Limb fracture pattern in different pediatric age groups: a study of 3,350 children

Childhood obesity is associated with increased risk of most lower extremity fractures

BACKGROUND

A number of studies have found an increased risk of lower extremity injuries in obese patients. Most studies, however, are unable to provide stable population-based estimates based on the degree of obesity and few assess the risk pertaining to more detailed fracture location in the lower extremities.

QUESTIONS/PURPOSES

We therefore investigated the relationship between obesity and lower extremity fractures in different age and fracture locations in a stable population.

METHODS

This is a population-based, cross-sectional study from the electronic medical records of 913,178 patients aged 2 to 19 years. The body mass index (BMI) for each patient in the cohort was used to stratify patients into five weight classes (underweight, normal weight, overweight, moderate obesity, and extreme obesity) based on BMI for age. Records were assessed for the occurrence of lower extremity fractures for each cohort member. The associations among the five weight classes and specific lower extremity fractures were estimated using multiple logistic regression models and expressed with odds ratios (ORs) and 95% confidence intervals (CIs) using multivariate analysis to adjust for patient demographic variables.

RESULTS

Overweight, moderately obese, and extremely obese patients all had an increased OR of fractures of the foot (OR, 1.14, 1.23, and 1.42, respectively, with 95% CI, 1.04-1.24, 1.12-1.35, and 1.26-1.61, respectively) along with the ankle, knee, and leg (OR, 1.27, 1.28, and 1.51, respectively, with 95% CI, 1.16-1.39, 1.15-1.42, and 1.33-1.72, respectively). The association was strongest in the 6- to 11-year-old age group. We found no association between increasing BMI and increased risk of fractures of the femur and hip.

CONCLUSIONS

Increasing BMI is associated with increased odds of foot, ankle, leg, and knee fractures in children.

LEVEL OF EVIDENCE

Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Pediatric hand and wrist injuries

In the last 40 years, childhood hand and wrist injuries have become progressively more common as children have become heavier and more active in high impact sports. The majority of children with such injuries do well, but treatment is not always straightforward. Distal radius fractures, scaphoid fractures, metacarpal and phalangeal fractures, nailbed injuries, and amputations are among the pediatric hand and wrist injuries most often seen by orthopedists. These are all discussed, with a focus on the most recent literature and areas of evolving controversy.

Risk factors for failed closed reduction of pediatric supracondylar humerus fractures

The purpose of this retrospective study was to examine pediatric supracondylar humerus fractures at a Level I trauma center. Data were analyzed to identify risk factors associated with closed reduction failure. Closed pediatric supracondylar humerus fractures that were treated at the authors' trauma center between October 1997 and January 2009 were reviewed. The main outcome variable was necessity of open reduction. To determine which factors were independently associated with a failed closed reduction, a multivariate logistic model was fit predicting open reduction status.A total of 174 patients required operative treatment. Of these, 23 underwent open reduction and 151 underwent with closed reduction and percutaneous pinning. For patients who required open reduction, 39.1% had an associated injury compared with 14.6% of patients treated with closed reduction (P=.008). Average time from presentation to surgery was 4.1 hours in the open reduction and 6.3 hours in the closed reduction group (P=.049). Risk factors that significantly predicted failure of closed reduction were the presence of an associated injury, initial fracture displacement, and Gartland type III fracture (P=.008, .03, and .023, respectively).Associated injury, large initial fracture displacement, and Gartland type III factures were statistically significant independent risk factors for closed reduction failure. Increased time from injury to presentation demonstrated a trend toward open reduction. Consideration should be given to the expedient transfer of patients with type III supracondylar humerus fractures with associated injuries when definitive care will be provided at another institution.

Distal radius fractures: what is the evidence?

PURPOSE

To discuss the evidence base behind treatment of pediatric distal radius fractures.

METHODS

We identified randomized controlled trials addressing the treatment of children with torus fractures, minimally displaced fractures, and displaced fractures of the distal radius.

RESULTS

Torus fractures and minimally displaced fracture is treated by removable splints instead of circumferential casts with improved secondary outcomes for the patient and family and with equal position at healing. Case immobilization versus immediate pinning was studied in 2 small randomized trials of displaced fractures. Long-term outcomes were equivalent, despite more loss of reduction in the cast groups and more pin complications in the pin groups.

CONCLUSIONS

Unbiased evalution of empirical patient outcomes using randomized trials has proven feasible for distal radius fractures and should continue to inform and guide our practice in the future.

Evidence-based review: management of open pediatric fractures

Open fractures in the pediatric population are rare. As such, recommendations for care based on high-level studies are scarce. Furthermore, most level I and II recommendations come from studies involving open fractures in adults. Although it is generally accepted that open pediatric fractures have better outcomes than open fractures in adults, the lack of quality studies provide ample opportunities to answer questions regarding care of these injuries. This review explores the available literature and gives corresponding recommendations based on the level of evidence.

Is bone mineral mass truly decreased in teenagers with a first episode of forearm fracture? A prospective longitudinal study

BACKGROUND

Forearm fractures are common in the pediatric population and are mostly treated by cast immobilization. The purposes of this study were first to determine whether forearm fractures in adolescents are associated with abnormal bone mineral density (BMD) or content (BMC) at the time of fracture, and second, to quantify the bone mineral loss at various sites due to cast-mediated immobilization.

METHODS

This longitudinal case-control study recruited 50 adolescents (age, 12.8 ± 1.8 y) who underwent cast-mediated immobilization for a forearm fracture and 50 healthy controls (13.0 ± 1.8 y). Using 2 dual-energy x-ray absorptiometries, BMD and BMC were measured at various skeletal sites (total body, lumbar spine, total upper limb, and forearm) at fracture time and at cast removal.

RESULTS

At the fracture time, BMD/BMC Z-scores at the lumbar spine and areal BMD at the peripheral wrist were not different among the injured and the healthy subjects. At cast removal, significant BMD decreases were observed in adolescents with fracture at the level of the radial and the ulnar diaphyses (-5.6% and -3.8%, respectively) and the total upper limb (-5.6%) compared with the noninjured side. Significant decreases in the BMC values were observed at the level of the radial diaphysis (-6.4%), ultradistal ulna (-10.2%), total upper limb, and total ulna (-8.2% and -4.9%, respectively).

CONCLUSIONS

These data demonstrate that total body, lumbar spine, or wrist bone mineral mass and density (BMC and BMD) are not reduced at the fracture time in adolescents sustaining a first episode of upper limb fracture when compared with healthy subjects. These findings suggest that forearm fractures are not related to osteopenia in youth. In addition, cast-mediated immobilization results in a significant bone mineral loss at the upper limb, which may explain the increased risk of sustaining a second fracture. Finally, bone callus formation may interfere when assessing bone mineral mass after cast removal and may lead to an erroneous underestimation of bone mineral mass decrease.

LEVEL OF EVIDENCE

Level IV.

Documentation of neurovascular status in supracondylar fractures and the development of an assessment proforma

BACKGROUND

Supracondylar fractures are associated with a high incidence of neurovascular complications. Comprehensive clinical evaluation is a necessity when children with these injuries present to the emergency department. Neurovascular assessment can be difficult due to pain, anxiety and the young age of these patients; however, it is crucial findings are well documented to identify patients requiring urgent surgical intervention, in addition to allowing the neurovascular status to be monitored over time. The aim of this study was to evaluate the preoperative neurovascular documentation in children presenting with displaced supracondylar fractures and devise an emergency department assessment proforma to facilitate comprehensive evaluation.

METHODS

A retrospective case-note review was performed on patients with Gartland grades 2 and 3 supracondylar fractures observed in a 2-year period from July 2008 to July 2010.

RESULTS

137 patients were included; only 12 patients (8.8%) and 19 patients (13.9%), respectively, had a complete preoperative neurological or vascular assessment documented. Regarding the individual nerves, 59 (43.1%) patients had median nerve integrity documented, 55 (40.1%) ulnar nerve and 49 (35.8%) radial nerve integrity documented. Only 18 patients (13.1%) had their anterior interosseous nerve (AIN) function documented.

CONCLUSIONS

Preoperative documentation of neurovascular status in children with displaced supracondylar fractures was poor. Documentation of AIN examination was particularly poor. The introduction of a proforma (Liverpool upper limb fracture assessment) is proposed to increase documentation of neurovascular assessment and optimise emergency department evaluation of children presenting with upper limb injuries.

Intramedullary osteosynthesis for metaphyseal and diaphyseal humeral fractures in developmental age

Diaphyseal and metaphyseal fractures of the humerus are relatively frequent in children. The treatment is often conservative, even in the case of displaced fractures for the high rate of spontaneous recovery of these fractures. The limits of nonsurgical treatment and its applications as well as the type of surgical treatment are controversial issues in the literature. The aim of this study is to review a series of metaphyseal and diaphyseal fractures of the humerus treated with intramedullary osteosynthesis, to discuss the results obtained and the problems found, and to propose some parameters that should be taken into account to choose the most appropriate osteosynthesis. The retrospective study was performed on a group of 105 proximal and distal metaphyseal fractures and of displaced diaphyseal fractures of the humerus (excluding epiphyseal trauma, supracondylar fractures, and pathologic fractures) treated from 2001 to 2005. Out of a total of 105 patients, only 22 had fracture reduction under anesthesia, followed by intramedullary osteosynthesis; in 11 cases, intramedullary osteosynthesis was performed using Kirschner wires and in the remaining 11 elastic nails were used. In all treated patients, fracture healing was achieved. In the patients treated with Kirschner wires, no complications were observed, whereas in the patients treated with intramedullary nails, there were three cases with involvement of the skin and subcutaneous layers at the nail insertion site and one case of temporary paralysis of the radial nerve disappearing spontaneously after 2 months. Considering the results obtained and the low number of technique-related complications (low anesthesiologic and infectious risk), we can conclude that intramedullary osteosynthesis is a simple, safe, and rapid method suitable at any age in childhood.

LEVEL OF EVIDENCE

level IV.

Displaced paediatric distal radius fractures--when should we use percutaneous wires?

PURPOSE

To establish the intra-operative radiographic parameters that predict the need for percutaneous wire fixation to prevent redisplacement following manipulation for displaced paediatric distal radius fractures.

MATERIALS AND METHODS

A retrospective study of 105 children, assessing pre-, intra- and post-operative radiographs. Optimal reduction was defined as less than 10% residual translation and less than 5° of angulation on anteroposterior and lateral radiographs. Redisplacement was defined as more than 20° angulation or 50% translation on either view.

RESULTS

No fracture that was optimally reduced redisplaced. 40% of fractures with suboptimal reduction redisplaced. Initial translation was significantly associated with redisplacement.

CONCLUSIONS

If our criteria for optimal reduction are met, closed reduction and casting can be confidently employed. If not, percutaneous wires should be employed to avoid redisplacement, especially in cases with a high grade of initial translation.

Effects of obesity on pediatric fracture care and management

Obese children have a theoretically increased risk of sustaining an extremity fracture because of potential variations in their bone mineral density, serum leptin levels, and altered balance and gait. Trauma databases suggest an increased rate of extremity fractures in obese children and adolescents involved in polytrauma compared with nonobese children and adolescents. Anesthetic and other perioperative concerns for obese pediatric trauma patients undergoing surgery include higher baseline blood pressures, increased rates of asthma, and obstructive sleep apnea. A child's weight must be considered when choosing the type of implant for fixation of pediatric femoral fractures. Fracture prevention strategies in obese pediatric patients consist of ensuring properly sized safety gear for both motor vehicles and sporting activities and implementing structured weight-loss programs.

An Asian perspective on the management of distal radius fractures

There is limited data regarding the epidemiology, pathology, and management of distal radius fractures from centers in Asia. The advanced economies in Asia include Hong Kong, Japan, Korea, Singapore, and Taiwan, whereas the prominent emerging economies are China, India, Malaysia, Philippines, and Thailand. This article examines the available epidemiological data from Asia, compares the management of distal radius fractures in the advanced and emerging Asian economies and how they compare with the current management in the west. It concludes by offering solutions for improving outcomes of distal radius fractures in Asia.

Comparison of complications and results of early versus delayed surgery for Gartland type III supracondylar humeral fractures in pediatric patients

OBJECTIVE

To investigate the effect of timing of surgery on clinical results and perioperative complications in pediatric patients with Gartland III type supracondylar humeral fractures without neurovascular compromise.

METHODS

Eighty-six consecutive children treated surgically at our hospital from April 2005 to June 2007 for displaced supracondylar humeral fractures were reviewed. All these patients were treated by the same group of doctors. The children were divided into two groups: early if treated within 12 hours after injury and delayed if treated later than that. Perioperative complications and clinical results, especially for open surgery, were compared between the two groups.

RESULTS

Forty pediatric patients underwent surgery in the early group and 46 in the delayed group. There were no significant differences between the two groups in perioperative complications such as pin tract infection, iatrogenic nerve injury, compartment syndrome and conversion to open surgery. For open surgery, both the clinical results and perioperative complications were not affected by delaying for more than 12 hours after injury. However, blood loss and operation time were greater in the early than in the delayed group, possibly due to relatively more edema.

CONCLUSION

Delay in surgery, regardless of whether it is closed or open, for more than 12 hours after injury does not influence the perioperative complications and clinical results for displaced supracondylar humeral fractures in children. However early open reduction and pinning may increase intra-operative blood loss and take longer.

Functional outcome following intramedullary nailing or plate and screw fixation of paediatric diaphyseal forearm fractures: a systematic review

PURPOSE

Unstable paediatric diaphyseal both-bone forearm fractures requiring fixation have traditionally been treated with rigid internal fixation with plate and screws. Intramedullary stabilisation has grown in popularity over the last 25 years but may be associated with rotational deformity and subsequent loss of pronosupination. This systematic review aims to establish which treatment method provides better functional outcome.

METHODS

A systematic review of the published literature was performed, searching Medline, Embase, Pubmed and the Cochrane Library for English-language studies comparing intramedullary nailing with plate and screws in patients less than 18 years old with both-bone diaphyseal forearm fractures.

RESULTS

Seven studies met the inclusion criteria. They were all retrospective comparative studies (level III or IV). One was age- and sex-matched. Three looked specifically at older children. No study reported a significant difference in functional outcome with either treatment.

CONCLUSIONS

The currently available literature shows no difference in functional outcome between intramedullary nailing and plate and screw fixation, even in older children with less remodelling potential. Intramedullary nailing may therefore be the treatment of choice for simple fracture patterns due to shorter operative time, better cosmesis and ease of removal. Plating may still have a role in more complex injuries.

Factors in redisplacement of paediatric distal radius fractures

Redisplacement after manipulation can occur in distal radius fractures. We performed a retrospective study of 73 patients undergoing manipulation with or without K-wire fixation. From the preoperative, intraoperative and postoperative films we measured anteroposterior and lateral angulation and translation. Reangulation of each fracture was calculated. Factors demonstrating significant correlation with reangulation were age, initial radial translation, ulna fracture, distance from fracture to physis and inadequate correction of translation or angulation. This emphasizes the importance of adequate fracture reduction. In those cases in which translation or angulation cannot be full corrected at manipulation, fixation with K-wires may be appropriate.

Simultaneous distal radial fractures and carpal bones injuries in children: a review article

Accurate diagnosis is crucial in effectively managing and treating both the radial and carpal fractures. Injuries to the carpal bones are not usually associated with fractures of the distal radius; however, the presence of a distal radius fracture does not preclude an associated carpal injury. The purpose of this review article is to compile cases of past reported distal radius fractures and simultaneous carpal injuries to restate its low prevalence within the pediatric population while still serving as a collective reference for management and treatment. After an electronic literature search was performed, we identified 18 published articles and 28 cases dealing with combined distal radial and carpal bones injuries in the pediatric population. As the mechanism of injury is similar for both fractures, despite the low incidence, orthopedic surgeons need to rule out carpal injury with a distal forearm fracture. Failure to treat both injuries appropriately may result in an unsatisfactory clinical result.

The "floating forearm" injury in a child: a case report

The case of a eleven-year-old girl who had a fracture dislocation of the left elbow with entrapment of the ulnar nerve into the dislocated ulnar epicondyle anlage and unstable forearm fracture of the ipslateral upper extremity is described. This severe injury to the elbow and the ipsilateral forearm is termed "floating forearm" injury. The forearm was stabilized percutaneously and the elbow fracture dislocation, remaining unstable after internal fixation was treated with a pediatric elbow fixator with motion capacity.

Rapid remineralization of the distal radius after forearm fracture in children

BACKGROUND

Bone mineral content (BMC) and density (BMD) have been shown to diminish after fracture and immobilization in adults. Distal radius fractures are common in children, and unlike adults, there is a low incidence of refracture. The primary aim of this study was to assess the change in radial BMC and BMD after upper extremity fracture and casting in healthy pediatric patients.

METHODS

Patients were recruited at the time of distal radius fractures casting. The nonfractured (non-Fx) distal radius was initially scanned by dual energy x-ray absorptiometry (baseline), and then both arms were scanned at the time of cast removal (CastOff), and 4, 8, 12, 24, and 52 weeks post CastOff.

RESULTS

Twenty-one patients were enrolled (13 male, 13 Caucasian; 10.4±2.5 y) with an average length of casting of 38±11 days. Eighteen patients (86%) completed all protocol requirements. At CastOff, there was no significant difference in total BMC or BMD between the Fx and non-Fx arms. From CastOff to 24 weeks, the overall change in BMC and BMD for the non-Fx arm was +4.2% and +0.2%, respectively, whereas for the Fx arm, the change was +8.3% and +3.4%, respectively. By 24 weeks, the difference in the overall change in BMD between the Fx and non-Fx arms was statistically significant (greater than instrumental error; P<0.05). However, by 52 weeks, these differences were no longer significant. The increased mineralization was unrelated to age, sex, arm dominance, or calcium intake.

CONCLUSIONS

These data show that there is rapid remineralization after a simple forearm fracture in children, with a transient elevation in BMD in the Fx arm after casting. This novel finding suggests that bone may be stronger around the site of fracture and could significantly change how we counsel young patients recovering from forearm fracture. Future research should focus on children immobilized for varying lengths of time and those with repeat fractures, using volumetric techniques of bone geometry and strength assessment.

CASE SERIES

Therapeutic Studies-investigating the results of treatment, Level IV.

Epidemiology of pediatric forearm fractures in Washington, DC

BACKGROUND

Pediatric forearm fractures result in substantial morbidity and costs. Despite the success of public health efforts in the prevention of other injuries, the incidence of pediatric forearm fractures is increasing. Our objective is to characterize the epidemiology of forearm fractures in Washington, DC, children evaluated in an urban pediatric emergency department (ED).

METHODS

This retrospective study includes Washington, DC, children, aged 0 years to 17 years, treated for an isolated forearm fracture in the Children's National Medical Center ED from 2003 to 2006. Patients with bone mineralization disorders and repeat ED visits for the same fracture event were excluded. Chart review was done to obtain demographic and clinical data. Descriptive epidemiologic and bivariate analyses were conducted.

RESULTS

This preliminary analysis included 929 patients. The majority of patients are male (64%) and African American (80%). The mean age (± standard deviation) is 8.4 years (±3.9). Weight-for-age percentile was ≥95% in 24.1% of cases. Most forearm fractures occurred during the spring season. The most common mechanism of injury was fall-related (83%) whereas direct trauma caused 10% of fractures. "Fall from monkey bars" was the specific mechanism of injury in 17% of all cases. The majority of forearm fractures (58%) resulted from minor trauma.

CONCLUSIONS

Falls from monkey bars and minor trauma are implicated in the majority of childhood forearm fractures. The prevention strategies should target playground safety. Further research is needed to evaluate factors, including obesity and bone health, which may contribute to forearm fracture risk associated with minor trauma.

The management of congenital and acquired problems of the distal radioulnar joint in children

Pain in the ulnar aspect of the pediatric wrist is an uncommon problem; however, when pain does occur it is usually the result of antecedent bony trauma or an underlying skeletal abnormality, which may lead to ulnar-sided wrist pain of varying etiology. The clinician must to be able to identify these entities within the pediatric wrist in order to make the appropriate diagnosis and plan for surgical intervention to prevent ongoing damage to the distal radioulnar joint (DRUJ). This article reviews the etiology, clinical presentation, and treatment strategies for the management of the unique problems that can affect the pediatric and adolescent DRUJ.

Pattern of fractures across pediatric age groups: analysis of individual and lifestyle factors

Background

Knowledge of the epidemiology of children's fractures is essential to develop preventive strategies. The aim of this study was to analyze the individual/lifestyle determinants of fractures across pediatric age groups.

Methods

A cross-sectional study was performed in the first six months of 2008 through questionnaire on a sample of children from an outpatient clinic for pediatric fractures. Differences in gender, anatomic site, circumstances and location of fracture occurrence, behavioural lifestyle, and calcium intake were investigated among three different age classes (pre-school children, school children, and adolescents).

Results

The sample consisted of 382 subjects (2-14 years of age) sustaining a fracture after low or moderate trauma. Males were at a higher risk of fractures than females; greater than two-thirds of injuries occurred after low-energy trauma and the upper limb was more frequently involved. With increasing age, the male/female ratio and time spent in sports participation increased (p < 0.001), while calcium intake and time spent in sedentary behaviors decreased (p < 0.001 and < 0.003, respectively). Gender discordance existed in pre-school children with respect to the anatomic location, and in school children and adolescents with respect to the dynamics. In the adolescent group, males were more physically active and also more sedentary than females. Fractures most frequently occurred in homes (41.6%), followed by playgrounds and footpaths (26.2%), sports facilities (18.3%), and educational facilities (13.9%), with gender differences existing only in adolescence. Twenty-three percent of the subjects sustained one or more fractures in the past. The percentage of recurrent fractures increased with age (p = 0.001), with a similar trend in both genders.

Conclusions

Gender differences were shown in the prevalence of injuries, characteristics, and circumstances across ages. These differences may be explained by the related changes in behaviors, together with attending different places. Individual and lifestyle factors can in part explain the variability in the occurrence of fractures and can also address targeted preventive strategies.

Isolated diaphyseal fractures of the radius in skeletally immature patients

Diaphyseal radius fractures without associated ulna fracture or radioulnar dislocation (isolated fracture of the radius) are recognized in adults but are rarely described in skeletally immature patients. A search of our database (1974-2002) identified 17 pediatric patients that had an isolated fracture of the radius. Among the 13 patients with at least 1 year follow-up, ten were treated with manipulative reduction and immobilization in an above elbow cast and three had initial operative treatment with plate and screw fixation. These 13 patients were evaluated for an average of 18 months (range, 12 to 45 months) after injury using the system of Price and colleagues. The incidence of isolated diaphyseal radius fractures in skeletally immature patients was 0.56 per year in our database and represented 27% of the 63 patients with a diaphyseal forearm fracture. All 13 patients, with at least 1 year follow-up, regained full elbow flexion and extension and full forearm rotation. According to the classification system of Price, all 13 patients (100%) had an excellent result. As in adults, isolated radius fractures seem to occur in children more frequently than previously appreciated. Treatment of isolated radius fractures in skeletally immature patients has a low complication rate, and excellent functional outcomes are the rule.

An update on the epidemiology of pediatric fractures

Despite public health measures to prevent childhood injuries, the incidence of pediatric fractures is increasing. This fracture incidence is dependent on many demographic factors, the various contributors to bone health, and an individual's risk-taking behavior. Although traditional play activities continue to be the prevalent causes for fractures, there is an evolving array of new sport and recreation activities that carry significant fracture risk. The following review article outlines the developing epidemiology of pediatric fractures by analyzing some of the individual risk factors that influence fracture incidence as well as the variety of activities that are associated with these fractures.

The incidence of neurologic injury in paediatric forearm fractures requiring manipulation

This study sought to evaluate the incidence of neurologic injury in children referred for manipulation in our hospital. A retrospective chart analysis of the first 100 children to be referred with a fracture of any segment of the radius and/or ulna was performed. The incidence of neurologic injury was found to be 15.6%. Neurological injury occurs most frequently with distal physeal fractures with an incidence of 37%. Clinicians require a high index of suspicion when evaluating forearm fractures. If neurologic injury is missed at initial assessment, the child may not receive a prompt reduction, thus increasing the likelihood of long-term sequelae.

Pediatric supracondylar fractures of the distal humerus

Supracondylar fractures of the humerus are a common pediatric elbow injury that are historically associated with morbidity due to malunion, neurovascular complications, and compartment syndrome. True anteroposterior and lateral radiographs are essential not only for an accurate diagnosis, but also for creating a treatment plan for these injuries. A staging system (based on the lateral radiograph) for classifying the severity of the fracture helps guide definitive management. Nondisplaced fractures are treated initially with a posterior splint, followed by a long-arm casting. Closed reduction and percutaneous pinning is the preferred treatment for displaced or unstable fractures. If there is any question about fracture stability, patients should be seen within 5 days postoperatively for repeat radiographs to ensure that the reduction and pin fixation has been maintained. Understanding the anatomy, radiographic findings, management options, and complications associated with this fracture allow physicians to limit the morbidity associated with this relatively common pediatric injury.

Eleven years experience in the operative management of pediatric forearm fractures

BACKGROUND

There has been a trend toward operative management of pediatric diaphyseal forearm fractures (DFFx). We studied our experience with surgical management of these injuries to assess indications, frequency, outcome, and complications.

METHODS

One hundred forty-four consecutive children had surgical management of 149 DFFx over 11 years at our Level 1 pediatric trauma center. A chart/radiographic review established perioperative events, intraoperative findings, time-to-union, range-of-motion, and complications. We developed the Children's Hospital of Philadelphia Forearm Fracture Fixation Outcome Classification to assess postoperative outcomes.

RESULTS

Over 11 years, we treated 2297 DFFx; 155 of 2297 (6.7%) had surgical management. Six were lost to follow-up and excluded. A 7-fold increase in operative management was observed over the study period [2 of 143 (1.4%) vs. 28 of 270 (10.4%), P<0.001]. One hundred and three of 149 (69.1%) were treated with intramedullary nailing (IMN); 44 of 149 (29.5%) with plates; and 2 of 149 (1.3%) had combined plate/nail fixation. Thirty of 103 (29.1%) had the fracture site opened to pass the IMN; in 23 cases, open fractures were exploited to assist nail passage. When managed with IMN, open fracture sites showed slowed healing: union was 8.6 weeks for those opened intraoperatively and 6.9 weeks for those remaining closed (P<0.001). Fractures opened secondary to injury achieved union at 9.75 weeks which was significantly longer than those opened intraoperatively (8.6 wk, P=0.04) and those remaining closed (6.9 wk, P=0.001). Compartment syndrome occurred in 6.7% (2 of 30) treated with IMN within 24 hours of injury versus 0 of 73 treated later (P=0.026). Delayed union after IMN occurred in 6 children 10 years of age versus none less than 10 years of age. Poor/fair outcome of IMN increased with age [6 of 47 (13%) < or =10 y of age, vs. 17 of 56 (30%)>10 y of age, P=0.03]. Overall complication rate for IMN was 14.6% (15 of 103).

CONCLUSIONS

Our center has operatively managed DFFx with increased frequency over the past decade. IMN had a complication rate of 14.6% and was frequently not "minimally invasive." An open fracture site delayed healing. Compartment syndrome was more frequent when IMN was used the day of injury and older children had poorer outcomes and higher rates of delayed union.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study.

Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review

PURPOSE

There is no clear evidence in the actual literature regarding which of the surgical approaches could bring about the best functional, cosmetic, and radiological outcomes, as well as fewer complications, when an open reduction and pinning of a severely displaced supracondylar humerus fracture is performed. We, therefore, performed a systematic review of the English literature to investigate the existing evidence regarding this issue.

METHODS

A MEDLINE and EMBASE databases search was performed to identify articles that focused on the functional, cosmetic, and radiological outcomes, as well as post-surgical complications, regarding different surgical approaches used for open reduction and pinning in severely displaced supracondylar humerus fractures in children. One hundred and ninety-four articles were identified, of which seven were included for review. Data analysis included weighted means for all contingency tables and the Chi-square test. Standardized residues were studied when the Chi-square test was statistically significant. Statistical analyses were conducted using Stata 9.1/SE (StataCorp., College Station, TX) and P-values lower than 0.05 were considered to be statistically significant for all analyses.

RESULTS

For functional outcome, a high frequency of excellent results was found within the lateral and medial approaches, and a high frequency of good results within the anterior approach. A high frequency of poor results was found within the posterior approach. For cosmetic outcome, there was a high frequency of fair results within the posterior and lateral approaches, and a high frequency of poor results within the posterior approach. No statistically significant difference regarding time to union, as well as complications, was found.

CONCLUSION

Our results suggest that a combined antero-medial approach could be the method which allows the achievement of better functional and cosmetic outcome according to Flynn's criteria. Time to union, as well as post-surgical complications, should not be an issue regarding surgical approaches used for open reduction and pinning in these fractures.

Low bone mass in patients with motor disability: prevalence and risk factors in 59 Finnish children

AIM

Children with motor disabilities are at increased risk of compromised bone health. This study evaluated prevalence and risk factors of low bone mass and fractures in these children.

METHOD

This cross-sectional cohort study evaluated bone health in 59 children (38 males, 21 females; median age 10 y 11 mo) with motor disability (Gross Motor Function Classification System levels II-V). Bone mineral density (BMD) in the lumbar spine was measured with dual-energy X-ray absorptiometry; BMD values were corrected for bone size (bone mineral apparent density [BMAD]) and skeletal maturity, and compared with normative data. Spinal radiographs were obtained to assess vertebral morphology. Blood biochemistry included vitamin D concentration and other parameters of calcium homeostasis.

RESULTS

Ten children (17%) had sustained in total 14 peripheral fractures; lower-limb fractures predominated. Compression fractures were present in 25%. The median spinal BMAD z-score was -1.0 (range -5.0 to 2.0); it was -0.6 in those without fractures and -1.7 in those with fractures (p=0.004). Vitamin D insufficiency was present in 59% of participants (serum 25-hydroxyvitamin D <50 nmol/l) and hypercalciuria in 27%. Low BMAD z-score and hypercalciuria were independent predictors for fractures.

INTERPRETATION

Children with motor disability are at high risk of peripheral and vertebral fractures and low BMD. Evaluation of bone health and prevention of osteoporosis should be included in the follow-up.

Oral midazolam for removal of Kirschner wires in the children's orthopaedic outpatient department: a randomized controlled trial

BACKGROUND

Use of Kirschner wires (K-wires) is common in pediatric elbow fracture treatment. We investigate whether anxiety levels at removal of wires may be reduced using oral midazolam.

METHODS

This was a prospective randomized controlled trial with 2 groups, with midazolam and with placebo.

RESULTS

Forty-two children with an average age of 7.1 years (range, 3.6-12.3 y) had complete documentation for analysis. The change in anxiety scores was not significantly different between the 2 groups. Forty-five percent of children in the midazolam group had reduced anxiety levels compared with 18% of children given placebo, but this difference was not significant (P=0.102). The anxiety scores before and after wire removal in the midazolam group were not significantly different from the placebo group scores.

CONCLUSIONS

We do not recommend the routine administration of midazolam (0.2 mg/kg) to all children requiring K-wire removal in the outpatient department.

LEVEL OF EVIDENCE

I.

Transitional fractures of the distal tibia: a minimal access approach for osteosynthesis

BACKGROUND

Transitional fractures typically occur in patients with partially closed growth plates. In case of displacements >2 mm, osteosynthesis is recommended. Open reduction and stabilization with lag screws is the most common approach. Infection and paraesthesia are common complications of this method. This study describes an alternative approach by closed reduction and cannulated screw fixation.

METHODS

All patients with transitional fractures treated by closed reduction and cannulated screw fixation were identified. All patients with >1 year after implant removal were included in this investigation. Of 27 patients treated by this technique, 21 met the inclusion criteria and were sent a standardized questionnaire including the Foot Function Index (FFI). All cases with impairments in the FFI were invited for a follow-up examination.

RESULTS

Postoperative complications occurred in two patients (8.3%): one reported paraesthesia of the hallux and one showed skin irritations above the screw insertion. Average follow-up time was 3.8 years after implant removal. Of 21 patients who returned the questionnaire, three patients (14.3%) had impairment in the FFI and were invited for clinical follow-up: one patient showed mild signs of osteoarthritis without visible gaps of the joint surface, one patient had minimally restricted pronation, and one had neither clinical nor radiologic correlates for the impairment reported. Sports activity was reduced in one patient.

CONCLUSION

If closed reduction can be achieved fixation with cannulated screws proved to be a satisfactory method with little scars and good clinical results.

Leading 20 at 20: top cited articles and authors in the Journal of Orthopaedic Trauma, 1987-2007

OBJECTIVE

To determine the 20 most cited articles and authors in the Journal of Orthopaedic Trauma during the first 20 years of publication, 1987 to 2007.

DESIGN

Review.

METHODS

We used Web of Science "cited reference search" to determine the most cited articles originating in the Journal of Orthopaedic Trauma from 1987 to 2007, the first 20 years of publication. The characteristics of each article were recorded. Next, we manually searched each author's citations for works in the same time period to determine the most cited authors. The number of first authorships for each author was then determined using Medline, and a relative citation impact ratio was calculated. Finally, citation reports for the journal overall were created to evaluate the citation impact of the journal over the last 10 years.

RESULTS

The top cited articles ranged from 64 to 566 citations with two articles over 100. Fifteen were clinical articles with the most common topic being tibia fractures (shaft, plateau, and pilon). The top cited authors ranged for 111 to 566 citations, whereas the citations per lead authorship ratio for the authors on that list ranged from 9.5 to 566 citations per lead authorship. The number of citations to the Journal of Orthopaedic Trauma overall over the last 20 years has increased from 181 in 1997 to 3050 in 2007.

CONCLUSIONS

The influence of the Journal of Orthopaedic Trauma, its articles, and its authors is readily apparent in this review of the most cited articles and authors in the journal over its first 20 years of publication. This journal is a source of highly cited original articles and the work of many highly cited leaders in the field of orthopaedic trauma.

Prospective analysis of a new minimally invasive technique for paediatric Gartland type III supracondylar fracture of the humerus

OBJECTIVE

The purpose of this study was to introduce a minimally invasive surgery using mosquito forceps for achieving the reduction of severely displaced supracondylar fracture of the humerus in children and evaluate the clinical outcome.

MATERIALS AND METHODS

Gartland type III supracondylar fractures of the humerus in children under the age of 12 were analysed from January 2000 to January 2007 at our institute. The control group cases were selected by successful reduction using the standard technique described by Rockwood and Wilkins (2001). The others composed the study group. This study included chart reviews, radiographic images of both the antero-posterior and the lateral views, physical examination, and Mayo elbow performance index scores preoperative, postoperative, and final follow-up.

RESULTS

Evaluations were completed for 42 cases. The mean age was 6.9 years and the group consisted of 23 boys and 19 girls. The mean follow-up time was 34.5 months. Twenty-six cases were of injuries to the left side, and 16 were of injuries to the right. The Mayo elbow performance index score was excellent in both groups. Operation time in the control and study groups was 46 and 79min, respectively. There was one case of iatrogenic ulnar nerve injury each in the study and control group. One case of loss of reduction and another with a combination of ulnar nerve injury and loss of reduction were noted in the control group. All four cases had an excellent final outcome. No mosquito-forceps-related complication was found, and in the final follow-up, no cubitus varus was found.

CONCLUSION

Minimally invasive surgery with the assistance of mosquito forceps for the reduction of severely displaced supracondylar fracture of the humerus in children was shown to be a safe and effective alternative method. The final functional outcome was the same as that of the standard technique.

Biomechanical analysis of supracondylar humerus fracture pinning for slightly malreduced fractures

BACKGROUND

The most common position of malreduced type III supracondylar humerus (SCH) fractures is internal rotation and medial collapse of the distal fragment. The purpose of this study was to determine the effect of SCH fracture rotational deformity on stability with various pin configurations. Specifically, is the biomechanical stability lost when an SCH fracture is pinned in slight malreduction (compared with anatomical pinning) improved by adding a third pin?

METHODS

Sixty-four synthetic humeri were sectioned in the mid-olecranon fossa to simulate an SCH fracture. Specimens were randomized to an anatomically reduced group or a group with 20 degrees of distal fragment internal rotation (n = 32 per group). Each was randomized to one of 4 pin configurations: 2 laterally divergent pins, 2 crossed pins, 3 laterally divergent pins, or 2 lateral with 1 medial pin (n = 8 per group). All fractures were stabilized with 1.6 mm (0.062 in) Kirschner wires. Models were tested in extension, varus, and valgus for 10 cycles between 5 N and 50 N. Internal and external rotations were tested between +/-1 Nm. Data for fragment stiffness (newtons per millimeter or newton millimeters per degree) were analyzed with a 2-way analysis of variance (p < 0.05).

RESULTS

Internally rotated fractures were significantly less stable than the anatomically reduced group for external rotation, internal rotation, and varus loading regardless of pin configuration. Within the malreduced group, 3-pin configurations were more stable than 2-pin configurations in internal rotation, varus, and extension loading. Two lateral divergent pins were similar to 2 crossed pins, except in extension, where 2 lateral pins had greater stiffness.

CONCLUSIONS

Construct stiffness for malreduced specimens after pinning was less than those pinned with an anatomical reduction when loaded in varus, internal rotation, and external rotation. For simulated fractures with residual internal rotation, the addition of a third Kirschner wire compared with an anatomically reduced 2-crossed-pin configuration resulted in increased stiffness of the model for all loading directions.

CLINICAL RELEVANCE

Consider a 3-pin pattern, either 3 laterally divergent pins or 2 lateral pins and 1 medial pin, for SCH fractures when a less than complete anatomical reduction is obtained.

Vitamin D: a growing perspective

Vitamin D deficiency has been widely reported in all age groups in recent years. Rickets has never been eradicated in developed countries, and it most commonly affects children from recent immigrant groups. There is much evidence that current vitamin D guidelines for the neonatal period, 5-10 microg (200-400 IU)/day, prevent rickets at the typical calcium intakes in developed countries. The annual incidence of vitamin D-deficiency rickets in developed countries ranges between 2.9 and 7.5 cases per 100,000 children. The prevalence of vitamin D deficiency in mothers and their neonates is remarkable, and the results of one study suggest that third-trimester 25-hydroxyvitamin D (25(OH)D) is associated with fetal bone mineral accrual that may affect prepubertal bone mass accumulation. Beyond infancy, the evidence indicates that 5 microg (200 IU)/day of vitamin D has little effect on vitamin D status as measured by the serum 25(OH)D concentration. Two randomized clinical trials show that higher vitamin D intake improves one-year gain in bone density in adolescent girls. The functions of vitamin D extend beyond bone to include immune system regulation and anti-proliferative effects on cells. Early life vitamin D inadequacy is implicated in the risk of bone disease, autoimmune disease, and certain cancers later in life; however, long-term interventional studies do not exist to validate the widespread implementation of greater vitamin D consumption. Here we review the available data concerning vitamin D status and health effects of vitamin D in pregnancy through to and including adolescence.

Sagittal plane analysis of the open and closed methods in children with displaced supracondylar fractures of the humerus (a radiological study)

OBJECTIVES

The aim of this study was to compare the radiological outcome of open and close reduction and osteosynthesis methods in the treatment of type II and III supracondylar humerus fractures in childhood with respect to the immediate post-operative reduction quality in sagittal plane.

METHOD

One hundred and forty four-pediatric patients with type IIb and III supracondylar humerus fractures treated at two centers between 1995 and 2005 were evaluated radiologically within a retrospective study. Seventy-six patients (54 boys, 22 girls, mean age 7.6, range 2-12) were treated by closed reduction and cross percutaneous pinning while 68 (49 boys, 19 girls, mean age 7.3, range 2-13) were treated by open reduction. The reduction quality of the open and closed groups was compared on immediate post-operative lateral radiographs by measuring of lateral humerocapitellar angle, anterior humeral line and anterior coronoid line criteria. The reduction quality was classified excellent, good, fair and poor according to the achievement of three, two, one or none of the criteria, respectively. Reductions classified as excellent and good were introduced as acceptable results.

RESULTS

At least one criterion was achieved in all the patients of both the groups. The mean humerocapitellar angle was 30.1 degrees in closed reduction group while the mean of it was 29.8 degrees in open reduced group. Radiograph of 48 (63.1%) patients with closed reduction were found to display the anterior humeral line intersecting the middle one-third of capitellum while this criteria was 45 (66%) in open reduction group. The anterior coronoid line was disturbed in three patients in each of both the groups. The reduction quality was evaluated to be excellent in 32 patients, good in 31, fair in 13 at the closed reduction group while these evaluations were 31, 20 and 17 in open reduction group, respectively. Successful reduction was achieved in 74.9% of the patients in closed reduction group and 75% of the patients in open reduction group.

CONCLUSION

It is concluded that there was no significant difference between closed and open reductions of pediatric displaced supracondylar fractures with regard to the radiological criteria of reduction quality in sagittal plane.

Children's daily living activities during immobilization of upper-limb fractures with an above- or below-elbow cast

BACKGROUND

The purpose of this prospective study was to assess the impact of cast immobilization on the activities of daily living in children with fractured upper limbs.

METHODS

Using the Activities Scale for Kids (ASK), 52 consecutive children (17 girls, 35 boys), aged 5-15 years (mean, 9 years), with upper limb fractures treated by means of above- or below-elbow casts were assessed. The files were reviewed for background and fracture-related data.

RESULTS

Mean score of the above-elbow group was 65.4 +/- 15.5 points on the ASK capability domain (ASK-c) (with cast) and 98.7 +/- 3 points on the ASK-performance domain (without cast). Corresponding scores for the below-cast group were 89.8 +/- 13 and 99.5 +/- 2. Factors that positively affected overall function were older age, male sex, shorter duration of pain, and less displacement. On multivariate analysis, only age proved to be a potential predictive factor. Cast position and hand dominance had no effect. The specific activities affected were personal hygiene, dressing, making a snack, and reaching high objects.

CONCLUSIONS

To ease their children's adjustment to forearm cast immobilization after fractures, parents should be educated in the areas of daily living that may be affected. This is particularly true for younger children with more displaced fractures that cause more pain.

The healing forearm fracture: a matched comparison of forearm refractures

BACKGROUND

Forearm fractures in children usually heal rapidly after closed treatment. Recent studies report forearm refracture rates of 5%. The purpose of this study was to identify risk factors for refracture based on radiographic variables.

METHODS

We performed a retrospective review of patients that sustained a second forearm fracture (refracture) between 1998 and 2005. Refractures were defined as having a second fracture of the same forearm within 18 months of the original fracture. A comparison group of single-fracture patients followed in a capitated insurance plan were included and matched based on age and sex. Radiographic assessment included initial/final angulation, displacement, and fracture-line visibility at latest follow-up.

RESULTS

Sixty-three refractures were compared with 132 age- and sex-matched single-fracture patients. Time to refracture averaged 10 months. Thirty-eight percent of the initial fractures in the refracture group occurred in the proximal or middle third of the forearm compared with 15% for the single-fracture patients (P < 0.001). Because location of the fracture was found to be a risk factor for refracture, a secondary analysis was performed with refracture patients matched to single-fracture patients based on age, sex, bone fractured, fracture location, and treatment method. Fracture-line visibility of the radius at latest follow-up was clearly visible in 48% of refractures compared with 21% of controls (P = 0.05). Initial fracture severity and residual deformity were not significantly different.

CONCLUSIONS

Proximal and middle one third forearm fractures are at greater risk of refracture compared with distal one third forearm fractures. There was a trend toward incomplete healing seen more commonly in those that refractured, emphasizing the importance of longer immobilization in these fractures.

LEVEL OF EVIDENCE

Prognostic study, level III, case-control study.

Proximal humerus and humeral shaft fractures in children

Proximal humerus fractures and fractures of the humeral shaft are relatively rare in children. The incidence of the former is about 1 to 3 cases/1000 population per year, comprising fewer than 3% of all pediatric fractures. Fractures of the humeral shaft represent fewer than 10% of all humerus fractures in children. Both types of fractures in babies and young children can be treated nonsurgically, because of the joint's ability to remodel. Simple swaddling with a sling or swaddling cloth can be the solution. For older children, splints and braces may be necessary for short periods of time. Fractures can sometimes be a sign of parental child abuse, so suspicion should remain high when evaluating children with these injuries.

Paediatric trauma epidemiology in an urban scenario in India

PURPOSES

To identify the epidemiology of paediatric trauma in an urban scenario of India and compare results with studies from developed countries, and to formulate preventive measures to decrease such traumas.

METHODS

Between January 2004 and 2005 inclusive, 500 paediatric, orthopaedic trauma patients presenting to our hospital were prospectively studied. Information was recorded in a prescribed proforma.

RESULTS

The children's ages ranged from 0 to 16 years; 274 were males. Most fractures occurred in children aged 7 to 12 years and decreased in older children. The ratio of fractures in left versus right upper extremity was 2:1. In children aged 0 to 6 years, the most common injured site was the elbow, whereas in children aged 7 to 16 years it was the distal radius. In descending order, most injuries were sustained at home (47%), in school (21%), due to sports (17%), and due to vehicular accidents (13%).

CONCLUSION

An effective accident prevention programme in developing countries requires changes in lifestyle and environment, and overcoming obstacles such as ignorance, illiteracy, and inadequate resources.

Reproducibility of the Gartland classification for supracondylar humeral fractures in children

PURPOSE

To evaluate the intra- and inter-observer reproducibility of the Gartland radiographic classification for supracondylar humeral fractures in children.

METHODS

Anteroposterior and lateral radiographs of 50 supracondylar humeral fractures in children were graded on 2 separate occasions by 4 orthopaedic surgeons according to the Wilkins modification of the Gartland classification. Data were analysed by calculating the Kappa values for intra- and inter-observer agreement to indicate the reproducibility of the classification.

RESULTS

There was moderate inter-observer agreement, except for poor agreement over type I fractures. Type II fractures only showed fair to moderate agreement. Type III fractures and the flexion group showed good to very good agreement. Intra-observer agreement was good to very good.

CONCLUSION

Surgeons should treat paediatric supracondylar humeral fractures based on an assessment of the degree of displacement rather than by employing the Gartland classification.

Nancy nail versus intramedullary-wire fixation of paediatric forearm fractures

Intramedullary nailing provides effective fracture fixation with satisfactory functional outcome without the risks associated with plating. Unfortunately, elastic stable intramedullary nailing devices are not always available in every hospital. We have examined the outcome of 23 children who underwent intramedullary fracture fixation of one or both forearm diaphyseal fractures in our department. We have compared the outcome of intramedullary Nancy nailing with the use of standard, available K-wires to achieve intramedullary fixation. We have assessed, over a 12-month period, rates of union (100% in both groups), function of the forearm and complication rates. We have found no significant increase in the rates or severity of complications when using K-wires compared with Nancy nails. Both groups had equal excellent functional outcome. We advocate that if elastic stable intramedullary nailing devices are unavailable, a K-wire can be used to achieve three-point compression of a paediatric forearm diaphyseal fracture.

Lateral versus crossed wire fixation for displaced extension supracondylar humeral fractures in children

Reduction and percutaneous pin fixation is widely accepted treatment for displaced humeral supracondylar fractures in children, but the best pin configuration is still debatable. This study examined the outcome for crossed and lateral pins placement in type IIB and III supracondylar humeral fractures. Clinical notes and radiographs of 131 children with an average age of 6 years were retrospectively reviewed. Lateral pins fixation was used in 66 children and crossed wires in 65. The groups were similar with regard to gender, age, follow-up, severity of displacement and number of closed/open reductions. There was no statistical difference between the two groups either clinically or radiologically in the quality of outcome. However, postoperative ulnar nerve injuries occurred in 6% of patients treated with crossed wire fixation, whilst none of the group with pins inserted laterally suffered this complication. We recommend fixation of displaced humeral supracondylar fractures with two or three lateral pins inserted parallel or in a divergent fashion. This method of fixation gives similar results to crossed wires but prevents iatrogenic ulnar nerve injuries.

Fractures and recurrent fractures in children; varying effects of environmental factors as well as bone size and mass

BACKGROUND

Fractures are frequent in childhood and cause considerable morbidity. Previous reports have indicated a variety of potential contributors to fracture risk including low bone mineral content and density, milk avoidance, lack of exercise, asthma, obesity, and a high consumption of carbonated beverages.

AIMS

We wished to test the hypothesis that children who sustain recurrent fractures have a lower bone mass and a higher prevalence of underlying risk factors for fracture than those who fracture once or not at all.

METHODS

We studied 150 children aged 4-16 years: 50 who had suffered recurrent fractures, 50 who had fractured for the first time, and 50 fracture-free controls. Subjects underwent assessment of bone size and mass by total body (TB) and lumbar spine (L2-4) dual energy X-ray absorptiometry (DXA). Values were adjusted for body size, based on the control group measurements as unadjusted DXA values are substantially influenced by size in children. Anthropometry and grip dynamometry were carried out, and information about factors implicated in fracture aetiology such as milk intake, physical activity levels, asthma prevalence and carbonated beverage consumption were recorded using questionnaires.

RESULTS

Children who had sustained one or more fractures had a significantly lower BMC and aBMD at all sites than controls after conversion to size adjusted z scores (L2-4 BMC P = 0.0002; L2-4 aBMD P < 0.0001; TB BMC P < 0.0001; TB aBMD P < 0.0001); estimates for TB excluded fracture sites. There was, however, no difference in adjusted bone mass between children with one and those with recurrent fractures. Children with recurrent fractures had a significantly lower milk intake, lower levels of physical activity, a higher BMI, and a higher consumption of carbonated beverages than controls. The prevalence of risk factors was not, however, significantly higher than controls in children with a single fracture.

CONCLUSIONS

Children with fractures have a lower bone mass for body size than children without fractures. Modifiable risk factors such as diet and exercise increase the risk of recurrent fractures.

School absence in children with fractures: is it unnecessary school regulations that keep children away from school?

We retrospectively reviewed school absence in 142 consecutive children aged 5-16 years who attended our clinic following upper or lower limb fractures that required hospital admission. A questionnaire was sent to all parents and the head teachers of the involved schools requesting details of their return to school policy following trauma. One hundred and forty-two children had fractures in the study period. One hundred and four parent questionnaires were completed. All 29 head teachers' responded. Children lost an average of 4 and 21 school days, respectively as a result of upper and lower limb fractures. Parents 92 or child 7 made the decision to return to school, this totals 95%. We concluded that school regulations rarely delay a child's return to school after a fracture.