Early or Delayed Spica Casting
Moderate evidence supports early spica casting or traction with delayed spica casting for children age six months to five years with a diaphyseal femur fracture with less than 2 cm of shortening.

Rationale
Two studies compared the use of early spica casting with traction followed by spica casting.  There were significantly more infections in the traction group and more spica softening and plaster breakage in the early spica group.19  There were no statistically significant differences between the treatment groups in time to union, femoral shortening, malalignment, or malrotation.19,20
 
Based on the summary of evidence, we did not find conclusive evidence that one modality of treatment (spica casting or traction) was superior and no studies compared flexible nails to spica casting in this age group. We suggest using early spica casting for social and economic considerations, specifically in relative ease of care and decreased length of hospital stay.21  While the work group suggests early spica for children in this age group, traction may be appropriate in some cases. This recommendation does not suggest against the use of traction. In keeping with current best medical practice, we further suggest careful clinical and radiographic follow-up during the course of treatment.
 
In addition, no trial has specifically examined children in the age group of 4-5 years. A  third study22 indicates that  in children as young as four more malunions occur with spica casting than with external fixation. Treatment decisions made on children who border any age group should be made on the basis of the individual. Until further research clarifies the possible harms associated with any treatment in this age group, decisions will always need to be predicated on guardian and physician mutual communication with discussion of available treatments and procedures applicable to the individual patient. Once the patient’s guardian has been informed of available therapies and has discussed these options with his/her child’s physician, an informed decision can be made. Clinician input based on experience increases the probability of identifying patients who will benefit from specific treatment options. 

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