Surgery · Fractures

Femur fractures: different surgical choices for different ages

The femur is the most important bone of the lower limb. The surgical strategy clearly changes with the child's age and weight: there is no single right answer.

The choice depends on both the child and the fracture

Younger children, with high remodelling potential

Good healing can often be achieved with a hip spica cast after reduction under anaesthesia. Femoral remodelling is generous at this age and tolerates small alignment imperfections well.

Older children and adolescents

In older children and adolescents, surgical stabilisation is often preferred according to weight, fracture pattern and stability, and functional needs. A hip spica cast protects the fracture, but may be harder to tolerate and manage in this age group. The choice remains individual.

Typical surgical procedures

Femoral ESIN — elastic intramedullary nails

Two elastic nails inserted from the distal femur and advanced across the fracture to stabilise the fragments. Weight-bearing depends on fracture pattern, stability, the child’s weight and healing; it is not automatically early.

Diaphyseal fractures in school-age children and adolescents, with weight compatible with elastic nail stability.

It is one of the most used techniques for the paediatric femur in school-age children. Nails are removed in a planned second operation.

Submuscular plating

Long plate inserted with minimally invasive technique under the muscles, fixed with percutaneous screws. More stable than ESIN.

Heavier adolescents, multifragmentary fractures, situations where ESIN does not offer enough stability.

Locked intramedullary nail

Metal nail passed inside the medullary canal, locked with distal and proximal screws. Similar to the adult technique.

Adolescents close to or at skeletal maturity, with no significant risk to the growth plates.

Entry point and technique are chosen to minimise risk to the femoral head.

Closed reduction + percutaneous screw fixation

After realignment, one or more screws are inserted under the skin to stabilise the fracture without opening it.

Fractures or fragments selected by location, size and geometry, such as certain metaphyseal or epiphyseal injuries, when a screw provides adequate stability and respects the physis. Isolated screws are not a generic alternative to elastic nails in shaft fractures.

Hip spica cast

A cast immobilising pelvis and lower limb. With or without surgery, after reduction under anaesthesia.

Young children with stable or well-reducible fractures, or in specific phases after surgery.

Impact on family organisation

A femur fracture — operated or not — always has a major impact on daily life. Mobility, hygiene, sleep, school and transport are all affected. A meaningful part of the visit is dedicated to building a realistic plan for the first weeks.

Elements guiding the choice

age and weight of the child
fracture site and geometry (simple, oblique, spiral, multifragmentary)
proximity to the proximal or distal growth plate
trauma energy and associated injuries
functional needs and family context

Other fracture sites

Wrist Forearm Elbow Humerus Knee Leg Ankle Foot

For parents

Paediatric femur fractures: information page

Context, checklist of clinical aspects and what to expect after the ER.

A second opinion on a paediatric fracture

Bring the ER report and the X-rays. A focused paediatric orthopaedic visit can clarify indication, timing and alternatives.

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Content for general informational purposes only. It does not replace a medical evaluation.