ORIGINAL ARTICLE

The Definition and Treatment of Pediatric Subtrochanteric

Femur Fractures With Titanium Elastic Nails
Mathew William Pombo, MD and Jeffrey S. Shilt, MD

able degree through which the femur can remodel with

Purpose: Titanium elastic nailing (TEN) has become more common
growth allowing for correction of shortening and angulation.
in the treatment of pediatric femur fractures in many European
Despite the excellent results and low nonunion rates
centers and in North America over the past several years. Prior
associated with conservative treatment of femur fractures,
studies have shown that the use of TEN for midshaft femur fractures
the prolonged immobilization, pin tract complications, and
results in excellent outcomes with an earlier return to activity, earlier
refracture rates have left room for improvements in manage-
mobilization, and a shortened hospital stay. However, subtrochan-
ment. The multicenter study conducted by Flynn et al3
teric femur fractures continue to remain a difficult subset of fractures
showed titanium elastic nailing (TEN) to be a more ideal and
to care for, with loss of reduction and nonunion being significant
effective method of surgical fixation in midshaft femur
complications. Studies have differed regarding the definition of
fractures, the same as what was discovered in Nancy, France
pediatric subtrochanteric femur fractures. The purpose of this study
leading to their popularity in Europe.4 Reports in the literature
is to establish a reproducible method of defining pediatric
have shown that TEN is ideally suited for midshaft transverse
subtrochanteric fractures and then apply that definition in a
pediatric femur fractures, allowing rapid mobilization, earlier
retrospective review of 13 patients who sustained subtrochanteric
return to activity, a shortened hospital stay, and decreased
femur fractures treated with TEN at North Carolina Baptist Hospital
complications.3
using a modified technique that allows for improved fracture
It has also been recognized in the literature, however, that
stability.
femur fractures occurring in the subtrochanteric region present
Methods: Charts and radiographs were retrospectively reviewed for
unique problems in fracture management.2,5Y8 This is caused by
all pediatric patients sustaining subtrochanteric femur fractures
a limited capacity to compensate for malalignment in this
treated with TEN from the period of 2000 to 2004 at Wake Forest
region and the strong deforming muscle forces pulling the
University. The TEN outcome measures scale was applied to
proximal fragment into a flexed, abducted, and externally
determine their results.
rotated position causing difficulty in maintaining fracture
Results: TEN allowed rapid mobilization with excellent or
reduction.5,6,9 Another confounding factor for fractures in this
satisfactory clinical and radiographic results in all patients.
region is the varied fracture patterns, such as long oblique and
Conclusions: Results suggest that the use of TEN for subtrochan-
spiral fractures, that make careful treatment selection important
teric femur fractures is a safe and effective method of fixation that
in obtaining a successful outcome. Fortunately, subtrochanteric
benefits patients through early mobilization, shorter hospital stays,
fractures are relatively rare in children, with incidences
and fewer complications.
reported to be as low as 4% to 10% of pediatric femur
Significance: By applying the definition of subtrochanteric femur
fractures.7,9 Many older series report a higher incidence as they
fractures described by the authors, results of future studies can be
tended to combine proximal one-third diaphyseal fractures with
objectively compared and classified. TEN is a safe and effective
true subtrochanteric fractures.2,9 Few studies in the orthopedic
alternative for treating most pediatric subtrochanteric fractures by
literature are dedicated to the management of pediatric
decreasing the morbidity that occurs with other treatment modalities.
subtrochanteric fractures, and there is no consensus regarding
Key Words: pediatric subtrochanteric femur fractures, titanium the mainstay of treatment.2,9 Some authors advocate open
elastic nails, fracture stability reduction, whereas others advocate nonoperative methods for
management.5,7,10 One of the major problems with pediatric
(J Pediatr Orthop 2006;26:364Y370) subtrochanteric femur fractures is the lack of agreement
regarding its definition.2,8,9 Ideally, this definition would be
M any previous studies of femoral shaft fractures in
children indicated that good results can be obtained
nonoperatively using traction or manipulation and cast
determined by an anatomical study of the range of locations on
the femur where a fracture produces the classic flexion,
abduction, and external rotation of the proximal fragment that
immobilization.1,2 These results are caused by the remark- describes a subtrochanteric femur fracture. These forces can
make it difficult to maintain reduction conservatively. The
From the Wake Forest University Baptist Medical Center, Medical Center literature describes several different definitions for pediatric
Boulevard, Winston-Salem, NC 27157-1034. subtrochanteric fractures, including (1) the proximal one third
None of the authors received financial support for this study. of the femoral shaft, (2) within 2 to 3 cm below the lesser
Reprints: Mathew William Pombo, MD, Wake Forest University Baptist
Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157- trochanter, and (3) the proximal one third of the femur.
1034 (e-mail: jchase@lww.com). However, there is no universally agreed upon definition, and it
Copyright * 2006 by Lippincott Williams & Wilkins is clear that a standardized definition of a subtrochanteric

364 J Pediatr Orthop & Volume 26, Number 3, May/June 2006

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J Pediatr Orthop & Volume 26, Number 3, May/June 2006
fracture in children is warranted.2,8,9,11 This is difficult because
of the varying lengths of the femur at different ages and the
complexity required for age-adjusted anatomical variations.
The goal of this study was to establish a definition so that results
from this study can be compared with other studies in a
standardized manner and provide orthopedic surgeons with a
reliable definition of the pediatric subtrochanteric femur.
TEN for femur fractures is a concept that has been used
in practice for the last 2 decades in Europe. Flynn et al3
reported on the North American experiences in a multicenter
study of TEN for femur fractures. The study revealed several
interesting observations. It is currently accepted that midshaft
transverse femur fractures can be treated successfully with
TEN, but of interest is the observation that 5 of 6 fractures
with more than 5 degrees of angulation were in the proximal
one third of the femur.3 The difficulty of treating fractures in
this region is recognized by the authors along with the need to
refine the indications, technique, and aftercare for patients
treated with TEN. Several questions need to be answered.
First, was the reason for angulation in subtrochanteric femur
fractures with TEN caused by technique? Second, can TEN
be used safely and successfully for stabilization of sub-
trochanteric femur fractures? It is hypothesized that with a
modification in technique, TENs can successfully be used to
treat all patterns of pediatric subtrochanteric femur fractures.
The purpose of this study was to establish a reproducible
definition of pediatric subtrochanteric fractures and then
apply the definition retrospectively to patients treated
surgically with a modified TEN technique, with the goal of
expanding the current treatment options for this difficult
subset of pediatric femur fractures.
MATERIALS AND METHODS
The charts and radiographs of all pediatric patients with
subtrochanteric femur fractures treated with TEN from the
period of 2000 to 2003 at Wake Forest University were
reviewed retrospectively. Demographic information, mecha-
nism of injury, fracture type, associated injuries, intraopera-
tive problems, postoperative immobilization, time of assisted
and unassisted weight bearing, time of nail removal, and
complications were recorded for the 13 patients selected
(Table 1). The radiographs were assessed for union, align-
ment, and position change of the nails. The patients were
followed until the nail was removed, and they returned to
normal function. Clinical assessments included limb lengths,
nail irritation, knee motion, and limb alignment with rotation.
Patients were selected based on a new definition of
pediatric subtrochanteric femur fracture the authors of this
study devised. Pediatric subtrochanteric fractures were
defined by noting that the adult definition of a subtrochanteric
femur fractures is any fracture within 5 cm below the lesser
trochanter.8,12,13 Anderson14 and Hensinger15 have report-
ed that the average 18-year-old man’s femur length is 47.23
cm, and the average 18-year-old woman’s femur length is
43.63 cm. Therefore, the average adult femur length is
45.43 cm. Inasmuch as a fracture 5 cm below the lesser
trochanter defines a subtrochanteric fracture in adults, sim-
ple math would make the percentile definition as 11% of
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Pediatric Subtrochanteric Femur Fractures
the total femur length below the lesser trochanter (5 cm/
45.43 cm  100). This percentile definition was simplified to
10% of the total femur length below the lesser trochanter to
improve clinical reproducibility and ease of calculation in a
clinical setting. Patients were selected by measuring femur
lengths preoperatively or postoperatively. The fractures
within 10% of the total femur length below the lesser tro-
chanter were defined as subtrochanteric fractures, and the
patients with these radiographs were included in the study.
Two retrograde TENs were used in all cases. All of the
surgeries were performed on a radiolucent table. Using
preoperative radiographs, the smallest diameter of the
femoral canal was measured. The equation described by
Beaty and Kasser5 was used to select the appropriately sized
nails. One centimeter was subtracted from the smallest
femoral canal diameter measured on anterior-posterior and
lateral radiographs, and the result was divided by 2. This
measurement correlated with the size of the nails used. Prior
studies have used 40% of the narrowest canal diameter to
determine nail size.3 This method correlates closely with the
method used in the current study, but this one is more difficult
to calculate in a clinical setting than the one described by
Beaty and Kasser. Patients were placed supine on the
operating table. An incision was made on the lateral aspect
of the distal thigh from the level of proposed nail insertion
distally 2 cm to facilitate insertion and minimize the size of
the required incision. The subcutaneous tissues were dissected
in line with the skin incision, exposing the lateral aspect of the
distal femoral metaphysis. A starting hole was placed
approximately 1.5 cm proximal to the distal physis by 1 of 2
methods: (1) a 4.5-mm drill was used to create the hole,
aiming the drill cephalad to allow easier passage of the nail;
(2) alternatively, an awl was used to initiate a start hole
manually. The latter method eliminates the need for a power
drill and minimizes thermal energy production near the distal
femoral physis.
A slight bend was placed in the distal end of the nail to
facilitate the passage of the nail beyond the far cortex and to
facilitate fracture reduction. The appropriately sized nail was
placed in the starting hole, and the intramedullary position was
verified using fluoroscopy. The lateral nail was advanced across
the fracture site and placed into or just distal to the greater
trochanteric apophysis depending on an intraoperative assess-
ment of fracture stability. This differs from previously
described TEN techniques that stopped the nail distal to the
greater trochanteric apophysis.3 Next, a medial incision was
made, and an equally sized nail was placed. The medial nail was
advanced into the femoral neck, directed toward the femoral
head until it stopped short of the proximal femoral physis
(approximately 1 cm). This is another technique modification
from prior studies that describes advancing the medial nail to
the same level as the lateral nail and pointing it toward the calcar
region of the femoral neck.3 To minimize soft-tissue irritation,
both nails were trimmed, allowing 1 cm to protrude from the
distal starting hole. The stability of the fracture was checked
intraoperatively under direct fluoroscopic guidance, and if
needed, supplemental immobilization was used.
The patients underwent gait training and physical
therapy on postoperative day 1, when concomitant injuries
365
 366
TABLE 1. Patient Demographics
Fracture Length
Below Lesser Femur Percentile Time of Time of
Pombo and Shilt

Fracture Trochanter Length Below Lesser Associated Prior Postoperative Weight Nail
Patients Sex Age Mechanism Pattern (cm) (cm) Trochanter Injuries Treatment Immobilization Bearing Removal Complications
1 M 5 yrs Pedestrian struck Transverse 3.4 39.1 8.69 Ipsilateral clavicle None None 6 wk 32 wk None
11 mo by car fracture,
contralateral
fibula fracture
2 M 7 yrs Fall from Long 2 32.2 6.21 None None None 5 wk 24 wk None
11 mo monkey bars oblique
3 M 11 yrs Skateboard injury Spiral 2.9 42.1 6.89 None None None 3 wk 19 wk None
5 mo
4 M 8 yrs Motor vehicle Short 0.5 35 1.43 CHI None None 6 wk 29 wk None
3 mo accident oblique
5 F 10 yrs Rollerblading Spiral 0 40.2 0 None None None 4 wk 22 wk None
6 mo injury
6 M 9 yrs Pedestrian Long 2.6 43 6.05 CHI, contralateral None None 6 wk 16 wk None
9 mo struck by car oblique humerus fracture,
pelvic ring
fracture
7 M 5 yrs Motorcycle Spiral 0.76 27.1 2.80 None Failed None 6 wk 11 wk None
4 mo accident spica
casting
8 M 4 yrs Fall Long 0.77 29.4 2.62 None None None 5 wk 52 wk None
1 mo oblique
9 M 10 yrs Pathological Pathological 0.74 35.8 2.07 None Failed B LLC with bar 7 wk 12 wk None
3 mo fracture, spica for 4 wk
unicameral casting
bone cysts
10 M 17 yrs Cerebral Long 2.43 37.6 6.46 Cerebral None Spica cast for Non- Retained None
J Pediatr Orthop

8 mo palsy/mental oblique palsy/mental 1 wk ambulatory

retardation, retardation
fractured during
wheelchair
transfer
11 M 8 yrs Struck by car Transverse 3.5 39.4 8.88 R pneumothorax, None None 3 wk 24 wk 1.6 cm limb
2 mo R rib fractures length
discrepancy
12 M 6 yrs Snow sledding Spiral 2.7 30.1 8.97 None None None 6 wk 16 wk None
1 mo accident
13 F 7 yrs Periprosthetic Short 3.1 36 8.61 Arthrogryposis, External None 7 wk 32 wk 1.3 cm limb
8 mo fracture of Oblique knee flexion fixation length
femoral external contracture discrepancy

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fixator
Averages 8 yrs 1.95 cm 35.92 cm 5.36 5 wk 2 d 24 wk
8 mo
CHI indicates closed head injury; B LLC, bilateral long leg casts.
& Volume 26, Number 3, May/June 2006

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J Pediatr Orthop & Volume 26, Number 3, May/June 2006
did not preclude. Ambulation was kept nonYweight-bearing
until radiographic and clinical evidence of fracture healing
were presentVat which time, the patient was allowed to
progressively advance their weight bearing. Nails were
scheduled for removal after clinical and radiographic
evidence of union, a period of full weight bearing, and a
time convenient to the patient and their family.
RESULTS
The mean age of patients at the time of injury was
8 years 8 months (range, 4Y17 years). There were 11 men and 2
women in the study. Six children sustained high-velocity
injuries, and 5 children had concomitant medical injuries from
their accidents. One child had an ipsilateral limb injury. All
children met the definition of subtrochanteric femur fractures
defined earlier as less than 10% of the femur length below the
lesser trochanter (range, 0%Y8.97%). Two patients underwent
TEN after initial treatment with hip spica casting failed
because of loss of reduction. Two patients were placed in casts
postoperatively, one secondary to the nailing of a pathological
fracture and the other secondary to the patient having a
neuromuscular disorder. Both were stable during intraopera-
tive stressing. Twelve of 13 patients walked with assistive
devices before discharge from the hospital. The remaining
patient was a wheelchair-dependent child with cerebral palsy.
The average time of partial weight bearing was 5 weeks 2 days.
The average time of nail removal was 24 weeks (6 months).
The TEN outcome scoring system was used to classify
the study results (Table 2).3 To be judged as having an
excellent result, the case had to meet all the criteria. Eleven
patients in the study had excellent results, and 2 had
satisfactory results. There were no poor results. The patients
with satisfactory results were 2 patients with 1 to 2 cm of limb
length discrepancy. In both of these fractures, the affected
limb was longer than the unaffected side by 1.3 and 1.6 cm,
respectively. This is in contrast to the expected outcome of
shortening associated with unstable subtrochanteric femur
fractures, which was caused by the fractures being left
distracted and the physiological overgrowth that occurs in
children with long bone injuries. Postoperatively, all patients
had less than 5 degrees of angulation, and there was no loss of
reduction, no soft tissue irritation, no refracture, and no
incidence of nail backing out. All nails were removed without
complication.
DISCUSSION
Over the past 25 years, femur fracture fixation has
evolved from traction, spica casting, and external fixation to
TABLE 2. TEN Outcome Scoring
Excellent Satisfactory
Limb length discrepancy (cm) G1 1Y2
Malalignment (degrees) G5 5Y10
Pain None None Present
Complication None Minor/resolved Major/lasting
Results 11 2 0
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Pediatric Subtrochanteric Femur Fractures
methods such as TEN, which allows rapid mobilization with
fewer complications. Earlier treatment modalities were
associated with high rates of union and satisfactory results.
However, with the increased awareness of patient and family
psychosocial and economic effects occurring from traction
and spica casting, along with the refracture risks, pin tract
complications, and arthrofibrosis associated with external
fixation, shifts in treatment algorithms toward intramedullary
implants for femur fractures have occurred.3,4,16Y20 TEN for
midshaft femur fractures has been used in Europe with
positive results since the early 1990s.4 In North America,
TENs have become the implant of choice for pediatric
midshaft femur fractures because of rapid mobilization and
relatively fewer complications.3 Flynn et al,3 however,
showed that 5 of the 9 proximal one-third femur fractures
in that study healed with greater than 5 degrees of angulation
and that 2 of 3 proximal one-third fractures that lost reduction
after nailing. The conclusion was made that the proximal one-
third femur fractures are a difficult subset of fractures and the
results for proximal one-third fractures were not as good as
midshaft fractures with TEN. Is this really true?
This study critically analyzed the results of TEN use for
pediatric subtrochanteric femur fractures using a new
definition for pediatric subtrochanteric femur fractures and
a modification in technique. The first question addressed was
establishing an objective definition of a pediatric subtrochan-
teric femur fracture because the literature does not provide a
clear definition. Prior studies have included conflicting
definitions, such as the proximal one third of the femur,
fractures within 2 to 3 cm of the lesser trochanter, and the
proximal one fourth of the femur.2,8,9,11,13 There is a disparity
among children of the same chronological age in regard to
their femur lengths. The definition established in this study is
dynamic enough to account for changes in femoral length that
occur with age. The following equation defines whether a
pediatric femur fracture can be classified as one in the
subtrochanteric region.
Percent of total femur length below the lesser trochanter
= (Distance below the lesser
trochanter / femur length)  100
If the result is less that 10.0%, the fracture qualifies as a
subtrochanteric fracture of the femur. An absolute definition
would require an anatomical study to determine the region of
the proximal femur where muscular insertions produce the
flexed, abducted, and externally rotated proximal fragment
that classically describes a subtrochanteric femur fracture.9
The study definition is an objective, easy, and reproducible
way to describe a pediatric subtrochanteric femur fracture
based on the established definitions in adults.21,22
Not only do definitions vary, but many surgeons feel
Poor that not all subtrochanteric fracture patterns will be stable
with TEN. The long oblique and spiral fracture patterns are
92
specifically questioned in this region. The study population
910
included 2 transverse fractures, 2 short oblique fractures, 4
long oblique fractures, 4 spiral fractures, and 1 pathological
fractureVall of which had excellent or satisfactory results
with TEN. Eight of the 13 patients had a spiral or long oblique
367
Pombo and Shilt J Pediatr Orthop & Volume 26, Number 3, May/June 2006

apophysis, where the primary surgeon in this study advanced

the nail to rest just distal or into the apophysis depending on
the need for added bicortical stability. Violation of the greater

FIGURE 1. Radiograph from the article of Flynn et al showing

angulation at the fracture site. Note the proximal extent of
the nail ending at the level just above the lesser trochanter of
the femur. This is an unstable fracture pattern due to the
forces on the proximal portion of the femur. More proximal
placement of the nails is important to resist angulation
and rotation. Reprinted with permission from J Pediatr Orthop.
2001;21:4.

fracture pattern, and none of these patients had a loss of

reduction or angulation. These results indicate that these
fracture patterns can be successfully treated using TEN. All
long oblique and spiral fracture patterns were stable after the
study technique of TEN, and intraoperative stressing and
further immobilization with casting were not needed. It is the
recommendation of the authors to stress all fractures treated
with TEN to determine if further casting is needed. Therefore,
with adequate placement of intramedullary nails, most
fracture patterns in the subtrochanteric region can be treated
safely and successfully.
Technique is important for subtrochanteric fracture
stability when using TEN. Flynn et al3 had a high percentage FIGURE 2. Notice the technique of advancing the nails more
of proximal one-third femur fractures with angulation greater proximally in this spiral subtrochanteric fracture. This is a
classic unstable fracture pattern that was treated successfully with
than 5 degrees. The surgeons in the study of Flynn et al used a TEN techniques described above in the methods. Notice the
technique different from the one presented in this article. more proximal advancement of the nails into the femoral neck
More proximal placement of nails is the critical modification medially and into the trochanteric apophysis laterally. The
that improved fracture stability in this study. Flynn et al3 proximal extension and distance between the 2 tips of the
described placing the proximal tip of the nail entering the nails provide more area of fixation and add stability and rotational
lateral cortex of the femur distal to the greater trochanteric control.

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J Pediatr Orthop & Volume 26, Number 3, May/June 2006 Pediatric Subtrochanteric Femur Fractures

FIGURE 3. AYF, This is a sequence of radiographs from a patient struck by a car. Notice the very proximal nature of the fracture
with an unstable butterfly fragment. This is historically felt to be a treatment dilemma. CYF, Initial nail radiographs and the
final radiographs after nail removal. This reveals the success of the technique in one of the study patients with a significant
subtrochanteric femur fracture and the ability to obtain excellent results with TENs.

trochanteric apophysis with a smooth pin does not seem to
have any clinical implications with regard to future growth
and outcome.23,24 The medial nail in Flynn’s group was
advanced to the same level as the lateral nail and pointed
toward the calcar region of the femoral neck. However, the
patients in this study had the lateral nail advanced up the
femoral neck to rest 1 cm distal to the proximal femoral
physis. It is clear from the radiograph in the article of
Flynn et al that more proximal fixation is needed for stability
(Fig. 1) in subtrochanteric femur fractures when compared
with radiographs from this study (Figs. 2, 3). The results from
this study compared with those of the Flynn multicenter study
show a decreased incidence of postoperative angulation. For
adequate fracture stability in the proximal part of the femur, it
is recommended by the authors that TEN be performed,
placing the nails more proximally to aid in the control of
rotation and angulation, decrease the forces at the fracture
site, and maintain fracture stability. An extensive search of
the literature reveals that to fully prove this theory, a
biomechanical study would be needed to show that proximal
placement of TENs limits the forces at the fracture site,
therefore adding stability. The laws of physics, however,
suggest that by placing more implant surface area in the
proximal fragment, the implant will share more of the forces
at the bone implant interface. The physical laws also reveal
that torsional forces at the fracture site are decreased when the
proximal nail tips are farther apart. Hence, placing one nail up
the femoral neck and one nail out of the greater trochanter
will increase the tip-to-tip distance and decrease fracture
torsional forces as compared with 2 tips left near the calcar.
Few published studies directly address the management
of pediatric subtrochanteric fractures.9 Current recommenda-
tions for operative management of pediatric subtrochanteric
fractures are for children with multiple injuries, open or
pathological fractures, closed head injuries, older than 10
years, or when satisfactory reduction of isolated subtrochan-
teric fractures cannot be achieved by traction.2,7Y9,12,25
Theologis and Cole,8 in the largest pediatric subtrochanteric
study to date, described the surgical management in 12 (12%)
of 99 patients with subtrochanteric fractures treated by a
variety of surgical methods. They concluded that the surgical
management of these fractures reliably yields satisfac-
tory medical outcomes, but only 60% satisfactory patient-
determined outcomes are caused by persistent incisional pain
in the thigh. Therefore, they recommended traction and
casting in children younger than 10 years and careful
selection of patients for surgical intervention. Schwarz25
described their operative experience in 16 of 29 patients with

* 2006 Lippincott Williams & Wilkins 369

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Pombo and Shilt
subtrochanteric fractures. They recommended secondary
osteosynthesis using a dynamic compression plate if fracture
reduction could not be achieved with traction. Conservative
management was their treatment of choice. Daum et al7
reported on 14 subtrochanteric fractures and preferred
operative treatment to obtain anatomical reduction and
prevent later complications. Ireland and Fisher2 reviewed
their experience with 20 subtrochanteric fractures and treated
only 1 of 5 children older than 10 years with internal fixation
and, therefore, advocated nonoperative treatment with 90-90
degree traction and delayed spica casting in children younger
than 10 years. For children older than 10 years, they concluded
that open reduction should be considered when good
alignment cannot be achieved by closed methods.
The current study compares well with the studies above
in terms of demographics. Patients in this study began
assisted weight bearing at an average of 5 weeks 2 days
compared with prior studies that had an average length of
immobilization in a cast of 9 weeks.2 The limb length
discrepancies in this study compare with results obtained in
prior studies and are caused by normal overgrowth that occurs
in the femur and not likely a complication of TEN itself.2,8,26
Patients in prior studies have an average of 22 days of
hospitalization and had 8% to 23% unsatisfactory early
results and 4% to 10% unsatisfactory late results with traction
and spica casting.8 The results of this article are clearly
superior to prior study results, with minimal hospital stays
and 100% excellent or satisfactory results. A larger prospec-
tive study is needed to add power to these results, but TEN
should be considered a valuable and safe option for treating
pediatric subtrochanteric femur fractures with minor changes
in current techniques. TEN provides short periods of
immobilization, minimally invasive techniques, and fewer
complicationsVall of which are beneficial to patients and
their families when compared with conventional methods of
traction, spica casting, external fixation, and open reduction
with internal fixation.
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