title: Treatments for paediatric femoral fractures: a randomised trial.
abstract: BACKGROUND
  Treatments for femoral fractures in children vary widely and have been investigated only in case series. We did a multicentre randomised trial to compare malunion rates after external fixation and after early application of a hip spica cast for paediatric femoral shaft fractures.
  
  
  METHODS
  All children aged 4-10 years with femoral fractures, admitted to four paediatric hospitals, were randomly assigned early application of hip spica or external fixation. The primary outcome was malunion at 2 years after the fracture. Secondary outcomes were scores on the RAND physical function child health questionnaire and the post-hospitalisation behavioural questionnaire, and parents' and children's ratings of overall satisfaction with treatment. Analysis was by intention to treat based on children who reached the 2 year evaluation.
  
  
  RESULTS
  Of 60 children assigned to the hip-spica group, 56 reached the 2-year assessment; of them, six (11%) required other forms of treatment because of unacceptable loss of reduction. Of 48 children assigned external fixation, 45 reached the 2-year assessment; two (4%) had refractures and five (11%) required operative adjustment of the fixator. The rate of malunion was significantly higher in the hip-spica group than in the external-fixator group (25/56 [45%] vs 7/45 [16%]; 95% CI for difference 12-46%; p=0.002). The two groups had similar mean scores for the RAND physical function health questionnaire (0.34 vs 0.45; 95% CI for difference, -0.57 to 0.34; p=0.61), for the post-hospitalisation questionnaire (106.8 vs 106.3; -4.9 to 5.9; p=0.86), and for parents' satisfaction (4.3 vs 4.2; -0.3 to 0.6; p=0.5) and children's ratings of happiness with treatment (6.9 vs 7.7; -2.2 to 0.5; p=0.21).
  
  
  CONCLUSIONS
  Early application of hip spica has a small role in the treatment of paediatric femoral fractures. Future trials need to compare external fixation with flexible intramedullary nails.
authors.affiliation: Division of Orthopaedic Surgery, Hospital for Sick Children, Toronto, ON, Canada. james.wright@sickkids.ca
authors.forename: James G
authors.initials: JG
authors.lastname: Wright
authors.forename: Elaine E L
authors.initials: EE
authors.lastname: Wang
authors.forename: Janice L
authors.initials: JL
authors.lastname: Owen
authors.forename: Derek
authors.initials: D
authors.lastname: Stephens
authors.forename: H Kerr
authors.initials: HK
authors.lastname: Graham
authors.forename: Michael
authors.initials: M
authors.lastname: Hanlon
authors.forename: Gary R
authors.initials: GR
authors.lastname: Nattrass
authors.forename: Rick A K
authors.initials: RA
authors.lastname: Reynolds
authors.forename: Peter
authors.initials: P
authors.lastname: Coyte
mesh_terms: D002370:Casts, Surgical / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D016267:External Fixators / Q000009:adverse effects; D005260:Female; D005264:Femoral Fractures / Q000601:surgery / Q000628:therapy*; D005592:Fracture Fixation / Q000009:adverse effects; D017759:Fractures, Malunited / Q000209:etiology; D006801:Humans; D007902:Length of Stay; D008297:Male; D017060:Patient Satisfaction