Practice Pattern Preferences Among Pediatric Orthopaedic Surgeons in North America for the Treatment of Femoral Shaft Fractures.

Background: The treatment of pediatric diaphyseal femur fractures varies based on many factors, and the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines (CPGs) are dependent on the quality and quantity of evidence in the literature. The purpose of this study is to assess current practice patterns in the treatment of femoral shaft fractures among pediatric orthopaedic surgeons to identify areas of variability.

Methods: From October 2023 to January 2024, the Pediatric Orthopaedic Association of North America (POSNA) Trauma Quality, Safety, and Value Initiative Committee surveyed North American POSNA members on pediatric femoral shaft fracture treatment. Responses were analyzed based on surgeon age, practice location, and practice type. "Usually" and "occasionally" were considered positive responses; "rarely" and "never" were considered negative responses.

Results: Of 1551 eligible members, 226 responded (14.6%), primarily aged 30-49 (56%) and in academic settings (77%). For infants (0-6 months), the Pavlik harness was most common, though usage declined with surgeon age (P = .052), while spica casting increased (P = .077). Regional differences were significant (P = .021), with lower Pavlik harness use in the West. For children (6 months-5 years), spica casting was most common. Flexible intramedullary nails (FIN) was polarizing (42% positive, 58% negative). Regional differences were significant for traction with delayed spica (P < .0001) and submuscular plating (P = .021). Surgeons aged 30-49 preferred single-leg spica over 1.5/2-leg spica (P = .009). For length-stable fractures (5-11 years), FIN was preferred, followed by rigid intramedullary nailing. Older surgeons and nonacademic surgeons favored nonoperative treatment (P < .0001, P = .005). For length-unstable fractures, operative treatment was predominant, though older surgeons more often considered nonoperative options (P = .006). For adolescents (11-18 years), rigid intramedullary nailing was most common. Submuscular plating and FIN were increasingly preferred with surgeon age (P = .010, P = .002). Sixty-nine percent supported waterproof spica casting, with no significant differences by age, setting, or region.

Conclusions: There are differences in practice patterns for the treatment of pediatric femoral shaft fractures based on surgeon age, practice location, and practice setting. This study identifies areas of variability in practice patterns where further studies are warranted to inform more evidence-based clinical practice guidelines.

Key concepts: (1)Treatment preferences for diaphyseal femur fractures vary uniquely based on the treating surgeon's age, practice location, and practice type.(2)In general, older surgeons tend to choose from a broader array of treatment options when treating pediatric diaphyseal femur fractures.(3)There are several areas of variability among surgeons in the treatment of pediatric diaphyseal femur fractures, highlighting areas of interest for future outcomes research.

Level of evidence: Level IV.