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- See:
      - Avascular Necrosis of Femoral Head
      - IM Nailing of Pediatric Femur Fractures

- Discussion:
    - AVN may not appear for one year or more after IM Nailing of the femoral shaft;
    - more common in young adolescents undergoing IM nailing of femoral shaft frx, due to vulnerable blood supply of the pediatric femoral head;
           - in these patients, the femoral physis impedes collateral circulation from the vessels of the ligamentum teres;
                  - hence, damage to the posterior branch of the MFCA
    - to avoid disruption of the femoral head vascular supply, some surgeons will insert the IM nail thru the greater trochanter;
           - insertion of the nail lateral to the piriformis fossa may lead to varus angulation at the frx site unless the nail is specifically designed to be inserted thru the greater trochanter (such as Kuntscher Nails);
           - alternatively, consider canal entry just anterior to the piriformis fossa;
    - coxa valga may be a risk factor for AVN;

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         - 13-year-old male sustained femoral shaft frx which was treated w/ IM nail;
         - one year later the patient developed AVN (the nail was subsequently removed)

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Osteonecrosis of the Femoral Head after Intramedullary Nailing of a Fracture of the Femoral Shaft in an Adolescent.

Femoral head avascular necrosis associated w/ intramedullary nailing in an adolescent.