Atypical femoral fractures related to bisphosphonate treatment

Aims: Treatment guidelines for atypical femoral fractures associated with bisphosphonates have not been established. We conducted a systematic review of the treatment of atypical femoral fractures first, to evaluate the outcomes of surgical fixation of complete atypical fractures and secondly, to assess whether prophylactic surgery is necessary for incomplete atypical fractures. Materials and Methods: Case reports and series were identified from the PubMed database and were included if they described the treatment of atypical femoral fractures. In total, 77 publications met our inclusion criteria and 733 patients with 834 atypical complete or incomplete femoral fractures were identified. Results: For complete fractures, internal fixation was predominantly achieved by intramedullary nailing. The mean time to healing post-operatively was 7.3 months (2 to 31). Revision surgery for nonunion or implant failure was needed in 77 fractures (12.6%). A greater percentage of fractures treated with plate fixation (31.3%) required revision surgery than those treated with intramedullary nailing (12.9%) (p < 0.01). Non-operative treatment of incomplete fractures failed and surgery was eventually needed in nearly half of the patients (47%), whereas prophylactic surgery was successful and achieved a 97% rate of healing. Conclusion: Intramedullary nailing is the first-line treatment for a complete fracture, although the risk of delayed healing and revision surgery seems to be higher than with a typical femoral fracture. Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. Radiographs of the opposite side should be obtained routinely looking for an asymptomatic fracture. Bisphosphonates must be discontinued but ongoing metabolic management in the form of calcium and/or vitamin D supplements is advisable. Teriparatide therapy can be considered as an alternative treatment. Cite this article: Bone Joint J 2017;99-B:295–302

Peer and sibling relationships

One of the most important roles of parents is to help their children learn to relate to peers, and find their place in the world of their peers. Siblings are often the child’s first peers in that they are relatively equal in terms of power, and they also typically engage together in play. Positive relationships with both peers and siblings protect children from adversity. However, problematic peer or sibling relating, including bullying or conflict, can have serious consequences for mental health and behavior. Parenting impacts the development of peer and sibling relationships in similar ways. The aim of this chapter is to review research and theory about how parenting affects these relationships. The paths through which parents influence peer and sibling relationships are explored. Evidence of the effectiveness of parenting interventions to improve children’s peer and sibling relationship issues is examined. It is recommended that future research seeks to further differentiate the interplay of genetics and parenting affecting child outcomes, and that intervention trials examine the impact of interventions on both sibling and peer relationships. To date, most school interventions to address bullying and victimization have involved parents only minimally. There is, however, a great deal of evidence that involvement of parents and families is critical in addressing serious problems in peer, as well as sibling, relationships