title: Intramedullary Nailing Compared with Spica Casts for Isolated Femoral Fractures in Four and Five-Year-Old Children.
abstract: BACKGROUND
  Flexible intramedullary nailing (IMN) is a valuable tool in the treatment of femoral fractures in school-age children, whereas spica cast immobilization has been the standard of care for younger children. We compared these treatment modalities in a group of preschool-age children (four to five years of age).
  
  
  METHODS
  A retrospective cohort of consecutive patients, four to five years of age, with an isolated, complete femoral shaft or subtrochanteric fracture treated with intramedullary nailing or early spica cast immobilization and followed until fracture-healing were identified from two centers. Radiographic and clinical outcomes were compared between the groups. Statistical methods included chi-square and Fisher exact tests for categorical variables and the Mann-Whitney test for continuous variables.
  
  
  RESULTS
  Two hundred and sixty-two patients followed for a mean of thirty-two weeks were identified. One hundred and four patients underwent IMN and 158 patients were treated with immediate spica cast immobilization at the surgeon's discretion. The patients who underwent IMN were older than those who underwent spica cast immobilization (mean, 5.2 versus 4.7 years; p < 0.001), were heavier (mean, 21.5 versus 18.0 kg; p < 0.001), and were more likely to have a higher-energy mechanism of injury (p = 0.025). At the time of final follow-up, there was no difference between groups with regard to the percentages of patients who had acceptable coronal angulation (≤15°), sagittal angulation (≤20°), and early fracture shortening (≤20 mm) (96.2% in the spica group versus 99.0% in the IMN group; p = 0.09). While there was no significant difference in the percentages who had an unplanned return to the operating room (3.8% in the IMN group versus 4.4% in the spica group; p > 0.99), the patients in the IMN group had more clinic visits (mean, 5.8 versus 4.0; p < 0.001) and longer follow-up (mean, forty-four versus twenty-five weeks; p < 0.001) than the patients in the spica group and a higher percentage of them underwent repeat procedures (89.4% versus 5.1%; p < 0.001), primarily for elective implant removal.
  
  
  CONCLUSIONS
  Preschool-age children (four to five years old) with an isolated femoral fracture have similar clinical and radiographic outcomes regardless of whether they are treated with immediate spica cast immobilization or IMN.
authors.affiliation: Texas Scottish Rite Hospital for Children, Dallas, Texas brandon.ramo@tsrh.org.
authors.forename: Brandon A
authors.initials: BA
authors.lastname: Ramo
authors.affiliation: Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Martus
authors.affiliation: Children's Medical Center, Dallas, Texas.
authors.forename: Naureen
authors.initials: N
authors.lastname: Tareen
authors.affiliation: Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee.
authors.forename: Benjamin S
authors.initials: BS
authors.lastname: Hooe
authors.affiliation: Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee.
authors.forename: Mark C
authors.initials: MC
authors.lastname: Snoddy
authors.affiliation: Texas Scottish Rite Hospital for Children, Dallas, Texas.
authors.forename: Chan-Hee
authors.initials: CH
authors.lastname: Jo
mesh_terms: D001858:Bone Nails; D002370:Casts, Surgical; D002675:Child, Preschool; D005260:Female; D005264:Femoral Fractures / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D005500:Follow-Up Studies; D005594:Fracture Fixation, Intramedullary / Q000295:instrumentation / Q000379:methods; D006801:Humans; D008297:Male; D011859:Radiography; D012189:Retrospective Studies; D016896:Treatment Outcome