The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 9

Current Concepts Review | May 02, 2012

Effects of Obesity on Pediatric Fracture Care and Management

Meredith A. Lazar-Antman, MD¹; Arabella I. Leet, MD²

¹ Pediatrics Division, Department of Orthopaedic Surgery, Winthrop-University Hospital 222 Station Plaza North, Suite 305, Mineola, NY 11501. E-mail address: Meredith.lazar@gmail.com
² Department of Orthopaedic Surgery, Shriners Hospital for Children-Honolulu, 1310 Punahou Street, Honolulu, HI 96826. E-mail address: Aleet@shrinenet.org

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Investigation performed at the Pediatrics Division, Department of Orthopaedic Surgery, Winthrop-University Hospital, Mineola, New York, and Johns Hopkins University, Baltimore, Maryland

J Bone Joint Surg Am, 2012 May 02;94(9):855-861. doi: 10.2106/JBJS.J.01839

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Abstract

Obese children have a theoretically increased risk of sustaining an extremity fracture because of potential variations in their bone mineral density, serum leptin levels, and altered balance and gait.

Trauma databases suggest an increased rate of extremity fractures in obese children and adolescents involved in polytrauma compared with nonobese children and adolescents.

Anesthetic and other perioperative concerns for obese pediatric trauma patients undergoing surgery include higher baseline blood pressures, increased rates of asthma, and obstructive sleep apnea.

A child’s weight must be considered when choosing the type of implant for fixation of pediatric femoral fractures.

Fracture prevention strategies in obese pediatric patients consist of ensuring properly sized safety gear for both motor vehicles and sporting activities and implementing structured weight-loss programs.

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Introduction

Introduction | Prevalence of Fractures in Obese Pediatric Patients | Rationale for Increased Fracture Risk in Obese Children and Adolescents | Perioperative Considerations for the Pediatric Obese Patient | Effect of Obesity on Treatment of Fractures | Fracture and Obesity Prevention

The prevalence of childhood obesity has been increasing steadily over the past several decades. While obesity has been linked to pediatric orthopaedic conditions such as Blount disease and slipped capital femoral epiphysis, the impact of the increased rate of obesity on the prevalence and management of pediatric fractures is not well understood. Obese children tend to be more sedentary than children with a normal weight and to have a higher bone mineral density and more soft-tissue padding, which are all protective against fractures. Conversely, obese children have more weight to support on impact, have poorer balance, and may not have enough of a relative increase in bone mineral density to support their increased weight. Recent reviews on the ramifications of adult obesity on fracture care and management have shown that, while obese adult orthopaedic trauma patients are at a higher risk for perioperative complications, safe fracture care can be provided if appropriate precautions are taken^1,2. The pediatric trauma literature suggests that the prevalences of extremity injuries are higher in obese children than in nonobese children^3-5. The present article reviews obesity in childhood as it relates to epidemiology, treatment, and prevention of fractures.

Childhood and adolescent obesity has become a world health concern. Public health officials have declared an obesity epidemic in the United States⁶. In 2010, the number of obese and overweight children worldwide reached forty-three million, with a worldwide prevalence of 6.7% (95% confidence interval [95% CI], 5.6% to 7.7%)⁷. Body mass index (BMI), a measure used to quantify obesity, is the ratio of weight in kilograms divided by height in meters squared. Obesity in children and adolescents is described with use of the 2000 Centers for Disease Control (CDC) sex-specific BMI-for-age growth charts⁶. Overweight children are defined as those between the 85th and 95th percentiles; obesity is defined as those at or above the 95th percentile. The most recent U.S. population data show that 32% of children and adolescents over the age of two years are overweight, and 17% are obese⁶. The national prevalence of obesity in children and adolescents had tripled between 1980 and 2002, with the trend starting to plateau between 1999 and 2004⁸. The obesity prevalence in developed countries is approximately double that in developing countries (11.7% and 6.1%, respectively), with certain minority groups more at risk for obesity than others⁶. The relative prevalence of obesity is approximately 50% to 75% higher among black and Hispanic children and approximately 30% lower among Asian children compared with white children⁹.

Pediatric obesity has been linked with many musculoskeletal conditions, and as its prevalence has increased, there has been a concomitant rise in many obesity-related conditions such as adolescent Blount disease and slipped capital femoral epiphysis^10,11. The prevalence of musculoskeletal pain is significantly greater in overweight children (odds ratio [OR], 4.04; 95% CI, 1.5 to 10.6; p = 0.0073)¹².

Fractures in children are extremely common, and annually 2.1% of all children sustain at least one fracture¹³. Many factors have been shown to influence childhood fracture risk¹⁴. When a cohort of children with fractures was compared with a cohort of age-matched controls, a multivariate analysis demonstrated that, when combined with data on age, height, and weight, an increased level of sports participation, absence of breastfeeding history, and increased inhaled corticosteroid usage were found to be significant clinical risk factors that increase the risk of sustaining a fracture (p = 0.03)¹⁵. Lower calcium and milk intake, especially with concurrent increases in the consumption of carbonated beverages, has also been shown to increase fracture risk^16,17. Vitamin-D deficiency is yet another risk factor and was identified in a pilot study to be at a high prevalence in healthy black children with forearm fractures^18,19.

Prevalence of Fractures in Obese Pediatric Patients

Children who are obese or overweight may have an increased risk of sustaining a fracture^3-5,12. Taylor et al. performed a cross-sectional analysis of 227 overweight and 128 normal weight children prospectively enrolled to ascertain the orthopaedic ramifications of excessive weight on children and adolescents. The prevalence of skeletal fractures was significantly greater in the overweight cohort (OR, 4.54; 95% CI, 1.6 to 13.2; p = 0.0053)¹². Although the results are suggestive of increased fracture risk in the overweight pediatric patient, a limitation of the study is that fracture information was obtained by child and parent recall as opposed to a review of the medical records, so specifics as to fracture site and pattern were not recorded¹².

Much of the data on fractures and obesity come from analyses of trauma registries that specifically review cases with high-energy mechanisms of injury. Rana et al. retrospectively reviewed the cases of 1314 pediatric trauma patients at a level-I trauma center and found that 294 patients (23%) were obese³. There was no significant difference in Injury Severity Score (ISS) or mechanisms of injury between children who were obese and those who were not. However, the obese patients had a significantly higher prevalence of extremity fractures compared with the nonobese group (55% and 40%, respectively; p < 0.001)³. Further analysis of the trauma registry demonstrated that the incidence of operative fracture management was significantly higher for the obese patients than for the nonobese patients (42% and 30%, respectively; p < 0.001)³. These results suggest that obese pediatric patients are more at risk for sustaining extremity fractures that require operative treatment than are nonobese pediatric patients.

Brown et al., in a retrospective review of the cases of pediatric trauma patients, also suggested that obese pediatric patients are at a higher risk for an extremity fracture⁴. They studied 316 pediatric trauma patients, which included fifty-four patients (17%) who were obese. In the fifty-four patients in the obese cohort, the extremity fracture rate was 46% (twenty-five patients), the pelvic fracture rate was 13% (seven patients), and the spine fracture rate was 11% (six patients). In the 262 patients in the nonobese cohort, the rates were 40% (106 patients), 12% (thirty-two patients), and 10% (twenty-seven patients), respectively. These data demonstrate a trend toward a higher prevalence of extremity, pelvic, and spine fracture; however, the differences are not significant (p = 0.45, p = 0.82, and p = 0.81, respectively)⁴.

Pollack et al. performed a study to assess how the BMI of an adolescent may affect the injury pattern sustained in motor vehicle collisions⁵. In 3232 children riding in 2873 vehicles, there was an overall injury rate of 1.78%, with a larger percentage of injuries occurring in overweight and obese children. The odds ratio of sustaining an extremity injury for overweight and obese children was 2.64 (95% CI, 1.64 to 4.77) and 2.54 (95% CI, 1.15 to 5.59), respectively, compared with normal weight children. The overweight and obese children sustained injuries to more distal aspects of the extremity, and leaner children sustained more injuries to the femur, pelvis, and clavicle⁵. In a similar study of 9327 children who had been in motor vehicle crashes, 0.96% had sustained an injury and increasing weight percentiles were found to be associated with more instances of lower-extremity injuries (p = 0.053)²⁰.

The studies involving trauma registries have suggested a higher rate of fracture in obese children involved in high-energy trauma. Obese children involved in playground injuries are likely to be more sedentary and better padded, but several studies have suggested that they are at increased risk for injury^18,21,22. In a recent retrospective study of 23,349 patients presenting to an emergency department after injury, with a population obesity rate of 16.5% (3861 of 23,349 patients), Pomerantz et al. compared injuries in obese children with those in nonobese children²². No significant difference was found between obese and nonobese patients who had fractures and dislocations. Although obese and nonobese children had similar percentages of upper extremity injuries, the obese children were more likely to have lower-extremity injuries (OR, 1.71; 95% CI, 1.56 to 1.87; p < 0.001). The obese children were also more likely to sustain a sprain (OR, 2.25; 95% CI, 2.04 to 2.47) and less likely to present with a concussion (OR, 0.68; 95% CI, 0.58 to 0.79). The limitation of that study was that it did not describe injury severity or the need for operative intervention²².

An epidemiologic study on forearm fractures in children in a major metropolitan area also noted a higher prevalence of such fractures in obese patients than population norms. In that population, 24.1% (224) of 929 patients were at or above the 95th percentile for BMI, exceeding the obesity rate for the city, which was reported to be 15% to 18%²¹.

Rationale for Increased Fracture Risk in Obese Children and Adolescents

Bone Mineral Density

In children, the data are inconclusive for correlations between bone mineral density (BMD) and fracture, which is due in part to the fact that some studies use areal BMD (aBMD), which is taken from a cross-sectional two-dimensional measurement, and others use volumetric BMD (vBMD), which is calculated from a three-dimensional computed tomography (CT) segment so the cortical and trabecular bone densities can be segregated. Ma and Jones compared multiple variables of risk for fracture in children and found that aBMD as a composite value from three different sites did not significantly contribute to fracture risk¹⁵. However, in a later study, these same investigators evaluated aBMD by both dual-energy x-ray absorptiometry and metacarpal index when trying to assess fracture risk and found that patients with a fracture had lower measures on dual-energy x-ray absorptiometry at all sites (p < 0.05) and that dual-energy x-ray absorptiometry and metacarpal index remained significant predictors for wrist and forearm fractures²³. Recent work has also attributed low trabecular vBMD, as measured with use of peripheral quantitative CT, to be independently associated with childhood fracture history²⁴.

The literature is also unclear as to how BMD is affected by childhood obesity. Some studies have described increased or normal bone mineral content in obese children, and others have concluded that obese children have decreased bone mass relative to bone size and body weight²⁵. Leonard et al. found that BMD relative to height was significantly greater in obese than in nonobese children, with use of lumbar spine (p < 0.0001) and whole-body dual-energy x-ray absorptiometry scan data (p < 0.0001)²⁶. Weight-bearing and mechanical stresses are important for increasing cortical mass; however, the increase in BMD may be insufficient to overcome the greater forces imparted on the bones during deceleration when obese children sustain injury; these extreme loads may overcome the higher cortical mass contributing to a theoretical increase in fracture risk in obese children.

Also, obese children may have lower bone area and bone mass for their weight than nonobese children. Goulding et al., in their evaluation of BMD in both boys and girls with forearm fractures, found that many of the upper extremity fractures occurred in obese children. The children with fractures had lower bone mass and aBMD throughout their skeletons than did case-matched controls^27,28. Goulding et al.²⁵ then evaluated bone mineral content and bone area compared with total weight in a nonfracture cohort and found that the overweight and obese children had lower bone area and bone mass for their body weight with adaptive increases in bone mineral content relative to both lean mass and fat mass in those with high adiposity. However, bone mineral content was still 8% to 10% lower than predicted values in the obese patients²⁵. Another study showed bone strength, as measured by means of qualitative ultrasound in the midpart of the tibial and radial bones, to be significantly reduced in obese children compared with nonobese children (p < 0.05)²⁹. Body fat indexes have also been shown to be associated with vitamin-D status, and obese adolescents have been demonstrated to be vitamin-D deficient; however, this has been shown not to correlate with a reduction in BMD³⁰. Given that the data continue to be unclear as to whether obese children do have relatively lower BMD for their weight, obtaining routine BMD measurements on obese children who have not had a fracture in order to assess their risk for fracture and offer treatment on the basis of that information is still not recommended³⁰.

Biomechanics, Gait, and Balance

In high-energy trauma, such as in motor vehicle crashes, the pattern and severity of injury depend on the interaction of biomechanical factors, seat-belt use, air-bag use, and type of impact. The increase in extremity injuries with increasing BMI may be attributable to increased patient mass and subsequent transfer of force and energy to the legs during the crash. The relative decrease in abdominal injury has been attributed to a so-called cushion effect or increase in insulation around the abdomen³¹. Also, with automobile accidents, increased body mass places increasing force of impact to the distal aspects of the limbs on the interior automobile structures; thus, heavier children are more likely to sustain distal injuries and leaner children are more likely to sustain injuries related to seat-belt wear because of less padding⁵.

A biomechanical analysis on a cohort of obese and nonobese boys was done with use of computer simulation to evaluate how increases in weight affects forearm fracture risk in falls. The study found that obese and nonobese children showed a similar risk of forearm fracture on impact; however, obese children were shown to be at much greater risk of fracture during the second peak force, which is when the body weight is transmitted through the arm. Also, the authors found obese children to be at relatively greater risk of fracture in falls from a low height. In falls from greater heights, the velocity component contributes most to the force at impact, which is independent of body weight. In falls from low heights, the body weight component dominates and has the most effect on relative risk for fracture³².

Gait pattern is also affected by childhood obesity, which may have fracture risk implications³³. At propulsion, obese children require greater power generation from hip flexors and ankle plantar flexors, to prepare for the swing phase and to propel the body forward, as well as increased power absorption of knee extensors to avoid limb collapse. An increase in power across the knee may predispose obese children to knee trauma and injury.

Obese pediatric patients have poorer balance, which also increases the risk of a fall. Goulding et al., in a study of ninety-three boys between the ages of ten and twenty-one years who performed balance tests, found that the cohort of forty-six patients with a history of forearm fracture had no poorer balance than the forty-seven boys without a fracture history³⁴. However, in that study, when the twenty-five obese patients were compared with the sixty-eight nonobese patients, the obese boys were found to have worse balance and posture irrespective of fracture history³⁴.

Leptin Elevation

Leptin is a polypeptide hormone that is produced by adipocytes in proportion to their triglyceride content and links changes in body fat stores to the central control of energy balance by binding to its receptor in the brain, LEPR-B³⁵. It has been shown to have a central role in regulating appetite by decreasing food intake while increasing energy expenditure. A major physiologic role is to respond to and defend against reductions of body fat that might affect survival and reproductive fitness³⁵. There is also awareness that bone-remodeling requires an energy source, and thus leptin has been targeted as a mediator of bone metabolism³⁶. Leptin acts through a central hypothalamus pathway to regulate bone mass and acts peripherally on osteoblasts³⁷. When leptin activates the hypothalamic pathway and stimulates the β2-adrenergic sympathetic receptor (ADRB2) on the osteoblast, trabecular bone formation decreases³⁷. Leptin also acts on the pluripotent mesenchymal progenitor stem cell in bone marrow and can influence its differentiation from an osteoblastic lineage to an adipocytic one (Fig. 1). Leptin has been shown to be a negative independent predictor of cortical bone density through its direct negative effect on the osteoblast in both non-weight-loaded bone (radius) and weight-loaded bone (tibia), suggesting a general inhibitory role of leptin on cortical bone size³⁶. Therefore, leptin is the most likely candidate as the mediator of a systemic inhibitory effect of adipose tissue on cortical bone size³⁶. Increased leptin levels have been measured in obese children³⁸, and the higher levels may contribute to the decreased bone strength; however, more conclusive data are needed to fully understand the role of leptin in decreasing BMD³⁹.

Fig. 1

Mechanism of central and peripheral leptin signaling. LEPR = leptin receptor, BMSCs = bone marrow stromal cells, and ADRB2 = β2 adrenergic receptor. (Reproduced, with permission of Macmillan Publishers Ltd., from: Kawai M, Devlin MJ, Rosen CJ. Fat targets for skeletal health. Nat Rev Rheumatol. 2009;5:365-72. Copyright 2009.)

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Perioperative Considerations for the Pediatric Obese Patient

Anesthetic Effects

Anesthetic management of an obese child has been associated with a higher prevalence of critical events during anesthesia⁴⁰. One study described a significantly higher prevalence of intraoperative oxygen desaturation (2% versus 0.19%) among obese patients undergoing a routine procedure (p = 0.001)⁴¹. Also, heavy sedation may cause respiratory depression and should be avoided perioperatively in the morbidly obese child⁴⁰. Difficult mask ventilation from local soft-tissue obstruction is also a problem in this population and can easily lead to gaseous distention of the stomach, compromising diaphragmatic function⁴⁰.

Pulmonary Effects

There are respiratory conditions that contribute to morbidity and mortality in obese pediatric patients, so a careful medical history must be obtained. Morbid obesity is associated with a reduction in all respiratory functions, characterized by decreases in diffusing capacity, ventilatory muscle endurance, airway narrowing, and increased work of breathing⁴⁰. There is a decrease in forced vital capacity and functional residual capacity, and as a result there are decreased tidal ventilation and ventilation-perfusion abnormalities that may cause hypoxemia⁴⁰. In the U.S., asthma has been diagnosed in 7.1 million children, which is approximately 10% of the pediatric population under the age of seventeen years⁴². The prevalence of asthma is known to be much higher in obese pediatric patients, and it was reported to be 28% (132 of 473 pediatric patients) in a recent prospective asthma management study⁴³. Obese children also have an increased risk for sleep apnea, which may result in abnormal sleep patterns, prolonged and severe oxygen desaturation, and central hypoventilation⁴⁰. These factors contribute to increased pulmonary morbidity with a more frequent need for prolonged intubation in the postoperative period⁴. In the trauma setting, there is not usually sufficient time for patients to have a comprehensive workup for sleep apnea or obstruction, which may be completed before elective operative treatment.

Cardiovascular Effects

Although children do not typically have cardiac disease or sustain myocardial infarctions, there is evidence that there are systemic cardiac effects as a result of childhood obesity⁴⁰. In one study of 5953 school-age children, the percentage of children with high systolic and diastolic blood pressures greater than the 90th percentile for their age, sex, and height was significantly higher in the obese cohort (20% to 30%) compared with the nonobese cohort (5% to 10%; p < 0.001)⁴⁴. In the study by Rana et al., the mean systolic blood pressure was reported to be significantly higher in the obese pediatric trauma patients (128 mm Hg) than in the nonobese pediatric trauma patients (124 mm Hg) on arrival to the emergency department (p < 0.001)³. However, no significant difference in mortality has been reported for obese compared with nonobese pediatric trauma patients^3,4.

Venous Thromboembolic Disease and Complications Related to Hospital Stay

From the National Trauma Data Bank of pediatric trauma patients, the prevalence of venous thromboembolic disease was 0.08% (ninety-one of 116,357)⁴⁵. Identified risk factors for venous thromboembolism in pediatric trauma patients are head injury, spinal cord injury, vertebral fracture, pelvic fracture, femoral fracture, and tibial fracture⁴⁶. On the basis of current recommendations from data compiled through the National Trauma Data Bank on pediatric patients who had received inferior vena cava filters for the prevention of pulmonary embolism, trauma patients with an ISS of >25, spinal cord injury, severe femoral fracture, or known lower-extremity deep venous thrombosis should have a vena cava filter placed near the time of admission^45,46.

In a large series of pediatric trauma patients, no significant differences in total length of stay, intensive care unit admission, or pulmonary embolism were detected between the obese and the nonobese patients^17,18. However, obese patients had a significantly higher rate of developing decubitus ulcers (1% versus 0.2%; p = 0.04) and deep venous thrombosis (0.7% versus 0%; p = 0.008)³. Obese patients were also likely to require an extended length of stay in the pediatric intensive care unit and required extra time to wean from ventilator support³. In obese children, although the incidence of deep venous thrombosis was higher, the incidence of pulmonary embolism was not; thus, a vena cava filter protocol is not recommended⁴⁷.

Effect of Obesity on Treatment of Fractures

While the literature on adult orthopaedic patients has many reports on the effect of obesity on fracture care and treatment results^48-51, there is less known about the ramifications of obesity on pediatric fracture management.

Leet et al. reported on their experience in the operative management of femoral fractures in obese children. In their study, 6% (six) of 103 children were obese and 50% (three) of the six children had complications, which was significantly higher than the rate of 12% (eleven) of ninety-three children with a normal weight who had complications (p = 0.004). The complications were refracture, wound infection, and wound dehiscence. Their study found no significant difference in operative times⁵².

In an effort to ascertain the best treatment option for obese children with femoral fractures, Weiss et al. reported their experience with treating femoral fractures with flexible intramedullary nails⁵³. Their study had seventy-one patients, and thirteen of them weighed >50 kg. The complication rate for the thirteen obese patients was 46.2% (six), which was significantly higher than the rate of 17.2% (ten) for the fifty-eight nonobese patients (p = 0.03). The complications included infection, peroneal nerve palsy, refracture requiring revision surgery, heel ulcer, ulcer from a fracture brace, and nonunion. These results discourage surgeons from using flexible elastic nails in children who are obese or weigh >50 kg. Moroz et al. combined data on titanium elastic nailing of femoral shaft fractures in children treated in six different institutions and found that children who weighed >49 kg were five times more likely to have a poor outcome with this treatment method⁵⁴.

Previously, knee dislocation had been considered an injury from high-energy trauma; however, the literature has demonstrated more cases of knee dislocations in obese patients from low-energy trauma⁵⁵. To our knowledge, the youngest patient to be reported with such an injury was a fifteen-year-old girl who sustained a complete popliteal arterial injury requiring saphenous vein graft and fasciotomy to treat compartment syndrome⁵⁶.

Obesity is a risk factor for worse outcomes following ankle fracture in adults⁵⁷. To date, there has been no study, as far as we know, on ankle fractures in obese children; however, obese children are more likely to sustain an ankle sprain and are more likely to have persistent morbidity (pain and swelling) from an ankle sprain six months after injury^22,58.

Fracture and Obesity Prevention

Prevention of fractures in obese children and adolescents should include implementing weight reduction programs and improving both playground and automobile safety measures. Outpatient training programs that consist of a combination of physical exercise, nutrition education, and behavior therapy have reported some success at improving adolescent BMI⁵⁹. Motivated children can lower their BMI, as there is evidence that obese children who participate in an organized sport are more likely to be successful with weight loss programs⁶⁰. However, a younger age at the time of weight loss intervention has been shown to be the most important predictor for success in treating childhood obesity⁶¹. Therefore, we recommend that, when treating an obese child for a fracture, an orthopaedist should address the child’s weight problem by providing counseling and appropriate referrals either through his or her pediatrician or directly to a nutritionist.

For automobile safety, all children under the age of thirteen should be seated in the rear of a vehicle and wear appropriately fitting restraining devices⁵. In a study examining the relationship of BMI to injury in children between the ages of three and eight years who were involved in motor vehicle crashes, no association was found between weight percentiles and overall injury prevalence after adjusting for the use of proper restraints (p = 0.71), which further validates the necessity of using properly sized restraining devices²⁰.

Obese children are also at risk for fractures sustained from low-energy falls. Prevention strategies should be targeted for improving playground safety²¹. There is evidence that safety surfaces have been effective in reducing the prevalence of head injury, but have not necessarily been effective at fracture prevention⁶².

In conclusion, childhood and adolescent obesity has an effect on the incidence and prevalence of pediatric fractures, with higher rates of extremity fractures in obese pediatric patients^9,17,18,21. The rationale for this phenomenon appears to be related to decreases in volumetric bone mineral density, difficulty with gait and balance, and an increase in serum leptin. Obese pediatric trauma patients are at risk for more anesthesia-related complications and complications related to longer hospital stays. There are encouraging results from some pediatric weight loss programs and organized sport programs, and we must continue to encourage patient participation in them to curtail the ever-growing problems with pediatric obesity and the orthopaedic sequelae of increased body weight^59,63.

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

obesity ; fracture ; pediatrics ; childhood obesity

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Meredith A. Lazar-Antman, Arabella I. Leet; Effects of Obesity on Pediatric Fracture Care and Management. The Journal of Bone & Joint Surgery. 2012 May;94(9):855-861.

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