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 52^nd 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.^3–5 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.^6–18

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.^2,19–21 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%).

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.

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).

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)

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).

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.

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Appendix 1

ICD 10 Coding for Diagnoses and Procedures