Pediatric Femur Fractures: Flexible Nail, Plate, or Rigid Nail

Pediatric diaphyseal femur fractures are a fairly common fracture type for which all trained orthopaedic surgeons should develop a treatment framework. Treatment goals are to restore an acceptable limb length, alignment, and rotation. Nuances exist regarding acceptable tolerances depending on the age and remaining growth of the patient. Various treatment modalities exist, including flexible nailing, plate fixation, and rigid nail fixation, each with its own advantages, disadvantages, and limitations. Proper identification of key patient factors and fracture type is important for optimal decision making regarding fixation modality. Flexible nailing is typically reserved for patients age 5 to 11 years with stable fracture patterns and who weigh less than 100 lb. Plate fixation, typically via a submuscular application, is typically indicated in patients with unstable fractures and can be a reasonable choice for patients older than 5 years with no weight limitation. Rigid nail fixation, specifically antegrade nailing via a lateral-entry starting point, can be indicated in patients older than 11 years with any fracture pattern. Understanding how each fracture and patient factor affects healing can help the savvy surgeon choose which fixation modality to use when the clinical situation inevitably falls in the gray zones shared by multiple modalities.