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Background Flexible intramedullary nailing is performed for femoral fractures in pediatric patients who may be too large for spica cast immobilization but who have substantial growth remaining and who are not a candidate for rigid intramedullary nailing. Flexible nailing allows the surgeon to obtain correct alignment of the femur fracture so as to allow for healing without a lower extremity deformity. Description The patient is positioned on a radiolucent table, flexible nails are chosen according to the diameter of the medullary canal, medial and lateral incisions are made along the distal aspect of the thigh, and access to the canal is obtained with use of a drill-bit of the appropriate size. Flexible nails are contoured to place the apex at the location of the fracture site and then passed 1 at a time up to the fracture through the medial and lateral corticotomies. Fracture reduction is obtained, and the nails are passed across the fracture 1 at a time. Leave a small amount of nail prominent at the entry site; the nails are then cut and advanced with a tamp. Alternatives Spica cast immobilization, rigid intramedullary nailing, external fixation, and submuscular plating. Rationale Flexible nailing provides relative stability of a femoral fracture similar to external fixation, submuscular plating, and rigid nailing; however, external fixators come with pin-track complications and infections, as well as a bulky device external to the thigh. Submuscular plating is beneficial for length-unstable fractures but is a longer procedure and implant removal is more difficult. In an older child with growth remaining, a rigid femoral nail is an option with similar outcomes to flexible nailing; however, the implant is harder to remove. Flexible nailing provides a cosmetic incision with reliable relative fixation in length-stable fractures, and easy removal of implants with equal or even improved outcomes compared with other surgical techniques. Expected outcomes The outcomes of this procedure are excellent. Most pediatric femoral fractures treated with flexible nailing heal well with few complications. Angulation at the fracture site is the most common complication and is more common in fractures of the proximal or distal third of the femur1. Worse outcomes occur in older children and children who are heavier1. Outcomes are improved when flexible nailing is done in length-stable fractures; however, postoperative immobilization in a single-leg spica cast or knee immobilizer can augment fixation in fractures that are not stable. Implant irritation can occur at the insertion site; however, the implants are easy to remove once the fracture has healed. There is a substantially lower rate of malunion when stainless-steel nails (6%) are utilized compared with titanium nails (23%). Consideration should therefore be given to the use of stainless-steel nails for pediatric femoral fractures2. Important tips Use a radiolucent table with either a post or a sheet for counter-traction aids during reductionUse stainless-steel nailsPass the easier nail firstAdvance into the femoral neck or trochanteric apophysisDo not wrap rods around each otherCut off the machined tip of the nail and custom-contour the nail in patients with poor bone quality.

Background: Examination of arthroscopic skill requires evaluation tools that are valid and reliable with clear criteria for passing. The Arthroscopic Surgery Skill Evaluation Tool was developed as a video-based assessment of technical skill with criteria for passing established by a panel of experts. The purpose of this study was to test the validity and reliability of the Arthroscopic Surgery Skill Evaluation Tool as a pass-fail examination of arthroscopic skill. Methods: Twenty-eight residents and two sports medicine faculty members were recorded performing diagnostic knee arthroscopy on a left and right cadaveric specimen in our arthroscopic skills laboratory. Procedure videos were evaluated with use of the Arthroscopic Surgery Skill Evaluation Tool by two raters blind to subject identity. Subjects were considered to pass the Arthroscopic Surgery Skill Evaluation Tool when they attained scores of ≥3 on all eight assessment domains. Results: The raters agreed on a pass-fail rating for fifty-five of sixty videos rated with an interclass correlation coefficient value of 0.83. Ten of thirty participants were assigned passing scores by both raters for both diagnostic arthroscopies performed in the laboratory. Receiver operating characteristic analysis demonstrated that logging more than eighty arthroscopic cases or performing more than thirty-five arthroscopic knee cases was predictive of attaining a passing Arthroscopic Surgery Skill Evaluation Tool score on both procedures performed in the laboratory. Conclusions: The Arthroscopic Surgery Skill Evaluation Tool is valid and reliable as a pass-fail examination of diagnostic arthroscopy of the knee in the simulation laboratory. Clinical Relevance: This study demonstrates that the Arthroscopic Surgery Skill Evaluation Tool may be a useful tool for pass-fail examination of diagnostic arthroscopy of the knee in the simulation laboratory. Further study is necessary to determine whether the Arthroscopic Surgery Skill Evaluation Tool can be used for the assessment of multiple arthroscopic procedures and whether it can be used to evaluate arthroscopic procedures performed in the operating room.