Immediate Hip Spica Casting for Femur Fractures in Pediatric Patients

A Review of 175 Patients

Abstract

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 weighed 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.

The treatment of isolated femur fractures in children is very controversial. Some orthopaedic surgeons advocate surgery for patients with these fractures.^1,3,11 The treatment modalities include external fixation,^1,3,6,10,24 Kuntschner type intramedullary nails,^{2,14,19,21,23} compression plates,^6,14,22 and small diameter, flexible nails.^6,11,15 These surgeries, which began as ways to treat the patient with polytrauma who had a femur fracture, now are being performed on children with isolated femur fractures.^1,3 The gold standard of hip spica casting for the child with an isolated femur fracture is being challenged.^4,12 The immediate spica cast technique and delayed application of a cast after skeletal traction are losing popularity. Immediate and early closed reduction and hip spica casting is an accepted nonsurgical treatment method for children with isolated femoral shaft fractures, especially in patients younger than 10 years of age.^4,15,28 However, many orthopaedic specialists still use the spica cast in conjunction with traction, which allows the fracture to get sticky. This technique keeps the child in traction in his or her bed for 2 to 3 weeks before cast application, which can cause complications,¹³ whereas when the immediate spica cast is applied, the child goes home within 24 hours. Shortening at the fracture, loss of reduction, peroneal nerve palsy and angulation at the fracture site are potential complications of hip spica casting, especially if the cast is placed immediately.^{1,3-5,9,20,29,31} These are valid concerns when deciding whether to treat pediatric patients with femur fractures in an immediate hip spica cast, although children heal rapidly and remodel angulated fractures.^19,25,30 Pin tract infections, wound dehiscence, osteomyelitis, lengthy hospital stays, increased costs, and avascular necrosis of the femoral head are not concerns when the child is treated with an immediate spica cast.^{1-4,10,11,15,18,19} Furthermore, unlike external fixation and intramedullary nailing, a second surgery is not needed for hardware removal when the immediate hip spica cast is chosen.^1,11 Any adjustments in the cast and cast removal can be done in the office.²⁸

The authors report their results of 190 children weighing less than 100 lb with isolated femoral shaft fractures who were treated with an immediate, well-molded, hip spica cast.

MATERIALS AND METHODS

Between 1988 and 1996, 190 children with isolated femoral shaft fractures were treated with acute reduction and hip spica casting at the authors' institution. All children underwent reduction and had a cast applied within 24 hours of their fracture. Fifteen patients were lost to followup, leaving 175 children for the study. These patients were followed up for at least 2 years (range, 2-10 years). Patients were separated into three groups by weight rather than age: Group 1, children who weighed 10 to 49 lb (121 patients), Group 2, children who weighed 50 to 80 lb (42 patients), and Group 3, children who weighed 81 to 100 lb (12 patients). These weights corresponded to ages 1 to 6 years, 7 to 11 years, and 12 to 13 years respectively, using the pediatric growth curve reference standards for boys and girls. The weight of the patient indicates the size of the leg that needs to be reduced and placed in the plaster cast. Younger, larger children may be placed into Group 2 or conversely, smaller, thinner, older children may be placed into Group 1. The larger the child, the more difficult the fracture reduction and maintenance are in the hip spica cast.

The patients' hospital and office records were reviewed. The age of the patient, gender, mechanism of injury, location and type of fracture all were recorded. Radiographs obtained in the emergency room, before and after reduction, and at followup were reviewed for displacement, shortening, and angulation. Patients with any angulation, shortening, or displacement at the time of the last followup were contacted by telephone and a questionnaire was completed by the patient's parent or guardian.

TECHNIQUE

If the radiographs obtained in the emergency department and the physical examination of the patient revealed an isolated femoral shaft fracture, the patient was treated with an immediate hip spica cast. Patients with other orthopaedic injuries or multiple trauma such as closed head or abdominal injuries were excluded because they were treated differently than patients with isolated femoral shaft fractures. The patient's size and weight determined whether closed reduction occurred in the emergency room with the patient under conscious sedation or with the patient under general anesthesia in the operating suite. Reductions were performed immediately in the emergency room for patients in Group 1. After conscious sedation, the patient's femur fracture was reduced in the cast room in the emergency department and placed in a 1 1/2 hip spica cast with the patient resting on a spica table. The ipsilateral leg was placed in a cast first so traction could be pulled through the cast. The pelvic and contralateral thigh portions of the cast then were applied while traction was maintained on the injured leg. The injured thigh then was placed in a cast and "four-corner molding" was performed by pressing in the anteroposterior (AP) direction and mediolateral direction as the cast hardened. Once the thigh portion of the cast hardened, it was incorporated with the other parts of the cast, making the complete hip spica cast. A wooden bar was placed between the patient's legs and incorporated into the cast to help the cast hold the legs and pelvis in the correct position. To facilitate toilet use, the bar was placed in the front of the thigh for girls and the back for boys. Careful four-corner molding with anteroposterior (AP) compression and mediolateral compression at the fracture site achieved proper fracture reduction and alignment. After evaluating radiographs obtained after reduction, the child was admitted to the hospital for 24-hours observation to ensure they did not have superior mesenteric artery syndrome (cast syndrome) develop. Heavier patients (Groups 2 and 3) who required general anesthesia for closed reduction were placed in Buck's traction until an operating room was available (all within 12 hours). All reductions done in the operating room were performed using fluoroscopy to visualize the reduction. During closed reduction, careful four-corner molding and compression at the fracture site achieved proper fracture reduction and alignment. After closed reduction, Groups 2 and 3 followed the same protocol as Group 1. Patients were seen in followup and radiographs were obtained weekly for 2 to 3 weeks depending on the size and age of the patient to confirm acceptable alignment and callus formation. Table 1 shows the goals for reduction of angulation and shortening after cast application. These goals were met in the majority of patients, but not in all patients.

TABLE 1: Acceptable Degrees of Angulation and Centimeters of Shortening After Cast Application

If the fracture angulated within the first 2 weeks of reduction greater than the acceptable degrees shown in Table 1, cast wedging was performed to correct the angulation. If unacceptable shortening occurred within the first 2 weeks, the cast was changed, the femur was reduced again and the four-corner molding was applied. Children who weighed less than 50 lb were treated for an average of 6 weeks in the spica cast; however, the spica bar and contralateral leg portion of the cast were removed at an average of 4 weeks. Children who weighed 50 to 80 lb were treated for an average of 7 weeks in the spica cast and the spica bar and contralateral leg portion of the cast was removed at an average of 5 weeks. Children who weighed more than 80 lb were treated for an average of 8 weeks in the spica cast and the spica bar and contralateral leg portion of the cast were removed at 6 weeks. After the cast was applied, the children returned for followup at 1 month, 6 months, and then annually, unless complications occurred.

RESULTS

The average age of the patients in Group 1 at the time of fracture was 3 years 9 months, (range, 1 month-6 years 10 months) and their average weight was 38 lb (range, 11-44 lb). The average shortening of the fracture before reduction was 1.7 cm (range, 0-3 cm) and the average shortening after reduction and application of the cast was .7 cm (range, 0-2 cm). The average time the children wore the cast was 6 weeks (range, 3-8 weeks). The average AP angulation before reduction was 10.4° (range, 0°-45°) and the average varus or valgus angulation was 8.6° (range, 0°-57°). The average final AP angulation was 7.6° (range, 0°-50°) and the average final varus or valgus angulation was 4.3° (range, 0°-35°). The average age and weight of the patients in Group 2 at the time of fracture was 7 years 6 months (range, 5 years 2 months-9 years 11 months) and 69 lb (range, 50-70 lb), respectively. The average shortening of the fracture before reduction was 1.5 cm (range, 0-4 cm) and the average shortening after reduction and application of the cast was 1 cm (range, 0-3 cm). The average time the children wore the cast was 7 weeks (range, 5-9 weeks). The average AP angulation before reduction was 9.4° (range, 0°-55°) and the average varus or valgus was 5.4° (range, 0°-26°). The average final AP angulation was 5.6° (range, 0°-20°) and the average final varus or valgus angulation was 2.6° (range, 0°-18°).

The average age and weight of patients in Group 3 at the time of fracture was 9 years 9 months (range, 7 years-11 years 8 months) and 88.9 lb (range, 81-110 lb), respectively. The average shortening of the fracture before reduction was 2.1 cm (range, 1-4 cm) and the average shortening after reduction and application of the cast was .9 cm (range, 0-2 cm). The average time the children wore the cast was 8 weeks (range, 6-10 weeks). The average AP angulation before reduction was 12° (range, 0°-45°) and the average varus or valgus was 14° (range, 0°-30°). The average final AP angulation was 6.8° (range, 0°-22°) and the average final varus or valgus angulation was 2.8° (range, 0°-16°). Tables 2 and 3 summarize these results.

TABLE 2: Summary of Results of Age, Weight, Shortening, and Time in Cast

TABLE 3: Summary of Results of Angulation

All of the patients were discharged from the hospital within 24 hours of the application of the spica cast. One of the children in Group 1 had a refracture when he fell at home 1 week after the removal of the spica cast. A new spica cast was applied and the fracture healed without complications. Two of the children required cast changes for shortening, one in Group 1 and the other in Group 2. The child in Group 1 required a rereduction at the first followup visit secondary to unacceptable angulation at the fracture site. This second procedure was done in the operative suite as opposed to the first reduction, which was done in the emergency department. Two children in Group 2 required scanograms for 2 cm clinical leg length inequalities and pelvic obliquity. They were observed and given 1-cm inside shoe lifts at their last followup visit. Their involved femurs corrected 1 cm of the 2 cm leg length inequality during the next year and according to their parents, the children functioned normally with the internal shoe lifts. Another child in Group 2 was screened at school and was evaluated for scoliosis. Original radiographs showed a 14° curve, which was corrected with a 1.5-cm block under the affected leg. A 1-cm shoe lift and overgrowth of the femur corrected the leg length inequality and the mechanical scoliosis enabling the patient to function normally while wearing the shoe lift. One other patient in Group 1 had a pressure sore develop from a quarter that slipped into the cast. Sixty-six questionnaires were completed by the caregivers of the children. Complaints included difficulty with hygiene (47 children), weight of the child and cast (36 children), inability of one of the parents to go to work in a two income family (16 children), and smell of the cast (13 children). All 66 caregivers who responded stated that their child did not have any disabilities secondary to their femur fractures and they were able to walk and run without a limp.

DISCUSSION

The treatment of children with isolated femur fractures has become controversial with external fixation and flexible intramedullary nails being recommended.^1,3,10,11,15 In the past, children with isolated femoral shaft fractures were treated in hip spica casts either with 90-90 traction then application of a cast or immediate application of a cast.^12,16,22,27 For years, these techniques were considered the standard of care with minimal complications. However, concerns for shortening, overgrowth.¹⁷ and angulation in the children from 4 to 12 years of age have increased. Also, using hip spica cast treatment is very user-dependent and time consuming for the physician and the caregiver. Another important consideration in the 1990s is that often, both parents work.³ For one of these two working parents to stay home with their child for 6 to 8 weeks with ensueing economic loss may cause financial hardship.¹² Staying home with the child and missing work was one of the parents main complaints reported in the followup questionnaire. This has prompted orthopaedic surgeons to pursue surgical treatment options for children with isolated femoral shaft fractures.^1,3,12 Aronson and Tursky¹ reported that the child is lighter and more mobile and usually can return to school or daycare sooner allowing the parent to go back to work.¹ The proponents for external fixation also include early weightbearing as an advantage over hip spica casting. In the current series, the children all were full weight-bearing out of the hip spica casts by Week 8, and by Week 16 they all had full range of motion of the hip and knee. This is 4 months of time sacrificed for a healed fracture without a surgical scar. Also treating these patients with an immediate hip spica cast significantly decreases the risk of infection, avascular necrosis of the femoral head, or osteomyelitis with the minimal risk of refracture, malalignment, or shortening. The minimal amount of shortening, angulation, and time a parent or caregiver lost from work when a child is treated with a hip spica cast is less detrimental than the complications with external fixation, rigid or flexible intramedullary nailing, and compression plating. External fixation has a higher refracture rate at the old fracture site and through the pin holes. Patients treated with external fixators can have pin site infections, deep infections, nonunions, and even osteomyelitis.^1,4,10,26 Intramedullary nails such as Enders nails and Nancy nails theoretically do not control rotation and sometimes a hip spica cast is required to control rotation at the fracture.⁴ Rigid antegrade nailing starting at the piriformis fossa puts the femoral head at risk during the initial surgery and during the hardware removal.^2,4,7 Finally, an open procedure, such as compression plating, carries infection as an added risk. The other major concern with these operative procedures is the second surgery that is required for hardware removal. There is an added cost, added risk of problems during anesthesia, and more down time to let the screw holes mature so there is not a refracture through the stress risers.

Each surgeon has his or her own beliefs on what is best for the child, the family, and the surgeon. The data presented in the current study show that age, as long as the physis is open, is not the only question of importance. The data show size and weight of the patient are key factors. Obviously, the larger the child the more difficult it will be to control the fracture with the hip spica cast and the harder it will be to transport the patient in the hip spica cast. The other significant issue is the socioeconomic impact on the family. The authors will consider operative treatment if the parents so desire to allow the parents to continue working and allow the child to return to school or daycare sooner. The complications of operative techniques must be discussed with the parents however, and the school and daycare rules must be obtained. If the schools and daycare centers do not allow children to participate with an external fixator or with crutches, then the benefits of operative fixation may not be realized. Aronson and Tursky¹ showed that even when the schools did allow the children back to school with an external fixator and crutches, the average time back to school was 4 weeks after surgery. Based on radiographic and clinical results the authors think using a well-molded hip spica cast still is the gold standard when treating isolated femur fractures in patients with open physes who weigh less than 80 lb. This includes the children in Groups 1 and 2. This current study shows that excellent results can be obtained using a well molded hip spica cast for isolated femur fractures in children who weigh 10 to 80 lb with minimal acute complications and without any long-term sequelae. This is different from the study's original hypothesis that children who weigh less than 100 lb would do well with immediate hip spica casts. The low number of patients in Group 3 is a problem, however, and the authors think these numbers are low because the actual number of femur fractures in adolescents is low because of the bimodal distribution of femur fractures in children (infants and teenagers). Also, when an adolescent sustained a femur fracture and presented to the emergency department, it usually was from a high-energy injury with other associated injuries and not a closed, isolated femur fracture. Because of these low numbers, the patients from Group 3 are not included in the authors' conclusions.

With excellent results, extremely high healing rates (100% in the current study), decreased costs,⁸ decreased complications, elimination of a second surgery, and minimal refractures, the gold standard of hip spica casting for children with closed, isolated femur fractures should not be discarded.