The treatment of femoral shaft fractures in children: a systematic overview and critical appraisal of the literature.

OBJECTIVE Through a critical systematic overview of the literature on the treatment of pediatric femoral shaft fractures to determine if any method of treatment can be recommended over others. DATA SOURCES A MEDLINE search was performed for all cohort and randomized clinical trials for the years 1966 to 1996. STUDY SELECTION Of 1217 identified articles, 15 cohort studies (where 2 or more treatments were compared in the same study) reported the treatment of children with femoral fractures. DATA EXTRACTION Information was abstracted and articles rated for quality blind to author, institution and journal. DATA SYNTHESIS Children having early application of a hip spica cast had an average hospital stay of 11 days (range from 5 to 29 days), average charges of $5784 (range from $590 to $11,800), average rates of limb-length discrepancy (greater than 2 cm) of 3% (range from 0 to 25%), angulatory malunion rates (greater than 10 degrees) of 8% (range from 0 to 19%), and rotational malunion rates (greater than 10 degrees) of 13% (range from 0 to 5%). The costs and malunion rates of early application of a hip spica cast were lower than for traction. Internal fixation (including intramedullary nails) had low angulatory malunion rates compared with early application of a hip spica cast but higher over-lengthening rates (greater than 2 cm) of 25% (range from 5% to 100%) and mean rotational malunion rates (greater than 10 degrees) of 25% (range from 11% to 32%). CONCLUSION Early application of a hip spica cast had lower costs and malunion rates than traction.