Treatment of femoral shaft fractures associated with acute spinal cord injuries

Twenty-seven femoral shaft fractures in 23 patients with acute spinal cord injuries were reviewed for evaluation of the outcome of operative versus nonoperative treatment. Three groups were identified: 11 nonoperative, eight early operative, and eight delayed operative. Patients treated initially by nonoperative methods developed five impending nonunions (31%), which subsequently were treated by open reduction and internal fixation. One femur in each of the operative groups developed a refracture after early removal of metal fixation devices. In the delayed operative group, four patients (50%) required manipulation under general anesthesia for treatment of poor knee motion. Patients with complete neurologic lesions whose femurs were treated nonoperatively incurred more complications, i.e., decubitus ulcers, than those treated operatively. Operative stabilization of the femur within six weeks of injury rendered the most favorable outcome with the least number of orthopedic or medical complications in patients with both complete and incomplete cord lesions. All of the eight fractures united.     

Fractures of the ipsilateral femur and tibia: emphasis on intra-articular and soft tissue injury

Twenty-one patients with fractures of the ipsilateral femur and tibia were treated at Boston City Hospital from 1982 through 1987. Fourteen (67%) of the 21 patients sustained a total of 17 open fractures (76% of which were grade II or III wounds). Over 50% of the patients suffered concomitant ipsilateral knee injuries. Associated injuries required 37 nonorthopaedic procedures; 30 orthopaedic procedures were required to stabilize the axial skeleton and the other three extremities. Five patients ultimately required amputation, reflecting the magnitude of the initial high-energy trauma. Superior results were achieved when early rigid intramedullary fixation of the femur and rigid stabilization of the tibia with either an intramedullary nail or an external fixator was undertaken. Patients that underwent initial rigid intramedullary fixation of both the femur and tibia required fewer secondary operative procedures than those treated with primary external fixation. Rigid internal fixation allowed for thorough evaluation and treatment of the ligamentous structures of the knee and facilitated management of the soft tissue trauma.     

Treatment of femoral fractures in children by pediatric orthopedists: results of a 1998 survey.

SUMMARY: This study aimed to determine treatment preference of various femoral fracture patterns in children by pediatric orthopedists and whether it is practice dependent. In September 1998, members of the Pediatric Orthopedic Society of North America were surveyed to determine their current preferences in treating each of four middle one-third femoral fracture patterns in four age groups. Forty-four percent (286/656) of those surveyed responded. For each fracture pattern, operative treatment was increasingly preferred over nonoperative as patient age increased, and the preferred treatments within the operative and nonoperative categories changed significantly as patient age increased. Fourteen specific cases of femoral head avascular necrosis were noted after rigid reamed and unreamed rodding. There is a statistically significant trend by pediatric orthopedists to treat older children's femur fractures operatively and younger children's nonoperatively. The consensus treatment is age dependent. The numerous cases of avascular necrosis after rigid rodding are a concern.     

Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective,randomized, controlled multicenter trial

BACKGROUND: Open reduction and internal fixation is the treatment of choice for displaced intra-articular calcaneal fractures at many orthopaedic trauma centers. The purpose of this study was to determine whether open reduction and internal fixation of displaced intra-articular calcaneal fractures results in better general and disease-specific health outcomes at two years after the injury compared with those after nonoperative management. METHODS: Patients at four trauma centers were randomized to operative or nonoperative care. A standard protocol, involving a lateral approach and rigid internal fixation, was used for operative care. Nonoperative treatment involved no attempt at closed reduction, and the patients were treated only with ice, elevation, and rest. All fractures were classified, and the quality of the reduction was measured. Validated outcome measures included the Short Form-36 (SF-36, a general health survey) and a visual analog scale (a disease-specific scale). RESULTS: Between April 1991 and December 1997, 512 patients with a calcaneal fracture were treated. Of those patients, 424 with 471 displaced intra-articular calcaneal fractures were enrolled in the study. Three hundred and nine patients (73%) were followed and assessed for a minimum of two years and a maximum of eight years of follow-up. The outcomes after nonoperative treatment were not found to be different from those after operative treatment; the score on the SF-36 was 64.7 and 68.7, respectively (p = 0.13), and the score on the visual analog scale was 64.3 and 68.6, respectively (p = 0.12). However, the patients who were not receiving Workers' Compensation and were managed operatively had significantly higher satisfaction scores (p = 0.001). Women who were managed operatively scored significantly higher on the SF-36 than did women who were managed nonoperatively (p = 0.015). Patients who were not receiving Workers' Compensation and were younger (less than twenty-nine years old), had a moderately lower B?hler angle (0 degrees to 14 degrees ), a comminuted fracture, a light workload, or an anatomic reduction or a step-off of < or =2 mm after surgical reduction (p = 0.04) scored significantly higher on the scoring scales after surgery compared with those who were treated nonoperatively. CONCLUSIONS: Without stratification of the groups, the functional results after nonoperative care of displaced intra-articular calcaneal fractures were equivalent to those after operative care. However, after unmasking the data by removal of the patients who were receiving Workers' Compensation, the outcomes were significantly better in some groups of surgically treated patients.     

Early Protected Weightbearing After Ankle Fractures in Patients With Diabetes Mellitus

The traditional protocol for treatment after ankle fracture in the diabetic patient involves a period of prolonged non-weightbearing to reduce the incidence of complications. The goal of the present study was to identify the risk factors and complications associated with early protected weightbearing after closed ankle fractures in patients with diabetes. The data from 73 diabetic patients with operatively and nonoperatively treated ankle fractures were retrospectively reviewed. All patients were allowed to begin protected weightbearing in a cast or removable boot at 2 weeks after the index injury or surgery. The mean follow-up period was 51 (range of 26 to 480) weeks. Complications occurred in 25% of the operative cases and 8% of the nonoperative cases. In both categories, the complication rate was less than that from existing reports using prolonged non-weightbearing. Wound dehiscence was the most common complication in the operatively treated patients (18.8%). A statistically significant difference was found in the complications rates for the patients aged >60 years (p = .0403). No statistically significant differences were identified according to hemoglobin A1c, the presence of peripheral neuropathy, smoking status, fracture type, or the presence of end-stage renal disease. The results of the present study suggest that early protected weightbearing after closed ankle fractures in diabetic patients is fairly safe, with an acceptable complication rate. However, the patients selected for early weightbearing had low comorbidity profiles, which might have accounted, in part, for the low complication rate.     

Upper extremity fractures in the acute spinal cord injured patient

Fifty-three long bone upper extremity fractures in 46 patients with recent spinal cord injuries were reviewed with reference to the outcome of operative versus nonoperative treatment. Twenty-four fractures had surgery and 29 fractures were treated nonoperatively. Criteria used in assessing outcome included range of motion, time to union, total rehabilitation time, and orthopedic and medical complications. Humeral fractures had similar outcomes with either operative or nonoperative treatment. Radial nerve injury occurring with humeral fractures prolonged the rehabilitation time. All three combined radial and ulnar fracture treated surgically developed synostosis whereas two of the three nonoperatively treated fractures had other orthopedic complications. Nondisplaced radial fractures responded appropriately to closed treatment. Displaced radial fractures treated nonoperatively had a high incidence of malunion. All ulnar fractures were treated operatively, and all achieved acceptable range of motion and fracture healing at the time of discharge. Medical complications such as deep venous thromboses and decubitus ulcers occurred more frequently in the nonoperatively treated group (28%) than in the operatively treated group (4%). Standard guidelines for upper extremity fracture care apply to the patient with a spinal cord injury. However, operative stabilization may be associated with a decreased risk of medical complications in these patients.     

Personal gait satisfaction after displaced intraarticular calcaneal fractures: a 2-8 year followup

BACKGROUND: Patients' satisfaction with gait after calcaneal fracture has rarely been studied. The objective of this paper was to determine how patient demographics, fracture type and treatment affected gait satisfaction after displaced intraarticular calcaneal fractures. The design of the study is a prospective randomized trial performed in four Level I trauma centers. METHODS: Three hundred and nineteen patients with 351 radiographically proven displaced intraarticular calcaneal fractures (DIACF) were randomly assigned to open reduction and internal fixation (ORIF), or nonoperative treatment. A 2- to 8-year follow-up was obtained, with patients completing SF-36 and a validated visual analogue scale to assess personal gait satisfaction. The final joint positions were confirmed using plain radiographs and CT scans for both treatment arms. Examination using a one-way analysis-of-variance was performed to determine if statistical differences existed in personal gait satisfaction between the treatment arms. RESULTS: Personal gait satisfaction scores were not significantly different between those DIACF treated with ORIF and those treated nonoperatively at 2- to 8-year follow-up. In patients treated with ORIF, improved personal gait scores were reported in those who were younger than 30 years of age, were non-WCB, had jobs requiring a moderate work-load before injury, and had Bohler angles restored to above 0 degrees. Factors not found to be significant in gait satisfaction included unilateral or bilateral calcaneal fractures, quality of initial reduction, and sex of the patient. CONCLUSIONS: Subcategories determined that younger patients who were self-employed and treated operatively had improved gait scores. Treatment (operative or nonoperative) of calcaneal fractures did not affect gait satisfaction according to patient outcome scores.     

Management of congenital pseudarthrosis of the tibia in children under 3 years of age: effect of early surgery on union of the pseudarthrosis and growth of the limb

The study was undertaken to determine whether the results of treatment of pseudarthrosis of the tibia in children under age 3 are so poor as to recommend that surgery be deferred until after 3 years of age. Radiographs and case records of 26 consecutive patients with Crawford type IV congenital pseudarthrosis of the tibia who were treated operatively were reviewed. Growth abnormalities of the tibia, fibula, and femur of the affected limb at presentation were identified. The outcome of treatment, in terms of union of the pseudarthrosis, refracture rate, and limb length, in 13 children treated operatively before age 3 years was compared with those operated on later. Union of the pseudarthrosis occurred in 12 of 13 children (92%) who were treated before 3 years of age by excision of the pseudarthrosis, intramedullary rodding, and dual-onlay cortical bone grafting. Union occurred in only five of seven children who underwent the same procedure between the ages of 3 and 12 years. The extent of shortening of the limb at the time of surgery was least in children younger than 3 years. The limb length discrepancy remained virtually static in 11 children who had transarticular Rush rodding before age 3. Growth abnormalities of the fibula, tibia, and femur were less pronounced in children operated on early. The study suggests that there is no need to defer surgery for pseudarthrosis of the tibia until the child is older than 3 years.     

An analysis of burst fractures of the spine in adolescents

Burst fractures are less common in children than in adults because of the greater mobility and elasticity of the pediatric spine. Because of these spine characteristics, these fractures may behave differently in childhood than in adulthood. To try to address these differences, we reviewed our experience with 11 children (5 boys, 6 girls) treated for burst fractures. Average age at time of injury was 14.4 years. Follow-up averaged 9 years. All fractures were categorized using the Denis classification system for burst fractures. Three children had associated spinal cord injury. Five children were treated with nonoperative bedrest and casting; the other 6 children, who had the most severe burst fractures, were treated with posterior spinal fusion and instrumentation. Satisfactory functional results were found in 90% of the children at follow-up. Radiological evaluation at initial and follow-up examination showed that children treated operatively improved or maintained their fracture kyphosis (range, 12 degrees - 19 degrees). Anterior vertebral compression improved an average of 15% (range, 24%-39%). In the children treated nonoperatively, kyphosis progressed an average of 9 degrees (range, 15 degrees - 24 degrees), and anterior vertebral compression increased a further 8% (range, 36%-44%). Our results showed that (a) the children who sustained burst fractures tended to develop mild progressive angular deformity at the site of the fracture, (b) operative stabilization prevented further kyphotic deformity as well as decreased the length of hospitalization without contributing to further cord compromise, and (c) nonoperative treatment of burst fracture was a viable option in neurologically intact children, but progressive angular deformity occurred during the first year after the fracture.     

Complications after ankle fracture in elderly patients

BACKGROUND: Controversy exists regarding the risks and benefits of ankle fracture treatment in elderly patients. The purpose of this study was to use the United States Medicare database to determine the complication rate for ankle fractures in elderly patients treated operatively and to compare it to fractures treated nonoperatively. METHODS: We used the National Medicare Claims History System to study all enrollees who sustained ankle fractures between 1998 and 2001. A total of 33,704 patients were identified and their outcomes at numerous time points were evaluated. These outcomes included mortality, rate of repeat hospitalization, rate of medical and operative complications, and the rate of additional surgery. The predictor variables were either nonoperative or operative intervention. Covariates included patient age, gender, race, medical comorbidity status, and fracture type. RESULTS: Patients treated nonoperatively had significantly higher mortality (p < 0.05) than those treated operatively at all time periods except for 30 days. However, patients treated operatively had significantly higher rehospitalization rates (p < 0.05) at all time periods studied. The medical and operative complication rates at all time periods were less than or equal to 2% for patients who had either operative or nonoperative treatment. In the group that had operative management, a relatively small number of patients had additional procedures. Eleven percent had removal of hardware. Less than 1% of all patients had revision of the internal fixation, arthroplasty, arthrodesis, or amputation. CONCLUSION: In properly selected cases, the complication rates of both operatively and nonoperatively treated elderly patients are low.     

Stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails (a technique paper).

The indications for surgical stabilization of a pediatric diaphyseal femur fracture are expanding. Children with multiple system injuries, a head injury, and/or multiple fractures have fewer local and distant complications if the femur fracture is treated operatively. Other indications include a pathological fracture in osteoporotic bone, a fracture in a child with a preexisting condition that prevents the application of a spica cast, a child older than 10 years of age, or a child less than 10 years of age who cannot be kept adequately aligned using conventional (traction/casting) methods of fracture management. Here we describe a technique of stabilizing pediatric diaphyseal femur fractures using flexible intramedullary nails (Ender). This technique can be used in children of all ages and with all patterns of diaphyseal fractures.     

Epidemiology and risk factors for loss to follow-up following operatively treated femur ballistic fractures

IntroductionEvidence regarding recommendations for treatment of ballistic fractures remains limited. This paucity of literature has largely been attributed to gunshot wound victims being a difficult population to study secondary to loss to follow-up. The purpose of this study was to examine the epidemiology of operatively treated ballistic femur fractures at our institution, the frequency of outpatient follow-up and risk factors for loss to follow-up.MethodsInpatient consults from 2013-2018 were queried for femoral gunshot wounds treated operatively. Cases without internal or external fixation were excluded from the study. Postoperative visits where a patient was hospitalized or had expired were excluded from the analysis. Demographic information, length of hospital stay, and operative characteristics were compared for different fixation methods and examined as risk factors for loss to follow-up.ResultsA total of 194 patients met inclusion criteria. The average age was 27 years old and 94% of the patients were male. Patient's stayed a median of 5 days post-operatively with patients treated with external fixation staying longer than internal fixation (14 days vs 5 days p=0.01). 9.3% of ballistic fractures had a concomitant vascular injury necessitating repair. 70.4% of patients attended their 2-week postoperative visit, 55.7% of patients attended their 6 week follow-up visit and 31.3% attended their 3 month follow-up visit. Risk factors for loss to follow-up at 3 month visit included younger age (p=0.028), decreased hospital length of stay (p=0.025) and intramedullary fixation (p=0.00015).Discussion and conclusionThis study reinforces the difficulty of studying ballistic fractures secondary to loss to follow-up. Younger age, shorter hospital stays and intramedullary fixation increased the risk for loss to follow-up at 3 months.     

微创PHILOS钢板内固定在儿童股骨粗隆下骨折中的应用

目的总结应用微创肱骨近端锁定钢板内固定与非手术治疗儿童股骨粗隆下骨折的结果和并发症。方法 2005年2月至2011年2月,我院采用肱骨近端锁定钢板和非手术治疗儿童股骨粗隆下骨折共24例患者,回顾性比较15例采用肱骨近端锁定钢板和9例采用非手术治疗的患者,从住院时间、完全负重时间和影像愈合时间以及结果评分和术后并发症等方面对两种治疗方法进行比较分析。结果 24例患者均获得随访,平均随访时间31.5个月,两组患者住院时间、完全负重时间和影像学愈合时间比较,差异有统计学意义(P0.05)。肱骨近端锁定钢板组结果评分更高(P0.05)。和非手术组相比,肱骨近端锁定钢板组总并发症发生率较低(P0.05)。结论对于儿童股骨粗隆下骨折,肱骨近端锁定钢板内固定系统与非手术组相比评分更高,总并发症率更低,是治疗儿童股骨粗隆下骨折的良好内固定之一。     

Operative treatment of unstable pediatric pelvis and acetabular fractures

The management of unstable pediatric pelvic and acetabular fractures continues to be controversial. Recent reports have suggested that closed management of unstable pelvic and acetabular fractures can result in significant long-term morbidity. The purpose of this study was to evaluate the results of operative stabilization of unstable pelvic and acetabular fractures in children and adolescents. Eighteen patients less than 16 years of age with unstable pelvic and acetabular fractures were treated operatively over a 7-year period. Fracture healing, time to union, complications, and functional outcome were assessed. All fractures healed by 10 weeks. No patients suffered wound complications, infection, or growth arrest at an average follow-up of 30 months. These results support operative fixation of unstable pediatric pelvic and acetabular fractures to restore pelvic symmetry and periarticular anatomy. Favorable clinical results can be achieved with a low incidence of complications.     

Internal fixation versus traction and casting of adolescent femoral shaft fractures

We compared the results of traction plus subsequent casting with rigid internal fixation in a large series of adolescent femoral shaft fractures. Of 90 patients with 96 femoral shaft fractures, 49 (52 fractures) underwent rigid internal fixation, whereas 41 (44 fractures) underwent traction and subsequent casting until healing occurred. The traction and casting group had a mean hospital stay of 26 days. The operative group had a mean hospital stay of 9 days and had fewer complications than the nonoperative group. Adolescent femoral shaft fractures can be operatively treated with excellent results and a decreased complication rate. Operation results in shorter hospitalization, which has psychological, social, educational, and economic advantages over conservative treatment.     

Does morbid obesity negatively affect the hospital course of patients undergoing treatment of closed, lower-extremity diaphyseal long-bone fractures?

Obesity is prevalent in the developed world and is associated with significant costs to the health care system. The effect of morbid obesity in patients operatively treated for long-bone fractures of the lower extremity is largely unknown. The National Trauma Data Bank was accessed to determine if morbidly obese patients (body mass index >40) with lower extremity fractures have longer length of hospital stay, higher cost, greater rehabilitation admission rates, and more complications than nonobese patients. We identified patients with operatively treated diaphyseal femur (6920) and tibia (5190) fractures. Polytrauma patients and patients younger than 16 years were excluded. Morbidly obese patients were identified by ICD-9 and database comorbidity designation (femur, 131 morbidly obese; tibia, 75 morbidly obese). Patients meeting these criteria who were not morbidly obese were used as controls. Sensitivity analyses were performed to analyze patients with isolated trauma to the tibia or femur. Morbidly obese patients were more likely to be admitted to a subacute facility. Length of stay trended higher in morbidly obese patients. There was no significant relationship between obesity and inpatient mortality or inpatient complications. These trends held true when considering patients with multiple injuries and patients who had isolated long-bone injuries. Our study showed that morbidly obese patients may have greater rehabilitation needs following long-bone fractures in the lower extremity. Our study showed no difference in mortality or complications, although further studies are needed to confirm these findings.     

Management of supracondylar fractures of the femur with the GSH intramedullary nail: preliminary report

The GSH supracondylar nail is a closed section rigid intramedullary device that combines the biomechanical advantages of intramedullary fixation with the stability of rigid internal fixation for the management of supracondylar fractures of the femur. The use of this implant is indicated in the management of distal comminuted nonarticular fractures and fractures with intraarticular extension. Intramedullary fixation provides improved fracture stabilization in both elderly patients with osteoporotic metaphyseal bone and in younger patients with extensively comminuted fractures. The experience with the GSH supracondylar nail has shown that it provides better results than supracondylar plating for the stabilization of acute fractures or revision of failed internal fixation.     

Comparison of nonoperative versus operative management in pediatric gustilo-anderson type I open tibia fractures

BackgroundRecent studies suggest pediatric Gustilo-Anderson type I fractures, especially of the upper extremity, may be adequately treated without formal operative debridement, though few tibial fractures have been included in these studies. The purpose of this study is to provide initial data suggesting whether Gustilo-Anderson type I tibia fractures may be safely treated nonoperatively.MethodsInstitutional retrospective review was performed for children with type I tibial fractures managed with and without operative debridement from 1999 through 2020. Incomplete follow-up, polytrauma, and delayed diagnosis of greater than 12 h since the time of injury were criteria for exclusion. Data including age, sex, mechanism of injury, management, time-to-antibiotic administration, and complications were recorded.ResultsThirty-three patients met inclusion criteria and were followed to union. Average age was 9.9 ± 3.7 years. All patients were evaluated in the emergency department and received intravenous antibiotics within 8 h of presentation. Median time-to-antibiotics was 2 h. All patients received cefazolin except one who received clindamycin at an outside hospital and subsequent cephalexin. Three patients (8.8%) received augmentation with gentamicin. Twenty-one patients (63.6%) underwent operative irrigation and debridement (I&D), and of those, sixteen underwent surgical fixation of their fracture. Twelve (36.4%) patients had bedside I&D with saline under conscious sedation, with one requiring subsequent operative I&D and intramedullary nailing. Three infections (14.3%) occurred in the operative group and none in the nonoperative group. Complications among the nonoperative patients include delayed union (8.3%), angulation (8.3%), and refracture (8.3%). Complications among the operative patients include delayed union (9.5%), angulation (14.3%), and one patient experienced both (4.8%). Other operative group complications include leg-length discrepancy (4.8%), heterotopic ossification (4.8%), and symptomatic hardware (4.8%).ConclusionNo infections were observed in a small group of children with type I tibia fractures treated with bedside debridement and antibiotics, and similar non-infectious complication rates were observed relative to operative debridement. This study provides initial data that suggests nonoperative management of type I tibial fractures may be safe and supports the development of larger studies.     

Displaced intraarticular calcaneal fractures: long-term outcome in women

BACKGROUND: This study compared the outcomes of displaced intraarticular calcaneal fractures in women treated operatively or nonoperatively. This was part of a prospective, randomized, controlled, multi-center, clinical trial performed at four level I trauma hospitals. In addition, we compared the long-term outcomes in women with those reported in men in an earlier study. METHODS: Forty-one women (43 fractures) required treatment for displaced intraarticular calcaneal fractures. Patients' ages ranged from 17 to 65 years at the time of injury. All fractures were closed injuries and had posterior facet displacement of more than 2 mm. Patients were randomly assigned to either the nonoperatively or operatively treated groups. Nonoperative treatment included ice and elevation, while operative treatment consisted of open reduction and internal fixation using a standard lateral approach. Outcomes were measured using the validated Short Form-36 Health Survey (SF-36) and the Visual Analogue Scale (VAS). RESULTS: Women were 3.18 times (RR 3.18, 95% CI 1.03- 9.79) more likely to report high SF-36 scores after operative treatment than those who received nonoperative treatment. Operative outcomes in women were better than those reported in an earlier study in men (SF-36: 77.47 in women compared to 67.56 in men, p = .07; VAS: 81.47 in women compared to 67.04 in men, p = .01). In women the fractures generally were caused by low-energy trauma that produced less severe injuries (higher Bohler angles). Most patients were not receiving Workman's Compensation benefits and did light to moderate work. CONCLUSION: Operative treatment of the fractures showed statistically significant better results when compared to nonoperative treatment (SF-36: p = .04; VAS: p = .10) in women. Displaced intraarticular calcaneal fractures in women should be treated by open reduction and internal fixation through a lateral approach.     

What is the best treatment for displaced Salter–Harris II physeal fractures of the distal tibia?

Background and purpose — The optimal treatment of displaced Salter–Harris (SH) II fractures of the distal tibia is controversial. We compared the outcomes of operative and nonoperative treatment of SH II distal tibial fractures with residual gap of >3?mm. Factors that may be associated with the incidence of premature physeal closure (PPC) were analyzed.

Patients and methods — We retrospectively reviewed 95 patients who were treated for SH II distal tibial fractures with residual gap of >3?mm after closed reduction. Patients were assigned to 1 of 2 groups: Group 1 included 25 patients with nonoperative treatment, irrespective of size of residual gap (patients treated primarily at other hospitals). Group 2 included 70 patients with operative treatment. All patients were followed for ≥ 12 months after surgery, with a mean follow-up time of 21 months. Logistic regression analyses were performed to identify risk factors for the occurrence of PPC.

Results — The incidence of PPC in patients who received nonoperative treatment was 13/52, whereas PPC incidence in patients who received operative treatment was 24/70 (p = 0.1). Multivariable logistic regression analysis determined that significant risk factors for the occurrence of PPC were age at injury, and injury mechanism. The method of treatment, sex, presence of fibular fracture, residual displacement after closed reduction, and implant type were not predictive factors for the occurrence of PPC.

Interpretation — Operative treatment for displaced SH II distal tibial fractures did not seem to reduce the incidence of PPC compared with nonoperative treatment. We cannot exclude that surgery may be of value in younger children with pronation–abduction or pronation–external rotation injuries.