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The Management of Pediatric Subtrochanteric Femur Fractures With a Statically Locked Intramedullary Nail
Abstract
Objectives:
To evaluate locked intramedullary (IM) fixation as an alternative treatment method for children with subtrochanteric fractures.
Design:
Retrospective review.
Setting:
Level 1 trauma center in a Children's Hospital.
Patients/participants:
Pediatric patients with subtrochanteric femur fractures with open growth plates.
Intervention:
All patients were treated with a lateral entry IM locking nail.
Outcome measurements:
Patients were followed until full fracture consolidation or until implant removal. Data on time to full weight bearing, return to full activity, residual pain, any form of gait abnormality, and any other complication from follow-up visits were collected.
Results:
There were 9 males and 1 female patient with an average age of 12 years and average follow-up of 22 months. Most of the fractures occurred secondary to high-energy trauma. Partial weight bearing was started at 24 days and full at 66 days. Implants were removed on average at 11 months after implantation. There were neither intraoperative complications nor major complications in the postoperative period recorded after removal. Two patients presented with a longer limb on the affected side, both 8 mm, and 2 presented with asymptomatic grade I heterotopic ossification.
Conclusions:
The use of a statically locked lateral entry IM nail for subtrochanteric femur fractures in children is a safe and efficacious method of treatment with few complications and risks and satisfactory outcomes in children over the age of 8 years.
Level of evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
... Osteosynthesis is the preferred method for children older than 6 years. The options are intramedullary fixation, open plating, submuscular plating, and external fixator with each technique having its own advantages and drawbacks [8][9][10][11][12][13][14][15][16]. ...
... To overcome these challenges, the treatment of EPFF should aim to restore alignment and provide stable fixation. There are limited evidence-based treatment recommendations Options such as hip spica, elastic stable intramedullary nailing (ESIN), rigid intramedullary nailing, open or submuscular plating, and external fixator with or without ESIN have been used with variable success rates [7][8][9][10][11][12][13][14][15][16]. The option of using a submuscular plate is appealing as it offers minimally invasive treatment without the need for hip spica cast or external fixation. ...
... Rigid intramedullary lateral entry nailing requires a wide medullary canal to accommodate the implant. The lateral entry nail, a specialized implant, is not easily available and its cost remains a major obstacle to its use [12,24]. External fixator alone or in combination with elastic nailing is an option. ...
The aim of this study is to evaluate the results of submuscular plating using nonlocking plates for extra-articular proximal femur fractures (EPFF) in children. From our hospital records, we retrieved data of 15 children treated with submuscular plating with nonlocking dynamic compression plates (DCP) for EPFF between January 2010 and September 2021. EPFF was defined as a proximal femur fracture within 10% of the femoral length below the lesser trochanter. Patients' demographics, as well as details of the duration of operation, type of DCP used, time to union, complications, and outcomes using Flynn criteria were noted. There were nine males and six females. Mean age of the patients was 10.8 ± 1.9 years (range 7-14 years). All the patients had fracture union and two patients had union with an angulation less than 10°. All fractures healed uneventfully with a mean time to union of 11.8 ± 1.2 weeks (range 10-15 weeks). No patient required surgery for complications or malunion. Using Flynn criteria, excellent outcomes were seen in 13 out of 15 patients. There were no poor outcomes. Our study shows that submuscular plating using nonlocking plates is an effective option for treating pediatric EPFF. Treatment of these tricky fractures with submuscular plating using nonlocking plates shows excellent outcomes with minimal complications.
... It is suitable only for older patients who have a sufficiently large medullary canal for nail placement. There is a potential risk of growth arrest in the greater trochanter apophysis, resulting in coxa valga and heterotopic bone formation when the trochanteric physis is violated (19). Very proximal and distal femoral fractures remain challenging to treat with rigid nails. ...
Background
Treating subtrochanteric femur fractures in pediatric patients remains challenging, and an optimal fixation device has yet to be established. This study aimed to asess the clinical and radiological outcomes of Ortho-Bridge System (OBS) treatment for length-unstable subtrochanteric femur fractures in children aged 5–16 years.
Methods
We conducted a retrospective review of pediatric patients with subtrochanteric femur fractures treated with OBS between January 2018 and December 2021. The study included 19 children (12 boys, 7 girls) with an average age of 10.4 ± 2.6 years. Two of the patients had pathological fractures associated with aneurysmal bone cyst. Demographic information, mechanism of accident, fracture type, associated neurovascular injuries, surgical duration and blood loss, were collected from the hospital database. Time to union and postoperative complications were recorded. Clinical and radiological outcomes were assessed using the Harris scoring system at the latest follow-up.
Results
Injuries resulted from vehicle accidents in 10 patients (52.6%), falls over 3 meters in height in 3 patients (15.8%), and sports-related injuries in 6 patients (31.6%). The average patient weight was 41.5 kg (range: 21–78). Of the fractures, 14 (73.7%) were complex, and 5 (26.3%) were spiral. The average surgical duration was 111 min (range: 90–180), and the average surgical blood loss was 134 ml (range: 70–300). The mean time to union was 12.7 weeks (range: 8–16). No cases of infection, malunion, implant failure, or femoral head osteonecrosis were reported. Leg length discrepancy of 10 mm was observed in one patient. All patients achieved excellent results according to the Harris scoring system.
Conclusion
This study suggests that the OBS may serve as an effective alternative fixation option for managing length-unstable subtrochanteric femur fractures in school-aged children.
... Some authors have included intramedullary interlocking (IMIL) nails for the treatment of these fractures in children aged eight years and above [4]. A subtrochanteric femoral fracture in a child from 5-12 age group is difficult to treat. ...
Introduction Uncertainty exists regarding the ideal course of therapy for subtrochanteric fractures in children of intermediate age. These fractures are challenging to treat, with scarce literature-based evidence to support a definitive implant. The ideal course of treatment should consider the patient's weight, age, femoral canal size, associated injuries, fracture stability, and surgeon's experience. A subtrochanteric femoral fracture in a child between the age of 5-12 is difficult to treat. For these patients, there is debate concerning the optimal internal fixation, hence this study was conducted to try and determine the superior mode of treatment for these fractures. The objective of this study is to compare functional outcomes of subtrochanteric fractures in the paediatric age group operated on with titanium elastic nail and plate fixation and the complications associated with both treatment modalities. Materials and methods This is a retrospective observational study of 40 cases that were admitted and operated on in the hospital of the current study from May 2007 to November 2021. Twenty patients underwent titanium elastic nailing system (TENS) nailing and the other 20 patients underwent plating for subtrochanteric fractures. The surgeries were conducted at our institute and patients were followed up at one-, three-, and six-month intervals. The final functional results were calculated with the help of the Flynn scoring system. Results Out of 40 patients involved in the present study, 17 were female while 23 were male. Twenty patients received treatment with titanium elastic nails, and the remaining twenty received plating. The majority of the patients were males around 9.6 years of age on average in the plating group and 8.9 years in the nailing group. In comparison to 75% of participants in the plating group, 40% of patients who received nailing showed excellent results. Results were satisfactory for five patients who received titanium elastic nails and one who received plating. The only poor outcomes were noticed in six people (30%) in TENS and three people (15%) in the plating group who went through unplanned surgery for complications. In comparison to the plating group, the overall rate of complication was much greater in the TENS group. Conclusion We would like to conclude our study that, in accordance with Flynn's score, both elastic nailing and plating stabilization can produce positive functional outcomes. Both groups have a similar percentage of excellent and good results. We also conclude that the overall complication rate is slightly higher for patients treated with TENS when compared to plating for subtrochanteric fractures.
... The selection of appropriate internal fixation for subtrochanteric fractures in children is crucial, and the commonly used internal fixation in clinical practice includes elastic intramedullary nails, locked compression plates, and locked intramedullary nails (3). Although the locking intramedullary nail can better control rotation and angulation, it can easily damage the epiphyseal plate and lead to developmental disorders of the limb and is limited by the diameter of the medullary cavity in children, which is not yet accepted by most surgeons (4). For subtrochanteric fractures in children, flexible intramedullary pins and splints are more commonly used for internal fixation, but both choices are still controversial. ...
Objective:
Titanium elastic nails (TENs) and locking plates (LPs) are currently the main internal fixation for treating pediatric subtrochanteric femur fractures, and the optimal choice of internal fixation is controversial. This study aimed to systematically evaluate the effectiveness and safety of TENs and LPs in treating subtrochanteric fractures in children to provide a theoretical basis and reference for clinical treatment.
Methods:
The literature related to TENs and LPs for treating subtrochanteric fractures in children was searched using the CNKI, PubMed, Cochrane, Embase, and Web of Science, and the search time frame was from the establishment of the database to October 2022. Two evaluators screened the literature according to the inclusion and exclusion criteria and extracted relevant data. Meta-analysis was performed using Stata14.0 software.
Results:
A total of 9 studies with 407 patients with subtrochanteric femur fractures were included in the final screening, including 210 cases with TENs and 197 cases with LPs. Meta-analysis results showed that compared with the locking plate, TEN had a shorter operative time [WMD = -1.3, 95%CI(-1.94,-0.66), p < 0.01], less intraoperative bleeding [WMD = -84.45, 95%CI(-111.09, -57.82), p < 0.01], shorter fracture healing time [WMD = -1.3, 95%CI(-1.94,-0.66), P < 0.01], shorter hospital stays [WMD = -2.80, 95% CI(-4.63,-0.98), p < 0.01], and earlier full weight bearing [SMD = -0.48, 95% CI(-0.91,-0.04), p < 0.05] but more intraoperative fluoroscopy [WMD = 28.23, 95% CI(15.22,41.25), p < 0.05]. The overall complication rate was high [OR = 3.52, 95% CI(1.96,6.34), p < 0.05], and the postoperative period was prone to angulation, rotation, and inversion deformity [OR = 3.68, 95% CI(1.40, 9.68), p < 0.05]. No significant difference in the incidence of lower limb inequality between the two types of internal fixation [OR = 0.83, 95% CI(0.38, 1.85), p > 0.05] and no significant difference in the Harris score of the hip at the last follow-up between the two types of internal fixation [WMD = -0.67, 95% CI(-2.01,0.67), p > 0.05] were found.
Conclusion:
In comparison to LPs, TENs have a shorter operation time, less intraoperative bleeding, and a shorter fracture healing time, and the child can be fully weight-bearing earlier. Locking plates can reduce the operator's x-ray exposure, and the incidence rate of postoperative angulation, rotation, and inversion deformity is low. Therefore, TENs and LPs are the best internal fixation methods for treating subtrochanteric fractures in children.
... As such, intermedullary nail systems have gained wide popularity and are recognized as the preferred internal fixation option for subtrochanteric fractures. [34][35][36][37] The Gamma Nail, a relatively new intramedullary nail system, was introduced by Grosse in the 1990s. [19,38,39] The Gamma Nail system consists of a lag screw and a rod to overcome problems in sliding-screw fixations, and has superior efficacy in the fixation of intertrochanteric and subtrochanteric fracture. ...
The aim of this study was to clinically compare the therapeutic effects of internal fixation using a third-generation Gamma Long Nail (TGLN) with that of INTERTAN in the treatment of Seinsheimer Type V subtrochanteric femoral fractures in elderly patients.
The therapeutic effect of internal fixation with TGLN, compared with that with INTERTAN, was retrospectively analyzed in elderly patients diagnosed with Seinsheimer Type V subtrochanteric fracture. Twenty-five cases were divided into 2 groups based on the fixation devices: the TGLN group (13 cases; 5 men and 8 women) and the INTERTAN group (12 cases; 5 men and 7 women). Patients were followed up postoperatively, and their clinical history, intraoperative blood loss, fracture healing, Harris Hip Scores, and postoperative complications were recorded and compared.
Patients in the TGLN group had shorter operation time and less intraoperative blood loss, compared with those in the INTERTAN group (P < .05). There were no significant between-group differences in postoperative complications, fracture healing time and Harris Hip Scores during the follow-up (P > .05).
... 20 Improvements in the design of locked nails to allow smaller nails to be inserted, along with avoidance of ;osteonecrosis of the femoral head afforded by a lateral entry approach, may be other explanations for the growing popularity of this form of fixation in younger patients. 21,22 In a concurrent, retrospective study from 2007 to 2012 of patients treated for femoral fractures at a single center, Oetgen et al 23 analyzed the results of 361 patients to determine adherence to the CPG. They found the AAOS publication of CPG had little clinical impact at that institution; they also found a significant decrease in flexible nailing in ages 5 to 11. ...
Background:
To determine if the AAOS clinical practice guidelines (CPG) for the treatment of pediatric femoral shaft fractures (2009) changed treatment, we analyzed pediatric femoral shaft fractures at 4 high-volume, geographically separated, level-1 pediatric trauma centers over a 10-year period (2004 to 2013).
Methods:
Consecutive series of pediatric femoral shaft fractures (ages, birth to 18 y) treated at the 4 centers were reviewed. Treatment methods were analyzed by age and treatment method for each center and in aggregate.
Results:
Of 2646 fractures, 1476 (55.8%) were treated nonoperatively and 1170 fractures operatively. Of the operative group, flexible intramedullary nails (IMN) were used for 568 patients (21.5%), locked intramedullary nails (LIMNs) for 309 (11.7%), and plating for 188 (7.1%). In total, 105 fractures were treated with external fixation or skeletal traction. Analysis before and after the CPG publication revealed a significant increase in the use of interlocked IMNs in patients younger than 11 years (0.5% before, 3.8% after; P<0.001). Over the same time period there was an increase in surgical management, regardless of technique, for patients younger than 5 years (6.4% before, 8.4% after; P=0.206). There were considerable differences in treatment among centers: 74% of fractures treated with plating were from a single center (center A), which also contributed 68% of patients younger than 5 years treated with plating; center B had the highest rate (41%) of flexible IMN in children younger than 5 years; center C had the highest rate (63%) of LIMN in children younger than 11 years; and center D treated the fewest patients outside the CPG guidelines.
Conclusions:
Following publication of the AAOS CPG, there was a significant increase in the use of LIMNs in patients younger than 11 years old and a trend toward surgical treatment in patients younger than 5 years. The considerable variability among centers in treatment methods and adherence to the CPG highlights the need for further outcome studies to better define optimal treatment methods and perhaps update the AAOS CPG guidelines.
Level of evidence:
Level III-therapeutic.
Background:
The treatment modalities for pediatric femoral shaft fractures are determined by their age, weight, and fracture pattern. Rigid intramedullary nailing (RIN) is usually recommended for patients >11 years of age, and elastic intramedullary nailing (EIN) has been used for patients under 10 years. However, little is known about the use of RIN in patients aged 8 to 10 years. We examined the differences in patients with femoral shaft fractures who were treated with EIN or RIN in terms of (1) fracture healing; (2) changes of anatomic parameters; and (3) related complications.
Methods:
We retrospectively reviewed 54 patients between 8 and 10 years of age, with femoral shaft fractures, who were treated with either EIN or RIN between 2011 and 2020. Lateral trochanteric entry was used for RIN procedure. The mean follow-up period was 26.4 months (range, 6 to 113 mo). There were 17 patients in the EIN group and 37 patients in the RIN group. The mean age at the time of surgery was 1 year younger in the EIN group (P<0.01). The mean weight of the patient was significantly heavier in the RIN group compared with the EIN group.
Results:
Complete union of the fracture was achieved slightly faster in the RIN group at 3.4 months compared with 3.7 months in the EIN group (P=0.04). There were no clinically significant changes of the anatomic parameters in either group, including neck shaft angle and articulotrochanteric distance. There was no evidence of avascular necrosis at the time of final follow-up for either group. There were no significant differences in postoperative complications between the groups.
Conclusion:
RIN using lateral trochanteric entry is a feasible surgical option for femoral shaft fractures in patients 8 to 10 years of age that are heavier than 40 kg or with unstable fracture patterns.
Level of evidence:
Level III, retrospective cohort study. See the Guidelines for Authors for a complete description of levels of evidence.
Purpose:
Management of pediatric subtrochanteric femur fractures (SFFs) is difficult. The aim of this study was to evaluate the outcomes of adolescent SFFs treated with adult proximal humeral locking plates (PHLPs).
Materials and methods:
A retrospective analysis of 18 adolescents (11 male, 7 female) with a diagnosis of SFF who underwent internal fixation with a PHLP was conducted. Data regarding injury mechanism, fracture pattern, and time to union were recorded for all patients. In addition, a clinical and functional evaluation of patients was performed using the Harris hip score (HHS), Iowa hip score (IHS), modified Merle d'Aubigne-Postel score (MMAPS), Flynn criteria, and hip range of motion (ROM).
Results:
The mean age of the patients was 12.72±2.05 years (range, 10-16 years). Radiological observation was performed for evaluation of five different injury mechanisms and different fracture patterns in patients. The mean postoperative HHS was 92.27±5.61, the mean IHS was 90.88±6.46, and the mean MMAPS was 17.22±0.94. According to the Flynn criteria, excellent results were achieved in 14 cases and satisfactory results were obtained in four cases. Measurements of the patients' mean hip ROM values were as follows: 17.77±3.52° in extension, 115.27±6.74° in flexion, 43.05±3.48° in abduction, 27.50±4.28° in adduction, 42.22±4.60° in internal rotation, and 42.22±3.91° in external rotation.
Conclusion:
Surgery performed on adolescent patients using an adult PHLP showed good, safe results. Therefore, it should be considered as an alternative option.
A wide range of implants are used in the treatment of pediatric fractures, including wires, plates, screws, flexible rods, rigid rods, and external fixation devices. Pediatric bones differ from adult bones both mechanically and biologically, including the potential for remodeling. Implants used in pediatric trauma patients present a unique set of circumstances regarding indications, risks, timing of implant removal, weight-bearing restrictions, and long-term sequelae. Indications for implant removal include wire/pin fixation, when substantial growth remains, and infection. When considering implant removal, the risks and benefits must be assessed. The primary risk of implant removal is refracture. The timing of implant removal varies widely from several weeks to a year or more with the option of retention depending on the fracture, type of implant, and skeletal maturity of the patient.
In this study, we aimed to show that subtrochanteric femur fractures, an uncommon type of fracture in the paediatric age group, can be treated with titanium elastic nailing (TEN). We reviewed the patients treated with TEN in the paediatric age group with subtrochanteric femur fractures who had been treated at the Orthopaedics and Traumatology Clinic of Izmir Tepecik Research and Training Hospital between January 2011 and December 2016 retrospectively. All fractures were fixed by retrograde nailing with supracondylar entry following reduction. Patients' demographics as well as data such as fracture type, fracture level, time of operation, reduction type, time to union, shortness, additional fixation, duration of additional fixation, Flynn scores and reduction loss were evaluated. The 20 patients included in our study were followed up for at least 1 year, had an age range of 54-173 months (mean, 104 ± 31.82 months) and were operated within 2-11 days after fracture. All patients had fracture union and only three patients had union with an angulation of less than 5°. None of the patients had limb length inequality. Fourteen patients underwent reoperation, all of these were routine operations for implant removal and no patients required reoperation for complications. We think that paediatric subtrochanteric femur fractures can be treated by TEN fixation using the proper technique, with a limited invasive intervention.
Objective:
To discuss the effectiveness of intramedullary nail fixation with selective cable wiring in the treatment of ipsilateral femoral neck fracture and subtrochanteric fracture.
Methods:
Between June 2012 and December 2015, a total of 19 patients with ipsilateral femoral neck fracture and subtrochanteric fracture underwent closed reduction of femoral neck fracture and intramedullary nail fixation combined with selective cable wiring. There were 5 males and 14 females with a median age of 52 years (range, 35-77 years). The cause of injury included traffic accident injury in 17 cases and falling injury in 2 cases. According to Garden classification for femoral neck fractures, 7 cases were rated as type Ⅱ, 8 as type Ⅲ, and 4 as type Ⅳ. Femoral subtrochanteric fractures were classified by Seinsheimer classification, with 9 cases as type Ⅱ, 5 as type Ⅲ, 3 as type Ⅳ, and 2 as type V. The interval from injury to operation ranged from 2 to 7 days with an average of 3.7 days.
Results:
The operation time was 58-125 minutes (mean, 82.4 minutes) and the intraoperative blood loss was 225-725 mL (mean, 289.5 mL). All incisions achieved healing by first intention and no early complication such as infection was observed. All patients were followed up 12-18 months (mean, 13.9 months). At 1 month after operation, the tip apex distance was 9-23 mm (mean, 15.2 mm). All patients achieved bone union with the healing time of 18-42 weeks (mean, 27.4 weeks). One case of hip varus and femoral neck re-displacement (femoral neck shaft angle was 122°) occurred at 3 months after operation, which achieved bone union at 42 weeks after operation. Five patients complained of postoperative pain with the visual analogue scale (VAS) score of 1-3 (mean, 1.8), which did not influence normal life. A total of 16 patients recovered preoperative hip function. During follow-up, no fracture nonunion, femoral head necrosis, implant failure, screw cut-out, and loosening of cable wiring was observed. The Harris hip score (HSS) was 72-92 (mean, 82.8) at last follow-up and 15 patients (78.9%) achieved good hip function.
Conclusion:
Intramedullary nail fixation combined with selective cable wiring was effective in the treatment of ipsilateral femoral neck fracture and subtrochanteric fracture.
Femoral shaft fractures are common injuries in the pediatric and adolescent age groups. Rigid intramedullary nailing is an excellent treatment option for older children and adolescents, particularly for length-unstable fractures and larger patients (>49 kg). Appropriate indications, contraindications, and preoperative assessment are described. The rigid nailing surgical technique is detailed including positioning, operative steps, pearls, and pitfalls. Complications and the reported outcomes of lateral trochanteric entry nailing are reviewed from the published series.
The objectives of this study were to determine the incidence of femur fractures in Colorado children, to assess underlying causes, to determine the prevalence and predictors of associated injuries, and to identify potentially modifiable risk factors.
The study population included all Colorado residents who were aged 0 to 17 years at the time of injury between January 1, 1998, and December 31, 2001. Cases of femur fracture were ascertained using the population-based Colorado Trauma Registry and International Classification of Diseases, Ninth Revision, Clinical Modification codes 820.0 to 821.39. Associated injuries with an Abbreviated Injury Scale of 2 or higher were classified into 5 categories. Poisson regression, small area analysis, and multivariate logistic regression were used to identify predictors of femur fractures and associated injuries, respectively.
During the study period, 1139 Colorado children (795 boys, 344 girls) sustained femur fractures, resulting in the incidence of 26.0 per 100000 person-years. Rates were higher in boys than in girls in all age groups (overall risk ratio: 2.19; 95% confidence interval: 1.92-2.47) but did not differ by race/ethnicity. Femur fractures that were caused by nonaccidental trauma showed more distal and combined shaft + distal pattern; their incidence did not differ by gender or race but was higher in census tracts with more single mothers and less crowded households. Associated injuries were present in 28.6% of the cases, more often in older children. Fatalities occurred only among children with associated injuries. Children who were involved in nonaccidental trauma, motor vehicle crashes, or auto-pedestrian accidents were 16 to 20 times more likely to have associated injuries than those with femur fractures as a result of a fall. In small-area analysis, the incidence of femur fractures in infants and toddlers was higher in census tracts characterized by higher proportion of Hispanics, single mothers, and more crowded households. Among children 4 to 12 years of age, the incidence was higher in census tracts with fewer single-family houses and more crowded households. Finally, the incidence of femur fractures among teenagers was higher in rural tracts and those with a higher proportion of Hispanics.
Femur fractures and associated injuries remain a major cause of morbidity in children. Predictors of femur fractures change with age; however, the risk is generally higher among children who live in the areas with lower socioeconomic indicators.
Pediatric subtrochanteric femoral fractures are rare and have received limited attention in the literature Treatment is controversial. Different treatment options are used: skin traction, 90/90 skeletal traction, spica casting, cast bracing, internal fixation and external fixation. The aim of this study is to present our results with internal fixation of subtrochanteric femoral fractures in children using a reconstruction plate. Between 2000 and 2004, eighteen patients with closed subtrochanteric femoral fractures were treated in the Mansoura Emergency Hospital. The average age at the time of injury was 8.2 years (range 5.3 years to 11.5 years). Pathological fractures and fractures associated with neuromuscular diseases were excluded from this study. Eight patients had head injuries and/or multiple injuries. In all cases a single 4.5 mm contoured reconstruction plate was used and a 6.5 mm cancellous screw was inserted through the plate into the femoral neck. Average follow-up was 38 months (range, 12 to 47 months). All fractures united with anatomical alignment within an average of 8 weeks (range 6 to 12 weeks). There were no deep infections and no significant limb length discrepancies. At the latest follow-up, no patient had any restriction of activities. Internal fixation with a reconstruction plate appears as a good treatment option for children with subtrochanteric femoral fractures.
Subtrochanteric femoral fractures are complicated injuries that may be associated with other life-threatening conditions. Patients should be carefully evaluated and appropriately treated for hypo-volemic shock. These fractures can be effectively stabilized with 95 degrees plates, femoral reconstruction nails, or trochanteric femoral nails with interlocking options. Nails produce very stable constructs and consistently can be placed with the patient in the lateral position on the radiolucent table or in the supine position on the fracture table. Standard antegrade femoral nails may be indicated in certain fracture patterns. The 135 degrees hip screw-plate is not suitable in the treatment of subtrochanteric femoral fractures; use of these implants may result in loss of fixation and fracture displacement. Chemical and mechanical prophylaxis for deep vein thrombosis should be initiated unless contraindicated by other medical comorbidities. An accurate reduction and excellent surgical technique with minimal soft-tissue dissection can routinely produce good results without the need for secondary procedures.
This study investigated the frequency and potential risk factors associated with the development of distal femoral valgus deformity following plate fixation of diaphyseal femoral fractures in children.
Records of eighty-five skeletally immature patients who underwent plate fixation of a diaphyseal femoral fracture at a tertiary-care pediatric center from January 2003 to December 2010 were reviewed. Demographic data and clinical information were analyzed. Radiographic measurement of the distance from the distal plate edge to the distal femoral physis and of the anatomic lateral distal femoral angle was performed. Development of distal femoral valgus deformity was defined as a change in the anatomic lateral distal femoral angle of ≥5° in the valgus direction. Logistic regression analysis and contingency tables were used to relate the development of distal femoral valgus deformity with retention of hardware, patient age, fracture site, plate-to-physis distance, and the location of a bend in the plate at fixation.
Midshaft fractures (45%) were more common than proximal or distal diaphyseal fractures. Intraoperatively, the plate was bent proximally or distally, or both, in 80% of the patients. Distal femoral valgus deformity of ≥5° was seen in ten patients, eight of whom had distal diaphyseal fractures. Three of the ten patients developed symptoms as a result of the distal femoral valgus deformity that required at least one unplanned additional surgical procedure. On the basis of the statistical analysis, patients with a plate-to-physis distance of ≤20 mm (relative risk= 12.77, p = 0.005) and a distal fracture (relative risk = 11.0, p < 0.001) were at a significantly higher risk of developing distal femoral valgus deformity. Although not clearly an independent factor, a distal bend was also found to be associated with distal femoral valgus deformity (p = 0.004) but was not predictive of the pathology.
Distal femoral valgus deformity occurred in 30% of patients with distal diaphyseal fractures and in 12% overall. We advocate long-term monitoring of patients with femoral plate fixation, particularly those in whom the plate is placed ≤20 mm from the distal femoral physis.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
: Locking compression plates (LCPs) are being increasingly utilized in fixation of fractures and osteotomies in the pediatric population. However, plate insertion or removal may pose a risk of femoral fractures or refractures. The goal of this study was to analyze failure patterns associated with LCPs and identify possible contributing factors.
: The sample included all patients who underwent fixation of femoral fractures or osteotomies utilizing straight LCPs at a tertiary pediatric medical center from 2004 to 2009. All were followed up until fracture union. The charts and radiographs were reviewed, and data on demographics, indications, surgical technique, and timing of plate removal were summarized. In cases of failure, the timing, circumstances, fracture location, and refixation method were recorded.
: Thirty-seven patients underwent 41 straight LCP fixations during the study period. The indication for surgery was acute femoral fracture in 25 procedures (25 patients) and elective osteotomy or limb lengthening in 16 procedures (12 patients). Thirty-five plates were removed after complete clinical and radiographic union. The time from plate fixation to removal averaged 13 months (range, 5 to 34 mo) in the fracture group and 17.6 months (range, 7.5 to 28 mo) in the osteotomy group. Five procedures (12%) were complicated by femoral fractures or refractures: 2 occurred after the index surgery-1 at the proximal screw and 1 through the original fracture site, with plate breakage. Three patients sustained refractures after plate removal, all at the original fracture or regenerate site: 1 after a fall and 2 spontaneously. The average time from plate removal to refracture was 18 days (range, 10 to 30). There were no differences in demographics, timing, or technique between patients with and without complications.
: Although LCPs are considered flexible fixators, they may carry the risk of overstiffness, similar to external fixators. Further clinical and biomechanical studies are needed to evaluate risk factors for fractures or refractures, particularly in children. There seems to be an increase in risk of refracture immediately after plate removal. Caution should be taken in the first weeks after plate removal.
: Level IV.
The treatment of femoral shaft fractures in older children and adolescents using rigid intramedullary (IM) nail fixation offers the advantages of decreased soft tissue stripping, low incidence of malalignment, leg length discrepancy, early ambulation, and decreased hospital stay. Recent reports have described the development of osteonecrosis of the femoral head in children after IM nailing through the piriformis fossa and the tip of the greater trochanter. Others have noted secondary proximal femoral valgus and femoral neck narrowing after antegrade IM nailing. Using the lateral aspect of the greater \trochanter as the starting point avoids the tenuous blood supply of the proximal femur and did not seem to produce avascular necrosis or proximal femoral deformity in early reports.
A retrospective clinical and radiographic review of 78 children and adolescents with 80 femoral shaft fractures who underwent IM nail fixation through the lateral aspect of the greater trochanter, with a mean follow-up of 99 weeks, was performed. Twenty-four fractures were observed until skeletal maturity. Final standing anteroposterior radiographs of both lower extremities were used to assess for evidence of osteonecrosis, limb length discrepancy, fracture alignment, and indices around the hips.
All patients went on to union in good clinical alignment without loss of reduction. No nonunions, delayed unions, or malunions were observed. Two patients developed infections postoperatively (2.5%). No patient had evidence of osteonecrosis of the femoral head. There was no significant difference in neck-shaft angle, articulotrochanteric distance, or femoral diameter when compared with the nonsurgical, normal side in these patients.
Intramedullary nail fixation through the lateral aspect of the greater trochanter in children and adolescents is effective. It does not produce clinically important femoral neck valgus or narrowing. We did not observe osteonecrosis of the femoral head.
: Level IV, case series.
The optimal treatment of femoral shaft fractures in older children and adolescents remains controversial. We hypothesized that fixation with a flexible interlocking intramedullary nail (FIIN) reduces perioperative complications and improves outcomes, including leg-length discrepancy, time to healing, and time to weight bearing compared with other fixation procedures (OFPs) including standard elastic nail implants.
Using a retrospective cohort study design, we reviewed medical records and radiographs of children, 7 to 18 years of age, with femoral shaft fractures requiring open treatment between July 1, 1998, and June 30, 2003. Patients selected for the study had unilateral fracture sites proximal to the supracondylar region and distal to the lesser trochanter, presence of open femoral growth plates, and open surgical treatment. Analyses compared inpatient measures and patient outcomes between FIIN and OFP groups.
Of the 160 patients eligible for inclusion, 23 were lost to follow-up. The remaining 137 patients had a mean follow-up of 396.3 days (SD, 320.4 days), with 58 receiving FIIN fixation and 79 OFP. Although the difference was not statistically significant, complications occurred in 19.0% of patients in the FIIN group and 30.4% in the OFP group. Trochanteric heterotopic ossification was the most common complication (13.8%) noted in the FIIN group and superficial infection (12.8%) in the OFP group. The FIIN group experienced less blood loss (P = 0.042) and shorter time to weight bearing (P = 0.001) without disturbance of proximal femoral geometry or avascular necrosis of the femoral head. In children weighing less than 45.5 kg (100 lb), complications were less common with FIIN (3.6%) compared with OFP (24.4%). A subgroup of patients less than 45.5 kg (100 lb) with standard elastic nail implants (n = 24) had 8.1 times the complications of patients with FIIN.
Older children and adolescents with femoral shaft fractures treated with a FIIN showed improved outcomes compared with patients treated with OFP.
Level III, therapeutic study.
Subtrochanteric fractures are relatively rare in children and usually result from severe trauma. The unique biomechnical forces about the hip following fracture tend to complicate treatment. Remodeling and growth stimulation generally ensure good results by nonoperative means in children under 10 years of age. Open reduction should be considered in older children when good alignment cannot be achieved by closed methods.
Ninety-five subtrochanteric femoral fractures were treated with an interlocking nail. There were 69 closed and 26 open fractures. This injury was the result of high-energy trauma in 77% of the cases. The average time to healing was 25 weeks. There were three delayed unions, one nonunion, and six malunions. Essentially all nonpathologic, subtrochanteric femur fractures can be stabilized by interlocking nailing, regardless of the fracture pattern or degree of comminution. Favorable mechanical characteristics of interlocking nails have eliminated the requirement of surgically reconstituting the medial femoral cortex. Closed interlocking nailing is the preferred treatment for subtrochanteric fractures of the femur resulting from trauma.
We studied a series of fifteen consecutive subtrochanteric fractures treated in a long quadrilateral cast-brace with a pelvic band. Patients with severely comminuted fractures in which stability cannot be obtained by internal fixation, as well as those with open fractures, are considered candidates for such treatment. Treatment with preliminary traction followed by a ambulatory cast-brace with a pelvic band resulted in a shorter period of treatment, an excellent range of motion of the hip and knee, and no non-unions in the fifteen comminuted or open fractures. Shortening, angulation, and rotational deformity were not significant complications. It must be emphasized that this treatment regimen requires exacting attention to detail by the treating physician. The amount of time needed from the physician in this form of treatment is considerably greater than that after open reduction and internal fixation.
Avascular necrosis of the hip was evaluated in two groups of patients. One group had sustained the insult to the epiphysis in infancy and had a mean growth loss in the proximal end of the femur of 21.5 millimeters at a mean age of 11.7 years. The other group had sustained the insult in mid-childhood (due to Legg-Perthes disease) and had a mean growth loss of 7 mm at 12.4 years. Based on this evaluation, the authors concluded that trochanteric epiphyseodesis was needed to prevent relative trochanteric overgrowth in the former group but was not necessary in the latter group.
We describe our experiences in 40 consecutive patients with subtrochanteric fractures treated with an AO 95 degrees condylar blade plate. Three patients died early due to multiple injuries. One patient developed a delayed union which ultimately resulted in repeated plate fractures due to fatigue. All other fractures heated despite deep postoperative wound infection in three cases. Based on our favourable results, we consider the condylar blade plate fixation of subtrochanteric fractures to be an excellent method, especially if an image intensifier and/or fracture table are not available.
One-hundred and thirty-two children with 139 femur fractures were treated with external fixation from 1984 to 1993. Average age at presentation was 8.97 years. All fractures were followed until union, with an average time of external fixation of 11.4 weeks. There were no nonunions. Of 18 patients with definitive radiographic measurements at 2-year follow-up, 15 patients developed overgrowth (average, 8.7 mm) and three demonstrated shortening (average, 7.7 mm). No patient required treatment for residual leg-length discrepancy. Although pin-tract inflammation was common, pin-tract infection requiring intravenous antibiotics occurred in only six patients (4.5%). No patient developed osteomyelitis. Two fractures (1.4%) were not healed at the time of elective fixator removal, necessitating additional time in the fixator. There were two refractures (1.4%) and one fracture through a healing pin tract after fixator removal (0.7%).
Fifteen children younger than 10 years of age with subtrochanteric fractures treated by a uniform method were evaluated. These patients had been treated with femoral skeletal traction, with the hip and knee flexed to 90 degrees until radiographic callus appeared, then with a hip spica cast. True neck to shaft and anteversion angles were calculated bilaterally using a biplanar method. Leg lengths were measured radiographically and clinically. Mean age at injury was 4.5 years, and mean followup was 6.5 years. Overgrowth averaged 10 mm after fracture. Anteversion at final followup differed only by a mean of 2 degrees from the contralateral side (range, -3 degrees to +4 degrees), and the mean neck shaft angle differed by only 1 degree. Remodeling of coronal angulation was 50% or more in all cases.
We report the results of treatment in 99 children with subtrochanteric fractures of the femur. Late reviews of 60 of the 65 children treated with traction and then a hip spica after stabilization of the fracture by callus, and of 20 of the 22 treated with early closed reduction and a hip spica yielded 80% satisfactory outcomes. However, 27% of the fractures treated with early closed reduction required remanipulation. The satisfactory outcomes in the traction and delayed spica group would be increased to nearly 100% by using only skin traction, as persistent lengthening of the femur and pin-site pain, the main long-term complications, were the result of skeletal traction. Late review of 10 of the 12 children treated surgically showed 100% satisfactory medical outcomes but only 60% satisfactory patient-determined outcomes. Persistent pain in the thigh incision used for open reduction was the main cause of patient dissatisfaction.
To determine whether the mechanical properties of first-generation interlocking femoral nails are different from those of second-generation interlocking femoral nails in a subtrochanteric femur fracture model.
Randomized laboratory investigation using a synthetic subtrochanteric femur fracture model.
Simulated stable and unstable fractures were created at three levels in the subtrochanteric region of synthetic femora. Instrumented specimens were tested elastically in a biomaterials testing system.
Synthetic femora were instrumented with either a statically locked first-generation femoral nail or a statically locked second-generation femoral nail.
Elastic stiffness for both the stable and unstable fracture groups was measured in both compression and torsion. Unstable fracture specimens were tested to failure in compression, and load to failure was measured.
Throughout the subtrochanteric region, second-generation femoral nail constructs were consistently stiffer in compression and torsion than were statically locked first-generation femoral nail constructs. In general, second-generation constructs also withstood larger loads to failure in the unstable fracture model.
Second-generation nails provided significantly enhanced mechanical stiffness compared with first-generation femoral nails when used to treat both stable and unstable subtrochanteric femur fractures. Although these results were obtained by using a well-controlled, mechanically consistent model, clinical validation of an increased incidence of fracture unions or of decreased time to union is required before we can recommend that second-generation nails be used routinely to treat subtrochantenic femur fractures.
To determine the stiffness and strength characteristics of certain plate-composite femur models designed to simulate unstable subtrochanteric femur fractures (OTA 31-A2.3).
Fifteen identical composite femora were osteotomized to produce like models of an unstable subtrochanteric femur fracture. The femora were fixed with either the Synthes 95 degree angled condylar blade plate, a 95 degree dynamic condylar screw plate (DCS), or a 135 degree dynamic compression hip screw (DHS).
A materials testing machine was used to apply compression to the femoral head through an adapter plate. Stiffness values were calculated from the load-deformation curves obtained.
The DHS-femur model was the stiffest (586 newtons/ millimeter), followed by the 95 degree DCS (404 newtons/millimeter) and the 95 degree condylar blade plate (260 newtons/ millimeter). The DHS also had the highest ultimate load-to-failure (4,877 newtons), followed by the 95 degree DCS (3,107 newtons) and the 95 degree condylar blade plate (2,272 newtons). All of these differences were statistically significant (p < 0.00001 ).
Our findings suggest that the Synthes 95 degree DCS has greater stiffness and strength than the Synthes 95 degree condylar blade plate when tested in this model of an unstable subtrochanteric femur fracture. This model may not be completely appropriate for testing the 135 degree DHS because the hard plastic "cortex" of the model prevented cut-out of the screw.
Thirty-seven femoral shaft fractures, in 33 patients, were treated with unilateral external fixation after reduction from 1992 through 1998. Ten girls and 23 boys ranged in age from 4 to 14 years. Thirteen children had multiple injuries, whereas 20 children had isolated fractures. Average follow-up was 3 years, 9 months, with only five children lost to follow-up. The average duration in fixator was 107 days. Thirty-six of 37 fractures healed, and there was one delayed union. There was minimal angulation, and limb-length inequality was generally <1 cm; 72.7% had pin-tract infections. Eight (21.6%) patients refractured; four occurred in the four patients with bilateral femur fractures. We agree with previous reports that external fixation remains a viable option for treatment of pediatric femoral shaft fractures. However, in our series, rate of refracture (21.6%) after removal of the external fixator is significantly higher than previously reported in literature. Children with bilateral femur fractures were at greatest risk.
Traditionally, the treatment of choice in managing pediatric femur fractures has been traction and casting. Newer methods have focused on earlier mobility and shorter hospitalization. Use of retrograde titanium elastic nails (TENs) can quicken stabilization while allowing enough motion at the fracture site to generate excellent callus. Since TENs were first introduced in North America, our Level 1 Pediatric Trauma Center has prospectively followed all of its TEN patients. In this article, we present lessons from the learning curve of our first 50 cases--focusing on complications and their prevention. In the course of obtaining predominately excellent results, we have learned several important principles regarding TEN preoperative planning, operative technique, and aftercare. The most common problem encountered has been irritation at the nail insertion site (18% of cases). Very proximal fractures may be more challenging; unstable fractures and fractures in larger, older children are best managed with a short period of adjunctive immobilization.
Femoral shaft fractures are the most common major pediatric injuries managed by the orthopaedic surgeon. Management is influenced by associated injuries or multiple trauma, fracture personality, age, family issues, and cost. In addition, child abuse should be considered in a young child with a femoral fracture. Nonsurgical management, usually with early spica cast application, is preferred in younger children. Surgery is common for the school-age child and for patients with high-energy trauma. In the older child, traction followed by casting, external fixation, flexible intramedullary nails, and plate fixation have specific indications. The skeletally mature teenager is treated with rigid intramedullary fixation. Potential complications of treatment include shortening, angular and rotational deformity, delayed union, nonunion, compartment syndrome, overgrowth, infection, skin problems, and scarring. Risks of surgical management include refracture after external fixator or plate removal, osteonecrosis after rigid antegrade intramedullary nail fixation, and soft-tissue irritation caused by the ends of flexible nails.
We conducted a small retrospective study of rates of early complications associated with external fixation of pediatric femur fractures and compared rates at our institution with those reported in the literature. In our series of 22 patients, early complications included 12 pin-track infections (54.5%), 2 cases of loss of reduction (9.1%), 1 pin-track abscess (4.5%), and 1 refracture (4.5%). Overall rates (ours combined with those reported by other investigators) were 4.7% (34/719) for refractures and 33.1% (224/677) for pin-track infections. Factors that correlated with refractures were open fracture, bilateral fracture, and longer time in fixator. Factors with inconclusive correlations were fracture pattern, dynamization status, fixator type, pin size, and number of pins.
There have been no studies that have specifically looked at the management of subtrochanteric femoral fractures in skeletally immature adolescents. It was the purpose of this study to investigate the treatment of this injury in this unique patient population.
A retrospective review of all subtrochanteric femoral fractures treated at a major pediatric trauma center since 1990 was performed.
There were 13 adolescents with an average age of 13 years and 6 months. The average length of follow-up was 2 years and 3 months. Eight of the 10 operatively treated patients had a satisfactory result, whereas the outcome was unsatisfactory in all three patients treated nonoperatively. Complications included three limb-length discrepancies, one case of avascular necrosis of the femoral head, one transient peroneal nerve palsy, and one case of asymptomatic heterotopic ossification. At the time of most recent follow up, all had returned to preinjury level of function.
Operative treatment provided more satisfactory results than nonoperative methods.
Titanium elastic nailing (TEN) has become more common in the treatment of pediatric femur fractures in many European centers and in North America over the past several years. Prior studies have shown that the use of TEN for midshaft femur fractures results in excellent outcomes with an earlier return to activity, earlier mobilization, and a shortened hospital stay. However, subtrochanteric femur fractures continue to remain a difficult subset of fractures to care for, with loss of reduction and nonunion being significant complications. Studies have differed regarding the definition of pediatric subtrochanteric femur fractures. The purpose of this study is to establish a reproducible method of defining pediatric subtrochanteric fractures and then apply that definition in a retrospective review of 13 patients who sustained subtrochanteric femur fractures treated with TEN at North Carolina Baptist Hospital using a modified technique that allows for improved fracture stability.
Charts and radiographs were retrospectively reviewed for all pediatric patients sustaining subtrochanteric femur fractures treated with TEN from the period of 2000 to 2004 at Wake Forest University. The TEN outcome measures scale was applied to determine their results.
TEN allowed rapid mobilization with excellent or satisfactory clinical and radiographic results in all patients.
Results suggest that the use of TEN for subtrochanteric femur fractures is a safe and effective method of fixation that benefits patients through early mobilization, shorter hospital stays, and fewer complications.
By applying the definition of subtrochanteric femur fractures described by the authors, results of future studies can be objectively compared and classified. TEN is a safe and effective alternative for treating most pediatric subtrochanteric fractures by decreasing the morbidity that occurs with other treatment modalities.
Between 1996 and 2003 six institutions in the United States and France contributed a consecutive series of 234 fractures of the femur in 229 children which were treated by titanium elastic nailing. Minor or major complications occurred in 80 fractures. Full information was available concerning 230 fractures, of which the outcome was excellent in 150 (65%), satisfactory in 57 (25%), and poor in 23 (10%). Poor outcomes were due to leg-length discrepancy in five fractures, unacceptable angulation in 17, and failure of fixation in one. There was a statistically significant relationship (p = 0.003) between age and outcome, and the odds ratio for poor outcome was 3.86 for children aged 11 years and older compared with those below this age. The difference between the weight of children with a poor outcome and those with an excellent or satisfactory outcome was statistically significant (54 kg vs 39 kg; p = 0.003). A poor outcome was five times more likely in children who weighed more than 49 kg.
Unlabelled:
Elastic stable intramedullary nailing (ESIN) has became a well-accepted method of osteosynthesis of diaphyseal fractures in children and adolescents for many reasons including the following: no need for postoperative cast, primary bone union with avoidance of growth plate injury, and minimum invasive surgery.
Operative technique:
The principle is to introduce 2 elastic nails, titanium or stainless steel, into the medullary canal through a metaphyseal approach. The bended nails must have their maximum of curve at the level of the fracture, and their orientation, most often face to face, is in charge of the reduction and, so far, the stabilization, of the fracture. The usual size of the nails is equal to 0.4 times the diameter of the medullary canal. As far as possible, a bigger diameter is better than a thinner one. Most fractures of the femur are treated with a bipolar retrograde ESIN when some distal fractures need an antegrade subtrochanteric approach. Forearm fractures need a combined retrograde radial and antegrade ulnar through the posterolateral part of the olecranon. Humerus and tibial diaphyseal fractures may also be treated with ESIN. Complications are mainly caused by technical errors including too-thin nails, asymmetry of the frame, and malorientation of the implants. Nonunion was never observed in fractures of the femur and the forearm; osteomyelitis rate is 2%, and mean overgrowth of the femur is less than 10 mm before the age of 10 years. Indications of ESIN are fractures of the diaphysis: all the fractures of the femur between the age of 6 years and the end of growth except for the severe open grade III fractures, all the unstable fractures of the forearm, and some unstable fractures of the humerus and the tibia during adolescence or before the end of growth. In addition, ESIN is indicated in polytraumatism and multiple injuries.
Conclusions:
The good results of this reliable technique are obtained when surgeons have a good knowledge of it, especially in the understanding of the principle of the correction of the fracture and its stability.
The cases of 40 pediatric femur fractures treated with external fixation were reviewed to determine whether stabilization with cortical contact resulted in clinical leg-length discrepancy (LLD). Mean follow-up was 29.4 months, mean age was 6.6 years (range, 2-10 years), 25 injuries were isolated, 100% of the fixators were applied with cortical contact, all fractures healed by a mean of 92 days, 72.5% were dynamized before removal, mean LLD was 0.24 cm short, and complications included 1 refracture (2.5%), early removal of 2 loose pins (1.25% of 160 pins), pin-tract infections in 21 patients (52.5%), and 1 LLD (2.5%) of more than 1.0 cm (5.0 cm short). External fixation with cortical contact was an effective treatment for pediatric femur fractures. It limited overgrowth and resulted in few refractures. Pin-tract infections were common.
Subtrochanteric femoral fractures are complicated injuries that may be associated with other life-threatening conditions. Patients should be carefully evaluated and appropriately treated for hypovolemic shock. These fractures can be effectively stabilized with 95 degrees plates, femoral reconstruction nails, or trochanteric femoral nails with interlocking options. Nails produce very stable constructs and consistently can be placed with the patient in the lateral position on the radiolucent table or in the supine position on the fracture table. Standard antegrade femoral nails may be indicated in certain fracture patterns. The 135 degrees hip screw-plate is not suitable in the treatment of subtrochanteric femoral fractures; use of these implants may result in loss of fixation and fracture displacement. Chemical and mechanical prophylaxis for deep vein thrombosis should be initiated unless contraindicated by other medical comorbidities. An accurate reduction and excellent surgical technique with minimal soft-tissue dissection can routinely produce good results without the need for secondary procedures.
The AO Pediatric Expert Group and the AO Pediatric Classification Group, in cooperation with the AO Investigation and Documentation Group introduce and present the first comprehensive classification of pediatric long bone fractures. The anatomy is related to the 4 long bones and their 3 segments defined as proximal (1), shaft (2) and distal (3). It is further described by the fracture subsegment recorded as epiphyseal (E), metaphyseal (M) and diaphyseal (D), whereby proximal and distal fractures are classified as E or M and shaft fractures are always D. The distinction between metaphyseal and diaphyseal fractures is achieved by localizing the center of fracture lines with regard to a square drawn over the respective growth plates. The morphology of the fracture is documented by a subsegment-specific child pattern code, a severity code as well as an additional code for displacement of specific fractures such as supracondylar fractures and radial heads. The classification process requires trained observers to read standard radiographic images.