Altered lower extremity fracture characteristics in obese pediatric trauma patients

Influence of Obesity in Children with Supracondylar Humeral Fractures Requiring Surgical Treatment at a Tertiary Pediatric Trauma Center

BACKGROUND

Almost everywhere in the world, childhood obesity is becoming a serious public health problem with negative effects on both children's health and society as a whole. The main objective of this study was to determine whether obesity has an effect on the severity of supracondylar humerus fracture in children, regardless of whether it is a low- or high-energy trauma.

METHODS

The electronic records of patients treated for the supracondylar fracture of the humerus in the ten-year period from 1 January 2013 to 1 January 2023 were reviewed retrospectively.

RESULTS

In the observed period, 618 children, including 365 (59.06%) boys and 253 (40.94%) girls, were hospitalized and treated surgically with the diagnosis of supracondylar fracture. The distributions according to the observed parameters were as follows: age (months) = 88.18 ± 32.64; height (cm) = 123.42 ± 16.83; weight (kg) = 27.18 ± 11.32; body mass index = 17.18 ± 3.06; body mass index-for-age percentile = 57.34 ± 32.11. Overall, 141 (22.82%) fractures were classified as Gartland II, while 477 (77.18%) were classified as Gartland III. A total of 66 (10.68%) fractures were flexion type, while 552 (89.32%) were extension type. The left elbow was affected in 401 (64.89%) children, while the right was affected in 217 (35.11%) children. The main mechanism of injury was a fall at ground level (33.33%). In relation to gender, a statistically significant difference was recorded in body mass index and percentile (p < 0.05). According to Gartland, the proportion of children below and above the 85th percentile in relation to the type of injury was statistically significant (p < 0.05). It was determined that the energy level does not significantly influence the injury's severity: p(GII) = 0.225; p(GIII) = 0.180.

CONCLUSIONS

In our study, we found that the proportion of overweight and obese children requiring surgical treatment was higher in Gartland type III injury, so there is no doubt that as a society we must prevent further increases in the prevalence of childhood obesity for this reason as well.

The Insidious Effects of Childhood Obesity on Orthopedic Injuries and Deformities

The current childhood obesity epidemic, affecting approximately 20% of American children and adolescents, is accompanied by unique orthopedic manifestations. The growing musculoskeletal system is susceptible to the endocrine effects of obesity, resulting in decreased bone mass and quality. As a result, obese children are at increased risk of musculoskeletal injury, fracture, and lower extremity deformities. The efficacy of nonoperative treatment such as casting or bracing may be limited by body habitus and surgical treatment is accompanied by increased risk of perioperative complications.

Adolescent tibial tubercle fractures in the time of the COVID 19: A single orthopedic trauma center experience

BACKGROUND

The purpose of this study is to assess the incidence and clinical characteristics of adolescent tibial tubercle fractures (TTFs) during the COVID-19 pandemic by sharing our experiences.

METHODS

Pediatric patients aged between 0 and 18 years old with confirmed diagnosis of TTFs who were treated at our center between April 2020 and May 2020 were included in the study. In addition to demographics, mechanism injury, treatment modalities, complications were also noted.

RESULTS

Sixteen patients were included in the study. The mean age was 14.8 ± 0.9 years (range: 13-16 years). The mean BMI of patients was 26.3 ± 2.3 kg/m² (range: 23.2-30.4 kg/m²). According to the BMI-for-age percentiles growth chart, eight patients (50%) were overweight, and eight patients (50%) were at a risk of being categorized as overweight. The most common cause for the injury was jumping due to basketball (50%). Twelve of 16 patients were treated operatively by open reduction and internal fixation. The remaining 4 patients were treated non-operatively with long leg cast.

CONCLUSION

The incidence of TTFs was 16 cases over about two months during the pandemic isolation period. Our results demonstrated that all adolescent TTFs occurred during periods when outdoor activities were permitted. This finding may be explained by sudden athletic activity after prolonged immobilization. We observed that all of our patients were male and either overweight or at risk of being overweight.

The Effect of Obesity on Pediatric Tibia Fractures

BACKGROUND

Childhood obesity affects nearly one fifth of all children in the United States. Understanding the unique injury characteristics and treatment of tibia fractures in this population has become increasingly important. This study aims to explore the different injury characteristics between tibia fractures in obese and non-obese children.

METHODS

215 skeletally immature children aged 2-18 who sustained tibia fractures between 2007.2019 were retrospectively reviewed. Patients were analyzed by weight group: underweight, normal weight, overweight, and obese as defined by body mass index (BMI) percentile based upon age. Analyses were performed on dichotomized groups: underweight and normal weight versus overweight and obese. Chi-square or Fisher's exact test was used to compare differences in categorical outcome between the 2-category BMI class variables; Wilcoxon test was used to compare continuous outcomes. A multivariate logistic regression model was used to evaluate BMI associations while controlling for age, sex, race, and mechanism of injury.

RESULTS

Distribution of BMI in the cohort included 6.5% underweight, 45.6% normal weight, 16.7% overweight and 31.2% obese. Overweight and obese children sustained fractures from low energy mechanisms at more than double the rate of normal and underweight children (20.5% versus 9.7%, p=0.028). Overweight and obese children sustained physeal fractures at a rate of 54.4% in comparison with 28.6% in their normal and underweight peers (p<0.0001, OR 2.50 (95% CI, 1.26-4.95)). Overweight and obese children sustained distal 1/3 tibia fractures at a higher rate of 56.9% compared to under and normal weight children at 33.9% (p=0.003, OR 2.24 (95% CI, 1.17-4.30)). Overweight and obese children underwent unplanned changes in treatment at a lower rate than normal and underweight children at 1% versus 8% rates of treatment change, respectively (p=0.013, OR 0.076 (95%CI, 0.009-0.655)). No significant differences were found in the rates of operative treatment, repeat reduction, post treatment complications, or physical therapy.

CONCLUSION

Overweight children sustain tibia fractures from low energy mechanisms at higher rates than their peers. Similarly, obese and overweight patients have higher rates of physeal injuries and higher rates of distal 1/3 tibia fractures. Complication rates are similar between obese and non-obese children undergoing treatment for tibia fractures. Level of Evidence: III.

Vitamin D level, body mass index and fracture risk in children: vitamin D deficiency and fracture risk

The objective of this study was to determine the impacts of preventable causes of fracture, such as vitamin D deficiency, disturbed calcium homeostasis and obesity on fracture occurrence in minor traumas. In this way, the effects of relevant parameters on fracture may be further elucidated. A prospective case-control study in children aged 2-18 years children with and without fractures was performed. Participants with a pediatric trauma score higher than 10 presenting to minor trauma were included to exclude the significant impact of severe trauma on fracture. The effects of obesity, parameters associated with vitamin D and Ca homeostasis on fracture occurrence were evaluated. Univariate and multivariate analyses were used to test for associations between fracture status and the assessed variables. The relationships between the variables and the odds of fracture occurrence were examined using logistic regression models. The sample consisted of 76 patients and 50 controls. There were no significant differences between the patients and controls in terms of age, sex, trauma type and pubertal period. The patients had a significantly higher mean BMI percentile (61.2 ± 30.7, 36.7 ± 30.7; P < 0.001). Likewise, patients were more likely than controls to have a lower mean 25(OH)D level and mean phosphorus level (respectively, 13.4 ± 7.0, 17.3 ± 7.8; P = 0.004, and 4.6 ± 0.7, 5.1 ± 0.8; P < 0.001). Moreover, fractures were substantially more frequent in children with vitamin D deficiency (<20 ng/mL, χ2: 7.781, df: 1, P = 0.005). In the multivariate logistic model, BMI percentile and vitamin D levels remained significantly associated with increased odds of fracture [1.02 (1.01-1.04), P < 0.001 and 0.93 (0.89-0.98), P = 0.01]. The present study supports an association of high BMI and vitamin D deficiency with an increased odds of fracture occurrence in children. The findings may help physicians to reduce the risk factors of fracture by preventive efforts. Thus, unexpected health costs and morbidity may be minimized.

Posterior Tibial Slope is Increased in Patients With Tibial Tubercle Fractures and Osgood-Schlatter Disease

BACKGROUND

Osgood-Schlatter disease (OSD) and tibial tubercle fractures are pathologies that affect the tibial tubercle apophysis in preadolescents and adolescents. Anatomic alignment of the proximal tibia may explain why some children develop OSD or sustain tibial tubercle fractures and some do not. Recent data has shown an association between posterior tibial slope angle (PTSA) and both OSD and proximal tibia physeal fractures. In this study, we compare radiographic parameters between patients with non-OSD knee pain, knees with OSD, and knees with tibial tubercle fracture to elucidate a difference between these groups.

METHODS

Patients treated for OSD, tibial tubercle fractures, and knee pain, from 2012 to 2018, were retrospectively reviewed. Radiographic parameters for each study group included PTSA, anatomic lateral distal femoral angle, anatomic medial proximal tibial angle, patellar articular height, and the distance from the inferior aspect of the patellar articular surface. Caton-Deschamps index was then calculated. Demographic data was collected including age, sex, and body mass index. Demographic and radiographic data was compared using analysis of variance tests, χ2 tests, 2-sample t tests, and multiple linear regression.

RESULTS

Two hundred fifty-one knees in 229 patients met inclusion criteria for the study. In all, 76% were male and the average age of the overall cohort was 14 years old. In patients with tibial tubercle fractures, the majority of fractures were Ogden type 3b (65%). After controlling for demographic variability, average PTSA in the fracture cohort was significantly greater than that in the control cohort (β=3.49, P<0.001). The OSD cohort had a significantly greater posterior slope (β=3.14) than the control cohort (P<0.001). There was no statistically significant difference between the fracture and OSD cohorts. There was also no difference in Caton-Deschamps index between the 2 study groups when compared with the control group.

CONCLUSION

This study demonstrates that patients with tibial tubercle fractures and patients with OSD have an increased PTSA when compared with the control group. This information adds to the body of evidence that increased tibial slope places the proximal tibial physis under abnormal stress which may contribute to the development of pathologic conditions of proximal tibia such as OSD and tibial tubercle fractures.

LEVEL OF EVIDENCE

Level III; retrospective comparative study.

Associations of childhood overweight and obesity with upper-extremity fracture characteristics

Childhood obesity is a growing epidemic in the United States, and is associated with an increased risk of lower-extremity physeal fractures, and fractures requiring operative intervention. However, no study has assessed the risk upper extremity physeal fractures among overweight children. Our purpose was to compare the following upper-extremity fracture characteristics in overweight and obese children with those of normal-weight/underweight children (herein, "normal weight"): mechanism of injury, anatomical location, fracture pattern, physeal involvement, and treatment types. We hypothesized that overweight and obese children would be higher risk for physeal and complete fractures with low-energy mechanisms and would therefore more frequently require operative intervention compared with normal-weight children.We performed a cross-sectional review of our database of 608 patients aged 2 to 16 years, and included patients who sustained isolated upper-extremity fractures at our level-1 pediatric tertiary care center from January 2014 to August 2017. Excluded were patients who sustained pathologic fractures and those without basic demographic or radiologic information. Using body mass index percentile for age and sex, we categorized patients as obese (≥95th percentile), overweight (85th to <95th percentile), normal weight (5th to <85th percentile), or underweight (<5th percentile). The obese and overweight groups were analyzed both separately and as a combined overweight/obese group. Demographic data included age, sex, height, and weight. Fractures were classified based on fracture location, fracture pattern (transverse, comminuted, buckle, greenstick, avulsion, or oblique), physeal involvement, and treatment type. Of the 608 patients, 58% were normal weight, 23% were overweight, and 19% were obese. There were no differences in the mean ages or sex distributions among the 3 groups.Among patients with low-energy mechanisms of injury, overweight/obese patients had significantly greater proportions of complete fractures compared with normal-weight children (complete: 65% vs 55%, P = .001; transverse: 43% vs 27%, P = .006). In addition, the overweight/obese group sustained significantly more upper-extremity physeal fractures (37%) than did the normal-weight group (23%) (P = .007).Compared with those in normal-weight children, upper-extremity fracture patterns differ in overweight and obese children, who have higher risk of physeal injuries and complete fractures caused by low-energy mechanisms.Level of Evidence: Level III, retrospective comparative study.

Clinical and epidemiological features of tibial tubercle avulsion fracture in Chinese adolescents

Background

Tibial tubercle avulsion fracture is rare in children. Accumulated knowledge on clinical and epidemiological features of this fracture is of practical significance for clinical colleagues to deal effectively with such fractures.

Methods

Clinical and epidemiological parameters were reviewed retrospectively in 29 patients with tibial tubercle avulsion fracture that was treated in our hospital in the past 7 years.

Results

Totally, 29 children with 30 tibial tubercle fractures were enrolled. They were all boys; the average age was 13.8 (12–15) years, and the average Body Mass Index (BMI) was 26.4 (19.2–34.3). Statistically, 41.4% of injuries occurred during jumping activities, and 1 (3.4%), 12 (41.4%) and 16 (55.2%) patients were injured bilaterally, on the right and left sides, respectively. The patients were classified into type I (4), II (3), III (13) and IV (10) fractures. Two patients (three knees) with fractures of type IV received close reduction and cast immobilization for 6 weeks. One patient with fracture of type IV underwent close reduction and was fixed with two cannulated screws. The remaining 26 patients underwent open reduction and were fixed with two or three cannulated screws. The average follow-up time was 38 (14–98) months; no complication was noted. Twenty-seven patients had an excellent outcome.

Conclusion

In Chinese adolescents, the tibial tubercle avulsion fracture predisposes to boys with higher body weight; jumping is the most common cause of injury; treatments show satisfactory outcome regardless of fracture types.

Obese Children Have Different Forearm Fracture Characteristics Compared With Normal-weight Children

BACKGROUND

Current estimates suggest that one third of children and adolescents are overweight and 1 in 5 are obese. Obese children are at increased risk of sustaining more complex fractures, failing nonoperative treatment, and experiencing more complications during treatment. The purpose of this study was to compare forearm fracture characteristics, treatment, and complications in grouped overweight and obese [OW+OB; body mass index-for-age percentile (BMI%) ≥85] pediatric patients compared with normal-weight (NW; BMI%≤84) patients.

METHODS

This was a retrospective comparative study of patients aged 2 to 17 years old who presented with a forearm fracture resulting from low-energy trauma between January 2010 and September 2017. Patients with incomplete height and weight data; an underlying condition that predisposes to fractures or altered fracture healing; and torus, greenstick, pathologic, and high-energy fractures were excluded. Demographics, fracture characteristics, treatment, and complications were recorded. Descriptive and inferential analyses were conducted.

RESULTS

A total of 565 patients (403 NW, 162 OW+OB) met the inclusion criteria. NW children sustained open fractures nearly twice as frequently as the OW+OB children but this was not statistically significant (9.7% vs. 4.9%; P=0.065). Subanalysis showed that NW children were 4.1 times more likely to sustain an open fracture compared with obese (BMI%≥95) children (9.7% vs. 2.4%; P=0.029). A significant relationship was found between BMI% and location of the fracture, the bones involved, and fracture type. The OW+OB children sustained more distal forearm fractures than midshaft and proximal forearm fractures. Isolated radial shaft fractures were more common in the OW+OB group, whereas isolated ulnar shaft fractures were more common in the NW group. There was no difference in associated neurovascular injury, initial nonoperative versus operative management, failure of nonoperative treatment, and treatment complications.

CONCLUSIONS

OW+OB children have different forearm fracture characteristics compared with their NW peers. The thick soft tissue envelope in obese children may be protective against an open forearm fracture. In contrast to previous studies, obesity was not associated with failure of nonoperative treatment or a higher rate of complications.

LEVEL OF EVIDENCE

Level III-prognostic.

A Perspective on Management of Limb Fractures in Obese Children: Is It Time for Dedicated Guidelines?

Limb fractures are the most common injuries in pediatric orthopedics. Early and late complications are often not preventable, even when providing the best treatment; furthermore, these injuries are largely implicated in medico-legal claims. The development of evidence-based guidelines is one of the main goals of medical research. Approved guidelines for diagnosis, treatment, and follow up are fundamental to obtain the best results in medical practice. Guidelines in pediatric traumatology have been developed, even though specific conditions, like obesity, could influence their drafting. The cast and fixation systems usually applied in pediatric fractures provide a growth plate sparing, a satisfying reduction, and good stress resistance, mostly because of a lower bodyweight compared to adults. Several studies suggest that obesity influences the bone quality, the management, and the outcomes in cases of fracture. High body weight increases the risk of trauma, modifies fracture characteristics, and increases the risk of incomplete reduction. Fractures in obese children have a higher rate of complications, regardless of conservative or surgical treatment. In obese children, surgical treatment is often used more frequently than with non-obese children. Such considerations are valid both for lower and upper limb fractures. The aim of this paper is to discuss recent scientific literature and provide a perspective on the benefits of a dedicated approach in the management of obese children. Guideline updates could improve healthcare quality in a pediatric setting, and also reduce medico-legal implications.

The role of PPARγ in childhood obesity-induced fractures

Globally, obesity is on the rise with ~ 30% of the world’s population now obese, and childhood obesity is following similar trends. Childhood obesity has been associated with numerous chronic conditions, including musculoskeletal disorders. This review highlights the effects of childhood adiposity on bone density by way of analyzing clinical studies and further describing two severe skeletal conditions, slipped capital femoral epiphysis and Blount’s disease. The latter half of this review discusses bone remodeling and cell types that mediate bone growth and strength, including key growth factors and transcription factors that help orchestrate this complex pathology. In particular, the transcriptional factor peroxisome proliferator-activated receptor gamma (PPARγ) is examined as it is a master regulator of adipocyte differentiation in mesenchymal stem cells (MSCs) that can also influence osteoblast populations. Obese individuals are known to have higher levels of PPARγ expression which contributes to their increased adipocyte numbers and decreased bone density. Modulating PPAR*gamma* signaling can have significant effects on adipogenesis, thereby directing MSCs down the osteoblastogenesis pathway and in turn increasing bone mineral density. Lastly, we explore the potential of PPARγ as a druggable target to decrease adiposity, increase bone density, and be a treatment for children with obesity-induced bone fractures.

Pediatric Femoral Shaft Fractures: A Multicenter Review of the AAOS Clinical Practice Guidelines Before and After 2009

BACKGROUND

To determine if the AAOS clinical practice guidelines (CPG) for the treatment of pediatric femoral shaft fractures (2009) changed treatment, we analyzed pediatric femoral shaft fractures at 4 high-volume, geographically separated, level-1 pediatric trauma centers over a 10-year period (2004 to 2013).

METHODS

Consecutive series of pediatric femoral shaft fractures (ages, birth to 18 y) treated at the 4 centers were reviewed. Treatment methods were analyzed by age and treatment method for each center and in aggregate.

RESULTS

Of 2646 fractures, 1476 (55.8%) were treated nonoperatively and 1170 fractures operatively. Of the operative group, flexible intramedullary nails (IMN) were used for 568 patients (21.5%), locked intramedullary nails (LIMNs) for 309 (11.7%), and plating for 188 (7.1%). In total, 105 fractures were treated with external fixation or skeletal traction. Analysis before and after the CPG publication revealed a significant increase in the use of interlocked IMNs in patients younger than 11 years (0.5% before, 3.8% after; P<0.001). Over the same time period there was an increase in surgical management, regardless of technique, for patients younger than 5 years (6.4% before, 8.4% after; P=0.206). There were considerable differences in treatment among centers: 74% of fractures treated with plating were from a single center (center A), which also contributed 68% of patients younger than 5 years treated with plating; center B had the highest rate (41%) of flexible IMN in children younger than 5 years; center C had the highest rate (63%) of LIMN in children younger than 11 years; and center D treated the fewest patients outside the CPG guidelines.

CONCLUSIONS

Following publication of the AAOS CPG, there was a significant increase in the use of LIMNs in patients younger than 11 years old and a trend toward surgical treatment in patients younger than 5 years. The considerable variability among centers in treatment methods and adherence to the CPG highlights the need for further outcome studies to better define optimal treatment methods and perhaps update the AAOS CPG guidelines.

LEVEL OF EVIDENCE

Level III-therapeutic.

Tibial tubercle avulsion fracture according to different mechanisms of injury in adolescents: Tibial tubercle avulsion fracture

Tibial tubercle avulsion fracture caused by knee extensor is very rare; furthermore, non-traumatic fractures during running or bilateral fractures have been reported. The purpose of this study was to evaluate any differences according to the mechanisms of injury in adolescents with tibial tubercle avulsion fracture.Thirty patients with tibial tubercle avulsion fractures were reviewed and the average age was 13 years 1 month. Seven patients (low-stress group) had a spontaneous fracture during running without definite trauma. Twenty-three patients (high-stress group) experienced pain during jumping and landing, or definite trauma. The mechanisms of injury, age, height, weight, body mass index (BMI), BMI percentile, fracture type, as well as any complication, such as limitation of motion and deformity related to the physeal arrest, were compared between groups.There was no definite difference in age, fracture type, and surgical outcomes between groups. There was no patient with significant early physeal arrest in both groups. The weight (P = .02), BMI (P = .03) and BMI percentile (P = .01) in low-stress group were higher than those in high-stress group. In low-stress group, 6 patients' BMIs were in the 97th percentile, and 1 patient's BMI was in the 5th percentile.Extreme BMI may be a risk factor for tibial tubercle avulsion fractures in adolescents during running without definite trauma. However, there was no difference in the final outcome according to injury mechanisms.

The Role of Obesity in Pediatric Orthopedics

Pediatric obesity has become a worldwide epidemic and leads to notable effects on the developing skeleton that can have lifelong implications. Obesity in the pediatric population alters bone metabolism, increasing the risk for fracture. It can alter the presentation of common pediatric orthopaedic conditions such as scoliosis. Obesity also leads to changes in the patterns and severity of pediatric fractures as well as alters conservative fracture treatment due to increased displacement risk. Obese pediatric trauma patients place a high burden on the nationwide hospital system in a variety of ways including the increased risk of perioperative complications. Obesity is modifiable, and addressing the issue can improve the orthopaedic and overall health of children.

Obesity in Pediatric Trauma

Obese children with high-energy injuries present with more severe injuries, more extremity injuries, and higher Injury Severity Scores. They are at increased risk for complications, prolonged ventilation, and ICU stay and have increased mortality. Obesity is associated with altered bone mass accrual and higher fracture rates. Obese patients have a higher risk of loss of reduction of forearm fractures, more severe supracondylar fractures, and a higher likelihood of lateral condyle fractures. Obese patients are more likely to have complications with femur fractures and have higher rates of foot and ankle fracture.

Obesity Increases Risk of Loss of Reduction After Casting for Diaphyseal Fractures of the Radius and Ulna in Children: An Observational Cohort Study

OBJECTIVES

To determine if high body mass index (BMI) increases the risk of loss of reduction (LOR) following closed reduction and casting for displaced concomitant fractures of the radial and ulnar shafts in pediatric patients.

DESIGN

Retrospective cohort study.

SETTING

A single, tertiary care, urban children's hospital.

PATIENTS/PARTICIPANTS

Pediatric patients 2-18 years of age with closed, displaced, concomitant diaphyseal fractures of the radius and ulna (OTA/AO 22-A3) who underwent closed reduction and casting at the study site.

MAIN OUTCOME MEASURES

BMI percentile of ≥95 was defined as obese. For nonobese patients, BMI percentile of ≥85 was defined as overweight. BMI percentile category, fracture angulation, sex, age, fracture location, and number of follow-up visits were recorded. Radiographs and health records were reviewed to note clinical and radiographic cases of LOR. The primary outcome was LOR (clinical or radiographic).

RESULTS

Overall, 124 subjects (74 male and 50 female subjects) underwent acceptable closed reduction and casting. Median patient age was 7.6 years (range, 2.2-17.8 years). There were 14 cases of LOR. LOR rates were 7.2%, 16.7%, and 44.4% for the nonoverweight, overweight, and obese cohorts, respectively (P = 0.005). Regression analysis revealed that LOR was positively associated with higher BMI category (odds ratio for overweight 4.49; P = 0.082; odds ratio for obese 7.52; P = 0.020) and patient age in years (odds ratio, 1.38; P = 0.001).

CONCLUSIONS

Given the high risk of LOR in overweight and obese children with displaced concomitant fractures of the radial and ulnar shafts, our findings suggest that attentive and frequent follow-up is warranted. In these patients, the initial reduction should be closely scrutinized, and a lower threshold for surgical fixation may be considered.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effects of a Randomized Weight Loss Intervention Trial in Obese Adolescents on Tibia and Radius Bone Geometry and Volumetric Density

Obese adolescents have increased fracture risk, but effects of alterations in adiposity on bone accrual and strength in obese adolescents are not understood. We evaluated 12-month changes in trabecular and cortical volumetric bone mineral density (vBMD) and cortical geometry in obese adolescents undergoing a randomized weight management program, and investigated the effect of body composition changes on bone outcomes. Peripheral quantitative computed tomography (pQCT) of the radius and tibia, and whole-body dual-energy X-ray absorptiometry (DXA) scans were obtained at baseline, 6 months, and 12 months in 91 obese adolescents randomized to standard care versus behavioral intervention for weight loss. Longitudinal models assessed effects of body composition changes on bone outcomes, adjusted for age, bone length, and African-American ancestry, and stratified by sex. Secondary analyses included adjustment for physical activity, maturation, vitamin D, and inflammatory biomarkers. Baseline body mass index (BMI) was similar between intervention groups. Twelve-month change in BMI in the standard care group was 1.0 kg/m² versus -0.4 kg/m² in the behavioral intervention group (p < 0.01). Intervention groups were similar in bone outcomes, so they were combined for subsequent analyses. For the tibia, BMI change was not associated with change in vBMD or structure. Greater baseline lean body mass index (LBMI) associated with higher cortical vBMD in males, trabecular vBMD in females, and polar section modulus (pZ) and periosteal circumference (Peri-C) in both sexes. In females, change in LBMI positively associated with gains in pZ and Peri-C. Baseline visceral adipose tissue (VFAT) was inversely associated with pZ in males and cortical vBMD in females. Change in VFAT did not affect bone outcomes. For the radius, BMI and LBMI changes positively associated with pZ in males. Thus, in obese adolescents, weight loss intervention with modest changes in BMI was not detrimental to radius or tibia bone strength, and changes in lean, but not adiposity, measures were beneficial to bone development. © 2017 American Society for Bone and Mineral Research.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)

Background and purpose - The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) describes the localization and morphology of fractures, and considers severity in 2 categories: (1) simple, and (2) multifragmentary. We evaluated simple and multifragmentary fractures in a large consecutive cohort of children diagnosed with long bone fractures in Switzerland. Patients and methods - Children and adolescents treated for fractures between 2009 and 2011 at 2 tertiary pediatric surgery hospitals were retrospectively included. Fractures were classified according to the AO PCCF. Severity classes were described according to fracture location, patient age and sex, BMI, and cause of trauma. Results - Of all trauma events, 3% (84 of 2,730) were diagnosed with a multifragmentary fracture. This proportion was age-related: 2% of multifragmentary fractures occurred in school-children and 7% occurred in adolescents. In patients diagnosed with a single fracture only, the highest percentage of multifragmentation occurred in the femur (12%, 15 of 123). In fractured paired radius/ulna bones, multifragmentation occurred in 2% (11 of 687); in fractured paired tibia/fibula bones, it occurred in 21% (24 of 115), particularly in schoolchildren (5 of 18) and adolescents (16 of 40). In a multivariable regression model, age, cause of injury, and bone were found to be relevant prognostic factors of multifragmentation (odds ratio (OR) > 2). Interpretation - Overall, multifragmentation in long bone fractures in children was rare and was mostly observed in adolescents. The femur was mostly affected in single fractures and the lower leg was mostly affected in paired-bone fractures. The clinical relevance of multifragmentation regarding growth and long-term functional recovery remains to be determined.

Risk factors for complications and readmission after operative fixation of pediatric femur fractures

PURPOSE

Operative fixation of pediatric femur fractures with intramedullary implants has grown in popularity in recent decades. However, risk factors for short-term adverse events and readmission have not been well studied.

METHODS

Pediatric patients who underwent intramedullary nailing of a femur fracture between 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Risk factors for any adverse event (AAE) and readmission after intramedullary nailing were evaluated using univariate and multivariate analysis.

RESULTS

A total of 522 pediatric patients who underwent intramedullary nailing of the femur during the study period were identified. The mean age of this patient cohort was 10.2 ± 3.8 years. Review of the cases revealed that 18 (3.4 %) patients had AAE and that 20 (3.8 %) patients were readmitted, of whom 13 (2.5 %) underwent a reoperation. Independent risk factors for AAE were a cardiac comorbidity [odds ratio (OR) 12.7, 95 % confidence interval (CI) 1.5, 103.7], open fracture (OR 10.2, 95 % CI 1.4, 74.4), and prolonged operative time (OR 17.5, 95 % CI 6.1, 50.5). Independent risk factors for readmission were a central nervous system disorder (OR 4.5, 95 % CI 1.3, 16.2) and a seizure disorder (OR 4.9, 95 % CI 1.0, 23.5).

CONCLUSIONS

The results of the multivariate analysis suggest that cardiac comorbidities, open fractures, and prolonged operative time increase the risk for AAE and that central nervous system disorders and seizure disorders may increase the risk for readmission. Surgeons should be aware of these risk factors and counsel the families of pediatric patients who undergo intramedullary nailing of femur fractures.