The treatment of pediatric femur fractures with early 90-90 spica casting

Twenty-three consecutive children younger than 6 years with a closed femoral shaft fracture stemming from low-energy trauma were treated with an early spica cast. With the patient under general anesthesia, a fiberglass cast was applied in sections. A short-leg cast was applied first, and then the patient was placed on the spica table. The hip and knee were flexed to 90 degrees, and traction was applied to the injured limb via the short-leg cast while the cast was completed. The popliteal fossa was well padded, and a valgus mold was placed at the fracture site. The average number of days in the spica cast was 42 (range, 18-57 days). Average shortening of the fracture at the time of cast removal was 1.0 cm (range, 0.1-2.1 cm). Final patient examinations were performed 18-24 months after the fracture. Overgrowth averaged 1.1 cm in the femur (range, 0.5-1.9 cm) and 0.4 cm (0-0.7 cm) in the tibia. Limb lengths in each patient were within 1 cm of the contralateral limb when measured by scanogram and by blocks. The success of early spica cast treatment in this series can be attributed to strict patient selection and meticulous cast application.     

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.     

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.     

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.     

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.     

Slotted acetabular augmentation: is a hip spica necessary?

Between 1988 and 1996, 16 patients who underwent a total of 18 slotted acetabular augmentation procedures were managed postoperatively without a spica cast, by using instead a protocol of limited weight bearing and restriction of hip range of motion. Postoperatively, no patients experienced hip stiffness. No patients exhibited any migration or change of position of their bone graft. Radiographic examination revealed the following: center-edge angle (CEA) averaged 3 degrees preoperatively and 54 degrees postoperatively. Acetabular index averaged 35 degrees preoperatively and 18 degrees postoperatively. No patients experienced any deleterious effects by not using a spica cast. We believe that by obviating the spica cast, we may ease the postoperative recovery for patients, avoid postoperative hip stiffness, and thereby expand the applications of this safe and reliable method of acetabular reconstruction in selected patients.     

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.     

Treatment of congenital dislocation of the hip. Management before walking age

Neonatal infants with Ortolani-positive dislocated hips are easily managed by reduction and maintenance of the reduction using a divarication splint, cast, or Pavlik harness. Sixty-six patients with 85 complete, congenitally dislocated hips (Ortolani negative) unassociated with other neuromuscular disorders were examined to assess a method of prereduction traction in the treatment of congenital dislocation of the hip. Forty of the 66 patients were six months of age or younger at the beginning of traction treatment. The remaining 26 were younger than 12 months of age prior to the treatment protocol. Overhead traction with the hip flexed to 90 degrees was employed. Gradual hip abduction to 70 degrees (140 degrees combined abduction) was accomplished over the next ten to 14 days. If the dislocated hip was still in a station above Hilgenreiner's line, then cross traction was applied to add another vector of force to pull the femoral head distally. At an average of 18 days into the treatment protocol, an examination under anesthesia with closed reduction was performed and the patient immobilized in a double hip spica in the "human" position for six to eight weeks. This was followed by use of an Ilfeld divarication splint for nine months. This traction/reduction program was effective in 91% of these cases (60 of 66). Six patients (ten hips) required an open procedure because of persistent instability in spite of reducibility. To date, there is no incidence of avascular necrosis using the criteria of Salter for whole head avascular necrosis and the criteria of Kalamchi and MacEwen for partial head avascular necrosis.     

Reliability of hip range of motion using goniometry in pediatric femur shaft fractures

INTRODUCTION: The purpose of this study was to determine the interrater reliability of the assessment of range of motion of the hip joint through goniometry. METHODS: We included children aged 4 to 10 years with a femoral shaft fracture, from 4 study sites, who had had either an early hip spica cast or an external fixator. An assessor blind to treatment received at each site measured range of hip joints motion, using a standardized goniometric technique at 15 and 24 months postfracture. RESULTS: The intraclass correlation coefficient (ICC) was used to quantify concordance or agreement. Most ICCs for the different aspects of hip range were between 0.2 and 0.5, indicating only slight agreement. The most reliable measure was hip flexion, with an ICC of 0.48 (95% confidence interval 0.29-0.63). CONCLUSION: Goniometric measurement, using standardized protocols for the hip, has low reliability. Only when differences in rotation exceed at least 30 degrees and in flexion-extension exceed 50 degrees should clinicians conclude that true change has occurred.     

Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children

BACKGROUND: Titanium elastic nails are commonly used to stabilize femoral fractures in school-aged children, but there have been few studies assessing the risks and benefits of this procedure compared with those of traditional traction and application of a spica cast. This prospective cohort study was designed to evaluate these two methods of treatment, with a specific focus on the first year after injury, the period when the treatment method should have the greatest impact. METHODS: Eighty-three consecutive children, six to sixteen years of age, were studied prospectively. Factors that were analyzed included clinical and radiographic data, complications, hospital charges, and outcome data. Outcome and recovery were assessed both with the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collections Instrument, version 2.0, and according to a series of important recovery milestones including the time to walking with aids, time to independent walking, time absent from school, and time until full activity was allowed. RESULTS: Thirty-five children (thirty-five fractures), with a mean age of 8.7 years, were treated with traction and application of a spica cast, and forty-eight children (forty-nine fractures), with a mean age of 10.2 years, were treated with titanium elastic nails. All fractures healed, and no child sustained a complication that was expected to cause permanent disability. At one year after the fracture, eighty of the children had acceptable alignment and no inequality between the lengths of the lower extremities. The remaining three children, who had an unsatisfactory result, had been treated with traction and a spica cast. Twelve patients (34%) treated with traction and a cast had a complication compared with ten patients (21%) treated with titanium elastic nails. Compared with the children treated with traction and a cast, those treated with titanium elastic nails had shorter hospitalization, walked with support sooner, walked independently sooner, and returned to school earlier. These differences were significant (p < 0.0001). We could detect no difference in total hospital charges between the two groups. CONCLUSIONS: The results of this prospective study support the recent empiric observations and published results of retrospective series indicating that a child in whom a femoral fracture is treated with titanium elastic nails achieves recovery milestones significantly faster than a child treated with traction and a spica cast. Hospital charges for the two treatment methods are similar. The complication rate associated with nailing compares favorably with that associated with traction and application of a spica cast.     

Treatment of refracture occurring after external fixation in paediatric femoral fractures

With a mean follow-up of four years, we assessed the outcomes of 11 refractures which occurred following paediatric femoral fractures treated by external fixation; the refractures were treated conservatively with simple immobilisation in a spica cast. A total number of 104 children with a femoral fracture were treated with external fixation between 1993 and 2000 in our institution. Refracture occurred in 11 cases after fixator removal. These patients were immediately placed in a hip spica cast. All 11 patients were boys, with a mean age of 7.3 years (range: 6 to 9), and the mean follow-up time was 4 years (range: 2 to 7). Mean hospitalisation time after refracture was 2 days (range: 0 to 4). Refractures occurred an average of 8 days (range: 1 to 21) after fixation removal. The mean time to union after refracture was 55 days (range: 35 to 62). On final evaluation, a mean limb length discrepancy of 0.9 cm (range: 0 to 2.5) was noted. Radiological study showed a mean lateral angulation of 5.6 degrees (range : 0 to 17) and a mean anterior angulation of 7.4 degrees (range: 0 to 20). Based on these findings, we believe that closed reduction and spica cast immobilisation is sufficient in cases with refracture of the femur after external fixation, but the option of surgical treatment should be considered when satisfactory anatomic reduction is not achieved.     

Femoral shaft fractures in children treated with early spica cast

We retrospectively reviewed 51 patients aged 3-11 years with femoral shaft fractures selected for treatment with early spica cast immobilization. Shortening greater than 20 mm was the most common complication, occurring in 22 (43%) of the 51 patients. Factors associated with unacceptable shortening were shortening at the time of spica cast application greater than 10 mm, shortening greater than 20 mm at initial examination, and increasing age. Achieving less than 1 cm shortening at the time of cast application and close follow-up during the first 2 weeks after cast application are advised in order to achieve an acceptable final outcome.     

Femoral fractures in children, is early interventional treatment beneficial?

A protocol of early intervention (flexible intramedullary nails, early hip spica, and external fixation) was started in 1999 and during a 3-year period there were 25 children who sustained a femoral shaft fracture (early intervention group). These were prospectively reviewed with a minimum follow up of 24 months (Range 24-35 months). A historical control group of 41 children was used. These children were injured between February 1996 and February 1999 and were retrospectively reviewed. They had traditional in patient treatments with either Gallows or Thomas splint traction (traditional treatment group). Over the 6-year period from 1996 to 2002 there were a total of 66 femoral shaft fractures in the study that presented to our hospital. The mean length of hospital stay was 29 nights in the traditional group and 10 nights in the early intervention group. This difference is significant (p<0.001). The malunion rate was slightly higher in the early active group at radiological union but most of these remodelled over the 2 years of follow up. The protocol of early intervention used in our institution, of flexible nails, early hip spica or external fixation depended on the age of the child, and has resulted in a shorter hospital stay for the children. This has benefits for the child, the family and the hospital.     

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.     

Valgus intertrochanteric osteotomy for malunion and nonunion of trochanteric fractures

OBJECTIVE: To evaluate the results of valgus intertrochanteric osteotomy for varus nonunion and malunion of trochanteric fractures. SETTING: University hospital. DESIGN: Retrospective clinical study. PATIENTS: Fifteen patients (age range 29-84 years) with varus malunion (11 cases) or varus nonunion (4 cases). Indication for surgery was nonunion or varus malunion with limb shortening greater than 2 cm associated with limp, abductor muscle insufficiency, hip pain, and back pain. INTERVENTION: The patients were treated by a valgus intertrochanteric osteotomy fixed with a 120 degrees double-angled blade plate. RESULTS: Average follow-up was 5.5 years (range 2-10 years). Fourteen patients healed without complications: 12 patients within 4 months; 2 delayed unions within 6 months. One patient required revision surgery for a loss of fixation due to a fall 6 weeks after surgery. This osteotomy also healed. Average lengthening achieved by osteotomy was 2 cm (range 1-5 cm). In all patients, the resulting range of flexion in the hip joint was greater than 90 degrees, Harris hip score before surgery was 73 points (range 61-83), and after surgery 92 points (range 76-98). Osteoarthritis or avascular necrosis of the femoral head did not develop in any of the cases. CONCLUSION: Valgus intertrochanteric osteotomy is an effective procedure that reliably restores hip function in trochanteric malunion or nonunion.     

Displaced fractures of the hip in children. Management by early operation and immobilisation in a hip spica cast

Fractures of the hip in children have been associated with a very high rate of serious complications including avascular necrosis (up to 47%) and coxa vara (up to 32%). Over a period of 20 years, we have treated displaced fractures by early anatomical reduction, internal fixation and immobilisation in a spica cast to try to reduce these complications. We have reviewed 18 patients who had a displaced non-pathological fracture of the hip when under 16 years of age. Their mean age at the time of the injury was eight years (2 to 13). They returned for examination and radiography at a mean follow-up of eight years (2 to 17). Each patient had been treated by early (" 24 hours) closed or open reduction with internal fixation and 16 had immobilisation in a spica cast. By Delbet's classification, there was one type-I, eight type-II, eight type-III, and one type-IV fractures. There were no complications in 15 patients. Avascular necrosis occurred in one patient (type-III), nonunion in one (type-II, one of the two patients who did not have a cast) and premature physeal closure in one (type-I). There were no cases of infection or complications as a result of the cast. Our treatment of displaced hip fractures in children by early reduction, internal fixation, and immobilisation in a spica cast gave reduced rates of complications compared with that of large published series in the literature.     

Deformities in conservatively treated closed fractures of the shaft of the femur in children

We present the outcome of non-operative management of fractures of the shaft of the femur in children. Thirty children with non-operatively managed unilateral fractures of the shaft of the femur were studied. The mean age was 6.5 years (range: 1.2 to 12). Axial, angular and rotational malunion were assessed clinically and radiologically by plain films and computed tomography (CT). All children had shortening of the fractured limb with a mean shortening of 1.8 cm (range: 0.5 to 3.5). A significant level of shortening was seen in children over 7 years. In the sagittal plane, all had anterior angulation ranging from 4 degrees to 31 degrees (mean: 17.8 degrees) and in the coronal plane, lateral angulation (varus) was seen in 90% (27 patients) with a mean angle of 8.9 degrees. Rotational malunion ranged from -43 degrees to +43 degrees (mean: 9.5 degrees), 30% had rotational malunion of > 20 degrees compared to the uninjured side; 73% had internal rotation malunion and 27% had external rotation malunion. We conclude that non-operative management of fractures of the shaft of the femur in children often results in malunion at the fracture, particularly in the older age group and in comminuted fractures. Perhaps a longer follow-up might have shown lower levels of malunion. Frequent monitoring of fracture position may reduce the occurrence of deformity. It may be appropriate to consider reduction and operative stabilisation of such fractures whenever neces-     

Peroneal nerve palsy after early cast application for femoral fractures in children.

The incidence and contributing factors associated with post-casting peroneal nerve palsy were examined in a series of 110 consecutive pediatric femoral shaft fractures treated with early hip spica cast application. Four patients with peroneal nerve palsy were identified. All four had 90 degrees/90 degrees casts placed and underwent cast wedging for alignment. All palsies resolved with immediate cast removal. Other treatment options for certain femur fractures with significant initial shortening should be considered. We advise pre- and post-cast neurologic examination and avoidance of forceful distraction. Fracture manipulation, through wedging, should be delayed.     

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.     

Femoral shaft fractures in children treated by closed reduction and early spica cast with incorporated supracondylar Kirschner wires: a long-term follow-up results.

38 children between 1 and 10 years of age with femoral shaft fractures were treated by closed reduction and early spica cast with incorporated supracondylar Kirschner wires and followed up prospectively. Overrides of maximum 15 mm, medial and anterior angulations less than 15 degrees and lateral angulation up to 5 degrees were considered acceptable. Posterior angulation and malrotation were not accepted. Of the 38 children examined at a mean of 65.6 months (range, 58-80 months) after fracture, none had any residual skeletal deformity and joint stiffness. At long-term follow-up, maximal shortening was 11 mm and overgrowth was 6 mm. The only factor associated with unacceptable shortening was shortening > 15 mm at the time of spica cast application. We believe that close follow-up during the first 3 weeks after cast application is important in order to achieve an acceptable final outcome. On the other hand this method of treatment is simple, safe and effective. It dramatically decreases hospital stay and cost of treatment and allows rapid return of the patients to their family environment.