ORIF Pediatric Femur Fractures
Limited evidence supports rigid trochanteric entry nailing, submuscular plating, and flexible intramedullary nailing as treatment options for children age eleven years to skeletal maturity diagnosed with diaphyseal femur fractures, but piriformis or near piriformis entry rigid nailing are not treatment options.

Skeletally immature patients are at increased risk for avascular necrosis of the femoral head when piriformis or near piriformis fossa entry nails are used.  The rate of this potentially devastating complication is at least 4%.38 Every effort should be made to decrease the risk of avascular necrosis.
Fracture patterns that compromise post-reduction stability (i.e. axial and / or angular stability) as well as heavier patients may stimulate the surgeon to choose rigid trochanteric entry nailing or submuscular plating over flexible intramedullary nailing.  One Low quality study demonstrated a five times higher risk of poor outcomes for flexible nailing in patients whose weight met or exceeded 49 kg (108 lbs).27  In the expert opinion of the work group, external fixation is another option in the older patient with an unstable fracture pattern, but its significantly higher complication rates, as demonstrated in other age groups,23,26 make it less desirable than rigid trochanteric entry nailing or submuscular plating.