|Year : 2017 | Volume
| Issue : 2 | Page : 107-114
Treatment of pediatric closed femoral shaft fractures: A decline in use of external fixators over the last decade
Joseph Anthony Ippolito, Gerard F Marciano, Sanjeev Sabharwal
Departments of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
|Date of Web Publication||22-Aug-2017|
Department of Orthopaedics, Rutgers New Jersey Medical School, 90 Bergen Street Suite 7300, Newark, NJ 07103
Source of Support: None, Conflict of Interest: None
Background: Femoral fractures represent 2% of all fractures in children. While external fixation was popular for managing pediatric closed femoral shaft fractures, other methods have recently increased in popularity. The purpose of this study was to analyze trends in the treatment of closed femoral shaft fractures over the past decade and quantify the change in usage of external fixators compared to other treatment methods in the pediatric population. Methods: The Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) was utilized to generate the prevalence of closed femoral shaft fractures and treatment (open reduction internal fixation, closed reduction, closed reduction internal fixation, open reduction, and external fixation) from 2000 to 2012. Results: The total number of reported pediatric femoral fractures declined from 10,504 in 2000 to 7,798 in 2012. Male-to-female ratios and mean ages were comparable between years. Overall, treatment with external fixation for closed femoral shaft fractures decreased from 2000 to 2012. There was a decrease in external fixation in each year recorded compared to previously reported years. There were no significant differences in treatment by region or hospital size. However, over the 12-year period, the rate of external fixation declined more rapidly in pediatric hospitals compared to nonpediatric hospitals. Conclusions: Treatment of pediatric closed femoral fractures with external fixation has declined in favor of internal fixation over the past decade across all geographic regions and in both teaching and nonteaching hospitals in the United States. This decline in external fixation occurred more rapidly in pediatric hospitals compared to nonpediatric hospitals. The clinical and financial impact of this change in practice needs further investigation.
Level of Evidence: Level III.
Keywords: External fixation, femur fracture, trauma
|How to cite this article:|
Ippolito JA, Marciano GF, Sabharwal S. Treatment of pediatric closed femoral shaft fractures: A decline in use of external fixators over the last decade. J Limb Lengthen Reconstr 2017;3:107-14
|How to cite this URL:|
Ippolito JA, Marciano GF, Sabharwal S. Treatment of pediatric closed femoral shaft fractures: A decline in use of external fixators over the last decade. J Limb Lengthen Reconstr [serial online] 2017 [cited 2020 May 28];3:107-14. Available from: http://www.jlimblengthrecon.org/text.asp?2017/3/2/107/213568
| Introduction|| |
In the pediatric patient population, femoral shaft fractures represent 2% of all fractures, with an annual incidence of approximately 20/100,000., Treatment options depend on a number of factors including patient age and fracture pattern and include the use of Pavlik harness, spica casting, intramedullary nailing, submuscular plating, and external fixation., Advances in methods of fixation have further contributed to increased popularity of operative treatment, with benefits including shorter hospital stays and earlier mobilization.,
External fixation has traditionally been used with success in patients with open fractures, soft-tissue injuries, hemodynamic instability, and polytrauma. However, numerous studies have also encouraged the use of external fixation for managing isolated closed pediatric femoral fractures.,,,,, Advantages of external fixation include decreased invasiveness, blood loss, and operating time. Common, complications include refracture, malunion, delayed union, and pin tract infection.,,,,,,, Despite advances in external fixation techniques and design contributing to reduction in complications,,,,, an apparent decrease in popularity of this treatment method is reflected by clinical practice guidelines from the American Academy of Orthopaedic Surgeons, which does not even mention external fixation as a treatment option for diaphyseal femur fractures. We hypothesized that popularity in methods of internal fixation may have contributed to a decline in the use of external fixator devices. The purpose of our study was to analyze trends in the treatment of closed femoral shaft fractures over the past several years.
| Methods|| |
We utilized the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) to determine national estimates of pediatric closed femoral shaft fractures and the prevalence of treatment with external fixation as compared to other select interventions. HCUP inpatient data are based on administrative data – discharge abstracts created by hospitals for billing. The KID database is the largest publicly available all-payer pediatric inpatient care database in the United States. Unweighted, it contains data from approximately 3 million pediatric discharges each year. Weighted, it estimates roughly 7 million hospitalizations. The KID records inpatient hospitalizations of patients younger than 21 years old.
Data were extracted from the KID utilizing the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes. ICD-9-CM diagnosis codes are three numeric digits followed by a decimal, which contain one or two additional digits. The code for closed femoral shaft fracture is ICD-9-CM-821.01. For each fracture code extracted, the corresponding treatment procedure was identified among procedures of interest for the study. Femoral shaft fractures with a treatment procedure of interest were selected for inclusion in the study. ICD-9-CM procedure codes are two numeric digits followed by a decimal of either one or two additional digits. The list of procedures of interest for the study includes application of external fixator device, femur (ICD-9-CM-78.15), closed reduction (ICD-9-CM-79.05), open reduction (ICD-9-CM-79.25), closed reduction with internal fixation (ICD-9-CM-79.15), open reduction with internal fixation (ICD-9-CM-79.35), and internal fixation of bone without fracture reduction (ICD-9-CM-78.55).
Although there is a separate ICD-9 code for the application of external fixator to femur fractures, the code includes any external device placed on the femur (e.g., traction pins or Kirschner wires). For this reason, any patient with an additional internal fixation (closed reduction internal fixation [CRIF] or open reduction internal fixation [ORIF]) also reported during the same hospitalization was considered to have undergone internal fixation as their definitive treatment. Following the same reasoning, any patient reported to have undergone casting or splinting (ICD-9-CM-93.53 and 93.54, respectively) during the same hospitalization as external fixation and no other fixation procedures previously mentioned was considered to have undergone closed reduction with casting or splinting initially, with external fixation as their definitive treatment. Similarly, any patient who was reported to have undergone closed reduction alone but who also had another form of fixation (CRIF, ORIF, external) reported during the same hospitalization was considered to have undergone internal or external fixation, respectively, as their definitive treatment, dependent on their adherence to the aforementioned guidelines. Finally, patients who underwent casting or splinting and had no other forms of treatment coded for, were considered to have had this as their definitive treatment.
Estimates were extracted from the KID at 3-year intervals from 2000 to 2012. The endpoint years (2000–2012) and intervening years were used to determine trends over a 12-year period for external fixation utilization compared to other interventions. The KID uses a complex method to formulate weighted counts utilized for national estimates. All counts presented in this report are weighted counts that represent national estimates. It should be noted that this study compares relative usage of treatments within a specific diagnosis at the national level. Exact prevalence of the different treatment methods cannot be calculated as the KID only provides weighted estimates of the respective treatments but does not provide total population information. Other information in the analysis included age and gender of patients as well as the teaching status of the hospital, bed size, pediatric status, and geographic region. Statistics including student's t-test and Chi-squared analyses were computed using GraphPad Prism version 6.04 for Mac (GraphPad Software, La Jolla California USA). Statistical significance was considered when the P < 0.05.
| Results|| |
From 2000–2012, there were 48,292 reported closed femoral shaft fractures in children that were treated with ORIF, open reduction, CRIF, closed reduction, or external fixation. An overall decline in the number of reported pediatric femoral fractures was seen from 10,504 in 2000–7,798 in 2012. Male-to-female ratio was comparable between years ranging from 71.4%–72.9% male to 25.5%–28.6% female. Mean age was also comparable between years at a mean of 10.9 ± 6.3 years old [Table 1].
Overall trends for external fixation
Overall, treatment with external fixation for closed femoral shaft fractures decreased significantly from 2000 to 2012 (6.5% vs. 1.0%; odds ratio, 0.14; 95% confidence interval [CI], 0.11–0.18; P < 0.0001) [Table 2]. In addition, there was a significant stepwise decrease in external fixation in each year recorded compared to previous reported years, from 6.5% in 2000 to 4.6% in 2003 (P < 0.0001), to 2.3% in 2006 (P < 0.0001), to 1.8% in 2009 (P = 0.011), to 1.0% in 2012 (P < 0.0001). Over all years, mean total charges per discharge were as follows: closed reduction ($16,665), open reduction ($39,141), external fixation ($43,819), CRIF ($50,889), and ORIF ($53,236).
Decreases in external fixation led by pediatric hospitals
While there were no significant differences in treatment by region or hospital size, the rate of external fixation in pediatric hospitals declined more rapidly from 2000 to 2012 [Figure 1]. In 2000, rates of external fixation were comparable between pediatric and nonpediatric hospitals (5.5% vs. 6.6%; odds ratio, 0.82; 95% CI, 0.64–1.04; P = 0.170). However, in 2003 (2.8% vs. 5.0%; odds ratio, 0.55; 95% CI, 0.41–0.74; P < 0.0001), 2006 (1.7% vs. 2.4%; odds ratio, 0.67; 95% CI, 0.45–0.98; P = 0.039), and 2009 (0.8% vs. 2.0%; odds ratio, 0.38; 95% CI, 0.22–0.68; P < 0.001), the use of external fixation for closed femoral shaft fractures in children was significantly lower in pediatric hospitals. In 2012, rates of external fixation remained lower in pediatric compared to nonpediatric hospitals (0.5% vs. 1.1%, odds ratio, 0.51, 95% CI, 0.25–1.01; P = 0.051).
|Figure 1: Comparison of external fixation in pediatric versus nonpediatric hospitals by year|
Click here to view
Ages <5 years
There were 12,143 closed femoral shaft fractures in patients younger than 5 years. Among these patients, treatment with closed reduction was most commonly used but decreased from 2000 to 2012 (87.5% vs. 82.9%; odds ratio, 0.69; 95% CI, 0.59–0.81; P < 0.0001). Operative internal fixation (CRIF and ORIF) nearly doubled from 2000 to 2012 (8.3% vs. 15.8%; odds ratio, 2.1; 95% CI, 1.73–2.48; P < 0.0001) while external fixation declined (3.6% vs. 1.1%, odds ratio, 0.31; 95% CI, 0.19–0.48; P < 0.0001) [Figure 2] and [Table 3].
|Figure 2: Comparison of methods of fixation in pediatric closed femur fractures by year and age groups|
Click here to view
Ages 5–11 years
There were 12,123 closed femoral shaft fractures in children aged 5–11 years. Among these patients, treatment with operative internal fixation was most commonly used, increasing from 2000 to 2012 (56.8% vs. 91.2%, odds ratio, 7.87; 95% CI, 6.59–9.39; P < 0.0001). Again, the use of both closed reduction (26.2% vs. 6.9%, odds ratio, 0.21; 95% CI, 0.17–0.25; P < 0.0001) and external fixation (16.8% vs. 1.8%, odds ratio, 0.09; 95% CI, 0.06–0.13; P < 0.0001) declined from 2000 to 2012 [Figure 2] and [Table 3].
Ages >11 years
There were 23,482 closed femoral shaft fractures in children older than 11 years. Although treatment with operative internal fixation made up an overwhelmingly large and increasing proportion care in this population (95.5% vs. 98.2%; odds ratio, 2.53; 95% CI, 1.92–3.33; P < 0.0001), external fixation still declined significantly (2.5% vs. 0.4%; odds ratio, 0.16; 95% CI, 0.10–0.28; P < 0.0001). Treatment with closed reduction remained unchanged at 1.4% [Figure 2] and [Table 3].
| Discussion|| |
In the 1980s and 1990s, treatment of femoral shaft fractures with external fixation gained increasing popularity. Utilization of external fixation in the treatment of femoral shaft fractures confers numerous advantages including rapid fracture stabilization with minimal soft-tissue dissection, optimal access for wound care in open fractures, decreased need for anesthesia for hardware removal, and earlier return to ambulation.,, A 1998 survey investigating surgeon preference in the treatment of various closed femoral shaft fractures showed a high prevalence of external fixation as a viable option in approximately 40% of cases in ages 1–9 years and 50% of cases in children older than 10 years. Within this survey, 14 cases of avascular necrosis (AVN) were reported following operative internal fixation, which may have contributed to hesitancy among surgeons to pursue rigid piriformis entry nailing in older children at that time.
Despite numerous studies with successful outcomes in femur fractures treated with external fixation, considerable rates of complications reported around the turn of the century, including pin tract infection,,, and refracture after fixator removal,,, may have contributed to the decline in external fixation nationally as shown in our study. Several authors in the mid-2000s noted a learning curve associated with external fixator application and reviewed surgical techniques in efforts to reduce complications., In addition, despite advances in external fixator and half-pin design, application technique, and infection prevention protocols (hydroxyapatite-coated half-pins, avoidance of self-drilling half-pins, and early use of oral antibiotics for pin site drainage) that may have contributed to a reduction in both major and minor complications,,,,, there was a persistent decline in external fixation through 2012. This decline may be due in part to large increases in operative internal fixation as shown by Naranje et al. Interestingly, beginning in 2003, this decline was more rapid in pediatric hospitals, supporting survey results by Sanders et al., in which pediatric-only practices were less likely to utilize external fixation than practices that care for both adult and nonadult patients. While the motivation for these differences was not explored in great detail, these results from the early 2000s forecasted some of the changes that have occurred in the last decade.
Recently, studies regarding the cost burden of pediatric fracture care have focused on the challenges inherent to implant removal after fracture healing has occurred. Implants placed for a traumatic indication have been shown to undergo higher rates of removal, with elective removal rates of femoral plate fixation and flexible intramedullary nails found to be 61% and 25%, respectively., Dodwell et al. found socioeconomic factors to play a considerable role in both fracture care and follow-up care in children treated for femoral shaft fractures. Caucasian patients with private insurance were treated with ORIF more frequently than those without insurance. In addition, a similar cohort of patients – caucasian, privately insured, from highly educated families – were independently more likely to undergo elective removal of hardware. In addition to the obvious concerns with health-care disparity, a large proportion of surgeons consider routine implant removal to pose a considerable burden on health-care resources, supporting previous economic analyses on this issue.,
Children younger than 5 years
Although numerous treatment options for closed femoral fractures exist and vary by age, clinical outcomes are generally very good in young children. Nonoperative treatment has been associated with acceptable outcomes due to the remodeling potential of the growing skeleton in young children., Studies by Stannard et al. and Podeszwa et al. have shown that the use of a Pavlik harness in children younger than 18 months is well tolerated and allows for easy adjustment, while reducing the risk of skin complications associated with spica casting. While some studies have advocated a potential need for traction before spica casting in older children,, Yandow et al. found no significant differences in leg length discrepancy or angular or rotational deformity in patients treated with or without prior traction, while reducing hospital costs by 83%. In our study, closed reductions with casting and external fixation were the two least costly forms of treatment. However, in this patient population, the use of internal fixation nearly doubled from 2000 to 2012. Given the lack of granularity and absence of any clinical outcome in the KID database, we are unable to identify the factors contributing to this change in practice among orthopedic surgeons.
Children aged 5–11 years
While spica casting following closed reduction has been associated with good outcomes in children,,, studies by Hughes et al. and Kirby et al. have demonstrated poor tolerance of casting in older children due to missed school, lost work, and alterations in self-image. Perhaps representative of these concerns, our study showed a considerable reduction in treatment with closed reduction and casting in school-aged children younger than 12 years, from 26.2% in 2000 to 6.9% in 2012. De Bastiani et al. and de Sanctis et al. reported excellent outcomes following external fixation with minimal major or minor complications. It was postulated that these superior results were due to a reduction in overgrowth secondary to a restoration of the tension-band effect of the periosteum, as well as early weight-bearing allowed by the use of external fixation. Concurrently, the use of flexible intramedullary nailing was increasing in popularity toward the end of the century, with demonstration of excellent outcomes.,, In a comparison between flexible nailing and spica casting, Flynn et al. showed patients treated with flexible nailing had fewer complications, quicker return to ambulation, and equivalent costs of care. With advantages similar to external fixation including immediate fracture stabilization, early mobilization, and avoidance of the physis, the use of flexible nailing has understandably increased as closed reduction with casting has declined in popularity. However, with similarities in both frequency and type of complications compared to external fixation,, greater difficulty in controlling and adjusting length and rotation compared to external fixation,, and nearly $10,000 more in cost compared to external fixation, it is interesting that operative internal fixation in ages 5–11 increased from 57% to 91% as the use of external fixation decreased from 17% to 2%.
Children 12 years and older
The use of operative internal fixation, while already high in this age group, continued to grow in popularity over the past decade. Although heavier children may have a higher rate of malunion following elastic intramedullary nailing, studies reporting risks of AVN of the femoral head after rigid nailing through the piriformis entry site in older children have generated considerable concern among surgeons.,,, However, following a report on early results of intramedullary nailing of femoral fractures through trochanteric entry in years 2000, studies in 2003 and in 2006 further demonstrated excellent clinical outcomes, with no cases of AVN and minimal femoral neck narrowing or valgus deformity. These studies may have also contributed to the increases in operative internal fixation seen throughout our 2003, 2006, and 2009.
There are several limitations in our study. Due to the nature of a large database such as KID, details of patient and fracture characteristics were limited to ICD-9 coding. We were unable to track or compare clinical outcomes of patients treated with different methods of fracture care. Furthermore, the data available in KID do not allow for comparative analysis of flexible nailing, rigid nailing, or submuscular plating– instead, our analysis was limited to fracture care being coded collectively as ORIF or CRIF. However, the overall increases of CRIF and ORIF remain representative of a shift in the orthopedic surgeon's practice from a decade ago. In addition, some components of this data have been previously reported on by Naranje et al. However, as their study included both open and closed femur fractures at various locations and did not analyze rates of external fixation use, we felt that a dedicated study to analyze rates of external fixation in closed femoral shaft fractures was worthwhile. Finally, while previous studies have reported similar findings of increased operative internal fixation, this is the first report to separately analyze closed femoral shaft fractures as well as clearly document the decreasing prevalence of external fixation in femoral shaft fractures in the United States over a 12-year period.
Perhaps, the psychosocial burden of having an external fixation and the reported “complications” with external fixation as well as the gaining popularity of newer internal fixation devices for pediatric long bone fractures contributed to the decline in external fixation in the United States. Whether this changing trend in clinical practice is justified based on a cost-benefit analysis and should be recommended for resource-limited environments across the world needs further study. In summary, the use of external fixation for managing closed femoral shaft fractures in children has declined in favor of internal fixation over the past decade across the United States, irrespective of the teaching status of the hospital. This decrease in popularity of external fixation was noted earlier in pediatric hospitals than nonpediatric hospitals. The clinical and financial impact of this change in practice needs further investigation.
| Conclusions|| |
Treatment of pediatric closed femoral fractures with external fixation has declined in favor of internal fixation over the past decade across all geographic regions and in both teaching and nonteaching hospitals in the United States. This decline in external fixation occurred more rapidly in pediatric hospitals compared to nonpediatric hospitals. The clinical and financial impact of this change in practice needs further investigation.
Financial support and sponsorship
This study was financially supported by the Department of Orthopaedics, Rutgers New Jersey Medical School.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Heideken JV, Svensson T, Blomqvist P, Haglund-Škerlind Y, Janarv PM. Incidence and trends in femur shaft fractures in Swedish children between 1987 and 2005. J Pediatr Orthop 2011;31:512-9.
Hinton RY, Lincoln A, Crockett MM, Sponseller P, Smith G. Fractures of the femoral shaft in children. Incidence, mechanisms, and sociodemographic risk factors. J Bone Joint Surg Am 1999;81:500-9.
Anglen JO, Choi L. Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-33.
Kuremsky MA, Frick SL. Advances in the surgical management of pediatric femoral shaft fractures. Curr Opin Pediatr 2007;19:51-7.
Wright JG, Wang EE, Owen JL, Stephens D, Graham HK, Hanlon M, et al.
Treatments for paediatric femoral fractures: A randomised trial. Lancet 2005;365:1153-8.
Alonso JE, Horowitz M. Use of the AO/ASIF external fixator in children. J Pediatr Orthop 1987;7:594-600.
Aronson J, Tursky EA. External fixation of femur fractures in children. J Pediatr Orthop 1992;12:157-63.
Blasier RD, Aronson J, Tursky EA. External fixation of pediatric femur fractures. J Pediatr Orthop 1997;17:342-6.
Kapukaya A, Subasi M, Necmioglu S, Arslan H, Kesemenli C, Yildirim K. Treatment of closed femoral diaphyseal fractures with external fixators in children. Arch Orthop Trauma Surg 1998;117:387-9.
Sabharwal S. Role of Ilizarov external fixator in the management of proximal/distal metadiaphyseal pediatric femur fractures. J Orthop Trauma 2005;19:563-9.
Tolo VT. External skeletal fixation in children's fractures. J Pediatr Orthop 1983;3:435-42.
de Sanctis N, Gambardella A, Pempinello C, Mallano P, Della Corte S. The use of external fixators in femur fractures in children. J Pediatr Orthop 1996;16:613-20.
Gregory P, Pevny T, Teague D. Early complications with external fixation of pediatric femoral shaft fractures. J Orthop Trauma 1996;10:191-8.
Miner T, Carroll KL. Outcomes of external fixation of pediatric femoral shaft fractures. J Pediatr Orthop 2000;20:405-10.
Skaggs DL, Leet AI, Money MD, Shaw BA, Hale JM, Tolo VT. Secondary fractures associated with external fixation in pediatric femur fractures. J Pediatr Orthop 1999;19:582-6.
De Bastiani G, Aldegheri R, Renzi Brivio L. The treatment of fractures with a dynamic axial fixator. J Bone Joint Surg Br 1984;66:538-45.
Domb BG, Sponseller PD, Ain M, Miller NH. Comparison of dynamic versus static external fixation for pediatric femur fractures. J Pediatr Orthop 2002;22:428-30.
Hedin H, Hjorth K, Larsson S, Nilsson S. Radiological outcome after external fixation of 97 femoral shaft fractures in children. Injury 2003;34:287-92.
Moroni A, Vannini F, Mosca M, Giannini S. State of the art review: Techniques to avoid pin loosening and infection in external fixation. J Orthop Trauma 2002;16:189-95.
Sabharwal S, Kishan S, Behrens F. Principles of external fixation of the femur. Am J Orthop (Belle Mead NJ) 2005;34:218-23.
Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM, et al.
American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of pediatric diaphyseal femur fracture. J Bone Joint Surg Am 2010;92:1790-2.
Porat S, Milgrom C, Nyska M, Whisler JH, Zoltan JD, Mallin BA. Femoral fracture treatment in head-injured children: Use of external fixation. J Trauma 1986;26:81-4.
Shih HN, Chen LM, Lee ZL, Shih CH. Treatment of femoral shaft fractures with the Hoffmann external fixator in prepuberty. J Trauma 1989;29:498-501.
Sanders JO, Browne RH, Mooney JF, Raney EM, Horn BD, Anderson DJ, et al.
Treatment of femoral fractures in children by pediatric orthopedists: Results of a 1998 survey. J Pediatr Orthop 2001;21:436-41.
Mishra V, Perkins RD. Recalcitrant soft tissue pin-tract infection: A delayed complication of pediatric femoral shaft fracture treated with external fixator. J Trauma 2004;57:895-7.
Hedin H, Larsson S. Technique and considerations when using external fixation as a standard treatment of femoral fractures in children. Injury 2004;35:1255-63.
Kong H, Sabharwal S. External fixation for closed pediatric femoral shaft fractures: Where are we now? Clin Orthop Relat Res 2014;472:3814-22.
Naranje SM, Stewart MG, Kelly DM, Jones TL, Spence DD, Warner WC Jr., et al.
Changes in the treatment of pediatric femoral fractures: 15-year trends from United States Kids' Inpatient Database (KID) 1997 to 2012. J Pediatr Orthop 2016;36:e81-5.
Shrestha R, Shrestha D, Dhoju D, Parajuli N, Bhandari B, Kayastha SR. Epidemiological and outcome analysis of orthopedic implants removal in Kathmandu University Hospital. Kathmandu Univ Med J (KUMJ) 2013;11:139-43.
May C, Yen YM, Nasreddine AY, Hedequist D, Hresko MT, Heyworth BE. Complications of plate fixation of femoral shaft fractures in children and adolescents. J Child Orthop 2013;7:235-43.
Morshed S, Humphrey M, Corrales LA, Millett M, Hoffinger SA. Retention of flexible intramedullary nails following treatment of pediatric femur fractures. Arch Orthop Trauma Surg 2007;127:509-14.
Dodwell E, Wright J, Widmann R, Edobor-Osula F, Pan TJ, Lyman S. Socioeconomic factors are associated with trends in treatment of pediatric femoral shaft fractures, and subsequent implant removal in New York State. J Pediatr Orthop 2016;36:459-64.
Hanson B, van der Werken C, Stengel D. Surgeons' beliefs and perceptions about removal of orthopaedic implants. BMC Musculoskelet Disord 2008 24;9:73.
Böstman O, Pihlajamäki H. Routine implant removal after fracture surgery: A potentially reducible consumer of hospital resources in trauma units. J Trauma 1996;41:846-9.
Schmalzried TP, Grogan TJ, Neumeier PA, Dorey FJ. Metal removal in a pediatric population: Benign procedure or necessary evil? J Pediatr Orthop 1991;11:72-6.
Shapiro F. Fractures of the femoral shaft in children. The overgrowth phenomenon. Acta Orthop Scand 1981;52:649-55.
Davids JR. Rotational deformity and remodeling after fracture of the femur in children. Clin Orthop Relat Res 1994;376:27-35.
Stannard JP, Christensen KP, Wilkins KE. Femur fractures in infants: A new therapeutic approach. J Pediatr Orthop 1995;15:461-6.
Podeszwa DA, Mooney JF 3rd
, Cramer KE, Mendelow MJ. Comparison of Pavlik harness application and immediate spica casting for femur fractures in infants. J Pediatr Orthop 2004;24:460-2.
Buehler KC, Thompson JD, Sponseller PD, Black BE, Buckley SL, Griffin PP. A prospective study of early spica casting outcomes in the treatment of femoral shaft fractures in children. J Pediatr Orthop 1995;15:30-5.
Martinez AG, Carroll NC, Sarwark JF, Dias LS, Kelikian AS, Sisson GA Jr. Femoral shaft fractures in children treated with early spica cast. J Pediatr Orthop 1991;11:712-6.
Yandow SM, Archibeck MJ, Stevens PM, Shultz R. Femoral-shaft fractures in children: A comparison of immediate casting and traction. J Pediatr Orthop 1999;19:55-9.
Nork SE, Bellig GJ, Woll JP, Hoffinger SA. Overgrowth and outcome after femoral shaft fracture in children younger than 2 years. Clin Orthop Relat Res 1998;357:186-91.
Ferguson J, Nicol RO. Early spica treatment of pediatric femoral shaft fractures. J Pediatr Orthop 2000;20:189-92.
Casas J, Gonzalez-Moran G, Albiñana J. Femoral fractures in children from 4 years to 10 years: Conservative treatment. J Pediatr Orthop B 2001;10:56-62.
Hughes BF, Sponseller PD, Thompson JD. Pediatric femur fractures: Effects of spica cast treatment on family and community. J Pediatr Orthop 1995;15:457-60.
Kirby RM, Winquist RA, Hansen ST Jr. Femoral shaft fractures in adolescents: A comparison between traction plus cast treatment and closed intramedullary nailing. J Pediatr Orthop 1981;1:193-7.
Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J. Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4-8.
Ligier JN, Metaizeau JP, Prévot J, Lascombes P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-7.
Heinrich SD, Drvaric DM, Darr K, MacEwen GD. The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: A prospective analysis. J Pediatr Orthop 1994;14:501-7.
Leet AI, Pichard CP, Ain MC. Surgical treatment of femoral fractures in obese children: Does excessive body weight increase the rate of complications? J Bone Joint Surg Am 2005;87:2609-13.
Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop 2003;23:443-7.
Beebe KS, Sabharwal S, Behrens F. Femoral shaft fractures: Is rigid intramedullary nailing safe for adolescents? Am J Orthop (Belle Mead NJ) 2006;35:172-4.
Mileski RA, Garvin KL, Crosby LA. Avascular necrosis of the femoral head in an adolescent following intramedullary nailing of the femur. A case report. J Bone Joint Surg Am 1994;76:1706-8.
O'Malley DE, Mazur JM, Cummings RJ. Femoral head avascular necrosis associated with intramedullary nailing in an adolescent. J Pediatr Orthop 1995;15:21-3.
Timmerman LA, Rab GT. Intramedullary nailing of femoral shaft fractures in adolescents. J Orthop Trauma 1993;7:331-7.
Townsend DR, Hoffinger S. Intramedullary nailing of femoral shaft fractures in children via the trochanter tip. Clin Orthop Relat Res 2000;376:113-8.
Gordon JE, Swenning TA, Burd TA, Szymanski DA, Schoenecker PL. Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85-A: 1295-301.
Kanellopoulos AD, Yiannakopoulos CK, Soucacos PN. Closed, locked intramedullary nailing of pediatric femoral shaft fractures through the tip of the greater trochanter. J Trauma 2006;60:217-22.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]