Research Article IncreasingRateofSurgicalFixation in Four ...ORIF were combined into a second group,...

Research Article

IncreasingRateofSurgical Fixationin Four- and Five-year-old ChildrenWith Femoral Shaft Fractures

Abstract

Background: The purpose of this study was to identify temporaltrends in themanagement of pediatric femoral shaft fractures in 4- and5-year-old children.Methods: The Kids’ Inpatient Database was used to extract data onpatients aged 4 and 5 years with closed femoral shaft fractures. Thefrequency of nonsurgical and surgical management was calculated,and temporal trends were evaluated.Results: Between 1997 and 2012, the absolute increase in surgicalfixation was 35% and 58% in 4- and 5-year-old patients, respectively.The surgical rate increased every 3 years by 13.8% in 4-year-oldpatientsand7.6% in5-year-old patients.Significant associationswerenoted based on demographics, comorbidities, and hospitalcharacteristics with management decisions.Conclusions: A clear and significant increase was noted in internalfixation for pediatric femoral shaft fractures in 4- and 5-year-oldchildren, and the lower age limit for surgical management of thesefractures is decreasing.Level of Evidence: Level III. Retrospective comparative study

Pediatric femur fractures areamong the most common injuries

treated by orthopaedic surgeons.1-3

Treatment of these fractures dependson factors such as age, size and weightof a patient, fracture pattern, soft-tissue integrity, comorbidities, con-current injuries, family preference, andsurgeon preference. Despite rare casesof significant morbidity, the over-whelming majority of pediatric pa-tients with femoral shaft fractures areexpected to heal with normal functionand radiographic alignment.4-6

Treatment options for the man-agement of pediatric femoral shaftfractures include Pavlik harnessapplication, spica casting, externalfixation, submuscular plating, andflexible or rigid intramedullary (IM)nailing.7 Currently no consensus

exists regarding the best treatmentmodality, and many surgeons followan age-based algorithm where pa-tients younger than 6 months aretreated with a Pavlik harness andpatients aged between 6 months to 6years are treated with spica casting,typically without traction. Olderchildren aged between 6 and 10years are often treated with flexibleIM nailing, whereas children in thisage group with length unstablefracture patterns may be treated withsubmuscular plating. A lateral entryrigid IM nail may be used in childrenolder than 10 years.7,8 The AmericanAcademy of Orthopaedic SurgeonsClinical Practice Guideline recom-mends, with moderate strength,spica casting of most diaphysealfemur fractures in children aged

Ram Kiran Alluri, MD

Andrew Sabour, BS

Nathanael Heckmann, MD

George F. Hatch, MD

Curtis VandenBerg, MD

From the Keck School of Medicine ofthe University of Southern California,Los Angeles, CA.

Correspondence to Dr. Alluri:[email protected]

Dr. Alluri or an immediate familymember has stock or stock optionsheld in AxoGen, Stryker, and ZimmerBiomet and has received nonincomesupport (such as equipment orservices), commercially derivedhonoraria, or other non–research-related funding (such as paid travel)from Acumed, Arthrex, and Trimed.Dr. Heckmann or an immediate familymember has stock or stock optionsheld in Masimo, Materialise NV, andNuVasive. Dr. Hatch or an immediatefamily member is a member of aspeakers’ bureau or has made paidpresentations on behalf of Arthrex andserves as a paid consultant to Arthrex.Neither of the following authors norany immediate family member hasreceived anything of value from or hasstock or stock options held in a com-mercial company or institution relateddirectly or indirectly to the subject ofthis article: Mr. Sabour andDr. VandenBerg.

J Am Acad Orthop Surg 2019;27:e24-e32

DOI: 10.5435/JAAOS-D-17-00064

Copyright 2018 by the AmericanAcademy of Orthopaedic Surgeons.

e24 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

mailto:[email protected]

http://dx.doi.org/10.5435/JAAOS-D-17-00064

6 months to 5 years and, with limitedstrength, the use of flexible IM nailsin patients aged 5 to 11 years.9

The success of flexible IMnailing ofpediatric femur fractures has resultedin a general transition away fromnonsurgical management towardsurgical intervention.10-12 Specifi-cally in younger patient cohorts, therelative safety and efficacy of flexibleIM nail placement along with greaterease of postoperative care comparedwith spica casting have resulted in aprogressive trend toward surgicalmanagement.13 The treatment of pre-school children, aged 4 to 5 years, isof particular interest and remainscontroversial. A recent study demon-strated no difference in clinical orradiographic outcomes when com-paring spica casting to flexible IMnailing in this age group.4

The purpose of this study was toidentify nationwide temporal trends inthe management of pediatric femoralshaft fractures in 4- and 5-year-oldchildren while identifying potentialdemographic, surgical, and hospitalcharacteristics that may predict surgi-cal versus nonsurgical management.We hypothesized that the surgicalmanagement of femoral shaft frac-tures in patients between ages 4 and 5years has progressively increased dur-ing the period examined in this study.

Methods

The Kids’ Inpatient Database (KID)is a national hospital dischargedatabase of patients younger than21 years. It is maintained by theHealthcare Cost andUtilization Projectand is the largest publicly availablepediatric database of inpatient hos-pitalizations in the United States.The release of data sets on a triennialbasis began in 1997, and these con-tain information on approximately2 to 3 million pediatric inpatientdischarges occurring in community,nonrehabilitation hospitals across

participating states. The HealthcareCost and Utilization Project defines acommunity hospital as a nonfederal,short-term (less than 30-day stay)hospital that is accessible to thepublic. The KID database uses asample of pediatric discharges fromall hospitals in the sampling frame,selecting 10% of “normal newborns”born in the hospital and 80%of otherpediatric cases from each framehospital.14 The KID database pro-vides sampling weights for obtainingnational estimates, which are based on

characteristics of the poststratifiedhospitals.14 The weighting algorithmcan allow for reliable estimates ofnational volumes for a given diagnosisor procedure, and this algorithm hasbeen previously validated.15

Data from the 1997, 2000, 2003,2006, 2009, and 2012 data sets werecompiled and retrospectively re-viewed. At the time of the study, the2012 data set was the most recentdata set. Patients aged between zeroand eight years were identified usingdata filters. The primary purpose of

Figure 1

Flow diagram showing patient selection (CR = closed reduction, CRIF = closedreduction and internal fixation, OR = open reduction, ORIF = open reduction andinternal fixation). The number of patients listed represents weighted numbers.

Ram Kiran Alluri, MD, et al

January 1, 2019, Vol 27, No 1 e25


this study was to identify trendsbetween nonsurgical and surgicalmanagement of femoral shaft frac-tures in patients aged between 4 and5years. We included ages zero to 3years and 6 to 8 years to serve as rel-ative comparison groups becausetreatment in these age groups isless controversial with nonsurgicalmanagement almost always recom-mended for the zero to 3 years agegroup and generally surgical manage-ment for the 6 to 8 years age group.3,16

After identifying all patients agedbetween zero and 8 years, we usedthe International Classification ofDiseases, Ninth Revision, ClinicalModification (ICD-9-CM) diagnos-tic code 82101 to identify patientswith a closed femoral shaft fracture.This subset of patients was againfiltered using an ICD-9-CM proce-dure code of either 7905, 7915,7925, or 7935 describing closedreduction (CR) of femur fracturewithout internal fixation (IF), CR offemur fracture with IF (CRIF), openreduction (OR) of femur fracturewithout IF, and OR of femur frac-ture with IF (ORIF), respectively. Allpatients with more than 1 of the

designated ICD-9-CM procedurecodes, a bilateral procedure or revi-sion surgery, or having undergone anapparent OR without IF (ICD-9-CMprocedure code 7925) were excluded.Patients who underwent CR withoutIF were designated as one group,“CR.” Patients who underwent eitherCRIF or OR of femur fracture with IFORIF were combined into a secondgroup, “IF.” Figure 1 illustrates ourpatient selection process.Closed femoral shaft fractures in

pediatric inpatients of ages 4 and5 years were analyzed in detail interms of demographic, surgical, andhospital/institutional characteristicsprovided by the KID database. Inpa-tient variables such as “risk of mor-tality” and “severity of illness” werealso analyzed. The “severity of ill-ness” variable is based on a numericvalue ranging from 1 to 4, with 1representing minor loss of functionand 4 representing extreme loss offunction. The KID database assigns anumeric severity of illness value atthe time of admission using analgorithm that factors in the under-lying comorbidities and primary andsecondary diagnoses.

The counts of inpatient admissionswereweightedusingprovidedweightsfrom the KID database to generatenational estimates for the “CR” and“IF” groups. All reported numbersare national estimates based on theweights provided by the KID data-base. Statistical analysis comparingdemographic, surgical, and hospital-level variables between the twogroups was performed using STATA13.0 (StataCorp LP). Fisher exactand chi-square analyses were per-formed to compare categoric databetween treatment groups andpopulations treated at differenthospital types. For continuous ordiscrete variables, a Student t-testwas used. Surgical trends over timewere analyzed using linear regres-sion, and the P value of the slopefrom the line of best fit was cal-culated. Categoric variables includeda prevalence percentage, whereascontinuous/discrete variables includedan SD. P # 0.05 was consideredstatistically significant.

Results

Between 1997 and 2012, 15,583pediatric femoral shaft fractures(71%) were treated with closed man-agement and 6,417 (29%) weretreated with IF in children aged ,8years. In patients aged less than 1 year,1,356 femoral shaft fractures (98%)were treated with closed management,whereas in 8-year-old children, 1,234(73%) were treated with IF (Figure 2).Linear regression demonstrated thatsurgical fixation increased by 9.1%(P , 0.0001) for every integral in-crease in age up to 8 years.Over the 15-year period that this

study examined, in 4-year-oldpatients, a total of 1,285 femoral shaftfractures (70%) were treated withclosed management and 554 (30%)were treated with IF. In 1997, 300(87%) were treated with closed man-agement and 44 (13%) were treated

Figure 2

Graph showing the comparison of CR versus IF between 1997 and 2012 forages zero to 8 years. CR = closed reduction, IF = internal fixation

Increasing Rate of Surgical Fixation in Four- and Five-year-old Children



with IF (Figure 3). In 2012, 149(52%) were treated with closedmanagement and 136 (48%) weretreated with IF (Figure 3). The abso-lute increase in IF over the 15-yearperiod was 35%. Linear regressiondemonstrated that surgical fixationincreased by 14% (P = 0.0003) everythree years from 1997 to 2012.For the same 15-year period, in

5-year-old patients, a total of 904femoral shaft fractures (53%) weretreated with closed management and810 (47%) were treated with IF. In1997, 334 (84%) were treated withclosed management and 64 (16%)were treated with IF (Figure 4). In2012, 62 (26%) were treated withclosed management and 178 (74%)were treated with IF (Figure 4).The absolute increase in IF over the15-year period was 58%. Linearregression demonstrated that sur-gical fixation increased by 8%(P = 0.003) every 3 years from 1997to 2012.Combined analysis of demographic

variables from patients aged both 4and 5 years demonstrated no differ-ences in closed management versus IFbased on sex, race, or paymentmethod(Table 1). Patients from families withhigher median household incomeswere more likely to undergo closedmanagement (P = 0.048) (Table 1).In both the 4- and 5-year-old patient

groups, patients with higher loss offunction were more likely to undergoIF than receive closed management(P , 0.001) (Table 2). No significantdifference was noted in the mortalityrisk between the two treatment groups(P = 0.517) (Table 2). Discharge dis-position was also similar (P = 0.182),and more than 90% of children wereroutinely discharged after closedmanagement or IF. The length ofstay was approximately 4 daysregardless of treatment modality (P =0.559) (Table 2); however, totalhospital charge was significantlyhigher for patients receiving IFcompared with closed management

(P , 0.0001) at $28,200 and$17,400, respectively (Table 2).Analysis of hospital variables

demonstrated no differences in closedmanagement or IF for 4 and 5 yearolds based on the percentage of pedi-atric discharges (P = 0.083), hospitalbed size (P = 0.249), or hospital

ownership (P = 0.101) (Table 3). Boththe region and teaching status of thehospital demonstrated significantdifferences. Teaching hospitals weremore likely than nonteaching hospi-tals to use IF (P = 0.034) (Table 3).Last, significant differences werenoted between geographic regions

Figure 3

Graph showing the comparison of CR versus IF between 1997 and 2012 forpatients of age 4 years. CR = closed reduction, IF = internal fixation

Figure 4

Graph showing the comparison of CR versus IF between 1997 and 2012 forpatients of age 5 years. CR = closed reduction, IF = internal fixation


January 1, 2019, Vol 27, No 1 e27


with respect to management: theSouth and Midwest more frequentlyusing IF compared with theWest andNortheast (P , 0.0001) (Table 3).

Conclusions

This study using a national pediatricdatabase demonstrated a significant

increase in IF compared with non-surgical management among 4 -and5-year-old children with closed fem-oral shaft fractures between 1997and 2012. Several demographic,surgical, and hospital variableswere associated with variations inmanagement. Although previousstudies have evaluated trends inpediatric femoral shaft fracturemanagement, this is the first study tospecifically assess 4- and 5-year-oldchildren, for which management iscontroversial.1,4,10,16-19

The increased use of IF in 4- and5-year-old children with closed femo-ral shaft fractures is likely due to in-creased utilization of flexible IM nailsin lieu of spica casting. Although thedatabase used for this study does notallow for assessment of the type of IFused, it can reasonably be assumedthat most of the 4 -and 5-year-oldpatients receiving IF for a femoralshaft fracture were treated with flexi-ble IM nails.Some studies have demonstrated

that spica casting can result in higherrates of malunion, delayed hip andknee range of motion, slower mobi-lization, and poorer functional out-comes compared with flexible IMnails.13,20,21 Aside from clinical andradiographic outcomes, certain socio-economic factors may affect femurfracture management decisions. Out-come surveys have revealed that flex-ible nails may decrease the burden ofcare on family members because spicacasts can be difficult to take care of.22

Furthermore, spica casting may forceparents to take increased time off workto care for their child who may not beallowed to return to school until thecast is off.20,23 Although several re-ported benefits of flexible nailing exist,surgery carries a risk of general anes-thesia complications, infection, bloodloss, and damage to surroundingneurovascular structures along withsurgical scarring and postoperativeskin irritation. In addition, a secondsurgery is usually required or

Table 1

Comparison of Demographic Variables in Patients of Ages 4 and 5 YearsUndergoing Closed Reduction Versus Internal Fixation

DemographicsClosed

ReductionInternalFixation P Value

Sex (female) 559 (25.51%) 357 (26.16%) 0.759Race 0.104White 1,070 (65.05%) 674 (63.67%) —

Black 237 (14.42%) 159 (15.02%) —

Hispanic 222 (13.46%) 143 (13.54%) —

Asian or Pacific Islander 37 (2.22%) 9 (0.85%) —

Native American 15 (0.91%) 11 (1.06%) —

Other 65 (3.93%) 62 (5.87%) —

Primary payment method 0.074Medicare 1 (0.06%) 3 (0.20%) —

Medicaid 742 (33.96%) 540 (39.72%) —

Private, including HMO 1,217 (55.67%) 691 (50.88%) —

Self-pay 125 (5.73%) 62 (4.59%) —

No charge 0 (0.00%) 0 (0.00%) —

Other payment 100 (4.58%) 63 (4.61%) —

Median household income 0.0480–25th percentile 579 (27.20%) 379 (28.43%) —

26–50th percentile 531 (24.96%) 349 (26.16%) —

51–75th percentile 449 (21.10%) 331 (24.77%) —

76–100th percentile 569 (26.74%) 275 (20.64%) —

HMO = health maintenance organization

Table 2

Comparison of Inpatient Variables in Patients of Ages 4 and 5 YearsUndergoing Closed Reduction Versus Internal Fixation

Inpatient VariablesClosed


Severity of illness ,0.001Minor loss of function 5 (0.44%) 0 (0.00%) —

Moderate loss of function 1,038 (92.76%) 897 (79.37%) —

Major loss of function 60 (5.33%) 202 (17.92%) —

Extreme loss of function 16 (1.46%) 31 (2.71%) —

Risk of mortality 0.517Minor likelihood of dying 1,063 (94.98%) 1,070 (94.69%) —

Moderate likelihood of dying 30 (2.68%) 34 (3.01%) —

Major likelihood of dying 25 (2.21%) 20 (1.78%) —

Extreme likelihood of dying 1 (0.13%) 6 (0.52%) —

Length of stay 4.196 5.96 4.046 5.45 0.559Total charge (dollars) 17,400 6 26,600 28,200 6 31,500 ,0.001




recommended to remove the flexiblenails.4,24 Although the data from thisstudy show a clear increasing trendtoward the use of IF, the manage-ment of closed femoral shaft frac-tures in 4- and 5-year-old childrenstill remains without consensus.The lack of consensus can be

attributed to limitations of studiesassessing this age group, along withnumerous patient characteristics,radiographic parameters, socioeco-nomic variables, and surgeon prefer-ences influencing managementdecisions.4,6,13 A recent retrospectivecohort study by Ramo et al4

demonstrated similar clinical andradiographic outcomes in 4- and 5-year-old patients treated with spicacasting or flexible nails, but averagefollow-up was less than 1 year forboth groups. A similar retrospectivestudy by Heffernan et al13 compar-ing spica casting with flexible nails inchildren aged 2 to 6 years demon-strated similar time to union betweenthe two groups, but the flexible nailgroup had shorter times to inde-pendent ambulation and returned tofull activity earlier than the spicacasting group. Average follow-up inthis study was 1.26 1.5 years for thespica group and 3.7 6 2.7 years forthe flexible nail group, which was apoint of concern brought up in thecommentary by Price.25 Price validlyargues that a minimum of 2-yearfollow-up should be obtained toadequately assess for radiographicovergrowth of the femur, which canoccur for up to 3.5 years aftertreatment.26 The less than 2-yearfollow-up in the spica casting groupand some patients in the flexible nailgroup in the study byHeffernan et al13

and the less than 1-year follow-up ofall patients in the study by Ramo et al4

likely inadequately assess femoralovergrowth. At the time of treatment,overgrowth can be mitigated withspica casting by intentionally im-plementing a 1-cm overlap of thefracture, but this is not possible with

an elastic IM nail. Ultimately, noclear conclusion can be drawnabout the superiority of eitherspica casting or flexible nailing ofclosed pediatric femoral shaftfractures in 4- and 5-year-old chil-dren in the absence of well-definedprospective studies with clinical andradiographic outcomes and adequatemidterm follow-up.Our analysis of demographic vari-

ables for patients aged 4 and 5 yearsdemonstrated no differences in race,sex, or insurance status betweenchildren receiving closed treatmentversus IF. This is consistent withsimilar studies in older children.18

However, we demonstrated thatpatients from families with highermedian household income weremore likely to undergo closed treat-ment. The greatest difference was

seen in median household incomesfrom the 75th to 100th percentile,where a 7% higher rate of CR wasnoted. Although this was statisticallysignificant, the clinical significance isunknown. It is possible that patientsfrom families with more economicresources would prefer nonsurgicaltreatment to avoid a first and pos-sibly second surgery while havingmore means to care for a potentiallyburdensome spica cast. On average,families may require up to threeweeks off to care for these patientswhich can have a significant finan-cial impact, particularly in single-provider homes.23

With respect to surgical variablesand patient selection criteria, ourstudy demonstrated that 4- and5-year-old children with higher pre-operative loss of function were more

Table 3

Comparison of Hospital-Level Variables in Patients of Ages 4 and 5 YearsUndergoing Closed Reduction Versus Internal Fixation

Hospital VariablesaClosed


% Of pediatric discharges 38.9% 6 30.8% 42.0%6 33.2% 0.083Bed size of hospital 0.249Small 202 (13.36%) 183 (15.28%) —

Medium 387 (25.57%) 273 (22.78%) —

Large 924 (61.07%) 743 (61.94%) —

Ownership of hospital 0.101Government/privatecollapsed category

977 (75.06%) 711 (80.31%) —

Government, nonfederal,public

54 (4.12%) 43 (4.85%) —

Private, nonprofit, voluntary 148 (11.41%) 79 (8.87%) —

Private, invest-own 58 (4.44%) 20 (2.25%) —

Private, collapsed category 65 (4.97%) 33 (3.71%) —

Region of hospital ,0.001Northeast 319 (20.54%) 169 (13.45%) —

Midwest 374 (24.02%) 399 (31.74%) —

South 449 (28.85%) 395 (31.43%) —

West 414 (26.59%) 294 (23.38%) —

Teaching status of hospital 0.034Nonteaching 404 (31.05%) 224 (25.33%) —

Teaching 897 (68.95%) 661 (74.67%) —

a The percent of pediatric discharges is defined as the number of total pediatric patientsdischarged divided by the total number of patients discharged from a given hospital.


January 1, 2019, Vol 27, No 1 e29


likely to receive IF, whereas thosewith lower loss of functionweremorelikely to undergo closed manage-ment. This difference in treatmentmay be due to surgeons electing for IFin patients with greater loss of func-tion, such as polytrauma patients, tofacilitate postoperative rehabilitationor because spica casting in a patientwith multiple injuries can be techni-cally challenging. This finding isconsistent with previous studies inwhich patients in this age group withgreater mechanisms of injury orpolytrauma were more likely to betreated with flexible nailing.4,13

From a financial standpoint, inpa-tient charges were $10,800 higher inthe IF group. This was an expectedfinding presumably due to implantand operating room cost; many hipspica casts can be applied in a proce-dure room or emergency departmentand do not require consumptionof operating room resources.27 Inaddition, the actual final cost offlexible nailing may be higher becauseour study does not account for costsassociated with removal of the nail,which can occur in greater than halfof patients.13 Conversely, the finalcost of spica casting could be higherbecause of costs associated with ad-justing the cast, replacing the cast, orhaving to covert to surgical manage-ment; these costs would not be cap-tured by the KID database. Previousstudies have demonstrated no differ-ence in cost between the two treat-ment options.21

Length of inpatient stay can alsosignificantly influence hospital charg-es. In our study, the length of stay wassimilar, 4 days, for both treatmentgroups. The literature reports mixedresults when comparing length of staybetween these two treatment modali-ties. Jauquier et al6 reported thatmedian hospital stay was 1 day forspica casting and 4 days for patientsreceiving a flexible nail in patientsaged 1 to 4 years. The longer lengthof stay with surgical treatment was

due to postoperative pain control.Other studies examining older chil-dren treated with spica casting havereported longer lengths of stay withspica casting, but this was mostly dueto the use of traction.21,28 A second-ary analysis of our data demonstratedthat 4 and 5 year olds undergoingCR received traction less than10% of the time (see Appendix I,Supplemental Digital Content 1,http://links.lww.com/JAAOS/A124).Overall, the reported 4-day length ofstay for spica casting is higher thanto be expected. This is likely due tothe sampling process of the KIDdatabase, which captures only inpa-tient admissions. It is not uncommonfor a spica cast to be placed in theemergency department, followedby discharge after a brief period ofobservation; therefore, our data maybe overestimating the true length ofstay for spica casting.Last, out study demonstrated several

differences based on hospital charac-teristics. Teaching hospitals weremorelikely to use IF in 4- and 5-year-oldchildren. This may be secondary toteaching hospitals having pediatricorthopaedic surgeons on staff whomay be more comfortable placingflexible nails in younger childrenand managing them postoperatively.There may also be financial motivepartially contributing to the trend forsurgical management in younger pa-tients; flexible IM nailing has a reim-bursement rate more than three timeshigher than placement of a spica cast.There are several limitations of this

study. First, we used a national data-base that is dependent on analyzingICD-9 codes to isolate procedures anddiagnosis. This lends our data subjectto coding error and also prevents usfrom differentiating between variousforms of IF. Perhaps the most signifi-cant limitation of this study is that wecould not assess fracture pattern,which is a critical factor when decid-ing to elect for nonsurgical or surgicalmanagement. It is a valid assumption;

however, that the distribution offracture patterns remained relativelyconstant over the 15-year periodstudied, and therefore, our resultsdemonstrating increased rates of IFfor femoral shaft fractures in 4- and5-year-old patients hold true. Simi-larly, this study categorized patientsprimarily on chronological age,which may not account for variabilityin patient weight, body mass index,skeletal maturity, or other patientfactors that could affect treatmentdecisions. The use of current proce-dural codes or ICD-10 codes mayoffset this limitation in the future,but are currently not available in anynational pediatric database.Further limitations of the KID data

set include its utilization of only dis-charge records to analyze patientdata, and therefore, analysis of sur-gical or other clinically relevant var-iables is not feasible. In addition, thisdatabase analysis may have under-reported the rates for CR becausesome institutions may perform CRand spica casting in an emergencydepartment setting without inpatientadmission; these instances wouldnot be captured by the KID. More-over, this study categorized patientsas either having undergone CR or IF,but data were not available regardingthe type of IF used; the authors ofthis study chose to refer to the IFgroup as primarily being flexible IMnailing. There is likely a smaller per-centage of the IF group that under-went another form of IF, such assubmuscular plating. In addition,it is possible that patients in theCR group actually received externalfixation and not a spica cast, butanalysis demonstrated that this wasless than 2% of patients (data notpresented). For the purposes ofthis analysis, the authors did not feelthat this potential heterogeneity offixation choices changed the con-clusions of the study.Over a 15-year period, the man-

agement of pediatric femoral shaft




http://links.lww.com/JAAOS/A124

fractures in 4- and 5-year-old chil-dren has progressively shifted.Recently, more surgeons are electingfor surgical management with IF, andcorrespondingly less are using closedmanagement with spica casting asdemonstrated by our study. Thecause of this shift in management isoutside the scope of this study butwarrants further investigation. Theselect studies comparing spica castingversus flexible nailing in childrenaged 4 to 5 years are limited by theirretrospective design and inadequatefollow-up. Both spica casting andflexible nailing are adequate treat-ment options, each with relativeadvantages and disadvantages. Cur-rently, treatment decisions are madebased on surgeon preference, familypreference, radiographic parameters,and potential socioeconomic varia-bles. The results of this study dem-onstrate a clear national paradigmshift in the management of closedfemoral shaft fractures in 4- and5-year-old patients, but additionalprospective studies with adequatefollow-up and appropriate clinicaland radiographic outcomes are neededto investigate whether this shift to-ward more surgical managementmay actually lead to better patientoutcomes.

References

Evidence-based Medicine: Levels ofevidence are described in the table ofcontents. In this article, references 5,21, and 22 are level II studies. Ref-erences 1, 2, 4, 6, 12, 13, 16-20, and26-28 are level III studies. References23 and 24 are level IV studies.

References printed in bold type arethose published within the past 5years.

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2. Sahlin Y: Occurrence of fractures in adefined population: A 1-year study. Injury1990;21:158-160.

3. McCartney D, Hinton A, Heinrich SD:Operative stabilization of pediatric femurfractures. Orthop Clin North Am 1994;25:635-650.

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9. American Academy of OrthopaedicSurgery: Treatment of PediatricDiaphyseal Femur Fractures Evidenced-Based Clinical Practice Guideline. 2015.http://www.aaos.org/research/guidelines/PDFF_ReIssue.pdf. AccessedJanuary 6, 2017.

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13. Heffernan MJ, Gordon JE, Sabatini CS,et al: Treatment of femur fractures inyoung children: A multicentercomparison of flexible intramedullarynails to spica casting in young childrenaged 2 to 6 years. J Pediatr Orthop 2015;35:126-129.

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17. von Heideken J, Svensson T, Blomqvist P,Haglund-Åkerlind Y, Janarv PM:Incidence and trends in femur shaftfractures in Swedish children between1987 and 2005. J Pediatr Orthop 2011;31:512-519.

18. Dodwell E, Wright J, Widmann R, Edobor-Osula F, Pan TJ, Lyman S: Socioeconomicfactors are associated with trends intreatment of pediatric femoral shaftfractures, and subsequent implant removalin New York state. J Pediatr Orthop 2016;36:459-464.

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