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Treatment of Femur Fractures in Young Children

A Multicenter Comparison of Flexible Intramedullary Nails to Spica Casting in Young Children Aged 2 to 6 Years

Heffernan, Michael J. MD; Gordon, J. Eric MD; Sabatini, Coleen S. MD; Keeler, Kathryn A. MD; Lehmann, Charles L. MD; O’Donnell, June C. MPH; Seehausen, Derek A. BA, MD; Luhmann, Scott J. MD; Arkader, Alexandre MD

Journal of Pediatric Orthopaedics: March 2015 - Volume 35 - Issue 2 - p 126–129
doi: 10.1097/BPO.0000000000000268

Background: Spica casting is the standard of care for femur fractures in children up to 6 years of age. The indications for surgery are controversial. We sought to compare immediate spica casting (Spica) and flexible intramedullary nailing [titanium elastic nailing (TEN)] in a group of children ages 2 to 6 years. We hypothesized that young children can be successfully treated with flexible nails, resulting in faster return to ambulation and an equivalent complication rate when compared with spica casting.

Methods: This was a multicenter retrospective review of 215 patients, 141 treated with immediate spica casting, and 74 treated with elastic nails. Patient demographics, fracture characteristics, mechanism of injury, associated injuries, outcomes, and complications were recorded and compared between the 2 groups.

Results: Patients in the elastic nailing group were more likely to be injured as a pedestrian struck by an automobile (Spica 8% vs. TEN 26%, P=0.001), and had increased rates of associated injuries (P<0.001). Time to fracture union was similar between the 2 groups (P=0.652). The TEN group had shorter time to independent ambulation (Spica 51±14 vs. TEN 29±14 d, P<0.001) and return to full activities (Spica 87±19 vs. TEN 74±28 d, P=0.023).

Conclusions: TEN is a reasonable option for treatment of femur fractures in young children when compared with spica casting with shorter time to independent ambulation and full activities. Fractures associated with a high-energy mechanism are especially appropriate for consideration of treatment with TEN.

Level of Evidence: Level III, this was a retrospective comparative study.

*Children’s Hospital New Orleans, Louisiana State University Health Science Center, New Orleans, LA

Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis Children’s Hospital, St. Louis Shriner’s Hospital for Children, St Louis, MO

Children’s Hospital & Research Center Oakland, University of California, San Francisco, San Francisco

§Children’s Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA

The authors declare no conflicts of interest.

Reprints: Alexandre Arkader, MD, Children’s Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 69, Los Angeles, CA 90027. E-mail:

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