The proximal tibia is the preffered insertion site, however alternatives exist and can be used in special situations, such as tibia fractures. Alternative sites for insertion include the distal tibia and femur. The distal tibia may be entered 1-2 cm superior to the medial malleolus. The landmarks for femoral insertion are the lower third of the femur, approximately 3 cm above the lateral femoral epicondyles. This slight angulation will minimize the risk of trauma to the growth plate.
Cellulitis overlying the insertion site is a relative contraindication.
An inferior vena caval injury is also a relative contraindication as the fluid infused be able to drain into the central circulation. If this injury is suspected, central venous access superior to the injury is preferred. Use of intraosseous infusion in the pediatric trauma patient. Textbook of Pediatric Emergency Procedures. Medicine is a constantly changing science and not all therapies are clearly established.