Session VII - Pediatrics

Immediate Hip Spica Application for Pediatric Femur Fractures: A Review of 175 Patients

Anthony F. Infante, Jr., DO; Michael W. Albert, MD; Bryan W. Jennings, DO; James T. Lehner, MD, Children's Medical Center, Grand View Hospital, Dayton, OH

Hypothesis: Immediate closed reduction and application of a well molded hip spica cast is a safe and effective treatment option for closed pediatric femur fractures in children weighing from 10-100 pounds.

Methods: Between 1988 and 1996, 190 immediate hip spica casts were placed on children with femoral shaft fractures who weighed between 10 and 100 pounds. Fifteen were lost to follow-up, leaving us with 175 children who were evaluated and followed for at least two years after hip spica removal (2-10 years). The femur fractures were either closed reduced and placed in a 1_ hip spica in the emergency room under conscious sedation or in the operating room with general anesthesia. All of the children with isolated femur fractures were able to be treated as same-day surgery patients leaving the hospital and returning home within 24 hours of the procedure. The patient's size and weight were key factors influencing whether the procedure was performed in the ER or OR. Flouroscopy was used to visualize the reduction on the heavier children in the operating room. Our patients were separated into 3 groups by weight: group 1= 10-50 pounds (121 pts), group 2=50-80 pounds (42 pts) and group 3=80-100 (12 pts). These weights corresponded to ages 1-6, 7-11 and 12-13, utilizing the pediatric growth curve reference standards for boys and girls. All data were obtained by reviewing emergency room charts, office charts, hospital records, and x-rays. Follow-up data were obtained by office visits and phone surveys.

Results: As a result of our treatment method, all 175 femur fractures united within 8 weeks with only one complication. This was a refracture of a 25 pound child who fell one week out of his spica. The average shortening for groups 1, 2 and 3 on initial ER x-rays were 1.7cm, 1.5cm and 2.1cm respectively. Final average shortening for the 3 groups after cast removal was .731cm, .976cm and .875cm, respectively. The average length of time in the hip spica was 6, 7 and 8 weeks, respectively. No significant residual angular deformities were present in any of the children at last follow-up. None of the children needed external shoe lifts, epiphysiodesis, antibiotics, irrigation and debridements or limb-lengthening procedures for leg length inequalities.

Discussion and Conclusion: Due to our radiographic and clinical results, we feel that a weight-based, rather than an age-based algorithm is a better approach to take when contemplating treatment options for children with femur fractures and open physes. We also believe that immediate closed reduction and placement of a well molded hip spica cast is the best treatment option for isolated, closed femur fractures in children ages 5-10 who are under 100 pounds. Hip spica casting allowed us to treat these femur fractures without any worry of wound dehiscence, pin site infections, or avascular necrosis of the femoral head. All of which are concerns with either internal or external fixation treatment options. By treating these femur fractures within 24 hours we also avoided skeletal traction and lengthy hospital stays.