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Spica Casting for Pediatric Femoral FracturesA Prospective, Randomized Controlled Study of Single-Leg Versus Double-Leg Spica Casts
Dirk Leu, MD1; M. Catherine Sargent, MD1; Michael C. Ain, MD1; Arabella I. Leet, MD2; John E. Tis, MD1; Paul D. Sponseller, MD1
1 c/o Elaine P. Henze, BJ, ELS, Medical Editor and Director, Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Bayview Medical Center, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780. E-mail address for P.D. Sponseller: ehenze1@jhmi.edu
2 Shriners Hospital for Children-Honolulu, 1310 Punahou Street, Honolulu, HI 96826-1099
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at the Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland

This article was chosen to appear electronically on June 13, 2012, before publication of the final, definitive version.

A commentary by Joel V. Ferreira, MD, and Jeffrey D. Thomson, MD, is linked to the online version of this article at jbjs.org.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Jul 18;94(14):1259-1264. doi: 10.2106/JBJS.K.00966
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At many centers, double-leg spica casting is the treatment of choice for diaphyseal femoral fractures in children two to six years old. We hypothesized that such patients can be effectively treated with single-leg spica casting and that such treatment would result in easier care and better patient function during treatment.


In a prospective, randomized controlled study, fifty-two patients two to six years old with a diaphyseal femoral fracture were randomly assigned to be treated immediately (after consent was obtained) with a single-leg (twenty-four patients) or double-leg (twenty-eight patients) spica cast. Serial radiographs were evaluated for maintenance of fracture reduction with respect to limb length, varus/valgus angulation, and procurvatum/recurvatum angulation. After cast removal, the performance version of the Activities Scale for Kids questionnaire and a custom-written survey were administered to the parents so that they could evaluate the ease of care and function of the children during treatment. Means were compared between treatment groups with use of Student t tests. P values of <0.05 were considered significant.


All limbs healed in satisfactory alignment. The children treated with a single-leg spica cast were more likely to fit into car seats (p < 0.05) and fit more comfortably into chairs (p < 0.05). Caregivers of patients treated with a single-leg cast took less time off work (p < 0.05). There were no major complications.


Treatment of pediatric femoral fractures with a single-leg spica cast is effective and safe, and postfracture patient care is facilitated.

Level of Evidence: 

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Howard R. Epps, M.D.
    Posted on August 02, 2012
    Some work has been done
    Baylor College of Medicine & Texas Children's Hospital

    The authors deserve congratulations for the production of this study.[1] Well-designed, controlled studies like this are critical to advance our knowledge and ability to care for children with traumatic injuries. I do have two comments on the study. First, the introduction suggests so previous work has been done regarding the single-leg or “walking” spica cast. Second, the authors limit the scope of the applicability of this technique by excluding patients using somewhat arbitrary criteria. After learning application of the immediate single-leg spica cast as a clinical fellow in Toronto, and using it routinely since I commenced practice in 1996, I was sufficiently confident in the merits of the technique that I lacked the equipoise required for the design of a more scientifically rigorous investigation. Careful reading of our published case series[2] about the technique does not support using a double-leg spica cast for isolated pediatric femur fractures. Flynn and colleagues also reported that absence of equipoise prevented randomization of their important prospective cohort trial on this topic that was recently published in this journal.[3] Perhaps both papers advancing simultaneously through the peer review process could explain the surprising omission of this level II paper from the references. However, Flynn had previously presented their work at a national meeting[4]. The most recent edition of arguably the leading pediatric fracture text, Rockwood and Wilkins’ Fractures in Children, specifically discusses the “walking spica” cast complete with illustrations.[5] Clearly this paper is not the first one published addressing this topic. On the second point, Leu et al recommended avoiding the technique if there is greater than 2.5 cm of shortening on injury films. I would submit that restoration of length when applying the cast is equally important. While 2.5 cm of shortening may provide surgeons some guidance for applicability of the technique, I believe that proper restoration of length can eliminate the need for arbitrary amounts of acceptable shortening. Successful restoration of length during application, which may require a single person focusing on pulling traction and properly positioning the injured leg, can prevent shortening an unacceptable distance in the postoperative period. Shortening in excess of 2.5 cm on injury films only reflects the position of the fracture the instant the radiograph was taken. Perhaps some of the patients successfully treated in this study would have been excluded if a more dynamic test like the “telescope test” that was described at the authors’ own institution had been used to document more significant shortening.[6] Flynn described applying the cast under sedation or general anesthesia, though recent work suggests that application of a spica cast in the emergency center yields comparable results.[7] Maximal restoration of length, particularly for more unstable fractures, may require application of the cast under general anesthesia, with adequate muscle relaxation provided by the anesthesiologist. Applying the cast under these conditions, combined with careful molding of the cast as described by Sugi and Cole[8], has allowed me to use this technique effectively irrespective of the amount of shortening on injury films. Despite these concerns, the authors have successfully elevated this technique to level I from level II evidence, making this paper a valuable, important contribution to the literature. Perhaps their efforts will persuade the remaining skeptical surgeons to adopt the immediate single-leg or “walking” spica cast into their practices.

    1. Leu, D., et al., Spica Casting for Pediatric Femoral Fractures: A Prospective, Randomized Controlled Study of Single-Leg Versus Double-Leg Spica Casts. J Bone Joint Surg Am, doi: 10.2106/JBJS.K.00966. [Epub ahead of print]2012.
    2. Epps, H.R., E. Molenaar, and P. O'Connor D, Immediate single-leg spica cast for pediatric femoral diaphysis fractures. J Pediatr Orthop, 2006. 26(4): p. 491-6.
    3. Flynn, J.M., et al., The treatment of low-energy femoral shaft fractures: a prospective study comparing the 'walking spica' with the traditional spica cast. J Bone Joint Surg Am, 2011. 93(23): p. 2196-202.
    4. Flynn, J.M., et al., A 'Walking Spica' Cast is Better than a Traditional Spica Cast for Low-Energy Femur Fractures: Results of a Prospective Cohort Trial, in Pediatric Orthopaedic Society of North America Annual Meeting. 2009, Pediatric Orthopaedic Society of North America: Boston.
    5. Flynn, J. and D. Skaggs, Femoral Shaft Fractures, in Rockwood and Wilkins' Fractures in Children, J. Beaty and J. Kasser, Editors. 2010, Wolters Kluwer Lippincott Williams & Wilkins: Philadelphia.
    6. Buehler, K.C., et al., A prospective study of early spica casting outcomes in the treatment of femoral shaft fractures in children. J Pediatr Orthop, 1995. 15(1): p. 30-5.
    7. Mansour, A.A., 3rd, et al., Immediate spica casting of pediatric femoral fractures in the operating room versus the emergency department: comparison of reduction, complications, and hospital charges. J Pediatr Orthop, 2010. 30(8): p. 813-7.
    8. Sugi, M. and W.G. Cole, Early plaster treatment for fractures of the femoral shaft in childhood. J Bone Joint Surg Br, 1987. 69(5): p. 743-5.

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