Review Article

Intramedullary Nailing of Pediatric

Femoral Shaft Fracture

Abstract
Harish S. Hosalkar, MD Intramedullary nail fixation of pediatric long bone fracture,
Nirav K. Pandya, MD particularly femoral shaft fracture, has revolutionized the care and
outcome of these complex injuries. Nailing is associated with a
Robert H. Cho, MD
high rate of union and a low rate of complications. Improved
Diana A. Glaser, MD understanding of proximal femoral vascularity has led to changes
Molly A. Moor, MPH in nail insertion methodology. Multiple fixation devices are
Martin J. Herman, MD available; selection is based on fracture type, patient age, skeletal
maturity, and body mass index. A thorough knowledge of anatomy
and biomechanics is required to achieve optimal results without
negatively affecting skeletal development.

F emoral shaft fracture is among

From the Department of
Orthopaedic Surgery, University of
California, San Diego School of
Medicine and Rady Children’s
Hospital San Diego, San Diego, CA
(Dr. Hosalkar, Dr Pandya, Dr. Cho,
Dr. Glaser, and Ms. Moor), and the
Department of Orthopedics, St.
Christopher’s Hospital for Children,
Philadelphia, PA (Dr. Herman).
J Am Acad Orthop Surg 2011;19:
472-481
Copyright 2011 by the American
Academy of Orthopaedic Surgeons.
the most common reasons for in-
patient admission; estimated annual
incidence is 19.5 per 100,000
children.1-3 Multiple treatment mo-
dalities are available, including Pav-
lik harness, spica cast, skeletal trac-
tion, external fixation, submuscular
plating, flexible intramedullary (IM)
nailing, and rigid trochanteric entry
IM nailing. Factors to consider in de-
termining treatment include patient
age, weight, skeletal maturity, social
situation (ie, involvement of caregiv-
ers, child abuse), fracture location,
mechanism of injury, and the pres-
ence of concomitant injuries.
In 2009, the American Academy of
Orthopaedic Surgeons (AAOS) re-
leased a clinical practice guideline on
the management of pediatric diaphy-
seal femoral fracture.4 In patients
aged ≤6 months, treatment with a
Pavlik harness or spica cast is an op-
tion. However, spica casting is asso-
ciated with an increased incidence of
skin breakdown.5 The AAOS guide-
line suggests performing early spica
casting in children aged 6 months to
5 years with diaphyseal femoral frac-
tures demonstrating <2 cm of short-
ening on initial postinjury radio-
graphs. Flexible IM nailing is
recognized as a treatment option in
children aged 5 to 11 years. Pro-
posed advantages of flexible nailing
compared with spica casting and ex-
ternal fixation are shorter time to
weight bearing (as tolerated) and re-
turn to activity.6-8 Rigid trochanteric
entry nailing, submuscular plating,
and flexible IM nailing are options in
patients aged ≥11 years; however, no
studies have directly compared all
three treatment methods. The AAOS
work group noted a lack of high-
quality evidence regarding the use of
these devices. As use of these devices
increases, it is imperative to deter-
mine the role of IM fixation in man-
aging pediatric femoral shaft frac-
ture.
Anatomic and Biologic
Considerations
Vascular Anatomy
Understanding of femoral head vas-
cularity, as well as the anatomy of
the hip joint and capsular structures,
has been clarified by the extensive

472 Journal of the American Academy of Orthopaedic Surgeons

 Harish S. Hosalkar, MD, et al

Figure 1 posterior to the obturator externus

tendon and anterior to the superior
gemellus, obturator internus, and in-
ferior gemellus tendons. The MFCA
has two central and five peripheral
anastomoses. The peripheral anasto-
moses are extracapsular; the largest
branch is located along the inferior
border of the piriformis. Damage to
these branches can have a disastrous
effect on the developing femoral
head (eg, osteonecrosis, collapse).
Therefore, these branches must be
left intact to prevent iatrogenic com-
plications and disability.10-13 Kalhor
et al14 demonstrated that the hip cap-
sule also receives contributions from
the medial and lateral circumflex ar-
teries distally and the superior and
inferior gluteal arteries proximally.
Because these branches of the MFCA
are close to the piriformis fossa, the
use of nails with a piriformis starting
A, Intraoperative photograph of the proximal femur demonstrating the point is associated with a risk of
perforation of terminal subsynovial branches of the medial femoral circumflex proximal femoral osteonecrosis in
artery (MFCA) into bone. These branches are located on the posterosuperior the pediatric population.10-13
aspect of the femoral neck and penetrate the bone 2 to 4 mm lateral to the
bone-cartilage junction. B, Schematic diagram showing the femoral head (1), Rhinelander15 demonstrated in an
gluteus medius (2), deep branch of the MFCA (3), terminal subsynovial animal model that the femoral blood
branches of the MFCA (4), insertion of the gluteus medius tendon (5), supply is two thirds endosteal and
piriformis tendon insertion (6), lesser trochanter with nutrient vessels (7),
one third periosteal. The normal di-
trochanteric branch (8), branch of the first perforating artery (9), and
trochanteric branches (10). (Panel A reproduced and panel B redrawn with rection of blood flow is centrifugal
permission from Gautier E, Ganz K, Krügel N, Gill T, Ganz R: Anatomy of the (ie, from the center outward). In
medial femoral circumflex artery and its surgical implications. J Bone Joint Rhinelander’s study, disruption of
Surg Br 2000;82[5]:679-683.)
endosteal vascularity resulted in cen-
tripetal blood flow.15

work of Ganz and colleagues.9 Blood
supply to the femoral head is deliv-
ered by the deep branch of the
medial femoral circumflex artery
(MFCA). This branch divides into
two to four superior retinacular ves-
sels and, in some cases, inferior reti-
nacular vessels9 (Figure 1). The
MFCA is composed of five branches:
superficial, ascending, acetabular, de-
scending, and deep. The primary par-
tition of the deep branch traverses
Femoral Growth
Understanding femoral remodeling
potential and vascularity in relation
to femoral growth in the pediatric
population is essential when consid-
ering IM nailing for the management

Dr. Hosalkar or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of and
serves as a paid consultant to or is an employee of Synthes; has received research or institutional support from Zimmer; and has
stock or stock options held in GlaxoSmithKline, Johnson & Johnson, and Pfizer. Dr. Glaser or an immediate family member has
received research or institutional support from Alphatec Spine, EOS Imaging, the Scoliosis Research Society, Growing Spine
Foundation, KCI, K2M, Naval Medical Center San Diego, the Pediatric Orthopaedic Society of North America, and Riverside County
Regional Medical Center. Dr. Herman or an immediate family member serves as a board member, owner, officer, or committee
member of the American Academy of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America; serves as a
paid consultant to or is an employee of Lanx; and is a member of the editorial or governing board of the Journal of Pediatric
Orthopaedics. None of the following authors or any immediate family member has received anything of value from or owns stock in a
commercial company or institution related directly or indirectly to the subject of this article: Dr. Pandya, Dr. Cho, and Ms. Moor.

August 2011, Vol 19, No 8 473

Intramedullary Nailing of Pediatric Femoral Shaft Fracture
Figure 2
Schematic illustration demon-
strating the ideal entry point for
elastic intramedullary nailing at the
distal femur. The nail is begun
approximately 2.5 cm proximal to
the physis.
of femoral shaft fracture. Most fem-
oral growth occurs at the distal fem-
oral physis, at a rate of approxi-
mately 10 mm per year.16,17 In
contrast, the proximal femoral
physis contributes <4 mm of growth
per year.16,17 Injury to the distal and
proximal physes could cause growth
arrest and angular deformity and
thus must be avoided. In children
and adolescents, IM nailing is predi-
cated on physeal avoidance, particu-
larly when selecting the nail entry
point (Figure 2).
Trochanteric Growth
To avoid osteonecrosis in skeletally
immature patients, the IM nail
should be started at the tip of the
greater trochanter rather than at the
piriformis fossa, away from the arte-
474
Figure 3
A, Schematic illustration demonstrating the lateral trochanteric intramedullary
nail entry position in relation to the proximal femoral perforators. The shaded
zone marks the tract for the nail beyond the offset lateral trochanteric entry.
B, Photograph demonstrating the trochanteric entry position (arrow) in a
model of the proximal femur in the frontal plane. The lateral trochanteric
entry point is offset approximately 12° to the anatomic axis of the femur (a).
rial supply. However, insertion of the
nail through the tip of the greater Surgical Timing
trochanter carries the risk of proxi-
In contrast to adult patients, no con-
mal femoral valgus, femoral neck
sensus exists regarding optimal tim-
narrowing, and greater trochanteric
ing of femoral shaft fracture fixation
physeal arrest.18-20 At birth, the prox-
in pediatric patients with poly-
imal femoral physis is combined,
trauma. Loder24 reported that pediat-
consisting of both the femoral head
ric polytrauma patients who under-
and the greater trochanter. Between
went early fracture stabilization (≤72
ages 1 and 4 years, a split occurs in
this growth zone, with delineation of hours postinjury) required shorter
the femoral head, physis, and tro- stays in intensive care and in the hos-
chanteric apophysis.21,22 It is believed pital as well as decreased time on
that a portion of the physis remains ventilator support. In contrast, Hed-
along the lateral aspect of the femo- equist et al25 reported that timing of
ral neck after the split.23 Damage to fracture stabilization did not appear
this growth zone can occur during to affect the prevalence of pulmo-
nailing through the tip of the tro- nary complications in pediatric
chanter, which may lead to complica- trauma patients.
tions.19 Current fixation techniques We believe that definitive fixation
favor a lateral trochanteric entry (ie, IM nailing) should be performed
point, which avoids the risk of proxi- in the pediatric polytrauma patient
mal femoral deformity and osteone- who is medically stable. Temporary
crosis (Figure 3). stabilization (eg, external fixation,
Journal of the American Academy of Orthopaedic Surgeons

traction) is used in patients who are
not sufficiently stable to undergo de-
finitive fixation. Conversion to IM
nailing from external fixation is safe;
however, it should be performed
within 2 weeks of injury to avoid
complications (eg, infection).26
Surgical timing of definitive fixa-
tion of open femoral shaft fractures
in the pediatric population remains
controversial. In a retrospective mul-
ticenter study of 554 open pediatric
fractures, Skaggs et al27 noted that
the rate of acute infection was simi-
lar regardless whether surgery was
performed within 6 hours or ≥7
hours after injury (3% versus 2%,
respectively). However, only 37 of the
554 fractures were open femoral frac-
tures, and the authors did not indicate
how many of those were diaphyseal.
Based on these data, it is difficult to
draw clinically significant conclusions
regarding the timing of surgical fixa-
tion of open femoral shaft fractures.
Timing of surgical fixation should be
individualized based on sound clinical
judgment following thorough patient
evaluation.
Vascular injury in combination
with femoral shaft fracture is rare in
the pediatric population.28 Immedi-
ate surgical intervention in consulta-
tion with a vascular surgeon is rec-
ommended in the patient with
suspected vascular injury.
Biomechanics of Flexible
Nailing
Material Considerations
Steel is a stiffer material than tita-
nium (modulus of elasticity, 200 and
110 GPa, respectively).29-31 Although
titanium has greater flexibility than
steel, titanium IM nails have been
shown to provide better biomechani-
cal stability than stainless steel nails
in torsion and axial compression.29,32
Titanium nails also provide better
gap closure and decreased nail slip-
August 2011, Vol 19, No 8
page. Axial compression stiffness
was found to be substantially greater
with titanium nails than with steel
nails (approximately 900 N/mm and
500 N/mm, respectively).29 At distal
femoral insertion sites, steel nails fail
under an axial compressive force of
only 185 N, which corresponds to
approximately 40% of the body
weight of a child weighing 45 kg.33
The better biomechanical stability
offered by titanium may be due to its
greater flexibility, which results in a
lower stress level and increased con-
tact with the canal walls.32
In contrast, Wall et al34 reported
better clinical outcomes with stain-
less steel elastic nails than with tita-
nium elastic nails in children with
femoral fracture. Fifty-six children
were treated with titanium elastic
nails, and 58 were treated with stain-
less steel elastic nails. Children in the
titanium nail group had a malunion
rate nearly four times that of chil-
dren in the stainless steel nail group
(23.2% and 6.3%, respectively). The
rate of major complications (eg, nail
irritation requiring revision surgery,
infection, delayed union, rod break-
age) was higher in the titanium nail
group than in the stainless steel nail
group (35.7% and 16.7%, respec-
tively). Based on these findings, in
addition to the lower cost of stainless
steel nails, the authors concluded
that stainless steel nails are clinically
superior to titanium nails. There is
no consensus in the literature regard-
ing which type of elastic nail is clini-
cally superior, and pediatric femoral
shaft fractures continue to be man-
aged successfully with both types of
nail.
Nail Dimensions
Factors to consider when selecting
the type and number of nails needed
to maximize stability include biome-
chanical properties, ease of use, abil-
ity to achieve fracture reduction, and
Harish S. Hosalkar, MD, et al
restoration of rotational alignment.
Various nail diameter combinations
and asymmetric combinations of
nails have been studied. A three-nail
configuration has been evaluated, as
well. The authors of a biomechanical
study of flexible IM nails reported
that combinations of single nails
with diameters measuring >40% of
the canal width prevented fracture
reduction and resulted in posterior
gapping.35 The use of two nails with
a combined diameter equal to 80%
of the IM canal at its narrowest
width has been recommended.36,37
Typically, surgeons are taught to use
two flexible nails of identical diame-
ter for fracture fixation. Although
combinations of large-diameter nails
(ie, >40% of the canal width) can re-
sult in greater stiffness, they present
an increased risk of fracture malre-
duction, posterior gapping, and rota-
tional malalignment.35
Biomechanical Properties
Poor clinical outcomes have been re-
ported in patients weighing >49 kg
who underwent femoral shaft frac-
ture fixation with titanium nails.36,38
In one study, increased sagittal angu-
lation was related to patient weight
and the diameter of the implanted ti-
tanium elastic nails.36 Moroz et al38
reported similar results, indicating a
correlation between poor outcome
and age ≥11 years and weight >49
kg.
Biomechanical studies support clin-
ical findings that titanium elastic
nails should not be used in patients
weighing >40 to 45 kg. Loads of ap-
proximately ≥600 N lead to struc-
tural sagittal and coronal deforma-
tion of the nails caused by loss of
fracture reduction in those planes.39
We prefer to use titanium nails for
patients aged <11 years who weigh
<45 kg. In patients aged <11 years
who weigh >45 kg, we use stainless
steel flexible nails.
475
Intramedullary Nailing of Pediatric Femoral Shaft Fracture
Figure 4
Schematic illustration
demonstrating relative fixation
points (arrows) of retrograde (left)
and antegrade (right) elastic nailing
in the pediatric femur.29 (Repro-
duced with permission from Mahar
AT, Lee SS, Lalonde FD, Impelluso
T, Newton PO: Biomechanical com-
parison of stainless steel and tita-
nium nails for fixation of simulated
femoral fractures. J Pediatr Orthop
2004;24[2]:638-641.)
Antegrade Versus
Retrograde Stabilization
Fricka et al40 noted that antegrade
stabilization of mid diaphyseal frac-
ture with one C-shaped and one
S-shaped nail demonstrated 69%
greater load at 5 mm of compression
than did retrograde stabilization
with two C-shaped nails (417 N and
247 N, respectively). These forces
correspond to 95% and 55%, re-
spectively, of the body weight of a
child weighing 45 kg.40,41 However,
retrograde fixation of mid diaphy-
seal fractures provides significantly
higher torsional and bending stiff-
ness than does antegrade nailing
(350 ± 72 N/mm and 195 ± 95
N/mm, respectively; P = 0.02)40,42
(Figure 4).
In biomechanical studies, retro-
476
grade nailing has been shown to be
less stable than antegrade nailing in
resisting shortening. When maximal
axial stability is required, proximal
insertion of C- or S-shaped nails is
recommended. Retrograde insertion
is routinely used for elastic nail inser-
tion because it is technically easier
than antegrade nailing. Additionally,
it provides better torsional stability
and greater surgeon comfort because
fewer vital structures are located in
the area of surgical dissection.
Surgical Management
Flexible Nailing
Compared with external fixation of
closed fractures, flexible nailing is as-
sociated with decreased time to full
weight bearing, full range of motion
(ROM), and return to school; in ad-
dition, flexible nailing is associated
with a lower incidence of complica-
tions (eg, pain, limb-length discrep-
ancy, malalignment).6 Salem and
Keppler43 prospectively studied 68
children who underwent elastic sta-
ble IM nailing for unilateral femoral
shaft fracture to evaluate for early
angular or rotational malalignment
and limb-length discrepancy (mean
age, 5.6 years; average weight, 21
kg). The authors concluded that elas-
tic stable nailing can provide satis-
factory results in terms of limb
length and axial alignment. How-
ever, in 32 children, they noted a
high rate of torsional malalignment
(≥15°).26
External fixation is an option in
medically unstable patients and in
patients with extensive soft-tissue in-
juries and/or neurovascular injuries
that require repair or reconstruc-
tion.44 We recommend flexible nail-
ing in children aged 5 to 11 years.
Our preferred technique is retro-
grade titanium elastic nailing with
the patient in a supine position on a
radiolucent flat-top operating table.
Journal of the American Academy of Orthopaedic Surgeons
The procedure can be performed on
a fracture table, as well. Prior to
prepping, the patient’s position is ad-
justed to allow adequate space for
the image intensifier. The leg is held
elevated off the table and prepped in
the standard fashion from the iliac
crest to the toes. We prefer to use a
radiolucent triangle for knee flexion
and ease of fracture reduction. Alter-
natively, a bolster or a bump may be
used.
The starting point is approximately
2.5 cm above the distal femoral
physis. Deep dissection in the area of
the distal femoral physis should be
avoided to decrease the chance of
growth arrest. Deep posterior dissec-
tion should be avoided to prevent in-
jury to the posterior neurovascular
structures. The entry point may be
made with a drill bit and a drill
guide sleeve to protect the soft tis-
sues. The tip of the nail is sharp
enough to negotiate the bone in the
area of the metaphysis. Medial and
lateral nails are inserted at the same
level in the AP and lateral planes.
Both nails should be introduced up
to the fracture site, but short of the
fracture line.
Fracture reduction is performed
with appropriate maneuvering (ie,
knee flexion, traction, muscle relax-
ation) and the use of an F-shaped re-
duction device (ie, F tool), if neces-
sary. Close attention should be paid
to rotational and angular alignment.
One at a time, titanium elastic nails
are advanced beyond the fracture
site. Nails are rotated such that the
concavities face each other and re-
main symmetric. In slightly proximal
diaphyseal fractures, better torsional
and rotational stability can be
achieved when one nail is progressed
into the region of the inferior neck
and the other into the trochanter.
Only 1 to 1.5 cm of the nail should
remain outside the bone. End caps
may be used. To avoid soft-tissue ir-
ritation, the nail tip should not be

Figure 5
AP radiograph demonstrating
fixation failure and fracture
displacement following elastic
intramedullary nailing to repair an
unstable comminuted femoral shaft
fracture in an 8-year-old patient.
bent away from the metaphysis. Ro-
tational stability and good cortical
apposition should be confirmed
prior to leaving the operating room.
A knee immobilizer or cast may be
required for additional stability.
Rigid Nailing
Flexible nailing must be done care-
fully in patients aged >11 years who
weigh >49 kg and who present with
very proximal and/or very distal
fractures and/or unstable commi-
nuted or long oblique fracture pat-
terns (Figure 5). In these cases, either
flexible nailing should be supple-
August 2011, Vol 19, No 8
Figure 6
Clinical photograph demonstrating
lateral patient positioning on a
radiolucent table for antegrade
trochanteric rigid nailing of a
femoral shaft fracture. This
technique is preferred by the senior
author (H.S.H.).
mented with adjunctive bracing,
casting, or prolonged immobiliza-
tion, or an alternative fixation device
(eg, rigid trochanteric entry nail)
should be inserted.
No study has compared rigid tro-
chanteric entry nailing with flexible
nailing. We believe that regardless
whether a patient has an unstable
comminuted or oblique fracture,
rigid nails are appropriate for pa-
tients aged >11 years who weigh >49
kg. We recommend the lateral tro-
chanteric approach to avoid the risks
associated with starting at or near
the piriformis and near the tip of the
trochanter.19 Keeler et al19 reported
excellent results in a retrospective re-
view of 78 patients (80 fractures)
treated with IM nail fixation through
the lateral aspect of the greater tro-
chanter. There were no reported non-
unions, delayed unions, malunions,
osteonecrosis, or clinically important
femoral neck valgus or narrowing.
High-quality data are lacking re-
garding pediatric patient positioning
Harish S. Hosalkar, MD, et al
and the type of table required for op-
timal femoral shaft fracture fixation
with rigid nails, but translational
studies from the adult literature are
instructive. A fracture table affords
the surgeon the ability to perform
the procedure with fewer assistants,
and it allows circumferential access
to the leg. Disadvantages associated
with the use of a fracture table in-
clude the risk of compartment syn-
drome of the well leg and increased
risk of rotational malalignment re-
sulting from limited access to the
contralateral leg.45,46 These complica-
tions, particularly internal rotational
malalignment, can be avoided with
the use of a radiolucent table; surgi-
cal time can be reduced, as well.47
Supine versus lateral patient posi-
tioning on a radiolucent table has
also been studied. Physician prefer-
ence is a significant factor in deter-
mining patient positioning. However,
the surgeon should have knowledge
of both positioning techniques be-
cause patient factors may preclude
the use of one or the other. Advan-
tages of the supine position include
ease of patient positioning and ad-
ministration of anesthesia. Addition-
ally, rotational malalignment of the
distal fragment is more easily identi-
fied with the patient supine. Accu-
rate identification of the entry point
and proximal insertion of instrumen-
tation can be challenging, particu-
larly in patients with a high body
mass index (eg, >30). Lateral posi-
tioning offers improved access to the
trochanteric starting point, particu-
larly in obese patients. This allows
access to the limb from both sides
and easier lateral imaging of the fem-
oral head and neck (Figure 6). The
lateral trochanteric starting point is
in a more accessible location, which
may make pediatric rigid nail inser-
tion easier (Figure 7). The senior au-
thor (H.S.H.) prefers to perform
femoral nailing on a radiolucent flat-
top table with the patient in the
477
Intramedullary Nailing of Pediatric Femoral Shaft Fracture

Figure 7 mally for ease of nail removal, if nec-

essary.

Open Fracture
When managing open femoral shaft
fractures in children and adolescents,
it is important not to underestimate
the amount of energy required to
create an open fracture. Immediate
IM nailing with flexible or rigid nails
is appropriate in patients with open
fractures in whom the external
wound can be closed and adequate
débridement performed. IM nailing
of extensive open injuries should be
carefully considered on an individual
basis because these injuries are asso-
ciated with longer time to union and
a higher complication rate.1
AP radiographs demonstrating a low subtrochanteric femoral fracture (A) and The decision to perform immediate
fracture fixation with an adolescent trochanteric entry nail (B) in a 13-year-old or delayed nailing depends largely on
boy. The patient returned to full function and range of motion 10 weeks the status of the soft tissues (ie,
postoperatively and to competitive sports 16 weeks postoperatively. C, AP
radiograph obtained 2 years postoperatively demonstrating complete healing whether closure is possible or soft-
with remodeling and no evidence of osteonecrosis. tissue coverage is required), the sta-
tus of the wound bed, the presence
of concomitant vascular injury
lateral decubitus position. the starting position lateral to the tip and/or bone loss, and the fracture
Antegrade titanium elastic nailing of the trochanter. Guide pin position pattern. External fixation should be
can be performed with the patient in can be confirmed radiographically. performed if soft-tissue coverage
a supine or lateral decubitus posi- Use of a guide pin requires the addi- cannot be achieved and/or the
tion. Advantages of using a radiolu- tional step of using a cannulated wound is grossly contaminated.
cent flat-top table include ease and drill. A ball-tip guidewire with a sub- Conversion to definitive fixation can
speed of setup, ease of imaging, and tle bend, placed at the end prior to be done when wound coverage can
the ability to perform multiple sur- insertion, is used to facilitate passage be obtained. In the interim, the
geries simultaneously in a poly- at the fracture site and positioning in wound can be managed with an anti-
trauma patient. We prefer to use hip the distal femur. Following fracture biotic bead pouch and/or a vacuum-
positioners rather than bean bags for reduction, the guidewire is advanced assisted closure device. Repeat irriga-
lateral positioning. distally, with care taken not to pene- tion and débridement should be done
The leg is held elevated off the ta- trate the distal femoral physis. When every 48 to 72 hours until definitive
ble and prepped in the standard fash- reaming is preferred, it is initiated soft-tissue coverage is achieved.
ion from iliac crest to toes. A 5-cm using the smallest end-cutting reamer
incision is made over the tip of the and progresses to the desired width
greater trochanter in line with the (typically 1 to 1.5 mm greater than Postoperative Care
femoral shaft. The fascia and abduc- the nail diameter). The nail is in-
tor muscles are split longitudinally to serted. For trochanteric entry nails Immobilization and Weight
expose the proximal trochanter. The with a built-in anterior bow, nail in- Bearing
trochanter is most prominent in the sertion is started with the convexity No consensus exists in the literature
lateral position, and exposure is easy. of the bow medial; then it is exter- regarding postoperative immobiliza-
Anterior and posterior margins of nally rotated to anatomic position. tion and the optimal progression of
the trochanter are palpated, and care Proximal and distal interlock screws weight bearing following IM fixation
is taken to protect the posterior ves- are placed in a standard fashion. We of pediatric femoral shaft fracture. In
sels. An awl or guide pin is placed in prefer to place an end cap proxi- particular, consensus is lacking re-

478 Journal of the American Academy of Orthopaedic Surgeons


garding the use of flexible nails,
which act as a load-sharing internal
splint. Flynn et al37 found that use of
a knee immobilizer until a callus is
visible radiographically (ie, approxi-
mately 4 to 6 weeks postoperatively)
helped to limit pain, provided sup-
port to legs with weak quadriceps
muscles, and led to decreased soft-
tissue irritation at the knee. In pa-
tients with questionable stability (ie,
unstable fracture pattern, question-
able fixation quality, uncertain pa-
tient compliance), 1 to 2 months in a
hip spica cast or a hinged knee-
ankle-foot orthosis was found to be
a viable supplement to treatment. In
a series of 39 patients treated with
flexible IM nails, Luhmann et al36
used postoperative immobilization in
patients with fracture comminution,
a narrow canal diameter that pre-
cluded adequate fracture stabiliza-
tion with the nail, and significant
soft-tissue stripping. (Increased pa-
tient size was not indicated as a rea-
son for postoperative immobiliza-
tion.) Patients were immobilized
with either a one and one-half leg
spica cast or a hinged knee-ankle-
foot orthosis until a callus was visi-
ble radiographically (20 days after
fracture). Immobilization is rare fol-
lowing fixation with rigid nails be-
cause this construct provides im-
proved canal fill and the strength of
a statically locked, rigid implant.19
Immediate postoperative weight
bearing and weight-bearing progres-
sion must be individualized, regard-
less which nail type is used for fixa-
tion. Once callus formation has
begun and radiographic and clinical
signs of progressive healing are evi-
dent, the patient is allowed to pro-
gress to full weight bearing.
Physical Therapy and
Return to Athletic Activity
Given the lack of evidence regarding
postoperative physical therapy fol-
August 2011, Vol 19, No 8
lowing management of pediatric
femoral shaft fracture, the AAOS
clinical guideline work group was
unable to recommend for or against
physical therapy to improve func-
tion.4 We recommend physical ther-
apy for patients who lag behind their
similarly treated counterparts in
terms of ROM, strength, and nor-
malization of gait.
Children and adolescents are in-
creasingly involved in athletics, and
determining when a patient can re-
turn to athletic activity is of para-
mount importance. The clinician
may therefore be inclined to pre-
scribe physical therapy to speed the
progression of ROM, strength, and
proprioception. In our protocol, re-
turn to sport occurs approximately
12 to 16 weeks after fixation, fol-
lowing solid bone healing with opti-
mized muscle strength and motion.
Implant Removal
Implants that cause soft-tissue irrita-
tion or pain, knee effusion, or loss of
knee ROM may be removed after
callus formation has occurred and
the fracture line is no longer visible
radiographically.1 The AAOS work
group could not recommend for or
against implant removal in asymp-
tomatic patients following manage-
ment of diaphyseal femur fracture.4
Other than soft-tissue irritation, few
complications have been reported in
association with retained implants in
the pediatric population. However,
premature implant removal can lead
to refracture.8 Implant removal, par-
ticularly removal of rigid nails, is as-
sociated with a risk of osteonecrosis
in the proximal femur in the setting
of extensive dissection.11
Summary
IM fixation of femoral shaft fracture
in children and adolescents has
changed substantially with improved
Harish S. Hosalkar, MD, et al
understanding of proximal femoral
vascularity. Typically, IM nailing is
associated with high union rates and
low complication rates. In children
aged 5 to 11 years, good results can
be obtained with elastic or flexible
retrograde nailing. Typically, rigid
nailing is reserved for the juvenile
patient with a high body mass index
(eg, >30) or the adolescent patient
(ie, aged ≥11 years).
Selection of a fixation method is
based on several factors, including pa-
tient age, body habitus, and femoral
morphology, as well as fracture char-
acteristics, the presence of associated
injuries, and the surgeon’s preferred
nailing technique. Other important
technical considerations include intra-
operative patient positioning, use of
traction or a fracture table, and poten-
tial IM reaming. Adherence to metic-
ulous surgical technique, particularly
nail starting point, reduction, and ro-
tational alignment, is of paramount im-
portance. Carefully planned and well-
executed IM fixation, followed by early
mobilization, is an effective and well-
accepted modality for managing fem-
oral shaft fracture in the pediatric
population.
Acknowledgment
The authors thank J. D. Bomar for
his assistance with the creation and
modification of illustrations and im-
ages.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 9,
11, 14, 15, 21, 22, 29, 31-33, 35,
39-42, 44, 45, and 47 are level I
studies. References 6 and 38 are level
II studies. References 1-5, 7, 8, 17-
19, 23-25, 27, 34, 36, and 37 are
level III studies. References 10, 12,
479
Intramedullary Nailing of Pediatric Femoral Shaft Fracture
13, 20, 26, 28, and 46 are level IV
studies. Reference 16 is level V ex-
pert opinion.
References printed in bold type are
those published within the past 5
years.
1. Flynn JM, Schwend RM: Management
of pediatric femoral shaft fractures. J Am
Acad Orthop Surg 2004;12(5):347-359.
2. Hinton RY, Lincoln A, Crockett MM,
Sponseller P, Smith G: Fractures of the
femoral shaft in children: Incidence,
mechanisms, and sociodemographic risk
factors. J Bone Joint Surg Am 1999;
81(4):500-509.
3. Poolman RW, Kocher MS, Bhandari M:
Pediatric femoral fractures: A systematic
review of 2422 cases. J Orthop Trauma
2006;20(9):648-654.
4. Kocher MS, Sink EL, Blasier RD, et al:
Treatment of pediatric diaphyseal femur
fractures. J Am Acad Orthop Surg 2009;
17(11):718-725.
5. Podeszwa DA, Mooney JF III, Cramer
KE, Mendelow MJ: Comparison of Pav-
lik harness application and immediate
spica casting for femur fractures in in-
fants. J Pediatr Orthop 2004;24(5):460-
462.
6. Barlas K, Beg H: Flexible intramedullary
nailing versus external fixation of paedi-
atric femoral fractures. Acta Orthop Belg
2006;72(2):159-163.
7. Buechsenschuetz KE, Mehlman CT,
Shaw KJ, Crawford AH, Immerman EB:
Femoral shaft fractures in children: Trac-
tion and casting versus elastic stable in-
tramedullary nailing. J Trauma 2002;
53(5):914-921.
8. Flynn JM, Luedtke LM, Ganley TJ, et al:
Comparison of titanium elastic nails
with traction and a spica cast to treat
femoral fractures in children. J Bone
Joint Surg Am 2004;86(4):770-777.
9. Gautier E, Ganz K, Krügel N, Gill T,
Ganz R: Anatomy of the medial femoral
circumflex artery and its surgical impli-
cations. J Bone Joint Surg Br 2000;82(5):
679-683.
10. Astion DJ, Wilber JH, Scoles PV: Avas-
cular necrosis of the capital femoral
epiphysis after intramedullary nailing for
a fracture of the femoral shaft: A case
report. J Bone Joint Surg Am 1995;
77(7):1092-1094.
11. Buford D Jr, Christensen K, Weatherall
P: Intramedullary nailing of femoral frac-
tures in adolescents. Clin Orthop Relat
Res 1998;(350):85-89.
12. Mileski RA, Garvin KL, Crosby LA:
Avascular necrosis of the femoral head in
an adolescent following intramedullary
480
nailing of the femur: A case report.
J Bone Joint Surg Am 1994;76(11):1706-
1708.
13. Mileski RA, Garvin KL, Huurman WW:
Avascular necrosis of the femoral head
after closed intramedullary shortening in
an adolescent. J Pediatr Orthop 1995;
15(1):24-26.
14. Kalhor M, Beck M, Huff TW, Ganz R:
Capsular and pericapsular contributions
to acetabular and femoral head perfu-
sion. J Bone Joint Surg Am 2009;91(2):
409-418.
15. Rhinelander FW: Effects of medullary
nailing on the normal blood supply of
diaphyseal cortex: 1973. Clin Orthop
Relat Res 1998;(350):5-17.
16. Stanitski DF: Limb-length inequality:
Assessment and treatment options. J Am
Acad Orthop Surg 1999;7(3):143-153.
17. Westh RN, Menelaus MB: A simple cal-
culation for the timing of epiphysial ar-
rest: A further report. J Bone Joint Surg
Br 1981;63(1):117-119.
18. González-Herranz P, Burgos-Flores J,
Rapariz JM, Lopez-Mondejar JA, Ocete
JG, Amaya S: Intramedullary nailing of
the femur in children: Effects on its prox-
imal end. J Bone Joint Surg Br 1995;
77(2):262-266.
19. Keeler KA, Dart B, Luhmann SJ, et al:
Antegrade intramedullary nailing of pe-
diatric femoral fractures using an inter-
locking pediatric femoral nail and a lat-
eral trochanteric entry point. J Pediatr
Orthop 2009;29(4):345-351.
20. Raney EM, Ogden JA, Grogan DP: Pre-
mature greater trochanteric epiphysiode-
sis secondary to intramedullary femoral
rodding. J Pediatr Orthop 1993;13(4):
516-520.
21. Ogden JA: Changing patterns of proxi-
mal femoral vascularity. J Bone Joint
Surg Am 1974;56(5):941-950.
22. Trueta J: The normal vascular anatomy
of the human femoral head during
growth. J Bone Joint Surg Br 1957;
39(2):358-394.
23. Siffert RS: Patterns of deformity of the
developing hip. Clin Orthop Relat Res
1981;(160):14-29.
24. Loder RT: Pediatric polytrauma: Ortho-
paedic care and hospital course.
J Orthop Trauma 1987;1(1):48-54.
25. Hedequist D, Starr AJ, Wilson P, Walker
J: Early versus delayed stabilization of
pediatric femur fractures: Analysis of
387 patients. J Orthop Trauma 1999;
13(7):490-493.
26. Della Rocca GJ, Crist BD: External fixa-
tion versus conversion to intramedullary
nailing for definitive management of
closed fractures of the femoral and tibial
Journal of the American Academy of Orthopaedic Surgeons
shaft. J Am Acad Orthop Surg 2006;
14(10 spec no.):S131-S135.
27. Skaggs DL, Friend L, Alman B, et al: The
effect of surgical delay on acute infection
following 554 open fractures in children.
J Bone Joint Surg Am 2005;87(1):8-12.
28. Atanda A Jr, Wahlgren CM, Piano G,
Sullivan CM: Repair of a vascular injury
associated with a pediatric femur frac-
ture. Am J Orthop (Belle Mead NJ)
2009;38(3):E61-E63.
29. Mahar AT, Lee SS, Lalonde FD, Impel-
luso T, Newton PO: Biomechanical com-
parison of stainless steel and titanium
nails for fixation of simulated femoral
fractures. J Pediatr Orthop 2004;24(6):
638-641.
30. Boresi AP, Schmidt RJ, Sidebottom OM:
Linear stress-strain-temperature
relations, in Boresi AP, Schmidt RJ,
Sidebottom OM: Advanced Mechanics
of Materials, ed 5. New York, NY, John
Wiley & Sons, 1993, pp 85-105.
31. Uhthoff HK, Bardos DI, Liskova-Kiar
M: The advantages of titanium alloy
over stainless steel plates for the internal
fixation of fractures: An experimental
study in dogs. J Bone Joint Surg Br
1981;63(3):427-484.
32. Perez A, Mahar A, Negus C, Newton P,
Impelluso T: A computational evaluation
of the effect of intramedullary nail mate-
rial properties on the stabilization of
simulated femoral shaft fractures. Med
Eng Phys 2008;30(6):755-760.
33. Lee SS, Mahar AT, Newton PO: Ender
nail fixation of pediatric femur fractures:
A biomechanical analysis. J Pediatr
Orthop 2001;21(4):442-445.
34. Wall EJ, Jain V, Vora V, Mehlman CT,
Crawford AH: Complications of tita-
nium and stainless steel elastic nail fixa-
tion of pediatric femoral fractures.
J Bone Joint Surg Am 2008;90(6):1305-
1313.
35. Green JK, Werner FW, Dhawan R, Ev-
ans PJ, Kelley S, Webster DA: A biome-
chanical study on flexible intramedullary
nails used to treat pediatric femoral frac-
tures. J Orthop Res 2005;23(6):1315-
1320.
36. Luhmann SJ, Schootman M, Schoe-
necker PL, Dobbs MB, Gordon JE: Com-
plications of titanium elastic nails for
pediatric femoral shaft fractures.
J Pediatr Orthop 2003;23(4):443-447.
37. Flynn JM, Hresko T, Reynolds RA,
Blasier RD, Davidson R, Kasser J: Tita-
nium elastic nails for pediatric femur
fractures: A multicenter study of early
results with analysis of complications.
J Pediatr Orthop 2001;21(1):4-8.
38. Moroz LA, Launay F, Kocher MS, et al:
Titanium elastic nailing of fractures of
the femur in children: Predictors of com-

plications and poor outcome. J Bone
Joint Surg Br 2006;88(10):1361-1366.
39. Li Y, Stabile KJ, Shilt JS: Biomechanical
analysis of titanium elastic nail fixation
in a pediatric femur fracture model.
J Pediatr Orthop 2008;28(8):874-878.
40. Fricka KB, Mahar AT, Lee SS, Newton
PO: Biomechanical analysis of antegrade
and retrograde flexible intramedullary
nail fixation of pediatric femoral frac-
tures using a synthetic bone model.
J Pediatr Orthop 2004;24(2):167-171.
41. Goodwin R, Mahar AT, Oka R, Stein-
man S, Newton PO: Biomechanical eval-
uation of retrograde intramedullary sta-
bilization for femoral fractures: The
effect of fracture level. J Pediatr Orthop
2007;27(8):873-876.
August 2011, Vol 19, No 8
42. Mehlman CT, Nemeth NM, Glos DL:
Antegrade versus retrograde titanium
elastic nail fixation of pediatric distal-
third femoral-shaft fractures: A mechani-
cal study. J Orthop Trauma 2006;20(9):
608-612.
43. Salem KH, Keppler P: Limb geometry
after elastic stable nailing for pediatric
femoral fractures. J Bone Joint Surg Am
2010;92(6):1409-1417.
44. Mani US, Sabatino CT, Sabharwal S,
Svach DJ, Suslak A, Behrens FF: Biome-
chanical comparison of flexible stainless
steel and titanium nails with external
fixation using a femur fracture model.
J Pediatr Orthop 2006;26(2):182-187.
Harish S. Hosalkar, MD, et al
45. Tan V, Pepe MD, Glaser DL, Seldes RM,
Heppenstall RB, Esterhai JL Jr: Well-leg
compartment pressures during hemi-
lithotomy position for fracture fixation.
J Orthop Trauma 2000;14(3):157-161.
46. Ricci WM, Gallagher B, Haidukewych
GJ: Intramedullary nailing of femoral
shaft fractures: Current concepts. J Am
Acad Orthop Surg 2009;17(5):296-305.
47. Stephen DJ, Kreder HJ, Schemitsch EH,
Conlan LB, Wild L, McKee MD: Femo-
ral intramedullary nailing: Comparison
of fracture-table and manual traction. A
prospective, randomized study. J Bone
Joint Surg Am 2002;84(9):1514-1521.
481