Brace vs Cast for Pediatric Femur Fractures

Source: Andras LM, Sanders JS, Phan TN, et al. A prospective, randomized comparison of functional bracing and spica casting for femoral fractures showed equivalent early outcomes. J Bone Joint Surg Am. 2025;107(16):1769-1776; doi: 10.2106/JBJS.24.01081.Investigators from Children’s Hospital Los Angeles, CA, and Children’s Hospital Colorado, Aurora CO, conducted a randomized controlled trial to compare the effectiveness of functional bracing to a spica cast for treatment of children with femur fractures. Study participants were patients 6 months to 5 years old with diaphyseal femur fractures treated at 2 medical centers. At enrollment, study participants were randomized to the spica casting or bracing treatment groups. Spica casts were placed under general anesthesia, and braces were applied at the beside. Initial study follow-up was at 6 weeks. The primary outcomes were femur shortening, varus angulation, and procurvatum, and they were compared between children in the spica casting and bracing groups with t-tests. Adverse events related to the treatment were assessed. Parents of study patients completed a questionnaire assessing satisfaction with treatment, stressfulness of the experience, whether their child could sit in their regular car seat, and ability of child to move independently. Questionnaire responses among parents of children in the 2 treatment groups were compared. Study participants also were followed up at 1 year. At this follow-up, femoral shortening, varus angulation, and procurvatum were reassessed.Follow-up data were analyzed on 80 children, including 40 treated with a spica cast and 40 with functional bracing. The mean age of these children at the time of enrollment was 2.0 ±0 years for those randomized to spica casting and 2.3 ±1.1 years for those treated with bracing. At 6-week follow-up, mean femoral shortening was 13.1 ±9.4 mm for patients treated with spica casting and 11.0 ±10.0 mm for those randomized to bracing (P = 0.35). There also were no significant differences between groups for varus angulation (mean, 2.4 ±7.3° and 5.3 ±6.3°, respectively; P = 0.06) or procurvatum (mean, 12.3 ±9.8° and 9.1 ±8.1°, respectively; P = 0.11). Rashes and skin breakdown occurred in 1 child in the spica cast group and 9 in the bracing group (P = 0.02). There were no differences between groups in parental satisfaction with treatment or stressfulness, but more children in the bracing group could sit in their regular car seat than among those in the spica cast group (86% vs 40%; P <0.01). In addition, parents of children treated with bracing indicated that their child had less difficulty moving independently than parents of those randomized to spica casting (P = 0.05). Among the patients completing 1-year follow-up, there were no significant differences between those in the 2 groups for femoral shortening or varus angulation, but those in the casting group had more procurvatum (11.7 ±8.3° vs 5.1 ±5.8°; P <0.01).The authors conclude that functional bracing was as effective as spica cast treatment for children with diaphyseal femoral fractures.Dr Hennrikus has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.For children age 6 months to 5 years of age with a closed, mid-shaft femur fracture, the American Academy of Orthopaedic Surgeons recommends treatment with a spica cast.1 The spica or 'body cast' can be applied in the operating room or in the emergency department (ED).2,3 Application of a spica cast is a lengthy procedure that often requires a radiolucent casting table, trained personnel, sedation or general anesthesia, and fluoroscopy.2Prefabricated braces are used to treat other long bone fractures such as the tibia and offer the advantages of being lightweight and easy to apply.4 Prefabricated braces for femur fractures avoid the use of anesthesia, the need for an NPO status for the child, and delays waiting for the availability of an operating room. The authors of the current study developed 4 standardized sizes of braces that were stocked and available at 2 hospitals for pediatric femur fracture treatment 24/7.The prefabricated brace extends from the belly and hips to the foot of the injured leg. Braces were applied in the ED or on the ward with morphine and valium for analgesia and muscle relaxation. Spica casts were applied in the operating room under general anesthesia. No intraoperative complications occurred during spica cast placement, and all braces were applied successfully without complication at the bedside.At the 6-week visit, all fractures had healed. Radiographic femoral shortening, varus angulation, and procurvatum were equal between the 2 groups. At the 1-year follow-up, all patients were ambulatory and able to participate in normal activities. Radiographic outcomes were equal in both groups, with slightly more procurvatum in the casting group.Prefabricated braces for femoral fractures provide outcomes equivalent to spica casts with improved efficiency, and reduced care burdens for patients, parents, and health care systems.Because of the lack of a method to assess noninferiority statistically, it is possible that clinically significant differences between children in the bracing and casting groups were not detected with the modest sample size.