SRS280 - Surgical treatment of midshaft femoral fractures in children over the age of 5: a systematic review of literature

Abstract Background Midshaft femoral fractures are among the most common long-bone injuries in paediatric populations. Treatment strategies have since evolved with Elastic Stable Intramedullary Nailing (ESIN) and Submuscular Plating (SMP) emerging as the predominant options. Despite this, the comparative long-term outcomes of these modalities remain inadequately defined. Methods A literature search was conducted across PubMed, Embase, Scopus, and the Cochrane Library. Eligible studies included randomised controlled trials and cohort studies involving children aged 5–16 years treated with ESIN or SMP published from 2010 to 2025. Data extraction focused on fracture union, complications, growth disturbances, and functional outcomes. Results Eight studies comprising 461 patients (266 ESIN, 195 SMP) were included. The systematic review revealed that SMP was associated with slightly faster radiographic union (mean 9.7–11.5 weeks) compared to ESIN (11.2–13.05 weeks). SMP also demonstrated superior outcomes in alignment, limb length discrepancy, and functional recovery, with Flynn’s criteria rating a higher proportion of SMP patients as ‘excellent’ (88–94%) versus ESIN (54.5–76%). While ESIN offered shorter operative times and earlier mobilisation, it was associated with higher rates of implant prominence, refracture, and reoperations. Conclusions Although initial literature favoured ESIN for its healing efficiency and minimal invasiveness, this systematic review found SMP to offer improved union times, alignment, and functional outcomes, particularly in older children or those with length-unstable fractures. Nonetheless, both techniques exhibit safe profiles with low rates of severe complications. The findings highlight the importance of individualising treatment decisions based on fracture pattern, patient weight, and age.