Spica Cast Research Articles

Post-operative radiograph assessment of children undergoing closed reduction and spica cast immobilization for developmental dysplasia of the hip: does experience matter?

Closed reduction and spica cast immobilization are routinely used for young patients with developmental dysplasia of the hip with reducible hips. Our primary objective was to assess the interpretation quality of immediate post-operative pelvis radiographs after treatment. A series of 28 randomly selected patients (30 hips) with pre- and post-operative pelvis radiographs and post-operative magnetic resonance imaging were included. Each was presented twice with an interval of twoweeks, in alternating orders. Raters with different experience and specialties from different institutions rated the quality of reduction (hip in or out) after treatment. Thirteen surgeons and three radiologists evaluated 30 hips (28 patients). Agreement was not satisfactory (κ = 0.12). Experienced clinicians demonstrated similar agreement to inexperienced raters (κ = 0.04). Consistency at a twoweek interval was moderate (κ = 0.48, percent of agreement at 82%). The mean number of errors from the two ratings were 8.6 ± 2.5 and 8.9 ± 2.7, respectively (P = 0.72). There was no significant difference between surgeons with different levels of experience; radiologists did better than surgeons, but the difference was insignificant. Raters from different institutions had similar performance in poor judgment. Our results show poor concordance between observers and ratings. Post-operative radiographs are unreliable for assessing the quality of hip reduction. The level of experience, subspecialty, and geographical origin do not impact the radiographic assessment. Based on the present findings, we recommend performing post-operative magnetic resonance imaging rather than anteroposterior pelvis radiograph to assess the hip. Compared to standard radiographs, magnetic resonance imaging allows more reliable interpretation while decreasing radiation exposure.

PAEDIATRIC FEMUR FRACTURE

Objectives: To evaluate the outcome of retrograde flexible intramedullary nailsin treatment of paedriatic diaphyseal fractures in comparison with the traditional treatment ofimmediate hip spica cast. Hypothesis: We hypothesised that in children with femur fracturewho are managed with flexible intramedullary nails have better outcome in comparison tothose managed with immediate hip spica cast. Study Design: Randomized control trail. Place& Duration of Study: Lady Reading Hospital, Peshawar from June 2016 to October 2017.Methods: A group of forty-eight children aged 6-12 were randomly allocated either elasticintramedullary nail or immediate hip spica casting and were followed up to six months. Fracturealignment (coronal and sagittal angulation, leg length discrepancy), time for fracture union,recovery mile stones (time to start weight bearing with aids, independent walking, knee rangeof movement) and the presence of complications including surgical site infection were recordedand compared between two groups. Results: Children treated with elastic intramedullary nailsin comparison with those treated with immediate hip spica had early union (p<0.001), shortertime to start weight bearing with support or independently (p<0.001). Leg Length discrepancy(p<0.001), coronal and sagittal angulation (p<0.001 and p=0.02) was significantly higher in hipspica group. Difference observed between the two groups regarding knee range of movement(p=0.085) and surgical site infection (p=0.076) was not significant. Conclusion: Children aged6-12 years treated with elastic intramedullary nail for femoral diaphyseal fracture had earlierunion, reduced rate of shortening, malunion and allowed earlier rehabilitation.

RETROGRADE ELASTIC INTRAMEDULLARY NAILS VERSUS IMMEDIATE HIP SPICA CAST IN TREATMENT OF PAEDIATRIC FEMUR FRACTURE: A PROSPECTIVE, RANDOMIZED STUDY

Objectives: To evaluate the outcome of retrograde flexible intramedullary nailsin treatment of paedriatic diaphyseal fractures in comparison with the traditional treatment ofimmediate hip spica cast. Hypothesis: We hypothesised that in children with femur fracturewho are managed with flexible intramedullary nails have better outcome in comparison tothose managed with immediate hip spica cast. Study Design: Randomized control trail. Place& Duration of Study: Lady Reading Hospital, Peshawar from June 2016 to October 2017.Methods: A group of forty-eight children aged 6-12 were randomly allocated either elasticintramedullary nail or immediate hip spica casting and were followed up to six months. Fracturealignment (coronal and sagittal angulation, leg length discrepancy), time for fracture union,recovery mile stones (time to start weight bearing with aids, independent walking, knee rangeof movement) and the presence of complications including surgical site infection were recordedand compared between two groups. Results: Children treated with elastic intramedullary nailsin comparison with those treated with immediate hip spica had early union (p<0.001), shortertime to start weight bearing with support or independently (p<0.001). Leg Length discrepancy(p<0.001), coronal and sagittal angulation (p<0.001 and p=0.02) was significantly higher in hipspica group. Difference observed between the two groups regarding knee range of movement(p=0.085) and surgical site infection (p=0.076) was not significant. Conclusion: Children aged6-12 years treated with elastic intramedullary nail for femoral diaphyseal fracture had earlierunion, reduced rate of shortening, malunion and allowed earlier rehabilitation.

Single-Centered; Social Media Sharing After Cast and Splint Application of Orthopedic Patients

Objective: Using orthopedic splint and cast is a basic orthopedic treatment method after orthopedic fracture, dislocation and soft tissue injury. We want to examine the sharing of these orthopedic practices in social media areas and their results. Method: in a single-centered study; we asked about face-to-face questions at the controls of the patients who suffered from cast and splint. Patients were asked questions before we prepared. Results: 105 patients who participated in the study 61 were male (58.1%) and 44 were female (41.9%). The mean age of patients was 14.5 ± 42.2 years.35 patients had distal radius fracture and had short arm cast,42 patient had ankle soft tissue injury and had short leg splint,6 patient had ankle fracture and had short leg cast,20 patient had boxer fracture and had short arm splint,2 patient had humerus shaft fracture and had long arm cast.56(53.3%) patients had social media account. Thirty-two (57.1%) of the 56 patients shared cast and splint in the official social media. Conclusion: increasing use of social media and orthopedic treatments such as cast, and splint are shared in social media, unnecessary splint application is requested from patients. Some of the patients comes in control in a later date late due to social media sharing.

How to account for the drift of femur fractures in spica casts into varus and flexion

Purpose: Femur fractures in children 6 mos-5 years are frequently treated with spica casting. Surgical texts recommend molding spica casts into some valgus and recurvatum to counter deforming muscular forces, but how much overcorrection to aim for has not been evaluated. Our goal was to determine how much valgus and recurvatum is optimal at the time of casting to end up with anatomic alignment. Methods: Patients 1-6 years old with femur fractures treated with spica casts between 1/1/2008-1/31/2014 …

Molding Spica Casts to Maintain Alignment of Femur Fractures.

Femur fractures in young children are frequently treated with spica casting. Texts recommend molding spica casts into valgus and recurvatum to counter deforming muscular forces, but how much overcorrection to aim for has not been evaluated. Our goal was to determine how much valgus and recurvatum is optimal at the time of casting to end up with anatomic alignment. Patients 1 to 6 years old with femur fractures treated with spica casts between January 1, 2008 and January 31, 2014 who were followed until radiographic union were included in the study. Patients with underlying medical comorbidities affecting bone quality, refractures, or preexisting femur deformities or that did not have intraoperative imaging were excluded. A total of 52 patients met the inclusion criteria. Average intraoperative angulation was 2.6 degrees of valgus (range: 9 degrees varus to 13 degrees valgus, SD: 4.5) and 1.1 degrees of recurvatum (range: 10 degrees recurvatum to 17 degrees procurvatum, SD: 4.8). At the initial postoperative visit, the average angulation was 2.7 degrees of varus (range: 21 degrees varus to 11degrees valgus, SD: 6.4) and 7.2 degrees of procurvatum (range: 6 degrees recurvatum to 25 degrees procurvatum, SD: 6.6). At the time of radiographic union/wedging average angulation was 2.0 degrees of varus (range: 15 degrees varus to 10 degrees valgus, SD: 5.8) and 8.5 degrees of procurvatum (range: 5 degrees recurvatum to 29 degrees procurvatum, SD: 7.5). Between the intraoperative period to time of union or wedging, fracture alignment gained an average of 4.6 degrees of varus (range: 17 degrees varus to 13 degrees valgus, SD: 6.6) and 9.8 degrees of procurvatum (range: 8 degrees recurvatum to 30 degrees procurvatum, SD: 9.1). Seven patients underwent cast wedging due to loss of reduction before radiographic union, 2 patients underwent reoperation due to excessive angulation in the early postoperative period, and 5 patients developed malunions. Femur fractures treated with spica casts gain 5 degrees of varus and 10 degrees of procurvatum between cast application and fracture union. Level IV.

Titanium Elastic Nails Versus Spica Cast in Pediatric Femoral Shaft Fractures: A Systematic Review and Meta-analysis of 1012 Patients.

There is a general consensus on the management of femoral fractures in children younger than two years and adolescents older than sixteen years. The best treatment for patients younger than sixteen years of age is still debatable. Titanium Elastic Nails (TEN), is widely used with some evidence, nonetheless, we undertook a systematic meta-analysis to assess the efficacy of TEN compared to Spica cast for the management of femoral shaft fracture in children aged between 2 to 16 years old. A computer literature search of PubMed, Scopus, Web of Science, CINAHL and Cochrane Central was conducted using relevant keywords. We included clinical trials and observational studies that compared TEN versus Spica cast; Records were screened for eligible studies and data were extracted and synthesized using Review Manager version 5.3 for Windows. Our search found 573 unique articles. After screening the abstract and relevant full text, 12 studies with a total of 1012 patients were suitable for the final analysis. In terms terms of union (in weeks), the reported effect sizes favoured the TEN group in two included studies only. Moreover, the overall standardized mean difference in sagittal (SMD -0.48, 95% CI [-0.70 to -0.26], P<0.001) and coronal angulations (SMD -0.66, 95% CI [-1.00 to -0.31], P<0.001) favored TEN fixation in management of femoral fractures younger than 16 years. The reported length of hospital stay was not consistent across studies. The overall risk ratio of malalignment (RR=0.39, 95% CI [0.27 to 0.57], P<0.001) favored the TEN as well as walking independently. Based on our analysis, TEN treatment is superior to traction and hip spica for femoral fractures in patients younger than 16 years old. Based on our analysis we recommend the use of TEN fixation in management of pediatric femoral fractures in patients younger than 16 years.

Obesity Increases the Risk of Loss of Reduction After Casting for Displaced Pediatric Both Bone Forearm Fractures

Purpose Obesity is known to increase complication rates associated with various medical interventions including cast treatment for pediatric distal radius fractures. We theorize that higher body mass index (BMI) increases the risk of loss of reduction (LOR) following successful closed reduction (CR) and casting for displaced pediatric both bone forearm fractures (BBFFs). Methods We performed a retrospective cohort study of children aged 2 to 18 years with closed BBFFs treated at our tertiary care children’s hospital. Potential subjects treated between 2012 and 2015 were identified using ICD-9 codes. Only encounters where radiographic review showed ipsilateral ulnar …

Utility of immediate postoperative hip MRI in developmental hip dysplasia: closed vs. open reduction.

Magnetic resonance imaging (MRI) of the hips is being increasingly used to confirm hip reduction after surgery and spica cast placement for developmental dysplasia of the hip (DDH). To review a single institutional experience with post-spica MRI in children undergoing closed or open hip reduction and describe the utility of MRI in directing the need for re-intervention. Seventy-four patients (52 female, 22 male) who underwent post-spica hip MRI over a 6-year period were retrospectively reviewed. One hundred and seven hips were included. Data reviewed included age at intervention, gender, type of intervention performed, MRI findings, the need for re-intervention and the interval between interventions. Gender was compared between the closed and open reduction groups via the Fisher exact test. Age at the first procedure was compared via the Wilcoxon rank test. Rates of re-intervention after closed and open reduction were calculated and the reasons for re-intervention were reviewed. The mean age at the time of the first intervention was 16.4months (range: 4 to 63months). Mean age for the closed reduction group was 10.5months (range: 4-24months) and for the open reduction group was 23.7months (range: 5-63months), which was significant (P-value <0.0001). Of the 52 hips that underwent closed reduction, 16 (31%) needed re-intervention. Of the 55 hips that underwent open reduction, MRI was useful in deciding re-intervention in only 1 (2%). This patient had prior multiple failed closed and open reductions at an outside institute. Post intervention hip spica MRI is useful in determining the need for re-intervention after closed hip reduction, but its role after open reduction is questionable.

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

PurposePaediatric 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.MethodsThe 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.ResultsIn 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.ConclusionThis 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 IIReview of level II evidence

Early Functional and Radiological Outcomes Between Plaster Cast and Fiberglass Cast in Stable Thoracolumbar Burst Fracture

Introduction: Burst fracture results from compression failure of both the anterior and middle columns under substantial axial loads. Conservative treatment was a method of treatment for fractures without neurological deficit. This cross sectional study was designed to evaluate the functional and radiological outcome of patient with thoracolumbar burst fracture treated conservatively. Methods: 40 cases were recruited from January 2013 till December 2015. They were followed-up with minimum period of 1 year and evaluated for the functional (Oswetry Disbility Index) and radiological outcomes (kyphotic angle deformity and anterior body compression). Results: 20 patients were treated with body cast made form plaster of Paris and remaining 20 patients with fiberglass cast. In plaster of Paris group, mean kyphotic angle deformity at last follow up was 16.60 ± 2.95 with a mean improvement 4.45 degree and anterior body compression at last follow up was 30.35% ± 10.2 with mean improvement of 9.30%. In fiberglass group, mean kyphotic angle deformity at last follow up was 15.55 ± 3.38 with a mean improvement 7.25 degree and anterior body compression at last follow up was 25.90% ± 7.81 with mean improvement of 3.45%. The functional outcome showed Oswetry Disability Index (ODI) score in plaster of Paris group was 23.70 (SD = 7.82) and in fiberglass group was 18.50 (SD = 5.94). Conclusions: Application of body cast using a fiberglass material give better radiological outcome hence less pain, more functional and higher patient’s satisfaction as compared to plaster of Paris.

A Prospective Study of Acute Undisplaced and Minimally Displaced Scaphoid Fractures Managed by Aggressive Conservative Approach.

To identify acute un-displaced and minimally displaced scaphoid fractures which are unlikely to unite with non-operative treatment at six weeks with CT scan and stabilize them with percutaneous screw fixation with the aim of preventing non-union. A scaphoid series radiographs of wrist were obtained for patients with undisplaced or minimally displaced fractures and were immobilized in a thumb spica cast for six weeks. At six weeks, CT scan was done for patients showing doubtful signs of clinical and radiographic union. Patients with a gap less than 2 mm were continued on cast for an additional two to four weeks. Those with gap more than 2 mm underwent percutaneous screw fixation. In both cases the immobilisation was discontinued when the fracture was considered to be united and mobilization was initiated. 21 out of 39 patients managed initially with cast for six weeks showed clinical and radiological evidence of union. 18 patients showed persistent tenderness of which eight showed a clear gap in radiographs and 10 patients had doubtful union. Eight of these 10 patients on CT scan showed fracture gap of more than 2 mm while two patients showed fracture gap of less than 2 mm. Hence, 16 patients underwent percutaneous fixation. Repeat radiographs showed progression to union at an average of 3.8 weeks from surgery. Remaining two eventually united on continuing the cast. All patients showed confirmed union at one year on follow up. An objective measurement of fracture gap by CT scan at six weeks is useful in predicting cases with tendency for delayed union. Early percutaneous fixation of fractures would not further jeopardize the blood supply of fracture site. This aggressive conservative management also avoids unnecessary surgery in all acute scaphoid fractures.

Management of femoral neck fractures in children: Experience of a short series in a developing country.

Background:Fractures of the femoral neck are rare injuries in children but can have many devastating complications. Their treatment is not standardized, but the objectives are early anatomic reduction to minimize the risk for complications. The aim of this study was to assess outcomes of a short series of femoral neck fractures managed in a resource-limited setting.Materials and Methods:The medical charts of 11 children who were managed in our institution for femoral neck fractures between January 2000 and December 2015 were assessed retrospectively. There were two cases (n = 2) of Delbet type I, 5 (n = 5) type II, and 4 (n = 4) type III fractures. Patients were treated either surgically by open reduction and internal fixation (n = 4) or conservatively by traction followed by spica cast (n = 7). Outcomes were assessed using Ratliff system.Results:Femoral neck fracture incidence was one case per year. Of the 11 patients, there were 7 boys and 4 girls, with a mean age 9.4 ± 3.28 years. At the mean follow-up of 3.64 ± 1.97 years (range, 2–8.8 years), outcome was fair to good in 8 (72.7%) and poor in 3 (27.3%) cases. Average union time was 13.5 ± 1.77 weeks. Complication rate was 72.7%. Avascular necrosis occurred in three cases (27.3%). Six patients (54.5%) developed coxa vara, with a mean neck-shaft angle of 102.16° ±12.07° (range, 90°–118°). Five patients (45.5%) had leg length discrepancy with a mean 18 mm (range, 7–35 mm).Discussion:Local conditions negatively influenced the management of femoral neck fractures. Conservative treatment led to many complications which increase the cost of management.

Outcome of curettage of peritrochanteric benign lesions in skeletally immature patients without internal fixation

Background Peritrochanteric benign lesions are common in skeletally immature patients, which might cause limping and bone destruction up to pathological fracture. Many techniques have been described for the treatment of such lesions; curettage is one of them, which may be combined with bone graft and internal fixation. Curettage without internal fixation is the principal technique used in this study. Patients and methods This study included 20 patients, with 12 males and eight females, and their mean age was 10.6 years (range, 4–15 years). The diagnosis was 12 cases of simple bone, three cases of aneurysmal bone cyst, two cases of fibrous dysplasia, two cases of nonossifying fibroma, and one case of osteoid osteoma. Treatment included curettage, either simple or extended by high-speed burr and phenol adjuvant, and only cast as external immobilization. Patients were placed in hip spica or antirotational cast for 6–8 weeks. The visual analog scale (VAS) and Harris hip score (HHS) were used for preoperative and postoperative clinical and functional assessments. Results The mean follow-up period was 30.5 months. Clinically, 17 patients had full recovery 3–6 months postoperatively with excellent results according to HHS for hip function and VAS for pain assessment. The VAS score decreased highly significantly, which denoted pain improvement after treatment. HHS increased highly significantly, which denoted improvement of functional activity after treatment. Three patients developed complications. Conclusion Curettage without internal fixation and its replacement by external immobilization by cast is effective, less morbid, and technically simple procedure for the treatment of peritrochanteric benign lesions in skeletally immature patients. Good satisfactory results in local tumor control and excellent long-term functional and radiological results with less emotional negative effects on the patient or his family have been recorded.

External Rotation Predicts Outcomes After Closed Glenohumeral Joint Reduction With Botulinum Toxin Type A in Brachial Plexus Birth Palsy.

Few studies have investigated outcomes after adjunct botulinum toxin type A (BTX-A) injections into the shoulder internal rotator muscles during shoulder closed reduction and spica cast immobilization in children with brachial plexus birth palsy. The purpose of this study was to report success rates after treatment and identify pretreatment predictors of success. Children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting were included. Minimum follow-up was 1 year. Included patients did not receive concomitant shoulder surgery nor undergo microsurgery within 8 months. Records were reviewed for severity of palsy, age, physical examination scores, passive external rotation (PER), and subsequent orthopaedic procedures (repeat injections, repeat reduction, shoulder tendon transfers, and humeral osteotomy). Treatment success was defined in 3 separate ways: no subsequent surgical reduction, no subsequent closed or surgical reduction, and no subsequent procedure plus adequate external rotation. Forty-nine patients were included. Average age at time of treatment was 11.5 months. Average follow-up was 21.1 months (range, 1 to 9 y). Thirty-two patients (65%) required repeat reduction (closed or surgical). Only 16% of all patients obtained adequate active external rotation without any subsequent procedure. Increased PER (average 41±14 degrees, odds ratio=1.21, P=0.01) and Active Movement Scale external rotation (average 1.3, odds ratio=2.36, P=0.02) predicted optimal treatment success. Limited pretreatment PER (average -1±17 degrees) was associated with treatment failure. Using the optimal definition for success, all patients with pretreatment PER>30 degrees qualified as successes and all patients with PER<15 degrees were treatment failures. Pretreatment PER>30 degrees can help identify which patients are most likely to experience successful outcomes after shoulder closed reduction with BTX-A and cast immobilization. However, a large proportion of these patients will still have mild shoulder subluxation or external rotation deficits warranting subsequent intervention. Level IV-therapeutic.

The treatment of femoral fractures in children with cerebral palsy.

The purpose of this study is to retrospectively evaluate a group of children affected by cerebral palsy with a recent femoral fracture, and to analyse the results and complications in relation to the treatment used. The analysis was performed on 36 children (21 M, 15 F, 8-14 years old) with cerebral palsy (7 diplegia, 28 tetraparesis, 1 hemiplegia) with a metaphyseal or a diaphyseal femoral fracture. The patients were subdivided into two groups according to their Gross Motor Function Classification System (GMFCS) level: level 2-3 (9 patients) and level 4-5 (27 patients), evaluating the presence of complications and malunions for each group at the end of each follow up. The fractures were displaced in 24 patients and nondisplaced in 12 patients. In 26 cases the treatment involved a closed reduction and immobilisation in a long leg hip spica cast for 7 weeks, while in 10 cases the treatment involved an open reduction-internal fixation (ORIF) followed by a 3-week period in a plaster coated fracture bandage. Taking into consideration the maximum possible recovery of function, an ORIF is preferable to prevent malunion, particularly in distal metaphysis and distal shaft fractures. In the GMFCS level 2-3 patients, surgery has allowed to recover, or at least maintain, the pre-fracture functional level, while in patients with GMFCS level 4-5, it has allowed to reduce the immobilisation times and prevent the development of decubitus lesions.

Thumb Immobilization in the Treatment of an Acute Hook of Hamate Fracture: A Case Report

A 65-year-old male presented with an acute nondisplaced hook of hamate fracture while lifting a suitcase. Conservative management was employed, and he was treated with a thumb spica cast. At the most recent follow-up, he demonstrated resolution of pain and restoration of motion. CT imaging confirmed osseous union. High nonunion rates following conservative management with short arm casting without thumb immobilization for hook of hamate fractures may be in part due to inadequate immobilization. Here, use of a thumb spica cast resulted in successful osseous union following an acute hook of hamate fracture.

Usefulness of anterior-half body cast using a soft brace or lumbar belt for spinal compression fracture: Toyohira orthopedic device with attachment

Usefulness of anterior-half body cast using a soft brace or lumbar belt for spinal compression fracture: Toyohira orthopedic device with attachment

Pelvic and lower extremity immobilization for cloacal exstrophy bladder and abdominal closure in neonates and older children

IntroductionSuccessful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction. MethodsThe authors reviewed an institutionally approved and daily updated database of 1311 patients with exstrophy–epispadias complex and identified patients with cloacal exstrophy born between 1975 and 2015 who had undergone primary or reoperative bladder closures. Only the closures that used spica casting or external fixation were included for analysis. Demographic, operative, and outcomes data were compared between patients with spica cast only and patients with external fixation and skin traction. ResultsOut of 140 patients with CE or a CE variant, a total of 71 patients with 94 bladder closures (66 primary and 28 reoperative) met inclusion criteria. Median follow-up time was 8.8 years (range 1.5–29.1). There were 37 closures performed at the authors’ institution and 58 from outside hospitals. Pelvic osteotomy was undertaken in 66 (70.2%) of all closures, and in 36 (97.3%) of closures at the authors’ institution. Postoperative immobilization was achieved with spica cast alone in 46 (48.9%) closures, external fixation and skin traction in 43 (45.7%), and spica cast and external fixation in 5 (5.3%) closures. For all closures, there were 33 failures (71.7%) among those immobilized with spica cast alone versus 4 failures (9.3%) for those immobilized with external fixation and skin traction (p<0.001). When restricted to closures performed with osteotomy, the failure rates were 50.0% and 9.3% respectively (p=0.002). There was minimal differences in complication rates between spica and external fixation groups (8.7% versus 23.3%, p=0.059). ConclusionFailure of CE closure can occur with any form of pelvic and lower extremity immobilization. This study, however, provides continued evidence that external fixation with skin traction is an optimal, secure technique (3.8% failure rate) for postoperative management in an older child (1–2 years). Level of EvidenceLevel III, Retrospective comparative study Study TypeTherapeutic study

Closed diaphyseal fractures of femur in children treated by hip spica: early result of a clinical study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Diaphyseal fracture of femur is a common injury in children with bimodal age distribution. The treatment modality of these fractures depend on several factors such as age of the patient, characteristics of the fracture– degree of displacement, location of fracture in femur, comminution, and open or closed injury. With the invention of titanium elastic nails, the recent trend in treating these fractures is by closed reduction and TENS, but the surgical management is not without complications hence we share our experience to reemphasize the role of hip spica cast immobilisation in treating these injuries.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;This is a prospective study of 30 cases of diaphyseal fractures of femur in children between the ages of 6 month to 6 years. History and mode of injury were recorded and complete physical examination was done. Plain anteroposterior and lateral radiographs confirmed diagnosis. Hip spica cast was applied under sedation or short general anesthesia. One and half spica was applied over thick padding with hip flexed 45 degrees abducted 30 degrees and external rotation of 10 degree.&lt;strong&gt; &lt;/strong&gt;No attempt was made to obtain an end to end reduction. Patients were allowed to go home the same day after giving instructions regarding spica care. Follow up was done and radiographs were taken at 1, 2, 4 and 12 weeks. Any malunion– LLD, angulation or rotation were recorded&lt;/span&gt;.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;The mean age of patients was 3.5 years (range 0.5 to 6 years). Of these 12 (40%) were male and 18 (60%) were female. The commonest mode of injury was fall while play in 73.33% (n=22) of patients. Mid shaft fractures are more common 53.33% (n=16) followed by upper third 40% (n=12). Average time for fracture union was 6 weeks (range 4-10 weeks). At one year all fractures healed in a satisfactory position without any LLD. Two patients had minor skin problems which were easily treated and cast continued. No stiffness of hip, knee or ankle was noted. &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Hip spica casting is an effective and reliable method for treating femoral shaft fractures in children with a union rate of 100%. The advantages of conservative treatment such as the avoidance of general anaesthesia on two occasions and the avoidance of surgery make a compelling argument in favour of this form of treatment.&lt;/span&gt;&lt;/p&gt;