Elastic Intramedullary Nails
Limited evidence supports the option for physicians to use flexible intramedullary nailing to treat children age five to eleven years diagnosed with diaphyseal femur fractures.

There are few statistically significant differences between treatments in healing of the fracture. The evidence reviewed included ten studies that examined one hundred varying outcomes. Of these one hundred outcomes twenty-one were significant. There were no studies that directly compared flexible nails to spica casting. When flexible nails were compared to external fixation and traction plus casting, nine outcomes were significant favoring flexible nails, one significant outcome favored external fixation and one significant outcome favored traction plus casting. (Please refer to Tables 6 and 7 below.)
The high quality study22 found to address this recommendation compared external fixation to spica casting. External fixation was favored over spica casting for malunions, including anterior/posterior angulation. Twelve other outcomes for this comparison had non-significant results. 
In summary, the overall body of evidence considered for this recommendation indicates that there are few significant outcomes when all comparisons are considered. Further, important comparisons have not been investigated (spica casting and flexible nails). 
Two moderate quality studies24, 50 shows more rapid return to walking and school with flexible intramedullary nailing and one low quality study25 illustrates less associated hospital costs when compared to traction and casting. The ability to mobilize the patient, return them to school rapidly, and suggested decrease in hospital costs leads the work group to suggest flexible intramedullary nailing over traction followed by casting. There is evidence that flexible intramedullary nailing has less adverse events and more rapid return to school than external fixation in both stable and unstable fractures.26
In making this recommendation, the work group acknowledges that they are including their expert opinion and they have therefore, downgraded the Grade of this Recommendation to a “limited” recommendation.  Based on the advantages suggested, less adverse events and more rapid return to school, flexible intramedullary nailing is a treatment option for children five to eleven years diagnosed with diaphyseal femur fractures.  
There is currently insufficient literature in specially designed pediatric rigid intramedullary nails and bridge plating for inclusion in the current guideline.
Patients over age 11 or with weight over 49 kg are at increased risk of a poor outcome27 with flexible intramedullary nailing. The mean weight between patients with a poor outcome and those with an excellent or satisfactory outcome was significant, but weight was not independent of age and had a sensitivity of only 59% in predicting poor outcomes. 


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