Where should hip spica casting be performed for femoral shaft fractures in children aged 2-5 years: Emergency department or operating room? A retrospective comparative cohort study.

IntroductionThis study compared emergency department hip spica casting under procedural sedation with operating room casting under general anesthesia and fluoroscopic guidance for femoral shaft fractures in children aged 2-5 years.MethodsThis retrospective comparative cohort included 87 children treated between January 2021 and December 2025: 42 in the emergency department (Group 1) and 45 in the operating room (Group 2). Clinical, radiological, functional, and healthcare-related outcomes were compared.ResultsRadiological union was achieved in all patients. Mean time to union did not differ significantly between groups (7.0 ± 1.1 vs. 6.6 ± 0.9 weeks; p = 0.067). Post-casting sagittal angulation was significantly greater in Group 1 (15.2 ± 5.4° vs. 12.1 ± 5.8°; p = 0.012), whereas coronal angulation did not differ significantly (12.8 ± 4.9° vs. 10.7 ± 5.2°; p = 0.060). Malunion occurred in 23.8% and 8.9%, respectively (p = 0.058). No patient required repeat reduction or corrective surgery. PedsQL Physical Health Summary Scores (92.07 ± 3.34 vs. 92.16 ± 3.47; p = 0.909) and overall complication rates (23.8% vs. 15.6%; p = 0.332) were similar. Procedure time, hospital stay, and inflation-adjusted direct hospital charges were significantly lower in Group 1 (all p < 0.001).ConclusionEmergency department casting achieved similar union and late parent-reported physical functioning but greater immediate post-casting sagittal angulation. Although this difference required no further intervention, its clinical relevance remains uncertain. In appropriately selected children and centres with experienced practitioners and suitable sedation and monitoring facilities, emergency department casting may reduce hospital resource use and direct hospital charges.