National trends in the treatment of femur fractures in the preschool population: Age and geography play a role.

Abstract Background Spica casting and elastic stable intramedullary nailing (ESIN) are options for diaphyseal femur fractures in preschool-age children (ages 3-6 years). Clinical practice guidelines (CPG) are only of moderate or limited strength, which may lead to variation in practice. The purpose of this study is to analyze the epidemiology of children undergoing these procedures in the United States. Methods The Pediatric Health Information System, a national database consisting of 49 children's hospitals, was queried for patients between the ages of 3 and 6 years undergoing spica casting or ESIN for a diaphyseal femur fracture between 2011 and 2017. Non-diaphyseal fractures, subjects with associated syndromes or neuromuscular disorders, and pathologic fractures were excluded. Census guidelines were used to categorize hospitals geographically into regions and divisions. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results Analysis included 4059 subjects. Spica casting was performed in 2878 children (71%) and ESIN in 1181 (29%). The median age of those undergoing spica casting was 3.0 years [interquartile range (IQR) 1 year] compared to 5.0 years for ESIN (IQR 2 years; p Conclusions In the United States, there is substantial variation in the chosen treatment for diaphyseal femur fractures in preschool-age children. ESIN is more likely to be chosen for older children. It is also most likely to be performed in the Midwest and least likely in the Northeast. These findings may have implications in terms of cost and resource utilization and suggest the need for more clinical data to guide surgical indications.