BACKGROUND:
Immediate spica casting for pediatric femur fractures is well described as a standard treatment in the literature. The purpose of this study is to evaluate the application of a spica cast in the emergency department (ED) versus the operating room (OR) with regard to quality of reduction, complications, and hospital charges at an academic institution.

METHODS:
An institutional review board-approved retrospective review identified 100 children aged 6 months to 5 years between January 2003 and October 2008 with an isolated femur fracture treated with a hip spica cast. Patients were compared based on the setting of spica cast application.

RESULTS:
There were 79 patients in the ED cohort and 21 patients in the OR cohort. There were no significant differences in age, weight, sex, fracture pattern, prereduction shortening, injury mechanism, duration of spica treatment, time to heal, or length of follow-up between cohorts. There were no significant differences in the rate of loss of reduction requiring revision casting or operative treatment (6.3% vs. 4.8%), the need for cast wedging (8.9% vs. 14.3%), or minor skin breakdown (12.7% vs. 14.3%). There were no sedation or anesthetic complications in either group. There were no significant differences in the quality of reduction or the rate of complications between the 2 groups. Spica casting in the OR delayed the time from presentation to cast placement as compared with the ED cohort (11.5 h vs. 3.8 h, P< 0.0001) and lengthened the hospital stay (30.5 h vs. 16.9 h, P=0.0002). The average hospital charges of spica cast application in the OR was 3 times higher than the cost of casting in the ED ($15,983 vs. $5150, P< 0.0001).

CONCLUSIONS:
Immediate spica casting in the ED and OR provide similar results in terms of reduction and complications. With the significantly higher hospital charges for spica casting in the OR, alternative settings should be considered.

LEVEL OF EVIDENCE:
III--Retrospective comparative study.



Polls results
1

On a scale of 1 to 10, rate how much this article will change your clinical practice?

NO change
BIG change
70% Article relates to my practice (7/10)
30% Article does not relate to my practice (3/10)
0% Undecided (0/10)
2

Will this article lead to more cost-effective healthcare?

80% Yes (8/10)
10% No (1/10)
10% Undecided (1/10)
3

Was this article biased? (commercial or personal)

0% Yes (0/10)
100% No (10/10)
0% Undecided (0/10)
4

What level of evidence do you think this article is?

0% Level 1 (0/10)
0% Level 2 (0/10)
90% Level 3 (9/10)
10% Level 4 (1/10)
0% Level 5 (0/10)