This pediatric patient is obese and weighs 146 lbs, and would be at risk of increased complications including nonunion if she underwent elastic intramedullary nail fixation.
Kocher et al provide a review of pediatric femoral shaft fixation. Options include pavlik harness, spica casting, flexible intramedullary nailing, trochanteric nailing, and submuscular plating. They stated that patients aged over 11 years old, or who weigh >49 kg (>108 lb), are at increased risk of a poor outcome with flexible intramedullary nailing and therefore should not be used in this scenario.
Moroz et al showed that a poorer outcome after titanium elastic intramedullary nailing in pediatric patients was five times more likely in children over 11 years of age, and who weighed more than 49 kg. These results were statistically significant.
Wall et al compared the use of titanium elastic nails vs stainless steel elastic nails for pediatric femur fractures. They found femoral nonunion rates were 4X higher in the titanium elastic nail group (23.2% vs 6.3%). Their conclusion was that less expensive stainless steel elastic nails were superior to titanium nails due to much lower rate of malunion.
Leet et al found that obese children had increased rate of complications following surgical treatment for femoral shaft fractures. They conclude that preoperative discussion with parents of obese children should include the higher risk of complications after surgical managment in this population of pediatric patients.
Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM, Matheney T, Sanders JO, Watters WC 3rd, Goldberg MJ, Keith MW, Haralson RH 3rd, Turkelson CM, Wies JL, Sluka P, Hitchcock K. Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg. 2009 Nov;17(11):718-25.
PMID:19880682 (Link to Abstract)
Moroz LA, Launay F, Kocher MS, Newton PO, Frick SL, Sponseller PD, Flynn JM. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br. 2006 Oct;88(10):1361-6.
PMID:17012428 (Link to Abstract)
Wall EJ, Jain V, Vora V, Mehlman CT, Crawford AH. Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures. J Bone Joint Surg Am. 2008 Jun;90(6):1305-13.
PMID:18519325 (Link to Abstract)
Leet AI, Pichard CP, Ain MC. Surgical treatment of femoral fractures in obese children: does excessive body weight increase the rate of complications? J Bone Joint Surg Am. 2005 Dec;87(12):2609-13.
PMID:16322608 (Link to Abstract)