Fig. 1Length stability is a factor in fixation approach for femoral shaft fractures. Radiographs show (A) a length-stable and (B) a length-unstable fracture.
Courtesy of Texas Scottish Rite Hospital for Children


Published 8/1/2018
Terry Stanton

Pediatric Fractures of the Femoral Shaft: Arriving at the Algorithm

Editor’s note: This article is part two of a three-part series on pediatric trauma based on an AAOS 2018 Annual Meetingsymposium.

There is no single treatment algorithm to guide in the management of fractures of the femoral shaft, said Anthony I. Riccio, MD, of Texas Scottish Rite Hospital for Children, during the AAOS 2018 Annual Meeting Symposium titled “Staying out of Trouble in Pediatric Trauma.”

“There are very few wrong ways to manage these injuries, and the preferred treatment modality is often based on local custom,” Dr. Riccio said. “At my institution, the treatment of a given fracture may be different from the way it’s done at another center because of variability in available implants or experience.”

Treatment guidelines are often based upon age, he said, but “you have to consider the other variables, including weight and fracture stability.” In school-age children, weight may a determining factor in the approach and hardware selection.

The literature provides little definitive guidance, Dr. Riccio said, noting that the AAOS clinical practice guideline on femoral fractures offered just two recommendations (out of 14) backed by good evidence, with the remainder having poor or insufficient evidence. (The two were: For children 36 months or younger, evaluate for abuse; and for children 6 months to 5 years of age, use immediate or delayed spica casting if there is less than 2 cm of shortening.) “Almost 10 years later, we haven’t advanced the literature too much,” he said.

Basic age-based guidelines are as follows:

  • 0 to 6 months: Pavlik harness
  • 6 months to 5 years: spica cast
  • 5 to 11 years: flexible intramedullary (IM) nails
  • 11 years: rigid IM nail

6 months to 5 years

Young children—5 years of age or younger—Dr. Riccio said, “are relatively easy.” At his institution, they are likely to get a spica cast. “Weight doesn’t really come into consideration, nor does length stability,” he said. “You can leave these kids a little short; frequently the fractured side will overgrow a little bit. But before you think about a spica cast, you do have to think about things like associated abdominal trauma or thoracic trauma, whether the child can tolerate a circumferential cast, and whether they were in a motor vehicle collision and have severe road burns and skin conditions that won’t let you put a cast on.” Walking casts may work as well as traditional spicas. “You should be prepared to modify the cast no matter which kind it is,” Dr. Riccio said. “Cast wedging is frequently done in our clinic to improve alignment; we might even put a new cast on as the fracture gets sticky to help maintain or improve alignment.”

The ages from 4 to 6 years are “the in-between age—where people debate whether a cast or nails are better,” Dr. Riccio said. “Studies show no difference in alignment at final union between the two modalities. An advantage of nailing is the patient can move the knee, and it’s probably easier on the family. Spica-cast advocates note that casting doesn’t have the risk of a surgery or carry the potential need for later implant removal.”

5 to 12 years (and older)—or > 60 kg

Fig. 1Length stability is a factor in fixation approach for femoral shaft fractures. Radiographs show (A) a length-stable and (B) a length-unstable fracture.
Courtesy of Texas Scottish Rite Hospital for Children
Fig. 2 Radiographs show a length unstable fracture (A) managed via flexible nailing with distal interlocking screws (B and C).
Courtesy of Texas Scottish Rite Hospital for Children

There are several treatment options for children aged 5 to 12 years, Dr. Riccio said, including:

  • flexible IM nails
  • submuscular plating
  • open plating
  • external fixation (when indicated)

In this cohort, age is “less important than patient weight and fracture stability,” he said. “Kids are getting heavier. Where I am from, in Dallas, diet habits lead to extra weight that can create huge deformity forces that can overcome a more flexible fixation construct.” Length stability is also important, he said, “because if you use IM fixation without some form of a locking construct, the fracture can shorten over the nails.”

Dr. Riccio displayed radiographs of length-stable and length-unstable fractures (Fig. 1).

For length-stable fractures, he considers flexible nailing to be the gold standard. “Kids can weight bear on these fractures early, but you have to consider weight. Once kids are 60 kg or more, even the transverse fractures can bend into sagittal coronal plane angulation, because even if the children are compliant with toe-touch weight bearing, they are putting a huge amount of deforming force across the construct,” he said.

Both titanium and stainless steel nails have been shown to be good options for fixation. Stainless steel nails, due to increased rigidity, have been shown to extend the indication of flexible nailing to heavier children.

Length-unstable fractures historically have carried a higher complication rate with non-locking flexible implants, “mostly because fracture shortening drives the nails distally, sometimes resulting in protrusion out the incision and frequently loss of alignment,” Dr. Riccio said. “Adding a distal interlocking mechanism can prevent that shortening; however, the end caps that are available for the titanium nails—the most commonly used type—biomechanically have been shown not to provide significant axial stability.”

Dr. Riccio’s preferred hardware for flexible nailing is Ender nails, which are stainless steel and have outlets at the distal end through which 2.7 mm screws can be placed to provide length stability (Fig. 2). “I reserve submuscular plating for more distal fractures,” he said.

In older children and those heavier than about 60 kg, regardless of age, “we want to think about rigid IM nails.”

The general algorithm for femoral shaft fractures is as follows:

  • In children younger than 5 years of age, “consider a spica cast unless there is some reason you can’t do it.”
  • In children aged 5 to 11 years who weigh less than 55 to 60 kg, “ask yourself [if the] length [is] stable or not. If it is, flex nails are the gold standard; if not, you want something that confers axial stability—either flexible stainless nails locked distally, submuscular plating, or locked rigid IM nail.”
  • In adolescents older than 12 years of age and who weigh more than 55 kg, “think about using a rigid IM nail. Understand that the location within the diaphysis will also guide your treatment.”

Terry Stanton is the senior science writer for AAOS Now. He can be reached at


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