BACKGROUND\nFractures of the femoral shaft in children are caused by major musculoskeletal trauma and result in high direct and indirect medical costs. To date, the American literature has focused on treatment options and outcomes, but the epidemiology of these injuries has been generalized from Scandinavian studies reported in the 1970s and early 1980s. The goals of the current study were (1) to determine the age, gender, and race-specific rates and mechanisms of fractures of the femoral shaft in children in a large United-States-based population and (2) to identify associations between the rates of these fractures and multiple sociodemographic indicators. Such information is vital for preventive efforts.\n\n\nMETHODS\nThe Hospital Discharge Database of the Maryland Health Services Cost Review Commission for the years 1990 through 1996 was used to obtain demographic data on 1485 cases of acute fracture of the femoral shaft in patients who were less than eighteen years old, and data from the United States Bureau of the Census for the state of Maryland for the year 1990 were used to obtain denominator data. Reliable external-cause data were available from the 1995 and 1996 databases for 472 patients. Small-area analysis was performed at the zip-code level to determine associations between numerous sociodemographic indicators and the rate of femoral shaft fracture.\n\n\nRESULTS\nThe annual rate of femoral shaft fracture in children was 19.15 per 100,000. With regard to age, there was a bimodal distribution, with peaks at two and seventeen years. Boys had higher rates of fracture than did girls at all ages, and blacks had higher rates than did whites. The primary mechanisms of fracture were age-dependent and included falls, for children less than six years old; motor vehicle-pedestrian accidents, for those six to nine years old; and motor-vehicle accidents, for teenagers. Firearm-related injuries accounted for 15 percent of the fractures among black adolescents. Adverse socioeconomic conditions were significantly associated with higher rates of fracture.\n\n\nCONCLUSIONS\nThe rates and mechanisms of femoral shaft fractures in children depend on age, gender, and race. For children living in the United States today, the epidemiology of these fractures is different than that described in earlier, Scandinavian reports.

Fractures of the femoral shaft in children : Incidence, mechanisms, and sociodemographic risk factors.

Fracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure and nonunion. The first part of this article reviews the clinical motivation behind finite element analysis of fracture fixation, its strengths and weaknesses, how models are developed and validated, and how outputs are typically interpreted. The second part reviews recent modeling studies of the femur and proximal humerus, areas with particular relevance to fragility fractures. There is some consensus in the literature around how certain modeling aspects are pragmatically formulated, including bone and implant geometries, meshing, material properties, interactions, and loads and boundary conditions. Studies most often focus on predicted implant stress, bone strain surrounding screws, or interfragmentary displacements. However, most models are not rigorously validated. With refined modeling methods, improved validation efforts, and large-scale systematic analyses, finite element analysis is poised to advance the understanding of fracture fixation failure, enable optimization of implant designs, and improve surgical guidance.

Finite Element Analysis of Fracture Fixation

Background The cross-sectional area of three parallel screws might affect the stability of the internal fixation of femoral neck fractures. The screws fixed in the oblique-triangle configuration (OTC) were assumed to have a larger cross-sectional area, but the biomechanical stability has not yet been validated. In this study, finite element analyses were performed to compare the biomechanical properties of the internal fixation fixed by the OTC and the traditional Inverted Equilateral Triangle Configuration (IETC). Method Pauwels type III fracture was established on the three-dimensional femoral model and three cannulated screws with the OTC and traditional IETC methods were applied. The oblique-triangle configuration with the largest area inscribed the femoral neck isthmus by the three screws was determined, the area and circumference of the cross-section formed by the OTC and IETC model were compared. Stress, strain, and displacement peaks of the two configuration models under different loads were compared. Twelve pairs of nodes on the fracture ends were selected and the displacement of the fracture ends was evaluated through the displacement between these nodes. Results The area and circumference of the cross-section formed by the OTC were larger than those in the IETC model. The degree of stress dispersion around the screw holes in the OTC model was better than that of the IETC, but the stress distribution order of the three screws in the two models was consistent. The maximum stress, strain, displacement, and displacement of the fracture end in the OTC model were smaller than those in the IETC model. The stress, strain, displacement, and fracture end displacement peaks of the two fixed models gradually increase with the increase of loads. Conclusion The oblique-triangle configuration showed superior mechanical properties than the IETC in finite element analyses. This study suggests that when three screws are fixed in parallel method, the larger the cross-sectional area of the screw configuration, the better stability of the internal fixation might be obtained. Furthermore, the biomechanical properties of various spatial configurations and screw holes of the three parallel screws need to be considered before clinical practice.

Comparison of oblique triangular configuration and inverted equilateral triangular configuration of three cannulated screws in treating unstable femoral neck fracture: A finite element analysis.

Comparison of 4 cannulated lag screws (3 inverted triangular cannulated screws + anti-rotating screws;4 CLS), dynamic hip screws + derotational screws (DHS + DS), and femoral neck fixation system (FNS) in the treatment of Biomechanical properties of middle-aged Pauwels type III femoral neck fractures.The femur CT data of a healthy young volunteer was selected and imported into Mimics software to construct a three-dimensional model of a normal femur. Pauwels type III femoral neck fractures were simulated according to the 70° fracture line. Use Geomagic and SolidWorks software to optimize and build CLS, DHS + DS, and FNS fracture internal fixation models. Finally, Ansys software was used to analyze the stress distribution, peak value, and maximum displacement of the proximal fracture fragment and internal fixation; the displacement distribution, and peak value of the fracture surface at the fracture end.① The stress peaks of the proximal fracture fragments in the three groups were concentrated near the femoral calcar. The peak stress of the FNS group was the largest, and the DHS + DS group was the smallest. ②The displacement of the fracture fragments was all located at the top of the femur. The peak displacement of the FNS group was the largest, and the DHS + DS group was the smallest. ③ The internal fixation stress of the three groups is concentrated in the middle part of the device. The stress distribution of the first two groups of models is more uniform than that of FNS. The peak stress of FNS is the largest and the CLS is the smallest. ④ The internal fixed displacements are all located at the top of the model. The peak displacement of the CLS is the largest, and the DHS + DS is the smallest. ⑤ The displacement of the fracture surface is in the upper part of the fractured end. The peak displacement of the FNS group was the largest, and the DHS + DS group was the smallest.Compared with the other two internal fixation methods, dynamic hip screw + derotational screw (DHS + DS) showed good biomechanical stability. When Pauwels type III femoral neck fracture occurs in young adults, DHS + DS can be given priority as the preferred treatment for this type of fracture. 

/pdf/finite-element-comparative-analysis-of-three-different-2kvaz0ak.pdf

Finite element comparative analysis of three different internal fixation methods in the treatment of Pauwels type III femoral neck fractures

The cross-sectional area of three parallel screws might affect the stability of the internal fixation of femoral neck fractures. The screws fixed in the oblique-triangle configuration (OTC) were assumed to have a larger cross-sectional area, but the biomechanical stability has not yet been validated. In this study, finite element analyses were performed to compare the biomechanical properties of the internal fixation fixed by the OTC and the traditional Inverted Equilateral Triangle Configuration (IETC).Pauwels type III fracture was established on the three-dimensional femoral model and three cannulated screws with the OTC and traditional IETC methods were applied. The oblique-triangle configuration with the largest area inscribed the femoral neck isthmus by the three screws was determined, the area and circumference of the cross-section formed by the OTC and IETC model were compared. Stress, strain, and displacement peaks of the two configuration models under different loads were compared. Twelve pairs of nodes on the fracture ends were selected and the displacement of the fracture ends was evaluated through the displacement between these nodes.The area and circumference of the cross-section formed by the OTC were larger than those in the IETC model. The degree of stress dispersion around the screw holes in the OTC model was better than that of the IETC, but the stress distribution order of the three screws in the two models was consistent. The maximum stress, strain, displacement, and displacement of the fracture end in the OTC model were smaller than those in the IETC model. The stress, strain, displacement, and fracture end displacement peaks of the two fixed models gradually increase with the increase of loads.The oblique-triangle configuration showed superior mechanical properties than the IETC in finite element analyses. This study suggests that when three screws are fixed in parallel method, the larger the cross-sectional area of the screw configuration, the better stability of the internal fixation might be obtained. Furthermore, the biomechanical properties of various spatial configurations and screw holes of the three parallel screws need to be considered before clinical practice. 

Comparison of oblique triangular configuration and inverted equilateral triangular configuration of three cannulated screws in treating unstable femoral neck fracture: A finite element analysis

The study utilized finite element method to determine displacements and stresses in a set of Pauwels Type III femoral neck fractures repaired using 3 techniques (cannulated screws (Triad), sliding ...

Hybrid triad provides fracture plane stability in a computational model of a Pauwels Type III hip fracture.

BACKGROUND Motor vehicle crashes are a significant source of pediatric mortality and morbidity. Studies indicate that booster seats significantly improve seat belt fit for children who have not attained a height of 145 cm (4' 9"). This study examined injuries occurring in booster age children up to age 12, as the majority of children do not attain 145 cm until this age. The purpose of the study was to identify differences in injuries due to the type of restraint used, with attention to musculoskeletal injuries. METHODS Vehicle and occupant data were obtained from a publically available statistical sample of tow-away crashes. Frontal crashes over an 8-year period were examined. A data set of cases was created involving children ages 5 to 12 years who were unrestrained, restrained using the vehicle's lap and shoulder belt, and restrained using a booster seat with the vehicle's lap and shoulder seat belt. Injury severity, frequency, and patterns of distribution were compared. RESULTS Unrestrained children experienced moderate to severe injuries 3.8 to 19 times more frequently than children using restraints. There were more injuries to the head and face in unrestrained versus restrained children, but the head and face was the most frequently injured region for all groups. There were no serious cervical spine injuries reported for any group. Lower extremity fractures were not observed in booster seat users but occurred at similar rates in both unrestrained and seat belt restrained children. These fractures occurred in older children who were involved in more severe crashes. CONCLUSIONS Unrestrained children were more likely to experience moderate and severe injuries than restrained children. The data sample suggests that booster use may reduce the risk of extremity fracture, as there were no extremity fractures in children restrained with booster seats. CLINICAL RELEVANCE This work provides evidence for the efficacy of booster use for preventing orthopaedic injury in children. This evidence can be used to inform parents and establish recommendations for best practices in transporting children.

The Effect of Booster Seat Use on Pediatric Injuries in Motor Vehicle Frontal Crashes.

Injury metrics are altered in spica-casted versus non-casted child ATDs in side-impact collisions with door intrusion

Background There is a paucity of data defining safe transport protocols for children treated with hip spica casting. Although restraint devices for casted children are available, all federally mandated testing uses a noncasted anthropomorphic test device (ATD or crash dummy). The purpose of this study was to evaluate current restraint options in simulated frontal crash testing using a casted pediatric ATD to determine injury risk to the head, cervical spine, chest, and pelvis. Methods Using a 3-year-old ATD, dynamic crash sled tests simulating frontal crash were performed in accordance with government safety standards. The ATD was casted in a double-leg spica and the following restraint devices were tested: a seat designed for spica casted children, a restraint vest-harness, a traditional booster seat, and 2 traditional forward-facing car seats. Results Although the presence of the cast increased many of the injury metrics measured, all seats passed current federal guidelines for the head and chest. No single seat performed best in all metrics. The greatest magnitude of neck loading and second-highest head injury criterion values were observed for the booster seat. The vest-harness produced the highest head injury criterion and the chest compression exceeded proposed federal limits. Conclusions The results suggest safe transport in commercially available seats is possible with the child properly restrained in a correctly fitting seat. However, parents should not assume a child restraint system is appropriate for use just based on fit as, for example, seats with harnesses outperformed an easy to fit booster seat. Clinical relevance Each child and the position of the child's cast are unique and discharge planning involves consideration of safe transportation. Although this study suggests several seats used to transport spica casted children pass the federal head and chest injury prevention requirements, it is important to recognize that some children may still require emergency vehicle transport.

Frontal Crash Injury Metrics Are Below Mandated Limits for a Spica Casted Child Dummy in Currently Available Restraints.

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Papers

Hybrid triad provides fracture plane stability in a computational model of a Pauwels Type III hip fracture.

The Effect of Booster Seat Use on Pediatric Injuries in Motor Vehicle Frontal Crashes.

Injury metrics are altered in spica-casted versus non-casted child ATDs in side-impact collisions with door intrusion

Frontal Crash Injury Metrics Are Below Mandated Limits for a Spica Casted Child Dummy in Currently Available Restraints.