Atypical Femur Fracture Risk versus Fragility Fracture Prevention with Bisphosphonates.

BACKGROUND: Bisphosphonates are effective in reducing hip and osteoporotic fractures. However, concerns about atypical femur fractures have contributed to substantially decreased bisphosphonate use, and the incidence of hip fractures may be increasing. Important uncertainties remain regarding the association between atypical femur fractures and bisphosphonates and other risk factors. METHODS: We studied women 50 years of age or older who were receiving bisphosphonates and who were enrolled in the Kaiser Permanente Southern California health care system; women were followed from January 1, 2007, to November 30, 2017. The primary outcome was atypical femur fracture. Data on risk factors, including bisphosphonate use, were obtained from electronic health records. Fractures were radiographically adjudicated. Multivariable Cox models were used. The risk-benefit profile was modeled for 1 to 10 years of bisphosphonate use to compare associated atypical fractures with other fractures prevented. RESULTS: Among 196,129 women, 277 atypical femur fractures occurred. After multivariable adjustment, the risk of atypical fracture increased with longer duration of bisphosphonate use: the hazard ratio as compared with less than 3 months increased from 8.86 (95% confidence interval [CI], 2.79 to 28.20) for 3 years to less than 5 years to 43.51 (95% CI, 13.70 to 138.15) for 8 years or more. Other risk factors included race (hazard ratio for Asians vs. Whites, 4.84; 95% CI, 3.57 to 6.56), height, weight, and glucocorticoid use. Bisphosphonate discontinuation was associated with a rapid decrease in the risk of atypical fracture. Decreases in the risk of osteoporotic and hip fractures during 1 to 10 years of bisphosphonate use far outweighed the increased risk of atypical fracture among Whites but less so among Asians. After 3 years, 149 hip fractures were prevented and 2 bisphosphonate-associated atypical fractures occurred in Whites, as compared with 91 and 8, respectively, in Asians. CONCLUSIONS: The risk of atypical femur fracture increased with longer duration of bisphosphonate use and rapidly decreased after bisphosphonate discontinuation. Asians had a higher risk than Whites. The absolute risk of atypical femur fracture remained very low as compared with reductions in the risk of hip and other fractures with bisphosphonate treatment. (Funded by Kaiser Permanente and others.).

The Relationship between the Lee Score and Postoperative Mortality in Patients with Proximal Femur Fractures / A relação do escore de Lee com a mortalidade pós-operatória em pacientes com fraturas de fêmur proximal

Abstract Objective To verify the predictive value of the Lee score for mortality in a one-year period after proximal femur fracture surgery. The present study also evaluated the isolated predictive capacity of other variables. Methods A sample of 422 patients with surgically-treated proximal femur fractures was evaluated. Data was collected through a review of medical records, appointments, and contact by telephone. Results The Lee score was applied to 99.3% of the patients with proximal femur fractures submitted to surgical treatment. Themortality rate was of 22% of the sample, and the majority were classified as class I risk. The Lee score had no significant association with mortality (p = 0.515). High levels of serum creatinine (p = 0.001) and age (p = 0.000) were directly associated with death. Conclusion The Lee score was not predictive of mortality in a one-year period after proximal femur fracture surgery; however, a statistical significance was observed between age and serum creatinine levels, considered separately, and death.

Resumo Objetivo Verificar o valor preditivo do escore de Lee para a mortalidade no primeiro ano pós operatório de fraturas de fêmur proximal. O estudo também avaliou a capacidade preditiva isolada de outras variáveis. Método Uma amostra de 422 pacientes com fraturas do fêmur proximal submetidos a cirurgia foi avaliada neste estudo. Os dados foram coletados por meio de revisão de prontuários, consultas presenciais e contatos telefônicos. Resultados O escore de Lee foi aplicado em 99,3% dos pacientes com fraturas de fêmur proximal submetidos a tratamento cirúrgico. A taxa de mortalidade da amostra foi de 22%, a maioria classificada como classe I de risco. O escore de Lee não apresentou associação significativa com a mortalidade (p = 0,515). Os valores elevados de creatinina sérica (p = 0,001) e a idade (p = 0,000) estiveram diretamente associados com o desfecho de morte. Conclusões O escore de Lee não é preditivo para amortalidade emumperíodo de um ano após cirurgia de fraturas de fêmur proximal; entretanto, observou-se significância estatística entre a idade e a dosagem sérica da creatinina, isoladamente, com o desfecho de morte.

Compression screws and buttress plate versus compression screws only for Hoffa fracture in Chinese patients: a comparative study.

OBJECTIVE: To compare compression screws and buttress plate (CS plus BP) with compression screws only (CS) in treating patients with Hoffa fracture. METHODS: This retrospective study included Chinese patients with Hoffa fracture treated by open reduction and internal fixation. Radiographs and clinical outcomes (range of movement [ROM], bone union and Knee Society Score [KSS]) were compared between patients treated using CS plus BP versus CS only. RESULTS: At 4 months following surgery, significantly better outcomes were shown in the CS plus BP group ( n = 24) versus CS only group ( n = 21) regarding ROM (120.4 ± 5.2° versus 110 ± 7.1°) and KSS (85.5 ± 4.1 versus 79.7 ± 3.3). At the 12-month follow-up, significantly better outcomes were maintained in the CS plus BP versus CS only group regarding ROM (126.2 ± 7.4° versus 120.5 ± 8.2°) and KSS (88.3 ± 4.6 versus 84.2 ± 4.0). At the final follow-up, all patients had normal fracture healing and no malunion, nonunion or reduction loss. CONCLUSIONS: Fixation with CS plus BP for Hoffa fracture is effective and reliable, and may provide more adequate stability and better outcomes versus CS only.

Current Understanding of Epidemiology, Pathophysiology, and Management of Atypical Femur Fractures.

PURPOSE OF REVIEW: To summarize reports published since the 2013 American Society of Bone and Mineral Research Task Force Report on atypical femoral fractures (AFF). RECENT FINDINGS: The absolute incidence of AFFs remains low. AFFs are primarily associated with prolonged bisphosphonate (BP) exposure, but have also been reported in unexposed patients and those receiving denosumab for osteoporosis and metastatic bone disease. Asians may be more susceptible to AFFs. Lateral femoral bowing and varus hip geometry, which increase loading forces on the lateral femoral cortex, may increase AFF risk. Altered bone material properties associated with BP therapy may predispose to AFFs by permitting initiation and increasing propagation of micro-cracks. Relevant genetic mutations have been reported in patients with AFFs. Single X-ray absorptiometry femur scans permit early detection of incomplete and/or asymptomatic AFFs. Orthopedists recommend intramedullary rods for complete AFFs and for incomplete, radiologically advanced AFFs associated with pain and/or marrow edema on MRI. Teriparatide may advance AFF healing but few data support its efficacy. Greater understanding of biological and genetic predisposition to AFF may allow characterization of individual risk prior to initiating osteoporosis therapy and help allay fear in those at low risk for this complication, which remains rare in comparison to the osteoporotic fractures prevented by antiresorptive therapy.

Radiographic study of the proximal femur morphology of elderly patients with femoral neck fractures: is there a difference among ethnic groups?

INTRODUCTION: This study aimed to determine ethnic differences in the proximal femur morphology of elderly patients with femoral neck fractures in Singapore. METHODS: We reviewed the medical records of 101 men and 288 women aged 60-109 (mean 76.4) years who underwent hip hemiarthroplasty for femoral neck fractures between 1 June 2010 and 31 December 2015. Patients' age, gender and race were recorded. Plain anteroposterior radiography was used to measure the following: calcar width to canal width ratio of the ipsilateral femur; neck-shaft angle; hip offset; neck length; and neck width of the contralateral proximal femur. RESULTS: Chinese women had slightly larger femoral heads (mean 43.88 mm) as compared to Malay (mean 42.92 mm, p = 0.044) and Indian (mean 42.34 mm, p = 0.025) women. Chinese women also had a significantly lower mean calcar-to-canal width ratio (0.606) as compared to Malay (0.664, p = 0.002) and Indian (0.693, p = 0.004) women. The mean neck-shaft angle of Chinese women was significantly greater than that of Indian women (137.48° vs. 127.00°, p = 0.001). CONCLUSION: We found statistically significant differences in the femoral head sizes and calcar-to-canal width ratios among women of different ethnic groups. There were also differences in neck-shaft angles between Chinese and Indian women, and between Malay and Indian women.

Factors related to curved femur in elderly Japanese women.

BACKGROUND: Multiple factors are involved in the development of atypical femoral fractures, and excessive curvature of the femur is thought to be one of them. However, the pathogenesis of femoral curvature is unknown. We evaluated the influence of factors related to bone metabolism and posture on the development of femoral curvature. METHODS: A total of 139 women participated in the present study. Curvatures were measured using antero-posterior and lateral radiography of the femur. We evaluated some bone and vitamin D metabolism markers in serum, the bone mineral density (BMD), lumbar spine alignment, and pelvic tilt. RESULTS: We divided the women into two groups, curved and non-curved groups, based on the average plus standard deviation as the cut-off between the groups. When univariate logistic regression analysis was performed to detect factors affecting femoral curvature, the following were identified as indices significantly affecting the curvature: age of the patients, serum concentrations of calcium, intact parathyroid hormone, pentosidine, homocysteine and 25-hydroxyvitamin D (25(OH)D), and BMD of the proximal femur (P < 0.05) both in the lateral and anterior curvatures. When we used multivariate analyses to assess these factors, only 25(OH)D and age (lateral and anterior standardized odds ratio: 0.776 and 0.385, and 2.312 and 4.472, respectively) affected the femoral curvature (P < 0.05). CONCLUSION: Femoral curvature is strongly influenced by age and serum vitamin D.

Racial/ethnic differences in hip and diaphyseal femur fractures.

UNLABELLED: Contemporary femur fracture rates were examined in northern California women and compared by race/ethnicity. During 2006-2012, hip fracture rates declined, but diaphyseal fracture rates increased, especially in Asians. Women with diaphyseal fracture were younger and more likely to be bisphosphonate-treated. These disparities in femur fracture should be further examined. INTRODUCTION: The epidemiology of diaphyseal femur fracture differs from proximal femur (hip) fracture, although few studies have examined demographic variations in the current era. This study examines contemporary differences in low-energy femur fracture by race/ethnicity in a large, diverse integrated health-care delivery system. METHODS: The incidence of hip and diaphyseal fracture in northern California women aged ≥50 years old during 2006-2012 was examined. Hip (femoral neck and pertrochanteric) fractures were classified by hospital diagnosis codes, while diaphyseal (subtrochanteric and femoral shaft) fractures were further adjudicated based on radiologic findings. Demographic and clinical data were obtained from health plan databases. Fracture incidence was examined over time and by race/ethnicity. RESULTS: There were 10,648 (97.3 %) hip and 300 (2.7 %) diaphyseal fractures among 10,493 women. The age-adjusted incidence of hip fracture fell from 281 to 240 per 100,000 women and was highest for white women. However, diaphyseal fracture rates increased over time, with a significant upward trend in Asians (9 to 27 per 100,000) who also had the highest rate of diaphyseal fracture. Women with diaphyseal fracture were younger than women with hip fracture, more likely to be of Asian race and to have received bisphosphonate drugs. Women with longer bisphosphonate treatment duration were also more likely to have a diaphyseal fracture, especially younger Asian women. CONCLUSION: During 2006 to 2012, hip fracture rates declined, but diaphyseal fracture rates increased, particularly among Asian women. The association of diaphyseal fracture and bisphosphonate therapy should be further investigated with examination of fracture pattern.

Are race and sex associated with the occurrence of atypical femoral fractures?

BACKGROUND: Prior studies have suggested that Asian patients and women may be more likely to sustain atypical femoral fractures in association with bisphosphonate use. However, they do not account for confounders such as asymptomatic patients who are long-term bisphosphonate users or patients sustaining osteoporotic fractures. QUESTIONS/PURPOSES: The purpose of this study was to determine the differences in sex and racial association with atypical femoral fractures by comparing demographic characteristics of patients who sustained an atypical bisphosphonate-associated fracture with patients on long-term bisphosphonates without fractures and with patients who sustained osteoporotic fractures. METHODS: Three groups from prospective registries were identified: (1) patients with atypical femur fractures associated with long-term bisphosphonate use (BFF) (n = 54); (2) patients on long-term bisphosphonates but with no associated fractures (BNF) (n = 119); and (3) patients with osteoporotic proximal femur fractures not associated with bisphosphonates (PFF) (n = 216). Age, sex, and self-reported race/ethnicity were documented and compared. Multivariate and univariate analyses were done as well as age- and sex-stratified analyses. RESULTS: Age and sex distributions of the BFF and BNF patients were similar. There was a higher percentage of Asian patients in the BFF group (17%) than in the BNF group (3%; p = 0.004) as well as Hispanics (13% versus 3% in BNF; p = 0.011). Patients in the BFF group were younger than those in the PFF group (67.5 versus 78.4 years; p < 0.001) and had fewer males (7% versus 14%; p < 0.001). CONCLUSIONS: These data suggest that Asians are at higher risk for atypical bisphosphonate-associated fractures. We recommend closer followup in Asian patients who are taking bisphosphonates. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Clinical correlates of atypical femoral fracture.

BACKGROUND: Reports of atypical femur fracture in bisphosphonate-exposed women have prompted interest in characterizing the clinical profiles of these patients. METHODS: Among women age ≥60 years with hip or femur fracture during 2007-2008, we identified 79 with low-trauma subtrochanteric or femoral shaft fracture. Radiographic images were reviewed to assign fracture pattern and distinguish atypical femur fracture from non-atypical femur fracture. Differences in clinical characteristics and pharmacologic exposures were compared. RESULTS: Among 79 women (38 subtrochanteric and 41 femoral shaft fracture), 38 had an atypical femur fracture. Compared to those with a non-atypical femur fracture, women with atypical femur fracture were significantly younger (74.0 vs 81.0 years), more likely to be Asian (50.0 vs 2.4%) and to have received bisphosphonate therapy (97.4 vs 41.5%). Similarly, the contralateral femur showed a stress or complete fracture in 39.5% of atypical femur fractures vs 2.4% non-atypical femur fracture, and focal cortical hypertrophy of the contralateral femur in an additional 21.1% of atypical cases. CONCLUSIONS: Women suffering atypical femur fractures have a markedly different clinical profile from those sustaining typical fractures. Women with atypical femur fracture tend to be younger, Asian, and bisphosphonate-exposed. The high frequency of contralateral femur findings suggests a generalized process.

Influence of race and socioeconomic status on the diagnosis of child abuse: a randomized study.

OBJECTIVES: To measure empirically the influence of race and socioeconomic status (SES) on the diagnosis of child abuse and willingness to report to child protection services. STUDY DESIGN: A total of 5000 pediatricians randomly selected from the American Medical Association's Masterfile received 1 of 4 randomly assigned versions of a fictional clinical presentation of a child (black/white + high SES/low SES) that described an unwitnessed event in a mobile 18-month-old child resulting in an oblique femur fracture. Outcome measures included ranking the degree to which the injury was accidental versus abuse and agreement with reporting the injury to child protection services. RESULTS: A total of 2109 of 4423 physicians responded (47.7%). Patient's race did not have an effect on a diagnosis of abuse (black, 45% versus white, 46%). Abuse was more likely to be diagnosed in patients with low SES (48% versus 43%, overall P = .02). CONCLUSION: This study supports earlier work demonstrating physicians' greater willingness to consider abuse as a potential cause of injury in low SES children. It failed to demonstrate the finding of retrospective, real world studies of an increased likelihood to consider abuse in black patients. Future work should try to understand why there remains a differential approach to evaluating minority children for abuse in real world settings.

Mismatch of anatomically pre-shaped locking plate on Asian femurs could lead to malalignment in the minimally invasive plating of distal femoral fractures: a cadaveric study.

BACKGROUND: LCP-DF (locking compression plate-distal femur) has been introduced as an anatomically pre-shaped plate that does not require further contouring. However, the LCP-DF was developed based on skeletal measurements in Caucasians. It is unknown whether the LCP-DF fits Asians. OBJECTIVE: The purpose of this study was to assess the conformity of the LCP-DF in Asian adult femurs and also to determine the matching pattern of this anatomically pre-shaped LCP-DF in normal Asian adult femurs and the clinical implications of the matching pattern. METHODS: Sixty adult cadaver femurs were obtained from 41 male and 19 female cadavers with an average age of 63 years (31-95). An 11-hole LCP-DF was applied to the lateral surface of the distal femur according to the contour. Any mismatches between the bone and the plate were recorded. Then the distance from the inner surface of the plate to the cortex was measured at the sites of mismatch. C-arm AP image of the distal femur was taken and the angle between the distal most locking screw and the joint line was measured, and it was named as joint screw angle (JSA). RESULTS: Mismatch was found at the level of proximal 4-5 holes of the plate with an average distance of 11.36 mm (range 0-32 mm) at the tip of the plate. Otherwise, the overall conformity of the LCP-DF was good. The average JSA was 2.15 ± 1.78° (ranged from 0° to 5°). CONCLUSION: A rather consistent pattern of mismatch was found at the proximal part of the 11-hole LCP-DF. An attempt to fit the plate to the bone at this level may cause valgus malalignment at the fracture site.

Racial odds for amputation ratio in traumatic lower extremity fractures.

BACKGROUND: Recent studies have demonstrated that black patients receive substandard care compared with white patients across healthcare settings. The purpose of this study was to evaluate the association of race on the management (salvage vs. amputation) of traumatic lower extremity open fractures. METHODS: Data analysis was conducted using the American College of Surgeon's National Trauma Data Bank. Open tibial and fibular (OTFF) and open femoral (OFF) fractures among adults above the age of 18 were identified by International Classification of Diseases, 9th Revision codes. Injuries were identified as amputated based on the presence of one of three types of knee amputations. Statistical analysis included logistic regression stratified for sex, age, race, mechanism of injury, severity, and insurance type. RESULTS: From the National Trauma Data Bank, 10,082 OFF and 22,479 OTFF were identified. Amputation rates were 3.1% for OFF and 4.2% for OTFF. With age stratification, the ratio of amputation odds for blacks to amputation odds for whites (i.e., the Racial Odds for Amputation Ratio [ROAR]) demonstrated a significant interaction between black and age in both the OFF (p = 0.028) and OTFF (p = 0.008) groups. In younger patients, a lower ROAR (p = 0.016) favored salvage in blacks, while the ROAR in older patients favored amputation in blacks (p = 0.013). The higher prevalence of penetrating injuries in blacks only accounted for 12.7% of the lower ROAR among younger adults. CONCLUSIONS: There exists a racial disparity in the management of lower extremity open fractures. Older blacks have greater odds of amputation that is not explained by mechanism. In contrast, younger blacks have lower odds for amputation that is only partially explained by mechanism of injury.

Surviving multi-trauma in the past.

BACKGROUND: Surviving multi-trauma is strongly associated with emergent resuscitation and treatment in modern medical facilities. Multi-trauma survival before the advent of modern medicine is likely to have been extremely uncommon, particularly in primitive societies. The aim of this study was to investigate the case of an ancient Australian Aboriginal who appeared to have survived multi-trauma. METHODS: We investigated the skeletal remains of an adult Australian Aboriginal with healed fractures of the right femur and humerus. The time of death was assessed by carbon dating. The sex and approximate age of the subject were assessed from the skeleton's morphometry. The fractured bones were assessed by visual inspection, plain radiographs and computer tomography (CT) scanning. RESULTS: The remains were of a male aged approximately 50 years at the time of his death, approximately 1000 years ago, preceding European settlement. Analysis of the malunions indicated that all fractures occurred in one traumatic event, normally a life-threatening injury combination, and that the subject survived for years after this incident, despite no or failed active treatment of his fractures. CONCLUSIONS: The survival of a man living in a primitive society after multi-trauma reflects an impressive depth of nursing and social support in a community of hunter gatherers.

Fratura supracondiliana do fêmur durante salto após reconstrução artroscópica do ligamento cruzado anterior / Supracondylar emur fracture during jump after anterior cruciate ligament arthroscopic reconstruction

CONTEXTUALIZAÇÃO: A fratura distal do fêmur é uma das possíveis complicações no período pós-operatório de reconstrução de LCA, porém, de incidência rara. RELATO DE CASO: Descreve-se o caso de um atleta de 34 anos, gênero masculino, no quinto mês de pós-operatório de reconstrução de LCA. O caso evoluía normalmente de acordo com o protocolo estabelecido; o paciente apresentava bom controle e estabilidade sensoriomotora, quando sofreu fratura supracondiliana do fêmur ao realizar um salto durante atendimento fisioterápico. A reconstrução ligamentar foi realizada com enxerto dos músculos flexores do joelho e a fratura, ocasionada posteriormente, reduzida e fixada com placa e parafuso. Dez meses após a redução aberta e fixação interna da fratura, apresenta função regular na escala Lysholm, amplitude de movimento normal e força muscular grau V em flexores e extensores da coxa. DISCUSSÃO: Poucos relatos de caso semelhantes ao presente foram encontrados na literatura; a maioria apresentou fratura do fêmur após a reconstrução do LCA com tendão patelar. Este caso mostra-se relevante pela associação da fratura supracondiliana do fêmur com reconstrução ligamentar com tendões dos flexores, visto que apenas um trabalho seguiu tal direção. Dentre as prováveis causas dessa fratura, destacam-se uma fragilidade óssea por desuso e túnel ósseo femoral de diâmetro maior que o padrão, apesar de não haver consenso em relação a essas alterações. Uma hipótese sugerida pelos autores deste relato é de que o túnel ósseo de fixação do enxerto pode ter sido um intensificador de estresse sobre o local da fratura.

BACKGROUND: Distal femoral fracture is one of the possible complications on the post operative period of the ACL reconstruction; however, with rare incidence. CASE REPORT: This study reports a male 34 year-old athlete, five months after ACL reconstruction surgery. The case developed normally in accordance with the established protocol. The patient presented good control and sensory-motor stability when he suffered a supracondylar femur fracture. This fracture occurred during a jump in the physical therapy treatment. The ligament reconstruction was done with the tendon graft of the knee flexors muscles, and the fracture caused later, was reduced and stabilized with plate and screw. Ten months after open reduction and internal fixation of the fracture, the patient showed regular function in the Lysholm scale, normal range of movement and muscular force grade V for knee flexors and extensors. DISCUSSION: Few case reports similar to the present one were found in the literature. The majority presented femur fracture after ACL reconstruction with patellar tendon. The present case shows significance by the association between supracondylar femur fracture with ligament reconstruction with flexors tendon, since only one case followed this direction. Two of the possible causes of this fracture are bone fragility for disuse and femoral tunnel bone bigger than the normal, despite not being a consensus. A hypothesis suggested by the authors of this paper is that the bone tunnel of graft fixation could have been a stress booster to the site of the fracture.

Impaction allograft with cement for the revision of the femoral component. A minimum 39-month follow-up study with the use of the Exeter stem in Asian hips.

We report the results of impaction bone grafting of the femoral side in revision total hip arthroplasty in Asian hips (South Korean patients) in which the surgery was performed with the use of the Exeter stem. The minimum follow-up was 39 months (mean, 48.4; range, 39-66). There was subsidence of the cement-graft interface (<1 mm) in three hips (5%), of the stem-cement interface (<1 mm) in 12 hips (21%) and of the stem-cement interface (1-2 mm) in 14 hips (25%). Five hips (9%) developed intraoperative femoral fracture and two hips (4%) femoral perforation in revision. The complications of femoral fracture and subsidence did not have an adverse effect on the final clinical outcomes. The impaction of fresh-frozen allograft and use of a cemented, polished, tapered stem (Exeter stem) were also successful with good clinical and radiographic outcomes in our study of Asian hips (South Korean patients). However, we used smaller stems than the usual ones used for Western patients because of the smaller femur sizes.

Racial and economic disparity and the treatment of pediatric fractures.

Disparity in the treatment of various medical conditions in patient groups with differing racial and economic backgrounds has increasingly been reported. This paper examines the relationship between baseline racial and economic factors and the treatment of pediatric long-bone fractures. The 2000 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) was used to retrospectively examine the incidence and treatment of pediatric fractures. Data were included for supracondylar humerus (n = 2,957), femoral shaft (n = 1,726) or radius and ulna forearm fracture (n = 828) as their primary diagnosis were studied. Hispanic (78%) and black (82%) patients were more likely to receive closed reduction with internal fixation (percutaneous pinning) of supracondylar humerus fractures than whites (73%, P = 0.02). Despite a fairly large sample size, differences in treatment of supracondylar humerus fractures across primary payer or income groups were not statistically significant. Patients with femur fractures and private insurance were more likely to be treated with an external fixation device (7.2%) than patients in the Medicaid (3.8%) or self-pay (4.5%) groups (P = 0.015). No statistically significant difference was found in the treatment of forearm fractures across racial, primary payer or income groups. Racial and economic disparity is an important issue in medicine today. This study did demonstrate statistically significant differences in the treatment of pediatric supracondylar humerus across racial groups, with Blacks and Hispanics being more likely to receive percutaneous pinning of these injuries than Whites. Private insurance patients were also more likely to have femoral shaft fractures treated with an external fixator device than patients with Medicaid or self-pay as their primary payer. However, the clinical significance of these differences is not clear. Further research is needed to gain a more complete understanding of disparities in medicine, and their etiologies, in order to work towards optimizing the quality of medical care for all patient groups.