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Scientific Articles   |    
The Treatment of Low-Energy Femoral Shaft Fractures: A Prospective Study Comparing the “Walking Spica” with the Traditional Spica Cast
John M. Flynn, MD1; Matthew R. Garner, BS1; Kristofer J. Jones, MD2; Joann D'Italia, MSN, CWOCN, CRNP1; Richard S. Davidson, MD1; Theodore J. Ganley, MD1; B. David Horn, MD1; David Spiegel, MD1; Lawrence Wells, MD1
1 Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104. E-mail address for J.M. Flynn: Flynnj@email.chop.edu
2 Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
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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 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Dec 07;93(23):2196-2202. doi: 10.2106/JBJS.J.01165
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Abstract

Background: 

A single-leg, walking hip spica cast has been shown to be a safe and effective treatment for a low-energy femoral shaft fracture in young children. We designed a prospective cohort trial comparing walking and traditional hip spica casting to determine whether a walking hip spica cast was superior to a traditional hip spica cast following a low-energy femoral shaft fracture in children one to six years old.

Methods: 

We studied forty-five consecutive low-energy femoral shaft fractures during a three-year period in children one to six years old. Three surgeons treated their patients with a walking hip spica cast, and three other surgeons treated their patients with a traditional spica cast. Complications and subsequent interventions were recorded prospectively. Caregivers were asked to complete the validated Impact on Family Scale as well as a ten-item questionnaire developed by the authors at the time of cast removal.

Results: 

Forty-five patients with a low-energy fracture were enrolled in the study. Nineteen patients were treated with a walking hip spica cast and twenty-six, with a traditional hip spica cast. The two cohorts were similar with respect to age, length of hospital stay, time to initial callus formation, and time to fracture union. Two children treated with a traditional hip spica cast and no children in the walking hip spica group returned to the operating room for the treatment of spontaneous loss of fracture reduction. Five of the nineteen children treated with a walking hip spica cast and one of the twenty-six treated with a traditional hip spica cast required wedge adjustment of the cast in the clinic to treat fracture malalignment (p = 0.04). One patient treated with a walking hip spica cast required repeat reduction in the operating room because of overcorrection during wedge adjustment. The malunion rate did not differ significantly between the groups (three of twenty-six in the traditional hip spica group compared with none of nineteen in the walking hip spica group). All patients treated with a walking hip spica cast were able to crawl in the cast, and 71% (twelve of seventeen) were able to walk. Use of the traditional hip spica cast resulted in a significantly greater care burden for the family as measured with use of the Impact on Family Scale (43.3 for the traditional hip spica group compared with 35.6 for the walking hip spica group, p = 0.04). Insurance-funded ambulance transportation was needed for eleven of the twenty-six patients treated with a traditional hip spica cast compared with none of the nineteen patients treated with a walking hip spica cast (p = 0.001).

Conclusions: 

The walking hip spica cast and the traditional hip spica cast resulted in similar orthopaedic outcomes, and the walking hip spica cast resulted in a lower care burden for the family. Surgeons and families should be aware that use of a walking hip spica cast rather than a traditional hip spica cast may be associated with a greater likelihood that wedge adjustment of the cast will be necessary to treat fracture malalignment.

Level of Evidence: 

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

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    References

    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.
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