This study confirmed that skin traction combined with braces was an appropriate treatment choice for FSF in children aged 3–5 years. Currently, the choice of non-surgical or surgical treatment of FSF for children in this age group remains controversial. It is recommended that children with FSF aged 6 months–5 years should be treated with plaster fixation [1, 6, 14, 15]. However, skin complications and loss of reduction are more common with plaster fixation [3, 4]. At our center, we were reluctant to choose the spica cast for the following reasons: (1) the weather was very humid, and many patients had skin irritations, which felt very itchy. (2) the fracture may be displaced during follow-up. The patient’s guardians would not tolerate this situation, which could even lead to lawsuits.
Compared to spica casts, braces were comfortable with less skin irritation [16, 17]. However, an obvious disadvantage was that the fixation was not as stable as the casts. Thus, the occurrence of displacement was higher than that with the use of a cast; therefore, in this study, we did not use the spica cast during the first treatment of FSF. Our method of skin traction combined with a spica brace resulted in fewer complications. First, when the patients were hospitalized for skin traction, the fractures were monitored using X-rays, and they could be adjusted immediately if the displacement was unacceptable. Once the bone callus grew and the fractures were stable, the spica casts were applied.
Some studies shown that compared with spica casts, elastic intramedullary nails can successfully treat 3–5 years old children with FSF, enabling faster walking recovery with the same complication rate [11, 18, 19]. To compare the effect of both treatment methods, we statistically compared clinical data, such as the side of the affected limb, fracture causes, and fracture types in both groups. No significant differences were observed in the variables between the two study groups (Table 1). To the best of our knowledge, there have been no studies on skin traction combined with braces for the treatment of FSF in children aged 3–5 years.
Economic factors, which are particularly important in lower-income countries, were considered when treating these patients. Some studies have reported that conservative treatment was the first choice . A multicenter study reported that an increasing number of surgeons performed FIN surgery in 3–5 years old children. FIN fixation costs more and requires reoperation to remove the internal fixation device [21, 22]. In this study, the cost of FIN surgery was significantly higher than that of traction combined with spica braces (p < 0.001). If the hospitalization time required for FIN removal was considered, no significant difference was observed (p = 0.122).
Some studies have reported that compared with non-surgical treatment, the use of elastic intramedullary nail fixation can enable 3–5 years old children with FSF to regain the ability to walk and return to school faster; this greatly reduces the cost of caring for the child [8, 11, 23,24,25]. In this study, the fracture healing times seems shorter in Group B than Group A. This was mainly because some patients underwent open reduction and fixation using FIN in Group A. Open reduction was considered a second injury for bone healing; hence, these patients could experience delayed bone callus healing. However, there was no significant difference between these groups. This may indicate that close reduction should be the first choice of treatment these patients.
Compared with hip brace fixation, elastic intramedullary nail fixation is associated with unique complications. A second operation to remove the internal fixation is necessary because of the elastic intramedullary nails , and skin irritation of the nail tail often causes incision pain, infection, and scars . All patients in this study underwent a second operation under general anesthesia to remove the elastic intramedullary nail between 4 and 7 months postoperatively . All the children's incisions healed within 2 weeks postoperatively, and no incision pain was reported. Some family members of the children were dissatisfied because of the noticeable scars resulting from the two procedures. However, cases of scar contracture affecting the children’s function were not observed.
This study showed no significant difference in postoperative knee joint function between children with elastic intramedullary nail fixation and hip brace fixation. The two groups of children experienced complications, such as joint dysfunction, pain, angular deformity, and limb length differences; however, the differences were not statistically significant. Pressure ulcers, nonunion fractures, and delayed union were not observed, and no infections or re-fractures occurred in the conservative group. Only one child with elastic intramedullary nails experienced a re-fracture at the surgical site due to trauma. Therefore, both treatment methods are acceptable. Both elastic intramedullary nail fixation and hip spica braces can fulfill the treatment requirements of 3–5 years old children with FSF.
Overall, our method of using skin traction combined with brace fixation did not require anesthesia using our method, and it was much more economical than surgery. We recommend that this method could be adopted for 3–5 years old children with FSF because it has almost similar clinical outcomes as surgery. In this study, patients aged 3–5 years, who were reluctant to undergo anesthesia and skin incision and could even afford the costs were advised to choose our method.
This study had some limitations. Generally, certain types of fractures tend to be treated conservatively or surgically. This may be influenced by the surgeons' advice or other reasons. In this study, we excluded patients who were only suitable for surgery or conservative treatment; however, both groups of patients can be treated with surgery or conservative treatment, and the final decision was made by the patients’ guardians. Some bias would still have been observed between the study groups even if the fracture types and other clinical data were compared. It is important to evaluate the societal cost; however, it was difficult to calculate it in this study because some of the caregivers were lost to follow-up. The other limitation was the lack of a control group treated with spica casts because this treatment method is no longer used at our facility. And for the compilations, the quantity of the patients was small, it cannot be compared by statistical analysis. Additionally, this was a single-center, retrospective study; therefore, prospective, multicenter studies are required in the future.