Systematic review of spica casting for the treatment of paediatric diaphyseal femur fractures

Abstract

Purpose

Paediatric femur fractures are commonly encountered and often successfully managed with spica casting. Despite spica casting's long history there is little formal guidance for optimal outcomes and no consolidation of existing literature. The purpose of this study is to review the available literature regarding the use of spica casting for the management of paediatric diaphyseal femur fractures.

Methods

The PubMed database was queried for all research articles including the phrase “spica”. A total of 788 abstracts were reviewed for relevance to the current study. Data was extracted from all available research studies which specified tolerance for fracture angulation or shortening in the cast. Additionally, all articles describing alternative materials, methods for spica application, and complications of spica casting were reviewed.

Results

In all, 106 articles were found relevant to the management of diaphyseal femur fractures in the paediatric population. The aggregated, accepted fracture shortening decreased from 16 mm to 18 mm before age ten years to 12 mm to 14 mm after puberty. Aggregated, accepted angulation decreased from 14° to 16° varus/valgus and 18° to 22° pro/recurvatum before age two years, to 6° to 8° and 10° to 12° by puberty, respectively. The overall reported complication rate was 19.6%, with the most common complication being skin compromise in 8.2% of patients, followed by unacceptable angulation at the fracture site in 4.2% of patients and excessive limb shortening in 1.9% of patients.

Conclusion

This article reviews the available spica casting literature and compiles the available data. Spica casting offers a safe, effective means for definitive management of paediatric diaphyseal femur fractures. Future research identifying the rate and pattern of remodelling as it relates to angulation and shortening at various patient ages, particularly beyond the aforementioned norms, would be valuable to identify true biological tolerances versus accepted expert opinion.

Level of evidence Level II

Review of level II evidence

Keywords

Spica cast femur fracture casting child adolescent

Introduction

Hip spica casting has been a widely used, effective method for the nonoperative management of paediatric diaphyseal femur fractures for over 80 years.¹ With an estimated 1.6% of children sustaining a femur fracture, femur fractures represent the third most common lower extremity fracture.² Among North American paediatric orthopaedic surgeons, spica casting is overwhelmingly the preferred management for patients less than six years old with any diaphyseal femur fractures, excluding polytrauma.³ The most recent American Academy of Orthopaedic Surgery guidelines for the treatment of diaphyseal femur fractures recommends the use of spica casting for children between six months and five years old with < 20 mm of fracture shortening.⁴ However, we were unable to identify any comprehensive review of available literature on spica casting.

The purpose of this systematic literature review is to consolidate the English language literature and present the best evidence for the use of spica casting in the management of paediatric diaphyseal femur fractures.

Literature search

A comprehensive PubMed search was performed to identify all English-language articles relating to spica casting of diaphyseal femur fractures. An initial search was performed for all articles containing the word “spica” from 1900 until March of 2017, which generated 788 results. Titles and abstracts were reviewed for relevance to the current study. Only English-language articles relating to hip and femur fractures were included for detailed evaluation. All others (e.g. thumb or shoulder spica, adult hip fracture and developmental dysplasia of the hip) were excluded. We additionally pursued all references of reviewed articles to further identify relevant literature. We selected 106 articles which met inclusion criteria and were related to the current topic.

Overview of the literature

Limb immobilization for the treatment of fracture has been dated as far back as the Ancient Egyptians, based on archaeological discoveries of wooden sticks surrounding a preserved mummy with a femur fracture.⁵ The development of plaster impregnated fabric strips which allowed the modern techniques of splinting and casting has been attributed to Mathijsen in 1851.⁶ Applying and maintaining controlled traction specifically to femur fractures may have originated with the Thomas splint, developed in 1865, and was popularized during World War I.⁷ These splints were for adults and were valued for their relative ease of application, enablement of patient transportation and in some instances allowed for patient ambulation. The earliest article we could find specifically mentioning hip spica casting for paediatric femur fractures was by Moore and Shafer,¹ who described a fixed traction spica in 1948. Dameron and Thompson⁸ provided the first available detailed description of spica casting application and short-term outcomes in 1959. Since these initial articles, five randomized control trials,^9–13 37 cohort studies,^1,14–50 37 retrospective reviews,^8,51–86 13 technique articles,^87–99 and three guidelines^4,100,101 have been published relating to the use of spica casting in paediatric diaphyseal femur fractures. This review focuses on three major aspects of over five decades of literature: 1) fracture position tolerance to prevent unacceptable limb alignment; 2) complications associated with spica casts; and 3) technique and material recommendations. Also included in this review are other notable spica cast concepts that do not fall within those main categories.

Fracture position tolerance

Traction and shortening

The degree of acceptable shortening in paediatric diaphyseal femur fractures has been the topic of academic interest since Aitken's 1940 article⁵¹ detailing the significant overgrowth phenomenon seen in long-term follow-up of paediatric femur fractures treated with traction. We found 53 articles identifying their shortening tolerance at initial casting or at follow-up.^{8,9,12–21,23,25–27,29–31,36,38,39,41,42,45–48,50,53,55,56,60,62–67,69, 71,73,74,76,79–83,89,97,100,102,103} The most recent (2009) American Academy of Orthopaedic Surgeons Guidelines for the management of diaphyseal femur fractures in the paediatric population is to use spica casting for those with < 2 cm of shortening.⁴ The mean and sd of all studies which specified their tolerances is shown in Figure 1. Tolerance values for the initial casting versus the final measurements at follow-up were evaluated separately, but found to have < 0.2 cm difference at all ages (data not shown). This aggregated analysis shows that throughout the literature, 17 mm to 18 mm shortening tolerance was acceptable until age ten years, with acceptable shortening decreasing to between 12 mm to 14 mm at the age of puberty and beyond. The rates of final shortening which exceeded acceptable limits were too low in any reported study to identify initial fracture shortening which correlated with increased rates of unacceptable shortening at final radiographic or clinical follow-up.

Fig. 1

Limb shortening limitations determined to be radiographically or clinically acceptable. Combined tolerances from 52 primary research studies.

Overgrowth phenomenon

Aitken⁵¹ identified the phenomenon that the shortened, fractured femurs of young children may outgrow the uninjured side. Our review is not intended to review the overgrowth phenomenon, but Hariga et al's⁶² review determined that overgrowth is more influenced by initial shortening than factors such as age, gender, treatment or type of fracture. Femoral overgrowth tends to peak in the first 18 months following fracture.^43,71 In patients younger than two years old, Nork et al showed that the average overgrowth in long-term follow-up was 5 mm.⁷³ Three long-term, follow-up studies have shown the average overgrowth to be between 9.6 mm and 13 mm.^51,62,71 Frech-Dorfler et al,⁶¹ in the longest available follow-up which looks at overgrowth, showed that in unstable fractures with an initial average shortening of 12 mm, 59.1% of patients had < 0.25 cm leg-length discrepancy and only one patient (4.5%) had a persistent leg-length discrepancy > 1 cm which was due to excessive overgrowth and not shortening at 7.5 year follow-up.

Angulation in the frontal and sagittal planes

We found 35 articles specifying accepted varus or valgus angulation^{8,9,11,13–16,18–21,23,25–27,29–31,36,38,41,45,47,48,53,55,56,60,65,69,74, 79,80,82,102} and 34 articles specifying the accepted sagittal plane angulation^{8,9,11,13–16,18–21,23,25–27,29,30,36,38,41,45,47,48,53,55, 60,65,69,74,76,79,80,82,102}. Figure 2 displays the mean and sd of accepted varus/valgus angulation at initial casting based on patient age. Approximately 16° varus or valgus is accepted for patients under two years old, decreasing to 6° for adolescents treated with a spica cast. Figure 3 displays the accepted angulation in the sagittal plane. Again, a general trend exists of less accepted deformity with increasing age, although at all ages the sagittal plane tolerance is greater than the frontal plane tolerance. It should be emphasized that these graphs represent only each author's preference. There are no longitudinal studies that have followed patients to correlate angular deformity to eventual femur alignment or leg length equality at skeletal maturity.

Fig. 2

Aggregated accepted coronal plane radiographic angulation (varus/valgus) from 35 primary research articles.

Fig. 3

Aggregated accepted sagittal plane radiographic angulation (procurvatum/recurvatum) from 33 primary research articles.

Complications

Minor complications

The most commonly reported complication from spica casting for paediatric femur fractures has been skin breakdown and other skin complications. Table 1 summarizes the complications of spica cast treatment identified in studies over the last ten years which specified the total number of patients in the studies and addressed complications. Only studies from 2007 to 2017 were included to minimize the effect of older techniques for casting, traction and materials. The most commonly reported radiographic complication was excessive final angulation; however, very few authors report long-term outcomes to provide insight whether the angulation remains purely radiographically substantial or represents a clinically significant complication resulting in limb length discrepancy, pain or re-fracture. The rate of cast removal or revision varied widely among studies and the reasons were inconsistently reported. Some authors reported increased angulation as a complication but did not specify whether this was detected at an early visit and accepted, or developed too late in the course to consider revision casting. Due to the inconsistent clarity of indications for re-casting, as well as the lack of long-term outcome studies showing clinical implications of the various unacceptable radiographic positioning assessments, we noted there is inadequate data to recommend a specific angulation or shortening as a tolerance limit.

Table 1

Compilation of all complications specified in randomized control trials, cohort studies, or retrospective reviews 2007 to 2017

		Complication type
Author	Number of patients	Return to OR	Shortening	Angulation	Skin	Wedging	Refracture	Cast breakage/soiling*	Rare
Ramo et al (2016)⁷⁷	158	7	4	2	1		1
Rapp et al (2016)⁷⁸	50				2
Jaafar et al (2016)⁶⁵	94	2	8	13	17	3	1
Heffernan et al (2015)⁶³	141	4			3
Memisoglu et al (2015)³⁸	16
Say et al (2014)⁸⁰	20		1	2	3
Catena et al (2014)⁵⁶	34			4
Ruhullah et al (2014)¹¹	25			1	3			n = 1 breakage
Sela et al (2013)⁸¹	151		7	10	12
Leu et al (2012)¹¹⁴	52		1	1
Flynn et al (2011)²⁵	45	3		2		6
Shemshaki et al (2011)¹⁰	23			3
DiFazio et al (2011)⁵⁸	300			5	77			n = 24 soiling
Mansour et al (2010)⁶⁹	100	6		26	13	10		n = 5 soiling, n = 1 breakage
Jauquir et al (2010)⁶⁶	19				2
Frech-Dorfler et al (2010)⁶¹	40	1			3
Hsu et al (2009)¹³	25				2
d'Ollonne et al (2009)²¹	35		1	3	2	1
Akhasin et al (2009)¹⁴	47				1	5
Wilson et al (2007)⁸⁵	46							2	Peroneal nerve palsy (1)
Lee et al (2007)⁶⁸	63
Esenyel et al (2007)²²	207		6		1		2
Epps et al (2006)⁶⁰	45		5			3		n = 5 breakage
	1736	23	33	72	142	28	4	38
		1.32%	1.90%	4.15%	8.18%	1.61%	0.23%	2.19%

requiring reapplication of cast

Devastating complications

Severe complications of spica casting in children, while rare, are noted in multiple case series in the literature. One author noted superior mesenteric artery syndrome in a 10-year-old female¹⁰⁴ and, subsequently, techniques for abdominal windows^93,96 and casting with adequate abdominal space to incorporate room for expansion during inhalation^89,91 have been described to avoid this specific complication. Mubarak et al¹⁰⁵ detailed a series of nine patients who developed compartment syndrome of the lower extremity in 90/90 spica casts fabricated with the below-knee cast portion used to impart traction on the femur while the above-knee cast portion was molded. This author recommended casting the hip and knee both at 45°, not elevating the cast, and not applying traction on the below-knee cast portion during application of the cast after reduction of the fracture. While no large cohort or retrospective studies in paediatric spica casting have suggested baseline rates of compartment syndrome or superior mesenteric artery syndrome, the techniques used in casting should be targeted at avoiding these rare, but serious, complications.

Techniques

In 1981, Kumar¹⁰⁶ described and illustrated what most orthopaedists would probably consider representative of modern standard spica cast fabrication technique. While his work is well cited, there are variations proposed in literature. A detailed description of the multiple relatively minor modifications described is beyond the scope of this review. Broadly, these variations include optimal positioning of patients during casting,^32,88,90,91 techniques to prevent soilage,^30,95 variations in home-care for spica-casted patients,^92,98 and materials used in the casting process.^99,107

Traction

In all, 51 articles specifically mentioned the use or non-use traction in their description of spica application and the course of patient care. Of the articles detailing the use of traction, seven specifically had no traction,^{12,15,23,25,27,61,103} 12 used isolated skin traction,^{20–22,35,36,46,48,53,59,62,68,76} and 19 used skeletal traction on some, if not all, of their patients via a Kirschner wire applied to either the distal femur,^{10,18,19,24,33,38,41,57,64,67,72,80,94} proximal tibia^13,26,45,97 or unspecified pin location.^52,82 Eight retrospective reviews had patients within their cohorts who had received either skin traction or skeletal traction,^{17,34,40,56,64,82,86,102} but no direct comparison was made between these two treatment options. Overall, in the last ten years, authors have preferred either no traction or skeletal traction, with only three articles^21,62,68 explicitly using skin traction.

Double-leg versus single-leg spica casting

There are multiple variations on the extent of casting needed for adequate femoral fixation when using a spica cast for primary management. In 1976, Irani et al³⁰ recommended not incorporating the foot into the spica cast, suggesting that pressure against the foot plate increases femoral shortening. Four articles have studied the use of less-restrictive spica casting in the paediatric population. Leu et al¹² performed a randomized controlled trial comparing single-leg versus double-leg casts in 52 patients which showed similar rates of fracture shortening, angulation and time in cast, but found that single-leg patients had improved fit in car seats and lower caregiver burden. Flynn et al²⁵ compared single-leg casts to double-leg casts with the single-leg group having increased rate of wedge adjustment (26% versus 4%) but decreased malunion (0% versus 8%), both statistically significant, and a similar need for repeat spica casting (5% versus 8%).²⁵ Epps et al⁶⁰ reviewed single-leg casting and reported that five of 45 patients’ casts failed at the hip joint and an additional five of 45 patients had shortening requiring recasting or operation; one additional patient fell sustaining a contralateral tibia fracture without shortening or increased angulation of either fracture three years later. Jaafar et al⁶⁵ showed similar rates for repeat reduction or cast wedging in single-leg versus double-leg casting. Overall, the rates of complication and acceptable radiographic outcome appear similar in all head-to-head comparisons of single-leg casts versus double-leg spica casting in the treatment of paediatric diaphyseal femur fractures.

Materials and mechanics

In all, 19 articles specifically mentioned the use or non-use of a cross-bar in their applications of the spica casting. Bar materials include wood,^22,29,40,108 fiberglass^12,89 and plaster¹ while the remainder of studies do not use a bar.^{14,19,25,28,35,44,55,60,74,87,90,106}

We found no studies comparing the failure rates, need for cast changes or cost between fiberglass spica casts and plaster-based casts in the treatment of paediatric diaphyseal femur fractures. However, Walter et al⁹⁹ suggests that using Gore-Tex liner (Newark, Delaware) instead of standard cotton may result in fewer cast changes for soilage, based on its use in extremity fractures.¹⁰⁹

Wan et al¹¹⁰ performed a biomechanical analysis of the strength of Kumar's standard spica application versus their proposed method incorporating strut wraps beneath the hips of the patient imparting increased stiffness and load-to-failure at the hip joint. This was a purely mechanical study and no patient outcomes or comparisons were reported.

Parental care

Few articles detail care of the children from the perspective of the parents or other caregivers. Common parental complaints and difficulty with management of these patients include how to maintain routine child washing, prevent cast soilage from excretion, manage the increased weight of the child in the cast and transportation.^29,44,92 Leu et al¹² and Flynn et al²⁵ surveyed parents or caregivers about their experience in double-leg versus single-leg spica casts and one-and-a-half leg versus walking cast, respectively. In both studies, the parents preferred the less restrictive of the two casts. The walking cast had a significantly lower Impact on Family Score compared with the one-and-a-half cast, while the single-leg cast resulted in fewer parent days off work, easier patient transport, and increased ease of sitting when compared with the two-leg cast.

Comparison to operative techniques

Common operative options for paediatric diaphyseal femur fractures include plating, flexible titanium nails and even conventional intramedullary nails for taller or heavier children. Comparing the surgical outcomes with one another and with spica casting is beyond the scope of the current article. A notable randomized control trial by Shemshaki et al¹⁰ showed that parents of older children, aged six to 12 years, preferred elastic nails over spica casting.

Summary

The spica cast has been used as a definitive treatment option for paediatric diaphyseal femur fractures since the mid-20^th century and remains an indispensable skill for an orthopaedist. A Cochrane review was published in 2014 of ten randomized and quasi-randomized controlled trials of diaphyseal femur fracture management in patients under age 18 years.¹¹¹ Seven studies were on operative options, and three reported on nonoperative care. One author¹¹² noted 4/21 children immediately placed in a spica cast had shortening or excessive angulation whereas only 1/21 children did who had skin traction before spica casting; this difference was not significant. Another author¹¹³ found 6/15 patients treated with a functional brace and 11/27 patients treated with a spica cast had radiographic malunion at five years (not significantly different) and both groups had a mean hospitalization of 26 days. The third author¹¹⁴ compared single- versus double-leg casts and was discussed elsewhere in our review. The authors of the Cochrane review assessed the quality of their evidence to be low for most outcomes measured and did not find adequate support to make guidelines or specific recommendations for nonoperative care. In this situation of insufficient prospective trial data, along with the most recent comprehensive review of nonoperative management techniques of paediatric femur fractures being over 15 years old, we felt it valuable to provide an updated assessment and interpretation of available literature.

Excessive radiographic shortening or angulation as defined in each reviewed study is a complication in 6.1% of patient based on our compiled data. Clinically significant adverse outcomes as patients grow, while lacking data from literature, likely represent an even smaller proportion of those who had radiographically unacceptable outcomes. With the currently available data, we find it difficult to identify specific tolerance limits for varus/valgus, procurvatum/recurvatum or shortening, but we were able to review what has been acceptable radiographically in each year of life to help inform future consensus. Our review does suggest that for patients under ten years old, 10° to 20° of angulation in any plane and 10 mm to 20 mm of shortening are consistent with published tolerances and can be expected to have < 10% rate of radiographic ‘failure’ and even lower rates of clinically significant complication. Variations in technique and home care may allow for easier, more durable and cost-effective treatment of these fractures. The devastating and common complications of spica casting treatment are reviewed and some recommendations exist for complication avoidance, but there is a scarcity of clinical evidence behind these recommendations.

Spica casting for the management of diaphyseal paediatric femur fractures continues to be a mainstay of modern orthopaedic management despite the push for operative management of paediatric fractures. This review investigates the available literature for the use of spica casting for the definitive management of diaphyseal femur fractures in the paediatric population.

Footnotes

Open access

This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed.

Compliance with Ethical Standards

References

Moore

, Schafer

. Treatment of simple fractures of the shaft of the femur by a fixed traction spica; a preliminary report. N C Med J 1948; 9: 514–519.

James

H Beaty

.; Kasser

J. R.

Rockwood & Wilkins’ Fractures in children. Sixth ed. Postgraduate medicine. Baltimore: Lippincott Williams & Wilkins, 2006.

Sanders

, Browne

, Mooney

, et al. Treatment of femoral fractures in children by pediatric orthopedists: results of a 1998 survey. J Pediatr Orthop 2001; 21: 436–441.

Kocher

, Sink

, Blasier

, et al. Treatment of paediatric diaphyseal femur fractures. J Am Acad Orthop Surg 2009; 17: 718–725.

Blomstedt

. Orthopedic surgery in ancient Egypt. Acta Orthop 2014; 85: 670–676.

De Maio

, McHale

, Lenhart

, et al. Plaster: our orthopaedic heritage: AAOS exhibit selection. J Bone Joint Surg [Am] 2012; 94-A: e152.

Robinson

, O'Meara

. The Thomas splint: its origins and use in trauma. J Bone Joint Surg [Br] 2009; 91-B: 540–544.

Dameron

Jr , Thompson

. Femoral-shaft fractures in children. Treatment by closed reduction and double spica cast immobilization. J Bone Joint Surg [Am] 1959; 41-A: 1201–1212.

Wright

, Wang

, Owen

, et al. Treatments for paediatric femoral fractures: a randomised trial. Lancet 2005; 365: 1153–1158.

10.

Shemshaki

, Mousavi

, Salehi

, Eshaghi

. Titanium elastic nailing versus hip spica cast in treatment of femoral-shaft fractures in children. J Orthop Traumatol 2011; 12: 45–48.

11.

Ruhullah

, Singh

, Shah

, Shrestha

. Primary hip spica with crossed retrograde intramedullary rush pins for the management of diaphyseal femur fractures in children: a prospective, randomized study. Niger Med J 2014; 55: 111–115.

12.

Leu

, Sargent

, Ain

, et al. Spica casting for paediatric femoral fractures: a prospective, randomized controlled study of single-leg versus double-leg spica casts. J Bone Joint Surg [Am] 2012; 94-A: 1259–1264.

13.

Hsu

, Diaz

, Penaranda

, et al. Dynamic skeletal traction spica casts for paediatric femoral fractures in a resource-limited setting. Int Orthop 2009; 33: 765–771.

14.

Akşahin

, Celebi

, Yüksel

, et al. Immediate incorporated hip spica casting in pediatric femoral fractures: comparison of efficacy between normal and high-risk groups. J Pediatr Orthop 2009; 29: 39–43.

15.

Allen

Jr , Schoch

III , Emery

. Immediate spica cast system for femoral shaft fractures in infants and children. South Med J 1978; 71: 18–22.

16.

Allen

Jr , Kant

, Emery

. Displaced fractures of the femoral diaphysis in children. Definitive treatment in a double spica cast. J Trauma 1977; 17: 8–19.

17.

Casas

, Gonzalez-Moran

, Albiñana

Femoral fractures in children from 4 years to 10 years: conservative treatment. J Pediatr Orthop B 2001; 10: 56–62.

18.

Celiker

, Cetin

, Sahlan

, Pestilci

, Altuğ

Femoral shaft fractures in children: technique of immediate treatment with supracondylar Kirschner wires and one-and-a-half spica cast. J Pediatr Orthop 1988; 8: 580–584.

19.

Curtis

, Killian

, Alonso

. Improved treatment of femoral shaft fractures in children utilizing the pontoon spica cast: a long-term follow-up. J Pediatr Orthop 1995; 15: 36–40.

20.

Czertak

, Hennrikus

. The treatment of paediatric femur fractures with early 90-90 spica casting. J Pediatr Orthop 1999; 19: 229–232.

21.

d'Ollonne

, Rubio

, Leroux

, et al. Early reduction versus skin traction in the orthopaedic treatment of femoral shaft fractures in children under 6 years old. J Child Orthop 2009; 3: 209–215.

22.

Esenyel

, Oztürk

, Adanir

, et al. Skin traction in hip spica casting for femoral fractures in children. J Orthop Sci 2007; 12: 327–333.

23.

Ferguson

, Nicol

. Early spica treatment of pediatric femoral shaft fractures. J Pediatr Orthop 2000; 20: 189–192.

24.

Flynn

, Luedtke

, Ganley

, et al. Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg [Am] 2004; 86-A: 770–777.

25.

Flynn

, Garner

, Jones

, et al. The treatment of low-energy femoral shaft fractures: a prospective study comparing the “walking spica” with the traditional spica cast. J Bone Joint Surg [Am] 2011; 93-A: 2196–2202.

26.

Gracilla

, Diaz

, Penaranda

, et al. Traction spica cast for femoral-shaft fractures in children. Int Orthop 2003; 27: 145–148.

27.

Henderson

, Morrissy

, Gerdes

, McCarthy

. Early casting of femoral shaft fractures in children. J Pediatr Orthop 1984; 4: 16–21.

28.

Hougaard

. Femoral shaft fractures in children: a prospective study of the overgrowth phenomenon. Injury 1989; 20: 170–172.

29.

Infante

Jr , Albert

, Jennings

, Lehner

. Immediate hip spica casting for femur fractures in paediatric patients. A review of 175 patients. Clin Orthop Relat Res 2000; 376: 106–112.

30.

Irani

, Nicholson

, Chung

. Long-term results in the treatment of femoral-shaft fractures in young children by immediate spica immobilization. J Bone Joint Surg [Am] 1976; 58-A: 945–951.

31.

Jamaludin

. Femoral shaft fracture in children treated by early hip spica cast: early result of a prospective study. Med J Malaysia 1995; 50: 72–75.

32.

Keren

, Sadia

, Eidelman

. The use of the lotus position during spica cast application for the treatment of developmental dysplasia of the hip: a technical note. Orthopedics 2011; 34: 708–709.

33.

Kesemenli

, Subasi

, Arslan

, et al. Is external fixation in paediatric femoral fractures a risk factor for refracture? J Pediatr Orthop 2004; 24: 17–20.

34.

Kohan

, Cumming

. Femoral shaft fractures in children: the effect of initial shortening on subsequent limb overgrowth. Aust N Z J Surg 1982; 52: 141–144.

35.

Malkawi

, Shannak

, Hadidi

. Remodeling after femoral shaft fractures in children treated by the modified blount method. J Pediatr Orthop 1986; 6: 421–429.

36.

Martinez

, Carroll

, Sarwark

, et al. Femoral shaft fractures in children treated with early spica cast. J Pediatr Orthop 1991; 11: 712–716.

37.

Martin-Ferrero

, Sanchez-Martin

. Prediction of overgrowth in femoral shaft fractures in children. Int Orthop 1986; 10: 89–93.

38.

Memisoglu

, Atmaca

, Kesemenli

. Treatment of femur fractures in preschool children with double pin technique: immediate incorporated hip spica casting by two K-wires. Indian J Surg 2015; 77: 635–639.

39.

Mesmar

, Amarin

, Akram

. Early spica cast for fracture shaft of femur in children: the north of Jordan experience. Eur J Orthop Surg Traumatol 2010; 20: 475–478.

40.

Miller

, Bramlett

, Kissell

, Niemann

. Improved treatment of femoral shaft fractures in children. The “pontoon” 90-90 spica cast. Clin Orthop Relat Res 1987; 219: 140–146.

41.

Şahin

, Baktir

, Türk

, Karakaş

, Aktaş

Femoral shaft fractures in children treated by closed reduction and early spica cast with incorporated supracondylar Kirschner wires: a long-term follow-up results. Injury 1999; 30: 121–128.

42.

Saseendar

, Menon

, Patro

. Treatment of femoral fractures in children: is titanium elastic nailing an improvement over hip spica casting? J Child Orthop 2010; 4: 245–251.

43.

Shapiro

. Fractures of the femoral shaft in children. The overgrowth phenomenon. Acta Orthop Scand 1981; 52: 649–655.

44.

Shesser

, Kling

Jr . Practical considerations in caring for a child in a hip spica cast: an evaluation using parental input. Orthop Nurs 1986; 5: 11–15.

45.

Splain

, Denno

. Immediate double hip spica immobilization as the treatment for femoral shaft fractures in children. J Trauma 1985; 25: 994–996.

46.

Staheli

, Sheridan

. Early spica cast management of femoral shaft fractures in young children. A technique utilizing bilateral fixed skin traction. Clin Orthop Relat Res 1977; 126: 162–166.

47.

Sugi

, Cole

. Early plaster treatment for fractures of the femoral shaft in childhood. J Bone Joint Surg [Br] 1987; 69-B: 743–745.

48.

Thompson

, Buehler

, Sponseller

, et al. Shortening in femoral shaft fractures in children treated with spica cast. Clin Orthop Relat Res 1997; 338: 74–78.

49.

Wolff

, James

. The prevention of skin excoriation under children's hip spica casts using the goretex pantaloon. J Pediatr Orthop 1995; 15: 386–388.

50.

Wong

, Boyd

, Keenan

, et al. Gait patterns after fracture of the femoral shaft in children, managed by external fixation or early hip spica cast. J Pediatr Orthop 2004; 24: 463–471.

51.

Aitken

. Overgrowth of the femoral shaft following fracture in children. Am J Surg 1940; 49: 147–148.

52.

Allison

, Dahan-Oliel

, Jando

, Yang

, Hamdy

. Open fractures of the femur in children: analysis of various treatment methods. J Child Orthop 2011; 5: 101–108.

53.

Buehler

, Thompson

, Sponseller

, et al. A prospective study of early spica casting outcomes in the treatment of femoral shaft fractures in children. J Pediatr Orthop 1995; 15: 30–35.

54.

Buess

, Kaelin

. One hundred paediatric femoral fractures: epidemiology, treatment attitudes, and early complications. J Pediatr Orthop B 1998; 7: 186–192.

55.

Cassinelli

, Young

, Vogt

, Pierce

, Deeney

. Spica cast application in the emergency room for select paediatric femur fractures. J Orthop Trauma 2005; 19: 709–716.

56.

Catena

, Sénès

, Riganti

, Boero

. Diaphyseal femoral fractures below the age of six years: results of plaster application and long term followup. Indian J Orthop 2014; 48: 30–34.

57.

Clinkscales

, Peterson

. Isolated closed diaphyseal fractures of the femur in children: comparison of effectiveness and cost of several treatment methods. Orthopedics 1997; 20: 1131–1136.

58.

DiFazio

, Vessey

, Zurakowski

, Hresko

, Matheney

. Incidence of skin complications and associated charges in children treated with hip spica casts for femur fractures. J Pediatr Orthop 2011; 31: 17–22.

59.

Edvardsen

, Syversen

. Overgrowth of the femur after fracture of the shaft in childhood. J Bone Joint Surg [Br] 1976; 58-B: 339–342.

60.

Epps

, Molenaar

, O'Connor

. Immediate single-leg spica cast for paediatric femoral diaphysis fractures. J Pediatr Orthop 2006; 26: 491–496.

61.

Frech-Dörfler

, Hasler

, Häcker

F-M

. Immediate hip spica for unstable femoral shaft fractures in preschool children: still an efficient and effective option. Eur J Pediatr Surg 2010; 20: 18–23.

62.

Hariga

, Mousny

, Docquier

P-L

. Leg length discrepancy following femoral shaft fracture in children: clinical considerations and recommendations. Acta Orthop Belg 2011; 77: 782–787.

63.

Heffernan

, Gordon

, Sabatini

, 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: 126–129.

64.

Illgen

II , Rodgers

, Hresko

, et al. Femur fractures in children: treatment with early sitting spica casting. J Pediatr Orthop 1998; 18: 481–487.

65.

Jaafar

, Sobh

, Legakis

, et al. Four weeks in a single-leg weight-bearing hip spica cast is sufficient treatment for isolated femoral shaft fractures in children aged 1 to 3 years. J Pediatr Orthop 2016; 36: 680–684.

66.

Jauquier

, Doerfler

, Haecker

, et al. Immediate hip spica is as effective as, but more efficient than, flexible intramedullary nailing for femoral shaft fractures in pre-school children. J Child Orthop 2010; 4: 461–465.

67.

Jeng

, Sponseller

, Yates

, Paletta

. Subtrochanteric femoral fractures in children. Alignment after 90 degrees-90 degrees traction and cast application. Clin Orthop Relat Res 1997; 341: 170–174.

68.

Lee

YHD

, Lim

, Gao

, et al. Traction and spica casting for closed femoral shaft fractures in children. J Orthop Surg (Hong Kong) 2007; 15: 37–40.

69.

Mansour

AAS

III , Wilmoth

, Mansour

, et al. Immediate spica casting of pediatric femoral fractures in the operating room versus the emergency department: comparison of reduction, complications, and hospital charges. J Pediatr Orthop 2010; 30: 813–817.

70.

Meals

. Overgrowth of the femur following fractures in children: influence of handedness. J Bone Joint Surg [Am] 1979; 61-A: 381–384.

71.

Nordin

, Ros

, Faisham

. Clinical measurement of longitudinal femoral overgrowth following fracture in children. Singapore Med J 2001; 42: 563–565.

72.

Nork

, Hoffinger

. Skeletal traction versus external fixation for pediatric femoral shaft fractures: a comparison of hospital costs and charges. J Orthop Trauma 1998; 12: 563–568.

73.

Nork

, Bellig

, Woll

, Hoffinger

. Overgrowth and outcome after femoral shaft fracture in children younger than 2 years. Clin Orthop Relat Res 1998; 357: 186–191.

74.

Pidgeon

, Schiller

. Preliminary report: the long leg cast with a pelvic band. Pediatr Emerg Care 2017; 33: 329–333.

75.

Podeszwa

, Mooney

III , Cramer

, Mendelow

. Comparison of Pavlik harness application and immediate spica casting for femur fractures in infants. J Pediatr Orthop 2004; 24: 460–462.

76.

Pollak

, Cooperman

, Thompson

. Spica cast treatment of femoral shaft fractures in children–the prognostic value of the mechanism of injury. J Trauma 1994; 37: 223–229.

77.

Ramo

, Martus

, Tareen

, 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: 267–275.

78.

Rapp

, Kaiser

, Grauel

, Gielok

, Illing

. 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: 719–724.

79.

Reeves

, Ballard

, Hughes

. Internal fixation versus traction and casting of adolescent femoral shaft fractures. J Pediatr Orthop 1990; 10: 592–595.

80.

Say

, Gürler

, Inkaya

, Yener

, Bülbül

. Which treatment option for paediatric femoral fractures in school-aged children: elastic nail or spica casting? Eur J Orthop Surg Traumatol 2014; 24: 593–598.

81.

Sela

, Hershkovich

, Sher-Lurie

, Schindler

, Givon

. Pediatric femoral shaft fractures: treatment strategies according to age–13 years of experience in one medical center. J Orthop Surg 2013; 8: 23.

82.

Song

, Oh

, Shin

, et al. Treatment of femoral shaft fractures in young children: comparison between conservative treatment and retrograde flexible nailing. J Pediatr Orthop B 2004; 13: 275–280.

83.

Soomro

, Kella

. Femoral shaft fractures in children treated by early spica cast. J Surg Pak 2008; 13: 103–106.

84.

Stans

, Morrissy

, Renwick

. Femoral shaft fracture treatment in patients age 6 to 16 years. J Pediatr Orthop 1999; 19: 222–228.

85.

Wilson

, Stott

. Paediatric femoral fractures: factors influencing length of stay and readmission rate. Injury 2007; 38: 931–936.

86.

Yandow

, Archibeck

, Stevens

, Shultz

. Femoral-shaft fractures in children: a comparison of immediate casting and traction. J Pediatr Orthop 1999; 19: 55–59.

87.

Charnley

. Improved short hip-spica cast. Lancet 1965; 2: 575.

88.

Buckley

, Sturm

, Buck

, Robertson

Jr . Upper extremity restraint during hip spica cast application. J Pediatr Orthop 1993; 13: 529–530.

89.

Chaudhry

, Kang

, Lee

. Reinforcing a spica cast with a fiberglass bar. Am J Orthop (Belle Mead NJ) 2015; 44: E423–E426.

90.

Fraser

. The hammock suspension technique for hip spica cast application in children. J Pediatr Orthop 1995; 15: 27–29.

91.

Gill

IPS

, Kolimarala

, Montgomery

. Application of hip spica cast using a box-and-bar technique. Ann R Coll Surg Engl 2008; 90: 700.

92.

Holland

. Up-to-date home care of a baby in a hip spica cast. Pediatr Nurs 1983; 9: 114–115.

93.

Kiter

, Demirkan

, Kiliç

, Erkula

. A new technique for creating an abdominal window in a hip spica cast. J Orthop Trauma 2003; 17: 442–443.

94.

McCarthy

. A method for early spica cast application in treatment of pediatric femoral shaft fractures. J Pediatr Orthop 1986; 6: 89–91.

95.

Pick

, Segal

. The pediatric spica cast: a sex-related modification. Clin Orthop Relat Res 1981; 154: 338–339.

96.

Sharma

, Azzopardi

. Reduction of abdominal pressure for prophylaxis of the mesenteric artery syndrome (cast syndrome) in a hip spica–a simple technique. Ann R Coll Surg Engl 2006; 88: 317.

97.

Spinner

, Freundlich

, Miller

. Double-spica technic for primary treatment of fractures of the shaft of the femur in children and adolescents. Clin Orthop Relat Res 1967; 53: 109–114.

98.

Streissguth

, Streissguth

. Planning for the psychological needs of a young child in a double spica cast. Including a plan for construction of a scooter. Clin Pediatr (Phila) 1978; 17: 277–283.

99.

Walter

, Holroyd

, Metcalfe

. Avoiding the unsanitary hip spica. Ann R Coll Surg Engl 2009; 91: 267.

100.

Flynn

, Schwend

. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004; 12: 347–359.

101.

Greene

. Displaced fractures of the femoral shaft in children. Unique features and therapeutic options. Clin Orthop Relat Res 1998; 353: 86–96.

102.

Theologis

, Cole

. Management of subtrochanteric fractures of the femur in children. J Pediatr Orthop 1998; 18: 22–25.

103.

Stannard

, Christensen

, Wilkins

. Femur fractures in infants: a new therapeutic approach. J Pediatr Orthop 1995; 15: 461–466.

104.

Chen

, Chen

, Chuang

. Superior mesenteric artery syndrome as a complication in hip spica application for immobilization: report of a case. J Formos Med Assoc 1992; 91: 731–733.

105.

Mubarak

, Frick

, Sink

, Rathjen

, Noonan

. Volkmann contracture and compartment syndromes after femur fractures in children treated with 90/90 spica casts. J Pediatr Orthop 2006; 26: 567–572.

106.

Kumar

. Hip spica application for the treatment of congenital dislocation of the hip. J Pediatr Orthop 1981; 1: 97–99.

107.

BSN Medical. Application manual hip spica cast for hip spica application two-way quick dry system, 2011. http://www.bsnmedical.us/fileadmin/z-countries/South_Africa/downloads/PDF/Delta-Dry_Hip_Spica_Application.pdf (date last accessed 8 February 2018).

108.

Hosalkar

, Jones

, Chowdhury

, Chatoo

, Hill

. Connecting bar for hip spica reinforcement: does it help? J Pediatr Orthop B 2003; 12: 100–102.

109.

Haley

, De Jong

, Ward

, Kragh

Jr . Waterproof versus cotton cast liners: a randomized, prospective comparison. Am J Orthop (Belle Mead NJ) 2006; 35: 137–140.

110.

Wan

, Shanmugam

, Lee

, Saw

. Comparing the mechanical strength of hip spica cast between a conventional and a new method of application. J Child Orthop 2016; 10: 387–394.

111.

Madhuri

, Dutt

, Gahukamble

, Tharyan

. Interventions for treating femoral shaft fractures in children and adolescents. Cochrane Database Syst Rev 2014; CD009076.

112.

Siddiqui

, Pirwani

, Naz

, Rehman

, Soomro

. Skin traction followed by spica cast versus early spica cast in femoral shaft fractures of children. Pak J Surg 2008; 24: 38–41.

113.

Malo

, Grimard

, Morin

. Treatment of diaphyseal femoral fractures in children: a clinical study. Ann Chir 1999; 53: 728–734.

114.

Leu

, Sargent

, Ain

, et al. Spica casting for pediatric femoral fractures: a prospective, randomized controlled study of single-leg versus double-leg spica casts. J Bone Joint Surg [Am] 2012; 94-A: 1259–1264.