Journal of Bone & Joint Surgery - American Volume:
Question: In children with femoral fractures, how does early application of hip spica compare with external fixation with regard to malunion rates, physical function, behavioral disturbances, and patient satisfaction?
Design: Randomized (allocation concealed), blinded (outcome assessor), controlled trial with 2-year follow-up.
Setting: 4 pediatric hospitals in Toronto, Ontario, Canada; Melbourne, Victoria, Australia; Los Angeles, California, United States; and Auckland, New Zealand.
Patients: 108 children who were 4 to 10 years of age (mean age, 6 y; 70% boys) and had femoral fractures. Exclusion criteria were hip fracture, distal femoral physeal fracture, head injury (Glasgow Coma Scale score <11), pathological fracture, or open fracture. 94% of children were followed.
Intervention: Children were allocated to early hip spica (n = 60) or external fixation (n = 48). Children in the hip-spica group received general anesthesia. The fractured limb, not including the foot, was placed in a cast with the hip and knee flexed about 70°. Treatment guidelines for early application of hip spica were followed. Adequate closed reduction was defined as 1 to 2 cm of shortening, no posterior angulation, <20° of anterior angulation, no varus angulation, and <15° of valgus angulation. Children in the external-fixator group received general anesthesia for a closed reduction of the fracture and application of a dynamized Orthofix external fixator (Orthofix, McKinney, Texas). Satisfactory reduction was defined as ≤1 cm of overlap, <15° of varus or valgus angulation, and <20° of anterior or posterior angulation. Children in both groups were allowed to walk with crutches, if able, and were discharged from the hospital and followed weekly as outpatients.
Main outcome measure: Fracture malunion (limb-length discrepancy of >2 cm, >15° of anterior or posterior angulation, or >10° of varus or valgus angulation). Secondary outcomes included physical function and behavioral disturbances (Children Health Information Rand scale) and patient satisfaction (rating scales completed by parents and children).
Main results: Analysis was by intention to treat. The malunion rate was higher in the hip-spica group than in the external-fixator group (Table). Groups did not differ with regard to total or subscale scores on the Children Health Information Rand scale or with regard to patient satisfaction scores.
Conclusions: In children with femoral fractures, hip-spica treatment led to a greater rate of fracture malunion than did external fixation. The scores on the Children Health Information Rand scale and with regard to patient satisfaction were similar in both groups.
Sources of funding: Medical Research Council of Canada and Canadian Orthopaedic Research Education Association.
For correspondence: Professor J.G. Wright, Department of Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada. E-mail: