TRAUMA SUPPLEMENT
Flexibility in Fixation: An Update on Femur
Fractures in Children
Unni G. Narayanan, MBBS, MSc, FRCS(C)* and Jonathan H. Phillips, BSc, MBBSw
Abstract: Although non-operative strategies remain a viable
option for the management of some children’s femur fractures,
surgical management has become more popular and predictable,
with potential complications better recognized and thus more
easily avoided. This paper addresses the operative management
of children’s femur fractures highlighting the multiple techni-
ques available to treat the spectrum of pediatric femur fractures.
We present the applications of Elastic Stable Intramedullary
Nailing and Locked intramedullary nailing, sub-muscular or
open plating, and external fixation, and discuss the relative ad-
vantages and shortcomings of each technique. Cases are pre-
sented for illustration.
Key Words: femur fracture, pediatric, children, operative
management, fixation
(J Pediatr Orthop 2012;32:S32–S39)
F ractures of the femur account for the most common
major orthopaedic injury in children.1 Femoral frac-
tures in children are generally perceived to heal satisfac-
torily irrespective of the form of treatment. Unlike adult
femoral fractures that are almost universally treated with
locked intramedullary nails, femoral fractures in children
are treated by a variety of methods including immediate
spica cast or traction followed by spica cast, internal
fixation with compression or bridge plating, external fix-
ation, and flexible or rigid intramedullary nailing. Indeed,
a systematic review of the literature provides little evi-
dence to support one method of treatment over another.2
The choice of treatment may be influenced by the age and
weight of the child, the level and pattern of the fracture,
and to a great extent, by regional, institutional, or sur-
geons’ preferences.3 The ideal treatment method should
From the *Divisions of Orthopaedic Surgery & Child Health Evaluative
Sciences, The Hospital for Sick Children, University of Toronto,
Toronto, ON, Canada; and wArnold Palmer Hospital Pediatric
Specialty Practice, Orlando, FL.
J.H.P. has received royalties and consultancy fees from Biomet for his
design of a flexible locked intramedullary nail for pediatric femur
fractures.
The authors declare no conflict of interest.
Reprints: Unni G. Narayanan, MBBS, MSc, FRCS(C), Divisions of
Orthopaedic Surgery & Child Health Evaluative Sciences, The
Hospital for Sick Children, 555 University Avenue, S-107, University
of Toronto, Toronto, ON, Canada M5G 1X8. E-mail: unni.
narayanan@sickkids.ca.
Copyright r 2012 by Lippincott Williams & Wilkins
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provide adequate stabilization to maximize comfort and
permit early mobilization, minimize caregiving needs,
avoid or minimize scarring, avoid serious complications,
and achieve these goals conveniently and cost effectively.
There is no single classification system of femur
fractures that has shown to have clinical utility. Prog-
nostic factors that will influence decision making include
the age and weight of the child, the level of the fracture
(proximal, middle, or distal), the fracture pattern (trans-
verse, oblique, spiral), magnitude of displacement, extent
of comminution, soft tissue injury including open frac-
tures, and the presence of other significant injuries.
NONOPERATIVE MANAGEMENT
No discussion of the operative management of fe-
mur fractures in children would be complete without a
brief note on the nonoperative methods, the mainstay of
which is the spica cast. Early application of spica cast
after a closed reduction, typically under a general anes-
thetic, remains an effective method of treatment for most
femur fractures in younger children.4–6 The optimal limit
for age, weight, or size has not been well studied, but most
believe that a spica cast is a viable treatment option for
children up to 60 pounds. This method has the advantage
of avoiding any scarring or risk of infection, requires
minimal hospitalization, and, if unsuccessful in maintain-
ing an adequate reduction, does not preclude switching to
an alternate method of treatment. It has the disadvantage
of being associated with a more frequent loss of reduction,
malunion, and shortening.7–10 The spica cast might be less
comfortable to endure especially in summer months and
imposes a greater burden on parents or caregivers for the
duration of the casting.11
METHODS OF FIXATION
Elastic Stable Intramedullary Nailing
The concept of “elastic stability” was popularized in
Nancy, France.12,13 Ligier et al14 reported the results of
the Nancy experience followed by others who have also
reported excellent clinical results with this technique,
which has been variously called “elastic stable intra-
medullary nail” fixation, “flexible intramedullary nail”
fixation, or “Nancy nail” fixation.15,16 Although other
flexible nails preceded the introduction of elastic nails, the
use of titanium and its superior elasticity distinguishes the
technique of elastic intramedullary nailing from previous
flexible nails such as Ender rods, which were made of
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J Pediatr Orthop  Volume 32, Number 1 Supplement, June 2012
FIGURE 1. Transverse mid-diaphyseal fracture in a 10-year-old
child, who weighs 40 kg (88 lbs).
FIGURE 2. A, Advance the nails so that the tips lie along the supracondylar flare of the distal femur, approximately 1.0 to 1.5 cm
outside of the actual bone entry site. B, Five years after insertion, the distal femur has grown away from ends of nails to become
prominent.
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Femur Fracture Fixation in Children
stainless steel. The flexibility of these, narrower and
therefore less rigid, rods facilitated easier introduction of
the nails into the medullary canal. The stability of the
fixation of Enders rods was derived from filling the me-
dullary canal with 2 or more rods to enhance cortical
contact. In contrast, elastic nails create stability when a
pair of prebent nails, of matched diameter and curvature,
generates an equal and opposite pair of 3-point bending
moments that counteract and balance each other. How-
ever, any significant imbalance in the magnitude or the
direction of the moment created by the 2 nails will result
in angulation of the fracture in the direction of the
stronger nail. Hence, it is important to use nails of the
same diameter, contour them to the same extent and in-
sert them so that the curves of both nails lie in the same
plane. The balanced construct provides elastic stability to
angular, translational, and torsional forces. An external
force applied to the fracture will cause the fracture to
bend, translate, or rotate, but when the force is removed,
the elastic nails will return (elastic recoil) the fracture to
its stable reduced position, as long as any external force
applied to the fracture (including body weight or weight
bearing) does not exceed the elastic limit of the nails. The
fixation is not rigid but sufficiently stable so that no
additional external immobilization is required.13
The ideal indication for elastic nails is a minimally
comminuted transverse (or short oblique) mid-diaphyseal
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Narayanan and Phillips J Pediatr Orthop  Volume 32, Number 1 Supplement, June 2012

femur fracture in a 6- to 12-year-old child who weighs
<60 kg (Fig. 1).
The most frequent complication associated with
elastic nails is pain and irritation noted at the nail in-
sertion site.16,17 For this reason, the developers of this
technique recommended routine removal of the elastic
nails after fracture healing and advocated leaving the nail
ends prominent to facilitate subsequent removal. How-
ever, this probably contributed to the irritation over the
prominent nail ends, making removal necessary. It has
been shown that cutting short the ends of the nails and
allowing them to lie against the supracondylar flare of the
distal femur minimizes their prominence and reduces the
rate of nail-site irritation17 (Fig. 2A). Nails should
probably be removed when used in young children, be-
cause the growth of the distal femur away from the ends
of the rods leaves the ends lying much more proximal in
the diaphysis where they become prominent and become a
source of pain and irritation (Fig. 2B). If left in situ, late
removal of these nails will necessitate a second set of more
proximal incisions and extraction can be difficult. Nails
should not be removed until the fracture has consolidated
and remodeled. In older children, it is unclear whether
nails should be routinely removed.
Loss of reduction and or malunion has been asso-
ciated with the severity of comminution (> 25%)17 and
length unstable fractures,18 which remain relative con-
traindications for elastic nailing. However, the use of
elastic nails can be extended to more proximal including
subtrochanteric fractures and some multifragmentary
fractures by modifying the technique to take advantage of
the principles of elastic stability outlined above.19 As the
body weight of older children and adolescents approaches
that of adults, there is a concern that elastic nails may not
provide sufficient stability to prevent loss of reduction.
Moroz et al20 found a 5 times higher risk of poor outcome
in children whose weight was >49 kg. In contrast, in a
more recent study comparing different methods of fixation

FIGURE 3. A 13-year-old boy (skeletally immature) who weighs 65 kg (143 lbs), with isolated closed femoral fracture from a
skiing injury. A and B, Radiographs demonstrate a long spiral, comminuted ( > 75%) fracture of the proximal and mid-diaphysis.
C and D, Postoperative radiographs following antegrade intramedullary nail through trochanteric entry point. E and F, Twelve
months after injury.

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J Pediatr Orthop  Volume 32, Number 1 Supplement, June 2012 Femur Fracture Fixation in Children

of femur fractures in adolescents (n = 194) that included
105 adolescents treated with elastic nails (12 to 18 y) who
had a mean weight of 47.6 kg (up to a maximum 80 kg),
there was no significant association between age and/or
body weight and the rate of complications in the entire
cohort or as well as within the elastic nail group, even after
adjusting for other risk factors.19 In response to these
concerns, some use stainless-steel rods for more rigidity.
Locked Intramedullary Nails
Rigid (locked) intramedullary nailing is the stand-
ard treatment for adult femoral fractures. Conventional

FIGURE 4. A and B, Same fracture as given case example, 1 week after retrograde elastic stable intramedullary nailing. C and D,
Eighteen months after injury with solid healing, before implant removal.

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Narayanan and Phillips
adult nail systems adopted the pirifomis fossa as the in-
sertion site, which has been shown in skeletally immature
children to be associated with a small but devastating risk
of avascular necrosis (AVN).21 This has prompted the
introduction of rigid nails through the tip of the greater
trochanter that does not entirely eliminate the risk. Newer
nails have been designed for antegrade introduction
through a lateral aspect of the greater trochanter. Some of
these have been designed to retain some flexibility al-
lowing for custom contouring to facilitate insertion and
reduction, while allowing for interlocking of the nails to
confer rotational stability.22 These locked nails are ideally
indicated in heavier children and adolescents and those
with comminuted and length unstable fractures who are
not optimal candidates for elastic nailing. In the absence
of any symptoms, there is little evidence to recommend
that locked intramedullary nails should be removed after
the fracture has healed.
Plate Fixation
Rigid internal fixation of femoral fractures in chil-
dren with compression plating necessitates a relatively
large incision to achieve the open reduction and appli-
cation of the plate.21 With the advent of alternatives that
FIGURE 5. A and B, Similar fracture as given case example, after submuscular plating.
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J Pediatr Orthop  Volume 32, Number 1 Supplement, June 2012
can achieve fixation of adequate stability using closed
techniques, plating for femoral fractures has generally
fallen out of favor. More recently, the concept of sub-
muscular plating has reintroduced plating into the ar-
mamentarium of femoral fixation techniques. Advances
in the design, instrumentation, and anatomic fit of inter-
nal fixation plates allows for the percutaneous insertion of
plates deep to the vastus lateralis and extraperiosteally
to bridge the fracture, which can be reduced by indirect
techniques and stabilized with percutaneous screws. Typi-
cally locking screws are used, which allows the submuscular
plate to facilitate biological fixation using minimally in-
vasive techniques.23 This technique is especially useful in
length stable diaphyseal or distal metaphyseal fractures of
the femur.24 In the absence of any symptoms, there is little
evidence to recommend that plates should be removed
after the fracture has healed. Removal of plates may
expose the child to the risk of refracture.
External Fixation
External fixation was once the most popular method
of fixation for children’s femoral fractures.25 In a multi-
centre randomized trial of isolated diaphyseal femur
fractures in children between 6 and 10 years old, external
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FIGURE 6. A, B, and C, Similar fracture treated with monolateral external fixator.
fixation was found to be superior to early spica cast ap-
plication in terms of preventing malunion but was
equivalent in terms of physical function and patient sat-
isfaction.7 Relative to other methods of fixation, however,
external fixation has been associated with a higher risk of
complications including refracture (at the pin sites or
fracture), pin-site infections, delayed union, and unsightly
scars at the pin sites.26 In a comparative cohort study of
different methods of fixation of femur fractures in ado-
lescents, external fixation had the worst record for loss of
reduction and malunion, even after adjusting for prog-
nostic patient and fracture characteristics.19 In younger
children, with stable fracture patterns, it has been re-
placed by elastic nails, and in older children and those
with unstable fracture patterns, it has been replaced by
locked intramedullary nailing and submuscular plating.
Nevertheless, there remains a role for external fixation
of the femur in cases of polytrauma and severe open
fractures.
Case 1
The first case was a 13-year-old boy (skeletally im-
mature) who was 65 kg (143 lbs), with an isolated closed
femoral fracture from a skiing injury. Radiographs
demonstrate a long spiral, comminuted (> 75%) fracture
of the proximal and mid-diaphysis (Fig. 3). This case
illustrates many treatment options that can be considered
with a length unstable femoral shaft fracture in an
adolescent.
The most popular option currently is an antegrade
rigid locked intramedullary nail, using a (lateral) tro-
chanteric entry point to avoid the piriformis fossa and the
risk of AVN of his femoral head (Figs. 3A–D).
Elastic nailing is an option for length unstable
fractures, but outcomes are less predictable than with a
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Femur Fracture Fixation in Children
rigid nail (Figs. 4A–D) Consider using elastic nails with
end caps to prevent shortening.
Submuscular plating is another option for treating
femoral shaft fractures. Although it can be performed
using a minimally invasive technique, submuscular plat-
ing usually requires multiple incisions and can be ex-
pensive if locked screws are used (Figs. 5A, B).
External fixation can also be used to treat
length unstable fractures. It has the advantages of being
quick and easy to apply with extensive dissection
(Figs. 6A–C).
Healing times, however, are longer, and the fixator
should not be removed until the fracture consolidates that
may be at least 4 months. Other disadvantages are more
frequent loss of reduction compared with other methods,
pin-site infections, scarring, knee stiffness, and increased
risk of refracture, either at the fracture site or through a
pin tract.
Case 2
The second case is that of a 9-year-old boy, who is
40 kg (88 lbs), with an isolated closed femur fracture from
a low-energy injury (fall playing soccer). Radiographs
show a long oblique/spiral fracture that is shortened 2 to
3 cm and is rotated B90 degrees (Figs. 7A, B).
Many would recommend treatment with elastic
nails. The patient was treated with a rigid trochanteric
entry nail locked proximally and distally. He was fully
weight bearing by 7 weeks postoperatively and had a
good result without evidence of proximal femoral growth
disturbance or (AVN) (Fig. 7C).
SUMMARY
In 2009, the American Academy of Orthopaedic
Surgeons published their guideline and evidence report
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Narayanan and Phillips
FIGURE 7. A and B, Nine-year-boy old who weighs 40 kg (88 lbs), with closed isolated low-energy injury. Long oblique fracture
shortened 3 cm and rotated. C, The patient was treated with a rigid trochanteric entry nail locked proximally and distally. He was
fully weight bearing by 7 weeks postoperatively and had a good result without evidence of proximal femoral growth disturbance
or avascular necrosis.
for the treatment of pediatric diaphyseal fractures.27 The
quality of the evidence available in current literature
made it impossible to make strong recommendations
about any specific treatment. There is no single technique
that can be universally applied to all femoral shaft frac-
tures in children. Each of these methods has its own set of
advantages and disadvantages and unique risk of com-
plications. Treatment strategy should be individualized to
the child with particular attention to the femur age and
weight, his/her fracture characteristics, and the experience
of the surgeon with a particular method. When >1 viable
solution is available, it is important to include the parents
and child (when possible) in the decision-making process
to take into consideration their preferences based on their
individual judgments of the relative pros and cons of each
option.
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