release in America, titanium elastic nails (TENs) were trialed at several major pediatric trauma centers. This multicenter study is a critical analysis of early results and complications of the initial experience. Overall, TENs allowed rapid mobilization with few complications. The results were excellent or satisfactory in 57 of the 58 cases. No child lost rotational alignment in the postoperative period. Irritation of the soft tissue near the knee by the nail tip occurred in four patients, leading to a deeper infection in two cases. As indications, implantation technique, and aftercare are refined, TENs may prove to be the ideal implant to stabilize many pediatric femur fractures, avoiding the prolonged immobilization and complications of traction and spica casting.     

Titanium elastic nailing versus hip spica cast in treatment of femoral-shaft fractures in children

Background  

There is no consensus on treatment of closed femoral-shaft fractures in children. We compared hip spica cast with titanium elastic nailing (TEN) in the treatment of femoral-shaft fractures in children.     

Flexible intramedullary nailing in the treatment of diaphyseal fractures of the femur in preschool children

Femur fractures in preschool children are mostly treated in a conservative way, by means of spica cast immobilisation or skin traction. In school age children the use of flexible intramedullary nails (FIN) is widely used and promoted. We performed intramedullary nailing in 9 preschool children aged 1.5-6 years. The mean length of postoperative hospital stay was 4 days (range: 3 to 6). The mean time to solid callus formation was 2.5 months (range: 2 to 3). Follow-up was available in all 9 children for a mean period of 18.9 months (range: 3 to 38). No complications were noted. Flexible intramedullary nailing of femur fractures is a valuable technique in this particular age group. However, further study and long-term follow-up are needed.     

Abduction pillow immobilization following hip surgery: a welcome alternative for selected patients

Background Studies have shown that when using a spica cast following hip surgery in children , there are associated complications such as soiling, pressure sores, and osteopenic fractures. Methods Charts were retrospectively reviewed for all patients who had undergone hip surgeries by one surgeon at one institution between 1999 and 2005. The method of post-operative immobilization (spica cast or abduction pillow) and complications were recorded for each patient. Results There was a total of 32 patients. Of these, 11—all of whom had a diagnosis of developmental dysplasia of the hip—were treated using a spica cast. In the 21 patients treated in an abduction pillow, 4 (19%) were switched to a spica cast for the following reasons: (1) distal femoral fracture as a result of vigorous resuscitation during a choking episode, (2) parental preference, (3) for added immobilization over concern of implant loss of fixation, and (4) concern of migration of the hip, which again migrated after being changed to a spica cast and eventually required a pelvic osteotomy. Conclusion It is our opinion that only one of these complications in the children treated with an abduction pillow (the case of possible implant migration) may have been avoided if the child had originally been placed in a spica cast. The child who was successfully resuscitated after a choking incident weeks after the surgery may have had a worse outcome if it had been in a spica cast. This incident occurred at home and the abduction pillow was easily and quickly removed to allow resuscitation. An abduction pillow is a welcome alternative to a spica cast following hip surgery for many patients with neuromuscular and syndromic conditions. However, in children with osteopenic bone at risk for implant failure and in children with unstable hip reductions, a spica cast may be preferable.     

Submuscular plating of pediatric femur fracture

Currently, surgical management of pediatric femur fracture consists of intramedullary nailing with flexible nails or rigid trochanteric entry nails. Rigid trochanteric entry nails are the implant of choice for femoral fractures in adolescents, whereas titanium elastic nails are popular for the management of length-stable diaphyseal femoral fractures in school-age children. However, higher complication rates have been reported in children with length-unstable diaphyseal femoral fractures treated with titanium elastic nails. These complications may require unplanned surgery. Fracture shortening or angulation can lead to nail prominence or exposure that may require nail shortening or removal. Recently, submuscular plating has been found to be a successful alternative option for management of length-unstable femoral fractures in school-age children. Submuscular plating can also be used in older and/or heavier children who have a femoral canal that is too small to accommodate a rigid intramedullary nail.     

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

Immediate closed reduction and application of a well-molded hip spica cast is a safe and effective treatment option for closed, isolated femur fractures in children who weigh between 10 and 100 pounds. Between 1988 and 1996, 190 immediate hip spica casts were placed on children with isolated femoral shaft fractures who weight between 10 and 100 pounds. Fifteen patients were lost to followup leaving 175 children who were evaluated and followed up for at least 2 years after the hip spica cast was removed (range 2-10 years). The femur fractures were reduced closed and placed in a 1 1/2 hip spica cast in the emergency room with the patient under conscious sedation or in the operating room with the patient under general anesthesia. All of the children returned home within 24 hours of the procedure. All 175 femur fractures united within 8 weeks. The only complication was a refracture in a 25 pound child who fell 1 week after the cast was removed. No significant residual angular deformities were present in any of the children at last followup. None of the children required external shoe lifts, epiphysiodesis, antibiotics, irrigation and debridements, or limb lengthening procedures for leg length inequalities. The authors think that immediate closed reduction and placement of a well-molded hip spica cast is a safe and reliable treatment option for isolated, closed femur fractures in children from birth to 10 years of age who weigh less than 80 pounds.     

Spica cast application in the emergency room for select pediatric femur fractures

OBJECTIVES: This study was designed to evaluate the efficacy and safety of immediate spica casting in the emergency room (ER) and evaluate the effect of discharge from the emergency room on short- term complications. DESIGN: Retrospective review of patients treated with immediate spica casting in the ER between June 1, 1993 and July 30, 2001. SETTING: Major, pediatric, orthopaedic trauma and referral center. PATIENTS: A total of 145 pediatric femur fractures in children, younger than age 7 years, treated with immediate spica casting in the ER were reviewed to determine radiographic outcome and short-term complication rates. INTERVENTION: All patients underwent immediate spica cast placement in the ER under conscious sedation. Patients meeting specific criteria were discharged immediately from the ER. MAIN OUTCOME MEASUREMENTS: Radiographic acceptability of alignment at fracture union (angulation, shortening), loss of reduction, number of return visits to the emergency room, and clinical outcome at final follow-up. RESULTS: Average follow-up was 20 +/- 16 weeks (range, 1-9 months). Forty-eight patients (33%) were discharged from the ER. No clinical complications were noted at last follow-up. All children younger than age 2 years, and 86.5% of children ages 2 to 5 years, met acceptable malalignment parameters on final radiographs. There were 16 ER visits (11%) for cast problems. Re-reduction in the operating room was needed in 11 patients (8.9%); 6.9% of patients had a cast problem noted during follow-up visits. Only 9% of patients developed a major complication. Initial shortening was the only independent risk factor found to be associated with loss of reduction. Admission status had no significant effect on the number of ER visits or development of a complication. CONCLUSIONS: If there are no associated factors requiring admission (ie, child abuse or polytrauma), spica casting in the ER for pediatric femur fractures followed by immediate discharge can be safely performed with a low complication rate in children younger than age 6 years, nearly eliminating the need for general anesthesia.     

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.     

Femoral shaft fractures in children

Femoral shaft fractures are the commonest diaphyseal fractures of childhood after those of the radial and ulnar shaft and the tibial shaft. Common mechanisms include falls, particularly from playground equipment, motor vehicle accidents and sporting injuries. Unlike in adults, femoral shaft fractures are commonly isolated injuries in children. In infants, they may be due to non-accidental injury. Treatment of femoral shaft fractures varies with the age and size of children, associated injuries and local practice. Current modalities used for the treatment of femoral shaft fractures include various forms of traction, immediate and late spica casting, elastic nailing, external fixation, plate fixation, and conventional intramedullary nailing for older children and adolescents. All these forms of treatment have been reported as being successful in cohort studies. Very few comparative studies exist. The main current controversies are the age at which elastic nailing becomes appropriate instead of conservative management, and secondly, the treatment of the older, heavier child for whom elastic nails may not be appropriate. Familiarity with several methods of femoral shaft stabilisation is appropriate. The major determinant in the choice of treatment is cultural.     

Treatment of diaphyseal femoral fractures in children: a clinical study

Many therapeutic modalities have been reported for the management of femoral shaft fractures in children and young adolescents but there is no consensus on the preferable method. PURPOSE: To compare the malunion rate of femoral shaft fractures in children treated either by traction and spica cast or traction and functional brace. MATERIAL AND METHODS: Between 1982 and 1984 a prospective study was carried out in a tertiary pediatric university hospital on 43 patients (24 boys, 19 girls) with a closed femoral shaft fracture. The patient's age ranged from 5 to 13 years old. Open, pathologic, subtrochanteric and physeal fractures were excluded. Fifteen (15) patients were treated by a functional brace and 28 were treated by a spica cast. Clinical and radiological assessments of all patients were performed 5 years or more after the fracture by an independent observer. A malunion occurred if one of these criteria were met: an angulation > or = 10 degrees in the coronal plane, an angulation > or = 15 degrees in the sagittal plane, a malrotation > or = 15 degrees by opposition to the other leg, and a discrepancy > or = 10 mm between femur's length. RESULTS: A malunion was found in 17 patients, 6 in the functional brace and 11 in the spica cast group (p > 0.05). The leg length discrepancy was the most common type of malunion. The length of stay was not significantly different between both treatment groups. The functional brace was worn longer than the spica cast. CONCLUSION: There was no statistical difference between the malunion rate of children treated by traction-spica cast and traction-functional brace. The functional brace appears to be a good alternative for the treatment for femoral shaft fracture in children allowing an earlier ambulation than spica cast.     

Comparison of Pavlik harness application and immediate spica casting for femur fractures in infants

This retrospective study compares Pavlik harness application versus spica casting for the treatment of children under 1 year of age with a femoral shaft fracture. The clinical and radiographic outcomes of 24 patients treated in a Pavlik harness were compared with 16 patients treated in a spica cast. The average age and weight of the two groups were significantly different, but there were no differences in radiographic outcomes between the Pavlik and spica cast groups. Approximately one third of all spica patients had a skin complication that added an additional risk to the patient. There were no similar complications in the Pavlik group. There were no differences in the outcome of the fractures in the two groups. The authors believe that all children under 1 year of age with a femoral shaft fracture are candidates for treatment with a Pavlik harness.