0
Commentary and Perspective   |    
Socioeconomic Implications of Spica CastingCommentary on an article by Dirk Leu, MD, et al.: “Spica Casting for Pediatric Femoral Fractures. A Prospective, Randomized Controlled Study of Single-Leg Versus Double-Leg Spica Casts”
Joel V. Ferreira, MD1; Jeffrey D. Thomson, MD2
1 University of Connecticut Health Center, Farmington, Connecticut
2 Connecticut Children’s Medical Center, Hartford, Connecticut
View Disclosures and Other Information
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. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, 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.

  • Disclosure statement for author(s): PDF

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


Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Jul 18;94(14):e107 1-2. doi: 10.2106/JBJS.L.00500
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case
Despite the recent trend for surgical stabilization of diaphyseal femoral fractures, hip spica casting is still an appropriate treatment option for children aged six months to five years1. When certain fracture criteria are met, early hip spica casting has a good track record of results, with acceptable leg length equality, healing time, and motion2-4. Also, the overall medical cost of hip spica casting, including the cost of supplies and overall hospitalization time, is significantly less than that of other treatment options5. However, although patients return home quickly, it is not to their baseline home lifestyle. Hip spica casting transfers the physical and financial burden of care to the family and community. Caring for a child in a hip spica cast, specifically a double-leg cast, is extremely challenging.
Unfortunately, as medical professionals, we do not witness the burden placed on the family at home and at school. As a result, these aspects can be overlooked. Transportation, daily supervision, hygiene, and patient tolerance of the cast are all issues faced by the family.
Hughes et al. found that mobility of the patient with a double-leg hip spica was the most difficult aspect experienced by the family5. They also found that parents with older children had more issues with the hip spica cast compared with parents of younger children, mainly because the older children were heavier, were more difficult to carry, and had a slower healing rate. Older children also had been walking independently for more time prior to the injury, which made the transition to non-weight-bearing much more difficult.
Safe vehicle travel is a major issue for families. Specialized car seats are required to transport children with a double-leg spica cast as their typical car seat is too small to accommodate them. Some parents cannot afford the purchase of another car seat, and as a result may forgo a car seat altogether when transporting the child. This puts the child’s safety at risk during transportation. More recently, some hospitals have set up car seat loaner programs to deal with this issue. However, the financial burden for this is placed solely on the hospital. This may be difficult for smaller community-based hospitals given the current state of the economy and health care. In some instances, these car seats are never returned and the hospital sustains a resultant monetary loss and cannot afford to buy replacements. This takes resources away from future families in need, and places us back at square one.
In these economic times, it may be difficult for working parents to care for a child in a hip spica. Although Hughes et al. did find that families with younger children had more preexisting care arrangements for them, they still found that, on average, families with two working parents required three weeks off from work to care for the patient5. In single-parent homes, this burden can be even greater and cause a stressful home environment.
What is so important about the study by Leu et al. is that it may help us to address some of these socioeconomic problems encountered with hip spica casting. Its results showed that use of a single-leg hip spica cast was associated with fewer parental missed workdays, better fit in a standard car seat, and overall better patient comfort when sitting in a chair. The authors also found that the single-leg-cast group exhibited a trend toward being able to walk in the cast. The study provided Level-I evidence that there is no difference between single and double-leg hip spica casting with regard to healing of diaphyseal femoral fractures in patients without an underlying bone or neuromuscular disorder.
In conclusion, the study reinforced the validity of hip spica casting as an acceptable treatment option for patients two to six years old who have a diaphyseal femoral fracture with <2.5 cm of shortening. However, most importantly, it showed that the healing results following single-leg hip spica casting are similar to those with double-leg casting, but with much less morbidity to the patient and family.
Kocher  MS;  Sink  EL;  Blasier  RD;  Luhmann  SJ;  Mehlman  CT;  Scher  DM;  Matheney  T;  Sanders  JO;  Watters  WC  3rd;  Goldberg  MJ;  Keith  MW;  Haralson  RH  3rd;  Turkelson  CM;  Wies  JL;  Sluka  P;  Hitchcock  K. Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg.  2009 Nov;17(  11):718-25.
 
Flynn  JM;  Schwend  RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg.  2004 Sep-Oct;12(  5):347-59.
 
Ferguson  J;  Nicol  RO. Early spica treatment of pediatric femoral shaft fractures. J Pediatr Orthop.  2000 Mar-Apr;20(  2):189-92.[CrossRef]
 
Infante  AF  Jr;  Albert  MC;  Jennings  WB;  Lehner  JT. Immediate hip spica casting for femur fractures in pediatric patients. A review of 175 patients.   Clin Orthop Relat Res. 2000 Jul;(  376):106-12.
 
Hughes  BF;  Sponseller  PD;  Thompson  JD. Pediatric femur fractures: effects of spica cast treatment on family and community. J Pediatr Orthop.  1995 Jul-Aug;15(  4):457-60.[CrossRef]
 

Submit a comment

References

Kocher  MS;  Sink  EL;  Blasier  RD;  Luhmann  SJ;  Mehlman  CT;  Scher  DM;  Matheney  T;  Sanders  JO;  Watters  WC  3rd;  Goldberg  MJ;  Keith  MW;  Haralson  RH  3rd;  Turkelson  CM;  Wies  JL;  Sluka  P;  Hitchcock  K. Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg.  2009 Nov;17(  11):718-25.
 
Flynn  JM;  Schwend  RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg.  2004 Sep-Oct;12(  5):347-59.
 
Ferguson  J;  Nicol  RO. Early spica treatment of pediatric femoral shaft fractures. J Pediatr Orthop.  2000 Mar-Apr;20(  2):189-92.[CrossRef]
 
Infante  AF  Jr;  Albert  MC;  Jennings  WB;  Lehner  JT. Immediate hip spica casting for femur fractures in pediatric patients. A review of 175 patients.   Clin Orthop Relat Res. 2000 Jul;(  376):106-12.
 
Hughes  BF;  Sponseller  PD;  Thompson  JD. Pediatric femur fractures: effects of spica cast treatment on family and community. J Pediatr Orthop.  1995 Jul-Aug;15(  4):457-60.[CrossRef]
 
Accreditation Statement
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.
CME Activities Associated with This Article
Submit a Comment
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe





Related Content
The Journal of Bone & Joint Surgery
JBJS Case Connector
Topic Collections
Related Audio and Videos
PubMed Articles
Guidelines
Treatment of pediatric diaphyseal femur fractures. -American Academy of Orthopaedic Surgeons (AAOS)
Results provided by:
PubMed
Clinical Trials
Readers of This Also Read...
JBJS Jobs
02/28/2014
District of Columbia (DC) - Children's National Medical Center
12/04/2013
New York - Icahn School of Medicine at Mount Sinai
12/31/2013
S. Carolina - Department of Orthopaedic Surgery Medical Univerity of South Carlonina
04/02/2014
W. Virginia - Charleston Area Medical Center