Dr. Matt Schmitz, JBJS Deputy Editor for Social Media, shares his thoughts on a new Level I study that compares the use of a prefabricated brace versus a spica cast in the treatment of pediatric femoral fractures.
The American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines recommend spica casting for most pediatric femoral fractures in patients between the ages of 6 months and 5 years. We have transitioned from routinely using double-leg spica casts to single-leg, but spica casts still present hygiene and transportation-related challenges in the care of young patients, with skin complications being another area of concern. In addition, spica casts are routinely placed in the operating room, with an associated increased cost, need for anesthesia, and potential delays due to OR availability.
Could comparable outcomes be achieved through treatment with functional bracing? Andras et al. investigated this question in a randomized prospective study conducted at 2 pediatric trauma centers—Children’s Hospital of Los Angeles and Children’s Hospital of Colorado. Their study is in the current issue of The Journal.
Specifically, the researchers evaluated functional bracing using prefabricated braces compared with spica casting in treating diaphyseal femoral fractures in children aged 6 months to 5 years. And they found that braces provide a viable alternative. You can find the study and related visual abstract at JBJS.org:
Eighty patients were included, with 40 receiving spica casts and 40 treated with functional braces. Excluded were patients with polytrauma, medical comorbidities affecting healing, and those with <6 weeks of follow-up. The mean age of participants was similar in both groups, approximately 2 years. Radiographic assessments indicated no significant differences in femoral shortening, varus angulation, or procurvatum between the 2 groups at the initial examination and at the 6-week follow-up. This suggests that both treatment methods yield comparable outcomes in terms of fracture healing.
However, the study did reveal some differences in complications and functional outcomes. The bracing group experienced more superficial skin issues compared with the casting group (9 versus 1), although all skin problems were resolved with local care. Patients in the casting group had more difficulty with independent movement (median score on the parent questionnaire, 8 of 10 versus 5 of 10 in the bracing group). Importantly, a significantly higher percentage of patients in the bracing group could fit into their car seats (86% compared to 40% in the casting group), highlighting a crucial advantage in terms of transportation.
At the 1-year follow-up, the study maintained its focus on radiographic and functional outcomes. Both groups demonstrated similar results in femoral shortening and varus angulation, with a slight difference in procurvatum favoring the bracing group. Parent-reported satisfaction remained high for both treatments, with no significant differences in overall satisfaction scores. The bracing group had a significantly better mean score for pain on the Pediatric Outcomes Data Collection Instrument (PODCI), with no other differences between the groups in PODCI scores.
The study supports the idea that bracing can achieve outcomes equivalent to those of spica casting, while reducing the burden on patients and their families. The findings suggest that the advantages of bracing—including ease of application, avoidance of anesthesia exposure, and improved mobility—may make it a promising option for pediatric fracture management.
Further research is needed to optimize the treatment protocols and potentially enhance the quality of care for young patients with femoral fractures. In addition, future research could explore the relative costs of treatment in more detail, to further elucidate the potential value of using a brace versus spica cast for pediatric femoral fractures.
It is exciting to see well-conducted Level I research into topics that have been treated the “same way” for years. Helping to improve care for all of our patients is critical, and if we’re able to lessen the burden on parents and caregivers of young patients with fractures, that’s important, too.
Read the full study: A Prospective, Randomized Comparison of Functional Bracing and Spica Casting for Femoral Fractures Showed Equivalent Early Outcomes
JBJS Deputy Editor for Social Media