Spica Casting Results in More Unplanned Reoperations than Elastic Intramedullary Nailing: A National Analysis of Femur Fractures in the Preschool Population

Background: Spica casting and elastic stable intramedullary nailing (ESIN) are treatment options for femur fractures in preschool-age children. Clinical practice guidelines are only of moderate or limited strength, which may lead to variation in practice. The purpose of this study was to compare the revision surgery rate in young children undergoing these procedures. Methods: The Pediatric Health Information System, a database of 49 children hospitals, was queried for patients aged 3 to 6 years undergoing spica casting or ESIN for a diaphyseal femur fracture. ESIN removal was not considered an unplanned revision surgery because the indication for removal could not be determined in the database. Univariate analysis was followed by multivariate regression. Results: Analysis included 4,059 subjects with a mean age of 3.9 ± 1.1 years. Unplanned revision surgery was done in 227/2,878 children (8%) with a spica cast and 35/1,181 (3%) of those with ESIN (P< 0.01). Approximately 2% of children in each cohort underwent ESIN or open reduction and internal fixation as a revision procedure (P = 0.35). In multivariate analysis, spica casting resulted in 4.4 times higher odds of unplanned revision surgery than ESIN (95% confidence interval [CI], 2.9-6.7; P< 0.01). In the spica cast cohort, each year of increasing age resulted in 1.3 times higher odds of revision surgery (95% CI, 1.1-1.6; P< 0.01). Children who were aged 5 or 6 years at the time of spica casting had 1.9 times higher odds of requiring a subsequent procedure compared with 3- and 4-year-olds (95% CI, 1.3-2.7; P< 0.01). Conclusions: In this large, nationally representative cohort, spica casting resulted in higher odds of requiring an unplanned revision surgery than ESIN, when nail removal was not included as an unplanned procedure. Spica casting in 5- and 6-year-olds yielded higher odds of revision surgery. Regardless of whether spica casting or ESIN is chosen as the initial treatment, 2% of patients will subsequently undergo ESIN or open reduction and internal fixation as a revision procedure.