Operative treatment of femoral shaft fractures in children and adolescents

Although femoral shaft fractures constitute fewer than 2% of all fractures in children and adolescents, their treatment has produced many pieces of literature and years of controversy. Prevailing opinion has favored nonoperative and operative treatment, and a variety of techniques have been advocated to avoid complications such as nonunion, limb-length discrepancy, malalignment, osteonecrosis, and growth disturbance. Currently, operative methods of treatment generally are favored to allow early ambulation and shorter hospital stays and to avoid detrimental psychological and social effects often associated with prolonged nonoperative treatment, and to avoid complications. Options for operative fixation include external fixators, flexible and locked intramedullary nails, and compression and bridge plating. Although all of these can obtain good results in particular situations, there is no clear consensus of the indications for each. My choice for fixation of each fracture is based on consideration of a number of factors, including the age and size of the child, associated injuries, the location and pattern of the fracture, and the social situation of the child. In general, I prefer flexible nailing for younger children (6-10 years old) and locked nailing for adolescents at or near skeletal maturity. Bridge plating may be chosen for segmental, grossly comminuted fractures, whereas external fixation usually is reserved for severely comminuted or severe open fractures for which internal fixation is not appropriate. Level of Evidence: Level V, Expert opinion. See the Guidelines for Authors for a complete description of levels of evidence.