Operative Treatment Versus Spica Casting for Treatment of Pediatric Femoral Shaft Fractures in Children Aged 4 to 6 Years: A Large Multi-Institutional Age-Stratified Comparative Analysis.

BACKGROUND: Femoral shaft fractures in children aged 4 to 6 years represent a clinical gray zone between closed reduction with casting and operative treatment. Traditional guidance favors closed treatment under age 6, yet recent reports suggest increasing use of operative treatment despite limited evidence. This study characterized national treatment rates from 2013 to 2024 and compared health care utilization outcomes.

METHODS: This retrospective cohort study used the TriNetX Research Network, a federated platform containing nationwide deidentified health records. Patients from 2013 to 2024 with femoral shaft fractures were identified through ICD codes. Data on closed versus operative treatment (defined by CPT codes), sex, race, and ethnicity were extracted. Annual treatment rates, both total and age-stratified, were calculated. Logistic regression and Rao & Scott adjusted χ2 testing with Bonferroni correction were performed. Propensity score matching was performed for the combined 4- to 6-year cohort; age-stratified analyses were unmatched.

RESULTS: A total of 2486 children aged 4 to 6 years with femoral shaft fractures were identified; 47.3% underwent operative treatment. The proportion treated with closed reduction and spica casting decreased overall, most notably among children aged 5 years (64.3% to 30.6%) and 6 years (51.4% to 23.7%), while rates remained stable at age 4 (67.4% to 77.8%). In the matched combined cohort, operative treatment was associated with fewer early emergency department visits (RR: 0.64; 95% CI: 0.42-0.97), more late postreduction procedures (RR: 4.20; 95% CI: 2.77-6.37), and more routine healing visits (RR: 1.76; 95% CI: 1.45-2.13). Differences were most pronounced at age 6 in unmatched analyses (early ED visits-OR: 0.32; 95% CI: 0.19-0.51; early postreduction procedures-OR: 0.23; 95% CI: 0.12-0.42).

CONCLUSIONS: The rate of operative management of femoral shaft fractures increased by 94% at age 5 and by 61% at age 6 during the study period, despite limited age-specific evidence supporting this shift. This change likely reflects multiple factors, including growing surgeon familiarity with minimally invasive fixation, family-centered considerations, and age-dependent challenges of spica casting, rather than evidence of clinical superiority.

LEVEL OF EVIDENCE: Level III-therapeutic study (retrospective comparative study).