Original Research


Trends in the Management of Femur Fractures in Young Children

Kian Niknam, MAS1; Andrew Gatto, BA2; Ishaan Swarup, MD3

1School of Medicine, University of California San Francisco, San Francisco, CA; 2California College of Osteopathic Medicine, Touro University, Vallejo, CA; 3Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA

Correspondence: Ishaan Swarup, MD, University of California, San Francisco, 747 52nd St., OPC First Floor, Oakland, CA 94609. E-mail: [email protected]

Received: July 22, 2023; Accepted: October 15, 2023; Published: November 15, 2023

DOI: 10.55275/JPOSNA-2023-766

Volume 5, Number 4, November 2023

Abstract

Background: Femoral shaft fractures in young children are commonly treated with closed reduction and spica casting; however, there is increasing literature and interest focusing on internal fixation. This study aims to assess trends in the management of femoral shaft fractures in patients under the age of 6.

Methods: This is a retrospective study utilizing the Pediatric Health Information System (PHIS) database. We queried for patients aged 1 to 6 years who had an isolated, closed femoral shaft fracture from October 2015 to December 2020. ICD10 procedure codes were used to determine treatment of the injury. Descriptive statistics and tests of trend were utilized in the analysis of this study.

Results: We identified 4608 patients with a femoral shaft fracture during the study period. The majority of patients were treated with spica casting (n=3398, 73.7%), followed by intramedullary fixation (n=600, 13.0%) and plate osteosynthesis (n=449, 9.7%). In this cohort, 3236 patients were between the ages of 1-3 years, and 1372 patients were between the ages of 4-6 years. There was a significant difference in management between these two age groups with lower rates of spica casting in older patients (92.1% vs. 30.5%) and higher rates of intramedullary fixation (37.3% vs. 2.7%) and plate osteosynthesis (28.2% vs. 1.9%) (p<0.01). There was a significant correlation with increasing rates of intramedullary fixation and plate osteosynthesis from 2016 to 2020 (p=0.03 and 0.01, respectively), and a decrease in rate of spica casting over time (p=0.04).

Conclusion: Femur fractures in young children are treated with spica casting, intramedullary nails, and plate osteosynthesis. There is a significant change in management over time, and children between the ages of 4 and 6 are more likely to be treated with intramedullary nails compared to younger children. Additional studies are needed to understand these trends as well as justify the increase in rates of intramedullary nails and plate osteosynthesis in young children.

Level of Evidence: Level III; Retrospective Cohort Comparison using Large Database

Key Concepts

  • Historically, spica casting was the gold standard for femur fracture treatment in younger patients.
  • There has been recent interest in the utilization of internal fixation for treatment of femur fractures in young children.
  • The use of intramedullary nails and plate osteosynthesis in young patients with femur fractures has increased by 34% and 25%, respectively, from 2015 to 2020.
  • Spica casting has remained the main treatment option for patients aged 1-3.
  • Intramedullary nails and plate osteosynthesis have been used increasingly over time for patients aged 4-6.

Introduction

Femoral shaft fractures account for nearly 2% of all pediatric fractures, and it is the second-most common fracture of the lower extremity.1,2 These fractures commonly occur in young children and may be challenging to treat due to fracture pattern and patient age.35 The management of this fracture in young children has traditionally been closed reduction and spica casting, which has shown excellent results.4,5 Original clinical practice guidelines from the American Academy of Orthopaedic Surgeons (AAOS) also suggested closed reduction and spica casting for diaphyseal femur fractures in patients between 6 months and 5 years of age with less than 2 cm of fracture shortening.5 However, there is emerging research and increasing interest in internal fixation for this younger age group.618

Internal fixation has become an increasingly popular option in pediatric femur fractures, though there is little consensus on its use in children under 6 years of age.2,1921 Updated clinical practice guidelines from the AAOS in 2015 continued to favor spica casting, though indicated that both treatment options may be appropriate.22 In practice, internal fixation may be considered for young patients with open injuries, length unstable fracture patterns, or the poly-traumatized patient.23 Despite guidelines, there has been a significant increase in the use of internal fixation and surgery in patients under the age of 11.24 Closed reduction and spica casting may offer lower complication rates and cost; however, it may result in increased recovery time, risk of skin irritation, compartment syndrome, and increased familial and social burden.17,25 Internal fixation has the benefit of earlier ambulation, shorter hospital stay, and lower rates of malunion and leg length discrepancy.21,26 However, significant limitations of internal fixation include the risk of infection, cost, and need for hardware removal.21,27

There is a growing body of literature focusing on operative management of diaphyseal femur fractures in young children.9,21,24,28 However, there are no large studies focusing on trends of management in young patients. This study aims to assess the trends in the management of femoral shaft fractures in patients between the ages of 1 and 6 years over time, as well as assess factors associated with management.

Methods

Patients were identified using the Pediatric Health Information System (PHIS). The PHIS database is an administrative database containing inpatient, emergency department, ambulatory, surgery, and observation encounter data from approximately 50 large, tertiary pediatric hospitals throughout the United States.29 These hospitals are affiliated with the Children’s Hospital Association, which assures data reliability amongst participating hospitals.

This study included patients between the ages of 1 and 6 years with international classification of diseases (ICD-10) diagnosis codes corresponding with a femoral shaft fracture and a corresponding ICD-10 procedure code (Appendix 1) between October 2015 and December 2020.

Demographic data such as race, ethnicity, sex, and age were obtained from the PHIS database. Race was standardized to White, Black, Asian, or Other. Ethnicity was made a binary variable reflecting Hispanic or non-Hispanic. Age was collected both as a continuous variable, as well as a binary variable defined as ages 1-3 vs. ages 4-6 years.

Given that the data was collected starting October 2015 at the inception of ICD-10 coding, we only included years 2016-2020 when assessing trends over time.

Descriptive statistics were used to summarize the data contained in the PHIS database. Student’s t-tests, Chi-squared tests, Mann-Kendall tests, and Fisher-exact tests were used, as appropriate, to summarize the data and assess trends of pediatric femur fracture management. We utilized STATA/SE 15.1 for all data analysis (StataCorp LP, College Station, TX).

Results

A total of 4608 patients were identified as having femoral shaft fractures between October 2015 and December 2020. The average age of our patient population was 2.9 years (SD: 1.6), with the majority of the patients being White, non-Hispanic males (Table 1). The most common type of treatment was spica casting (73.7%), followed by intramedullary nailing (13.0%) and plate osteosynthesis (9.7%).

Table 1. Demographics and Management Strategies for Pediatric Femoral Shaft Fractures in PHIS from 2016-2020

Pediatric Femoral Shaft Fractures
N 4608
Age yrs (mean, SD) 2.9 (1.6)
Age Group (%)
1-3 3236 (70.2)
4-6 1372 (29.8)
Sex
Male 3390 (73.7)
Female 1211 (26.3)
Race (%)
White 3031 (67.9)
Black 810 (18.1)
Asian 100 (2.2)
Other 524 (11.7)
Ethnicity (%)
Hispanic 784 (17.8)
Non-Hispanic 3416 (82.3)
Year (%)
2015 269 (5.8)
2016 1031 (22.4)
2017 944 (20.5)
2018 830 (18.0)
2019 807 (17.5)
2020 727 (15.8)
Treatment (%)
Spica Casting 3398 (73.7)
Intramedullary Nail 600 (13.0)
Plate Osteosynthesis 449 (9.7)
Splint 59 (1.3)
External Fixation 17 (0.4)
Brace 4 (0.1)
Other 81 (1.8)

When assessing overall trends in management among the entire cohort from 2016-2020, a significant decline in the use of spica casting was noted (Tau-b=−0.03, p=0.04), while there was an increase in the use of intramedullary nails (Tau-b= 0.03, p<0.01) and plate osteosynthesis (Tau-b=0.03, p=0.02) (Figure 1A). Rates of external fixation were also noted to significantly increase over time from 0.1% in 2016 to 1.2% in 2020 (Tau-b=0.05, p<0.01). There was no significant change in rates of bracing over time (Tau-b=0.00, p=0.83).

Figure 1. Trends in the use of spica casting, intramedullary nails, and plate osteosynthesis in pediatric diaphyseal femur fractures. (A) Ages 1-6, (B) Ages 1-3, (C) Ages 4-6.

jposna2023766_fig1.jpg

Trends were further stratified based on age. Among patients aged 1-3 years, spica casting was the most common management ranging from 89.8% to 94.1% of total femur fracture cases from 2016-2020, although the trend was not statistically significant (Tau-b=0.01, p-value=0.40). Similarly, trends in intramedullary nail use and plate osteosynthesis were not statistically significant but were noted to increase over the study period (Table 2) (Figure 1B). There was a significant increase in the use of external fixation, however, its utilization ranged from 0.0 to 1.0% of cases (Tau-b=0.06, p-value=0.01). Patients aged 4-6 years were managed most commonly by intramedullary nailing, ranging from 34.4-42.1% of cases. There was an increase in rate of intramedullary nailing and decrease in spica casting over time, although these changes were not statistically significant (p-value= 0.25 and 0.13, respectively) (Table 2) (Figure 1C).

Table 2. Trends in Pediatric Femoral Shaft Fracture Management by Age

2016 2017 2018 2019 2020 Tau-b p-value
All Ages
 Spica Casting 749 (72.6) 738 (78.2) 621 (74.8) 589 (73.0) 503 (69.2) −0.03 0.04
 Intramedullary Nail 133 (12.9) 101 (10.7) 104 (12.5) 112 (13.9) 115 (15.8) 0.03 0.03
 Plate Osteosynthesis 93 (9.0) 79 (8.4) 87 (10.5) 84 (10.4) 88 (12.1) 0.03 0.01
 Splint 24 (2.3) 7 (0.7) 10 (1.2) 9 (1.1) 5 (0.7) −0.04 0.01
 External Fixation 1 (0.1) 2 (0.2) 0 (0.0) 3 (0.4) 9 (1.2) 0.05 <0.01
 Brace 1 (0.1) 1 (0.1) 0 (0.0) 1 (0.1) 1 (0.1) 0.00 0.83
 Other 30 (2.9) 16 (1.7) 8 (1.0) 9 (1.1) 6 (0.8) −0.05 <0.01
Ages: 1-3
 Spica Casting 654 (89.8) 652 (93.9) 542 (94.1) 522 (93.4) 434 (90.4) 0.01 0.40
 Intramedullary Nail 19 (2.6) 15 (2.2) 13 (2.3) 19 (3.4) 11 (2.3) 0.01 0.75
 Plate Osteosynthesis 15 (2.1) 11 (1.6) 6 (1.0) 6 (1.1) 23 (4.8) 0.03 0.05
 Splint 18 (2.5) 6 (0.9) 9 (1.6) 6 (1.1) 4 (0.8) −0.04 0.31
 External Fixation 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 5 (1.0) 0.06 0.01
 Brace 1 (0.1) 1 (0.1) 0 (0.0) 1 (0.2) 1 (0.2) 0.00 0.80
 Other 21 (2.9) 9 (1.3) 6 (1.0) 4 (0.7) 2 (0.4) −0.06 <0.01
Ages 4-6
 Spica Casting 95 (31.4)  86 (34.4) 79 (31.1) 67 (27.0) 69 (27.9) −0.04 0.13
 Intramedullary Nail 114 (37.6) 86 (34.4) 91 (35.8) 93 (37.5) 104 (42.1) 0.03 0.25
 Plate Osteosynthesis 78 (25.7) 68 (27.2) 81 (31.9) 78 (31.5) 65 (26.3) 0.02 0.47
 Splint 6 (2.0) 1 (0.4) 1 (0.4) 3 (1.2) 1 (0.4) 0.04 0.15
 External Fixation 1 (0.3) 2 (0.8) 0 (0.0) 2 (0.8) 4 (1.6) 0.04 0.12
 Brace 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
 Other 9 (3.0) 7 (2.8) 2 (0.8) 5 (2.0) 4 (0.6) −0.03 0.19

When comparing patients between the ages of 1-3 and 4-6 years, a significant difference in management options was noted (p<0.01). Spica casting was the most common management for femoral shaft fractures amongst patients aged 1-3 years (92.1%) while intramedullary nails were most commonly used in patients aged 4-6 years (37.1%) (p-value <0.01). Spica casting and plate osteosynthesis were the second and third most common treatment modalities, respectively, in patients aged 4-6 years (Table 3). There was a significant change in management for patients aged 4-6 years over the study period with an increase in the use of intramedullary nails compared to spica casts (p<0.01)

Table 3. Demographic and Management Differences for Pediatric Femoral Shaft Fractures by Age

Age 1-3 yrs Age 4-6 yrs p-value
N 3037 1302
Sex 0.02
Male 2272 (74.9) 928 (71.4)
Female 760 (25.1) 372 (28.6)
Race (%) 0.11
White 2023 (68.6) 838 (66.8)
Black 543 (17.3) 267 (20.2)
Asian 69 (2.2) 31 (2.4)
Other 382 (12.2) 142 (10.8)
Ethnicity (%) 0.38
Hispanic 562 (18.1) 222 (17.0)
Non-Hispanic 2539 (81.9) 1082 (83.0)
Year (%) 0.02
2015 199 (6.2) 70 (5.1)
2016 728 (22.5) 303 (22.1)
2017 694 (21.5) 250 (18.2)
2018 576 (17.8) 254 (18.5)
2019 559 (17.3) 248 (18.1)
2020 480 (14.8) 247 (18.0)
Treatment (%) <0.01
Spica Casting 2980 (92.1) 418 (30.5)
Intramedullary Nail 88 (2.7) 512 (37.3)
Plate Osteosynthesis 62 (1.9) 387 (28.2)
Splint 46 (1.4) 13 (0.9)
External Fixation 8 (0.3) 9 (0.7)
Brace 4 (0.1) 0 (0.0)
Other 48 (1.5) 33 (2.4)

There were significant differences in treatment between males and females as well (Table 4). When assessing trends, males had significant changes in the use of splints and external fixation over the study period (Tau-b=−0.04, p=0.01 and tau-b= 0.04, p=0.01; respectively). In females, the rate of spica casting decreased over time (Tau-b= −0.06, p=0.02), and the rates of intramedullary nails and external fixation increased over time (Tau-b=0.06, p=0.04 and Tau-b=0.06, p=0.02, respectively).

Table 4. Demographic and Management Differences for Pediatric Femoral Shaft Fractures by Sex

Male Female p-value
N 3390 1211
Age Group (%) 0.010
1-3 yrs 2416 (71.3) 815 (67.3)
4-6 yrs 974 (28.7) 396 (32.7)
Race (%) <0.001
White 2293 (69.7) 735 (62.8)
Black 559 (17.0) 248 (21.2)
Asian 62 (1.9) 38 (3.3)
Other 374 (11.4) 149 (12.7)
Ethnicity (%) 0.59
Hispanic 581 (18.0) 201 (17.3)
Non-Hispanic 2653 (82.0) 963 (82.7)
Year (%) 0.25
2015 190 (5.6) 79 (6.5)
2016 782 (23.1) 247 (20.4)
2017 701 (20.7) 243 (20.1)
2018 596 (17.6) 234 (19.3)
2019 582 (17.2) 222 (18.3)
2020 539 (15.9) 186 (15.4)
Treatment (%) <0.01
Spica Casting 2564 (75.6) 830 (68.5)
Intramedullary Nail 398 (11.7) 201 (16.6)
Plate Osteosynthesis 316 (9.3) 132 (10.9)
Splint 40 (1.2) 19 (1.6)

Discussion

There is increasing literature and growing interest in the use of internal fixation for femoral shaft fractures in young children. In this study, we found that even though spica casting continues to remain the most common method of treatment for these fractures, the rates of intramedullary fixation and plate osteosynthesis are increasing over time in those 6 years old and younger. There was a 25% increase in the use of intramedullary nails over the study period (12.9% to 15.8%). Similarly, there was an over 33% increase in the use of plate osteosynthesis (9% to 12.1%). The change from spica casting towards these other modalities was most significant in patients between the ages of 4 and 6 years.

There may be several factors that explain these trends. Operative management gives the benefit of earlier mobilization and weight-bearing with potentially lower rates of malunion and leg length discrepancy.12,13,21,26 Moreover, one study showed that spica casting was 4.4 times more likely to require unplanned revision due to loss of reduction compared to fixation and this risk increased with patient age.30 Aside from clinical outcomes, quicker recovery with operative management may be associated with improved physical and social development while reducing familial burden.26,31 It is important to note that both modalities are subject to their respective complications and costs, and these are important factors to consider.12,13 Additional studies are needed to determine indications for intramedullary fixation in this patient population as well as understand patient clinical and radiographic outcomes.

Our findings are consistent with other studies on this topic. For example, Naranje et al. demonstrated in their 15-year assessment of trends in pediatric femoral fracture management using the Kids’ Inpatient Database (KID) that surgical management has become increasingly common in older patients.2 However, their study included patients from ages 0-17 years, and our study focused on specifically younger children that are traditionally managed with casting. Additionally, our study utilized the PHIS database, which provides continuous data, specifically from children’s hospitals, including pediatric trauma centers. It is possible that our rates are lower than national rates since we only included children’s hospitals; however, it is important that this trend is observed at specialized children’s hospitals.

This study has several limitations. This is a database study, and it is subject to errors in coding and classification. Additionally, the PHIS database gathers data from large, tertiary care referral pediatric hospitals, so the patient population it represents may not be generalizable to community or non-specialty hospitals.32,33 We are also unable to comment on indications for management or outcomes after surgery. Furthermore, only primary procedure codes were available for analysis, so it is possible that some patients underwent spica casting in addition to internal fixation, in which case, we would only have analyzed it based on the single primary code provided. Lastly, it is important to note the loss of statistical significance when assessing trends by age group. The likely reason for this is that the study may be further underpowered when stratifying the population further. Using the rates and trends shown in this study to achieve 80% power and at an alpha of 0.05 in ages 1-3 years, we would require at least 913 patients each year when assessing spica casting—1129 for intramedullary nails and 1095 for plate osteosynthesis.34,35

These estimations only increase with smaller differences between each year as is seen with spica casting trends in patients aged 1-3 years. Post-hoc power analysis shows we currently have a power of 78% which would only go down with stratifying the cohort by age group, especially in the 4-6 years group. Additionally, the differences in treatments in each age group do vary significantly, and it is possible that the ages 4-6 years group, for example, can be driving the significance we are seeing in spica casting, intramedullary nails, and plate osteosynthesis when looking at trends as a whole. As PHIS continues to be populated for the next 5-10 years and the sample size of this population grows, it would be beneficial to again assess trends and observe how these numbers and significance levels change.

Conclusion

In conclusion, there has been a significant increase in the use of internal fixation and significant decrease in the use of spica casting for the management of diaphyseal femur fractures in children ≤6 years old. Specifically, patients between the ages of 4 and 6 years are more likely to be managed with internal fixation. Additional multi-center studies are needed to validate these findings, investigate indications for management, and focus on clinical and radiographic outcomes.

Disclaimer

No funding was received. The authors report no conflicts of interest related to this manuscript.

References

  1. Joeris A, Lutz N, Blumenthal A, et al. The AO pediatric comprehensive classification of long bone fractures (PCCF). Acta Orthop. 2017;88(2):129-132.
  2. Naranje SM, Stewart MG, Kelly DM, et al. Changes in the treatment of pediatric femoral fractures: 15-year trends from United States Kids’ Inpatient Database (KID) 1997 to 2012. J Pediatr Orthop. 2016;36(7):e81-e85.
  3. Bassett WP, Safier S, Herman MJ, et al. Complications of pediatric femoral shaft and distal physeal fractures. Instr Course Lect. 2015;64:461-470.
  4. Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg. 2004;12(5):347-359.
  5. Kocher MS, Sink EL, Blasier RD, et al. Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg. 2009;17(11):718-725.
  6. Sink EL, Faro F, Polousky J, et al. Decreased complications of pediatric femur fractures with a change in management. J Pediatr Orthop. 2010;30:633-637.
  7. Flynn JM, Hresko T, Reynolds RA, et al. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop. 2001;21:4-8.
  8. Sigrist EJ, George NE, Koder AM, et al. Treatment of closed femoral shaft fractures in children aged 6 to 10. J Pediatr Orthop. 2019;39:e355-e359.
  9. Sanders JO, Browne RH, Mooney JF, et al. Treatment of femoral fractures in children by pediatric orthopedists: results of a 1998 survey. J Pediatr Orthop. 2001;21:436-441.
  10. Domb BG, Sponseller PD, Ain M, et al. Comparison of dynamic versus static external fixation for pediatric femur fractures. J Pediatr Orthop. 2002;22:428-430.
  11. Hedequist D, Starr AJ, Wilson P, et al. Early versus delayed stabilization of pediatric femur fractures: analysis of 387 patients. J Orthop Trauma. 1999;13:490-493.
  12. Ramo BA, Martus JE, Tareen N, et al. Intramedullary nailing compared with spica casts for isolated femoral fractures in four and five-year-old children. J Bone Joint Surg Am. 2016;98(4):267-275.
  13. Heffernan MJ, Gordon JE, Sabatini CS, et al. Treatment of femur fractures in young children: a multicenter comparison of flexible intramedullary nails to spica casting in young children aged 2 to 6 years. J Pediatr Orthop. 2015;35(2):126-129.
  14. Li Y, Hedequist DJ. Submuscular plating of pediatric femur fracture. J Am Acad Orthop Surg. 2012;20:596-603.
  15. Chen LK, Sullivan BT, Sponseller PD. Submuscular plates versus flexible nails in preadolescent diaphyseal femur fractures. J Child Orthop. 2018;12:488-492.
  16. Sink EL, Hedequist D, Morgan SJ, et al. Results and technique of unstable pediatric femoral fractures treated with submuscular bridge plating. J Pediatr Orthop. 2006;26:177-181.
  17. Lewis RB, Hariri O, Elliott ME, et al. Financial analysis of closed femur fractures in 3- to 6-year-olds treated with immediate spica casting versus intramedullary fixation. J Pediatr Orthop. 2019;39:e114-e119.
  18. Moroz LA, Launay F, Kocher MS, et al. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br. 2006;88:1361-1366.
  19. Alluri RK, Sabour A, Heckmann N, et al. Increasing rate of surgical fixation in four- and five-year-old children with femoral shaft fractures. J Am Acad Orthop Surg. 2019;27(1):e24-e32.
  20. Chen Z, Han D, Wang Q, et al. Four interventions for pediatric femoral shaft fractures: Network meta-analysis of randomized trials. Int J Surg. 2020;80:53-60.
  21. van Cruchten S, Warmerdam EC, Kempink DRJ, et al. Treatment of closed femoral shaft fractures in children aged 2-10 years: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2022;48:3409-3427.
  22. Jevsevar DS, Shea KG, Murray JN, et al. AAOS Clinical practice guideline on the treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg. 2015;23(12):e101.
  23. Devendra A, Nishith PG, Dilip Chand Raja S, et al. Current updates in management of extremity injuries in polytrauma. J Clin Orthop Trauma. 2021;12(1):113-122. Erratum in: J Clin Orthop Trauma. 2021;21:101559.
  24. Roaten JD, Kelly DM, Yellin JL, et al. Pediatric femoral shaft fractures: a multicenter review of the AAOS clinical practice guidelines before and after 2009. J Pediatr Orthop. 2019;39(8):394-399.
  25. Tisherman RT, Hoellwarth JS, Mendelson SA. Systematic review of spica casting for the treatment of paediatric diaphyseal femur fractures. J Child Orthop. 2018;12(2):136-144.
  26. Greisberg J, Bliss MJ, Eberson CP, et al. Social and economic benefits of flexible intramedullary nails in the treatment of pediatric femoral shaft fractures. Orthopedics. 2002;25(10):1067-1070.
  27. Barnett SA, Song BM, Yan J, et al. Intraoperative burden of flexible intramedullary nailing and spica casting for femur fractures in young children. J Pediatr Orthop. 2021;41(7):e499-e505.
  28. Rapp M, Kaiser MM, Grauel F, et al. Femoral shaft fractures in young children (<5 years of age): operative and non-operative treatments in clinical practice. Eur J Trauma Emerg Surg. 2016;42(6):719-724.
  29. Data Source: Pediatric Health Information Systems Database (PHIS). Children’s Hospital Association, Lenexa, KS. Available at: https://www.childrenshospitals.org/Programs-and-Services/Data-Analytics-and-Research/Pediatric-Analytic-Solutions/Pediatric-Health-Information-System.
  30. Brnjoš K, Lyons DK, Hyman MJ, et al. Spica casting results in more unplanned reoperations than elastic intramedullary nailing: a national analysis of femur fractures in the preschool population. J Am Acad Orthop Surg Glob Res Rev. 2020;4(10):e20.00169.
  31. Hughes BF, Sponseller PD, Thompson JD. Pediatric femur fractures: effects of spica cast treatment on family and community. J Pediatr Orthop. 1995;15(4):457-460.
  32. Tepolt FA, Feldman L, Kocher MS. Trends in pediatric ACL reconstruction from the PHIS database. J Pediatr Orthop. 2018;38(9):e490-e494.
  33. Hassan MM, Hussain ZB, Rahman OF, et al. Trends in adolescent hip arthroscopy from the PHIS database 2008-2018. J Pediatr Orthop. 2021;41(1):e26-e29.
  34. Nam JM. A simple approximation for calculating sample sizes for detecting linear trend in proportions. Biometrics 1987;43:701-705.
  35. Armitage P. Tests for linear trends in proportions and frequencies. Biometrics 1955;11:375-386.

Appendix 1

ICD 10 Coding for Diagnoses and Procedures

Diagnosis or Procedure ICD 10 code Description of code
Femoral Shaft Fracture
S72.326 Nondisplaced transverse fracture of shaft of unspecified femur
S72.356 Nondisplaced comminuted fracture of shaft of unspecified femur
S72.366 Nondisplaced segmental fracture of shaft of unspecified femur
S72.301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture
S72.302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture
S72.321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture
S72.322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72.323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture
S72.325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72.326A Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture
S72.332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture
S72.333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.334A Nondisplaced oblique fracture of shaft of right femur, initial encounter for closed fracture
S72.335A Nondisplaced oblique fracture of shaft of left femur, initial encounter for closed fracture
S72.336A Nondisplaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.341A Displaced spiral fracture of shaft of right femur, initial encounter for closed fracture
S72.342A Displaced spiral fracture of shaft of left femur, initial encounter for closed fracture
S72.343A Displaced spiral fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.344A Nondisplaced spiral fracture of shaft of right femur, initial encounter for closed fracture
S72.345A Nondisplaced spiral fracture of shaft of left femur, initial encounter for closed fracture
S72.346A Nondisplaced spiral fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.351A Displaced comminuted fracture of shaft of right femur, initial encounter for closed fracture
S72.352A Displaced comminuted fracture of shaft of left femur, initial encounter for closed fracture
S72.353A Displaced comminuted fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.354A Nondisplaced comminuted fracture of shaft of right femur, initial encounter for closed fracture
S72.355A Nondisplaced comminuted fracture of shaft of left femur, initial encounter for closed fracture
S72.356A Nondisplaced comminuted fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.361A Displaced segmental fracture of shaft of right femur, initial encounter for closed fracture
S72.362A Displaced segmental fracture of shaft of left femur, initial encounter for closed fracture
S72.363A Displaced segmental fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.364A Nondisplaced segmental fracture of shaft of right femur, initial encounter for closed fracture
S72.365A Nondisplaced segmental fracture of shaft of left femur, initial encounter for closed fracture
S72.366A Nondisplaced segmental fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture
S72.391A Other fracture of shaft of right femur, initial encounter for closed fracture
S72.392A Other fracture of shaft of left femur, initial encounter for closed fracture
S72.399A Other fracture of shaft of unspecified femur, initial encounter for closed fracture
Brace
2W3RX3Z Immobilization of Left Lower Leg using Brace
2W3PX3Z Immobilization of Left Upper Leg using Brace
2W3LX3Z Immobilization of Right Lower Extremity using Brace
Spica Casting
0PSGXZZ “Reposition Left Humeral Shaft, External Approach”
0QQ8XZZ “Repair Right Femoral Shaft, External Approach”
0QS6XZZ “Reposition Right Upper Femur, External Approach”
0QS7XZZ “Reposition Left Upper Femur, External Approach”
0QS8XZZ “Reposition Right Femoral Shaft, External Approach”
0QS9XZZ “Reposition Left Femoral Shaft, External Approach”
0QSBXZZ “Reposition Right Lower Femur, External Approach”
0QSCXZZ “Reposition Left Lower Femur, External Approach”
0QSGXZZ “Reposition Right Tibia, External Approach”
0SS9XZZ “Reposition Right Hip Joint, External Approach”
2W0LX2Z Change Cast on Right Lower Extremity
2W0MX2Z Change Cast on Left Lower Extremity
2W36X2Z Immobilization of Right Inguinal Region using Cast
2W39X2Z Immobilization of Left Upper Extremity using Cast
2W3LX2Z Immobilization of Right Lower Extremity using Cast
2W3MX2Z Immobilization of Left Lower Extremity using Cast
2W3NX2Z Immobilization of Right Upper Leg using Cast
2W3PX2Z Immobilization of Left Upper Leg using Cast
2W3QX2Z Immobilization of Right Lower Leg using Cast
2W3RX2Z Immobilization of Left Lower Leg using Cast
External Fixation
0QS935Z “Reposition Left Femoral Shaft with External Fixation Device, Percutaneous Approach”
0QS735Z “Reposition Left Upper Femur with External Fixation Device, Percutaneous Approach”
0QS73BZ “Reposition Left Upper Femur with Monoplanar External Fixation Device, Percutaneous Approach”
0QS835Z “Reposition Right Femoral Shaft with External Fixation Device, Percutaneous Approach”
0QS935Z “Reposition Left Femoral Shaft with External Fixation Device, Percutaneous Approach”
0QS905Z “Reposition Left Femoral Shaft with External Fixation Device, Open Approach”
0QS80BZ “Reposition Right Femoral Shaft with Monoplanar External Fixation Device, Open Approach”
0QS93DZ “Reposition Left Femoral Shaft with Hybrid External Fixation Device, Percutaneous Approach”
0QHC45Z “Insertion of External Fixation Device into Left Lower Femur, Percutaneous Endoscopic Approach”
0QS835Z “Reposition Right Femoral Shaft with External Fixation Device, Percutaneous Approach”
0QS235Z “Reposition Right Pelvic Bone with External Fixation Device, Percutaneous Approach”
0QS735Z “Reposition Left Upper Femur with External Fixation Device, Percutaneous Approach”
Plate Osteosynthesis
0QH804Z “Insertion of Internal Fixation Device into Right Femoral Shaft, Open Approach”
0QH834Z “Insertion of Internal Fixation Device into Right Femoral Shaft, Percutaneous Approach”
0QH904Z “Insertion of Internal Fixation Device into Left Femoral Shaft, Open Approach”
0QH934Z “Insertion of Internal Fixation Device into Left Femoral Shaft, Percutaneous Approach”
0QHC04Z “Insertion of Internal Fixation Device into Left Lower Femur, Open Approach”
0QP804Z “Removal of Internal Fixation Device from Right Femoral Shaft, Open Approach”
0QP904Z “Removal of Internal Fixation Device from Left Femoral Shaft, Open Approach”
0QS604Z “Reposition Right Upper Femur with Internal Fixation Device, Open Approach”
0QS644Z “Reposition Right Upper Femur with Internal Fixation Device, Percutaneous Endoscopic Approach”
0QS704Z “Reposition Left Upper Femur with Internal Fixation Device, Open Approach”
0QS734Z “Reposition Left Upper Femur with Internal Fixation Device, Percutaneous Approach”
0QS804Z “Reposition Right Femoral Shaft with Internal Fixation Device, Open Approach”
0QS80ZZ “Reposition Right Femoral Shaft, Open Approach”
0QS834Z “Reposition Right Femoral Shaft with Internal Fixation Device, Percutaneous Approach”
0QS904Z “Reposition Left Femoral Shaft with Internal Fixation Device, Open Approach”
0QS90ZZ “Reposition Left Femoral Shaft, Open Approach”
0QS934Z “Reposition Left Femoral Shaft with Internal Fixation Device, Percutaneous Approach”
0QSB04Z “Reposition Right Lower Femur with Internal Fixation Device, Open Approach”
0QSB34Z “Reposition Right Lower Femur with Internal Fixation Device, Percutaneous Approach”
0QSC04Z “Reposition Left Lower Femur with Internal Fixation Device, Open Approach”
0QSC34Z “Reposition Left Lower Femur with Internal Fixation Device, Percutaneous Approach”
0QSH34Z “Reposition Left Tibia with Internal Fixation Device, Percutaneous Approach”
0QSJ04Z “Reposition Right Fibula with Internal Fixation Device, Open Approach”
Intramedullary
0QH606Z “Insertion of Intramedullary Internal Fixation Device into Right Upper Femur, Open Approach”
0QH736Z “Insertion of Intramedullary Internal Fixation Device into Left Upper Femur, Percutaneous Approach”
0QH806Z “Insertion of Intramedullary Internal Fixation Device into Right Femoral Shaft, Open Approach”
0QH836Z “Insertion of Intramedullary Internal Fixation Device into Right Femoral Shaft, Percutaneous Approach”
0QH906Z “Insertion of Intramedullary Internal Fixation Device into Left Femoral Shaft, Open Approach”
0QH936Z “Insertion of Intramedullary Internal Fixation Device into Left Femoral Shaft, Percutaneous Approach”
0QHB36Z “Insertion of Intramedullary Internal Fixation Device into Right Lower Femur, Percutaneous Approach”
0QHC36Z “Insertion of Intramedullary Internal Fixation Device into Left Lower Femur, Percutaneous Approach”
0QS606Z “Reposition Right Upper Femur with Intramedullary Internal Fixation Device, Open Approach”
0QS636Z “Reposition Right Upper Femur with Intramedullary Internal Fixation Device, Percutaneous Approach”
0QS706Z “Reposition Left Upper Femur with Intramedullary Internal Fixation Device, Open Approach”
0QS736Z “Reposition Left Upper Femur with Intramedullary Internal Fixation Device, Percutaneous Approach”
0QS806Z “Reposition Right Femoral Shaft with Intramedullary Internal Fixation Device, Open Approach”
0QS846Z “Reposition Right Femoral Shaft with Intramedullary Internal Fixation Device, Percutaneous Endoscopic Approach”
0QS906Z “Reposition Left Femoral Shaft with Intramedullary Internal Fixation Device, Open Approach”
0QS936Z “Reposition Left Femoral Shaft with Intramedullary Internal Fixation Device, Percutaneous Approach”
0QSB06Z “Reposition Right Lower Femur with Intramedullary Internal Fixation Device, Open Approach”
0QSB36Z “Reposition Right Lower Femur with Intramedullary Internal Fixation Device, Percutaneous Approach”
0QSC06Z “Reposition Left Lower Femur with Intramedullary Internal Fixation Device, Open Approach”
0QSC36Z “Reposition Left Lower Femur with Intramedullary Internal Fixation Device, Percutaneous Approach”
0QSH06Z “Reposition Left Tibia with Intramedullary Internal Fixation Device, Open Approach”
0QS93ZZ “Reposition Left Femoral Shaft, Percutaneous Approach”
0QS63ZZ “Reposition Right Upper Femur, Percutaneous Approach”
0QS83ZZ “Reposition Right Femoral Shaft, Percutaneous Approach”
0Q883ZZ “Division of Right Femoral Shaft, Percutaneous Approach”
0QS83ZZ “Reposition Right Femoral Shaft, Percutaneous Approach”
Splint
2W38X1Z Immobilization of Right Upper Extremity using Splint
2W39X1Z Immobilization of Left Upper Extremity using Splint
2W3LX1Z Immobilization of Right Lower Extremity using Splint
2W3MX1Z Immobilization of Left Lower Extremity using Splint
2W3NX1Z Immobilization of Right Upper Leg using Splint
2W3PX1Z Immobilization of Left Upper Leg using Splint
2W3QX1Z Immobilization of Right Lower Leg using Splint
2W3RX1Z Immobilization of Left Lower Leg using Splint