The floating knee in the pediatric patient. Nonoperative versus operative stabilization

The results of nonoperative and operative or rigid stabilization of ipsilateral femur and tibia fractures in children and adolescents were evaluated. Twenty-nine consecutive patients with open physes (30 affected extremities) were reviewed. Their mean followup was 8.6 years (range, 1.1-18.6 years). The nonoperative group consisted of 16 patients and 16 extremities treated by skeletal traction of the femoral fracture, closed reduction and splinting or casting of the tibia fractures, and eventual immobilization in a hip spica cast. The operative group, was comprised of 13 patients and 14 extremities in which one or both fractures were treated by open reduction and internal fixation, intramedullary fixation, or external fixation. Despite higher modified injury severity scores and skeletal injury scores, the patients who were treated operatively had a significantly reduced hospital stay, 20.1 days versus 34.9 days, respectively; decreased time to unsupported weightbearing, 16.8 weeks compared with 22.3 weeks, respectively; and fewer complications. Operative stabilization of the femur had a significant effect on decreasing the length of hospital stay and the time to unassisted weightbearing. The patients also were analyzed according to their age at the time of injury: 9 years of age or younger and 10 years of age and older. The younger children who were treated nonoperatively had an increased rate of lower extremity length discrepancy, angular malunion, and need for a secondary surgical procedure as compared with younger children who were treated operatively with rigid fixation. Based on the results of the current study, operative stabilization of at least the femur fracture and, preferably, both fractures in the treatment of a child with a floating knee is recommended, even for younger children.     

Flexible intramedullary nailing in the treatment of diaphyseal fractures of the femur in preschool children

Femur fractures in preschool children are mostly treated in a conservative way, by means of spica cast immobilisation or skin traction. In school age children the use of flexible intramedullary nails (FIN) is widely used and promoted. We performed intramedullary nailing in 9 preschool children aged 1.5-6 years. The mean length of postoperative hospital stay was 4 days (range: 3 to 6). The mean time to solid callus formation was 2.5 months (range: 2 to 3). Follow-up was available in all 9 children for a mean period of 18.9 months (range: 3 to 38). No complications were noted. Flexible intramedullary nailing of femur fractures is a valuable technique in this particular age group. However, further study and long-term follow-up are needed.     

Unstable pediatric femoral and forearm shaft fractures. Comparison between conservative treatment and stable intramedullary nailing

Elastic intramedullary nailing represents a new surgical concept in the treatment of unstable shaft fractures in children. The present case control study wanted to examine the superiority of intramedullary nailing in comparison to conservative therapeutic concepts which had been applied so far. 13 children with forearm fractures who were treated initially by conservative measures were compared to 13 other children who received a primary intramedullary nailing. With femoral fractures, 12 children were included in each group. In each patient pair age, type and localisation of the fracture were comparable. During the observation period (until the termination of final therapeutic measures or until the third year after injury) we examined clinical variables and subjective findings. Both therapeutic concepts led to comparably good functional results. Also subjective judgement of the therapeutic success did not differ between groups. However, with intramedullary nailing of shaft fractures of the femur the mean hospital length of stay (7.0 +/- 3.5 days) was significantly shorter than with initial conservative treatment (36.5 +/- 2.2 days, P < 0.05). Irrespective of the localisation of the fracture intramedullary nailing required significantly less x-ray examinations during the observation period. These results suggest intramedullary nailing to be the procedure of choice to treat unstable forearm and femoral fractures in children.     

Pediatric femoral shaft fractures treated by flexible intramedullary nailing

Background: Nowadays pediatric femoral fractures are more commonly managed with operative treatment rather than conservative treatment because of more rapid recovery and avoidance of prolonged immobilization. Children between the ages of 5e13 years are treated either by traction plus hip spica and flexible/elastic stable retrograde intramedullary nail, or external fixators in the case of open fractures. The aim of this study is to evaluate the outcome of pediatric femoral shaft fractures treated by stainless steel flexible intramedullary nail in children between 5 and 13 years of age. Methods: There were 32 cases of femoral shaft fractures which were all fixed with stainless steel flexible intramedullary nail under fluoroscopy. Long leg cast was applied at the time of fixation. Partial weight bearing was started 2 weeks after surgery. Patients were evaluated in follow-up study to observe the alignment of fracture, infection, delayed union, nonunion, limb length discrepancy, motion of knee joint, and time to unite the fracture. Results: We were able to follow up 28 out of 32 patients. The patients were 8.14 years of age on average. The mean hospital stay after operation was 4 days and fracture union time was 9.57 weeks. There were 3 cases of varus angulation, 2 cases of anterior angulation, and 4 cases of limb lengthening. Conclusion: Patients aged between 5 and 13 years treated with flexible intramedullary nail for closed femoral shaft fracture have rapid union and recovery, short rehabilitation period, less immobilization and psychological impact, and cost-effective.     

Femoral fractures in children, is early interventional treatment beneficial?

A protocol of early intervention (flexible intramedullary nails, early hip spica, and external fixation) was started in 1999 and during a 3-year period there were 25 children who sustained a femoral shaft fracture (early intervention group). These were prospectively reviewed with a minimum follow up of 24 months (Range 24-35 months). A historical control group of 41 children was used. These children were injured between February 1996 and February 1999 and were retrospectively reviewed. They had traditional in patient treatments with either Gallows or Thomas splint traction (traditional treatment group). Over the 6-year period from 1996 to 2002 there were a total of 66 femoral shaft fractures in the study that presented to our hospital. The mean length of hospital stay was 29 nights in the traditional group and 10 nights in the early intervention group. This difference is significant (p<0.001). The malunion rate was slightly higher in the early active group at radiological union but most of these remodelled over the 2 years of follow up. The protocol of early intervention used in our institution, of flexible nails, early hip spica or external fixation depended on the age of the child, and has resulted in a shorter hospital stay for the children. This has benefits for the child, the family and the hospital.     

Different types of femoral shaft fracture; different types of treatment: their effects on postoperative lower llimb discrepancy

Femoral shaft fracture in child is a disabling injury. Different methods of treatment can be used for femoral shaft fracture and depends on patient condition.THE AIM OF THE STUDY was to evaluate lower limb discrepancy following different method of treatment and possible related factors especially type of fractures. MATERIAL AND METHODS. This retrospective cross sectional study was carried out in Imam Khomeini and Razi Hospital from 2003-2007 on children admitted to hospital with femur fracture. All children aged <12 years of age with diagnosis of femoral shaft fracture were included in this study. Different methods of treatment were flexible intramedullary nailing, rigid intramedullary nailing with Steinmann pin and spica casting, spica casting and closed reduction, and ORIF with plate and screw. Distance from hip to knee for each patient was determined in scanograms. Sex, age, side of involvement, type of fracture were recorded for each case. Analysis was done with SPSS ver. 16.0. ANOVAs, Chi-Square, and t-Test were used with CI=95%. RESULTS. In this study, 253 cases (M=182, F=71) were included. One hundred forty-six (57.7%) cases had right involvement and 107 (42.3%) of cases had left side involvement. From all cases, 135(53.4%) cases had no changes in lower limb length. Eleven (4.3%) cases had lower limb shortening and 107(42.3%) cases had lower limb lengthening. Type A1 and type A2 showed greatest lower limb discrepency among cases who underwent ORIF with screw & plate fixation, and spica casting with closed reduction respectively (p<0.05). CONCLUSIONS. There is significant difference among surgical and non surgical treatment for LLD. Spica casting and closed reduction has the least changes compared to other methods. Sex, side of involvement, type of fracture, and location had no effect in post operative length changes. Type of fracture, only, has a role in screw and plate fixation group and this is may be due to the differences between A1 and A3 fractures. Most of the changes were seen in the range of 60 through 120 months of age. Most of the changes were in the range +10 to +20 mm.     

Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children

OBJECTIVES: To evaluate the clinical results of intramedullary nailing of femoral shaft fractures using a rigid intramedullary nail placed through the lateral aspect of the greater trochanter in older children and adolescents. DESIGN: A retrospective study was carried out evaluating all skeletally immature patients with femoral shaft fractures treated using a modified rigid humeral intramedullary nail. PATIENTS/PARTICIPANTS: Fifteen children and adolescents with displaced femoral diaphyseal fractures and open physes. INTERVENTION: Femoral shaft fractures in children and adolescents were stabilized using a modified humeral intramedullary nail placed through the lateral aspect of the greater trochanter. MAIN OUTCOME MEASUREMENTS: Patients were evaluated to determine time to union, final fracture alignment, hospital stay, complications, clinical outcome, and proximal femoral changes including avascular necrosis or proximal femoral valgus with femoral neck narrowing. RESULTS: Fifteen patients were followed for a minimum of 1 year (range 70-157 weeks). The average age of the patients was 12 years and 5 months (range 8 years and 2 months-17 years and 1 month). All fractures healed at a mean of 7 weeks (range 5-14 weeks) after fracture. The average hospital stay for patients with isolated femur fractures (8/15) was 2.8 days (range 1-5 days). At an average follow-up of 141 weeks (range 70-326 weeks), no patient had developed avascular necrosis, femoral neck valgus, femoral neck narrowing, or other complications. CONCLUSIONS: The technique of intramedullary nailing in children through the lateral aspect of the greater trochanter seems to be safe, effective, and well tolerated by patients.     

The internal fixation of fractures in children

The internal fixation of fractures of shaft bones was spread out by a group of surgeons working together with Prevot. The principle of this method is a three point load carrying paragraph sign(entry point, height of fracture and cancellous bone of the metaphysis of the opposite fracture part). From 1996 to 1999 86 children with fractures of the humerus, the fore-arm and the femur were operated in the technique of intramedullary nailing. The fractures affected the humerus to 3.5 %, the fore-arm to 65.1 % and the femoral shaft to 31.4 %. The postoperative duration of stay in hospital after internal fixation of the fore-arm in the proximal and middle third lasted 7.2 days, the duration of immobilisation in a cast took 13.7 days. 96 % of the patients showed very good and good results after operation. The average stay in hospital for patients with femoral shaft fractures was 14.4 days. 17 weeks after operation the intramedullary nails were removed. At the time of first full weight bearing the legs showed an average shortening of 1.2 cm. The fractures of the humerus healed without any restriction of movements. Internal fixation is a minimal invasive operation technique with low risks and small operating trauma. Due to the stability a early mobilisation is possible. The reported results in the literature are all good. The only problem can be caused by too long nails irritating the skin.     

股骨重建髓内钉内固定治疗股骨干多节段骨折合并髋部骨折

目的探讨小切口复位股骨重建髓内钉内固定治疗股骨干多节段骨折合并同侧髋部骨折的疗效。方法对54例股骨干多节段骨折合并同侧髋部骨折行小切口复位骨折段及粉碎的股骨干,然后采用股骨重建髓内钉内固定。股骨干骨折合并股骨颈骨折37例,股骨干骨折合并股骨粗隆间骨折17例。结果54例均获得3～6个月的随访,平均4个月。骨折均一期愈合,发生髋内翻1例,股骨头切割2例。末次随访时髋关节功能Harris评分平均（92．22±2．17）分。结论小切口复位股骨干骨折同时采用股骨重建髓内钉内固定治疗股骨干骨折合并同侧股骨颈或股骨粗隆间骨折,具有手术时间短、出血少且固定牢靠等优点,是预防髋内翻发生和促进骨折愈合的有效术式。     

Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries

BACKGROUND: Optimal timing of femur fracture fixation remains controversial. This study examines the association between the timing of femur fracture fixation and outcome in patients with concomitant chest and head injuries. METHODS: A retrospective review of registry data from a Level I trauma center identified 1362 patients with a femoral shaft fracture over a 12-year period. Patients were categorized into five groups by timing of femur fracture fixation: Group 1, within 24 hours; Group 2, 24 to 48 hours; Group 3, 48 to 120 hours; Group 4, > 120 hours; and Group 5, patients with no operative fixation. Primary outcome measures included morbidity (specifically, pulmonary complications) and mortality. Secondary outcome measures were hospital length of stay, intensive care unit length of stay, and discharge Glasgow Coma Scale score. Subsets of patients were examined including all patients with multiple injuries (Injury Severity Score > 15), chest trauma (Chest Abbreviated Injury Scale score > or = 2), and head trauma (Head Abbreviated Injury Scale score > or = 2). RESULTS: Acute respiratory distress syndrome, pneumonia, hospital length of stay, and intensive care unit length of stay were lowest in the group fixed within 24 hours, even in patients with concomitant head or chest trauma. Fixation between 2 and 5 days was associated with a significantly increased incidence of acute respiratory distress syndrome, pneumonia, and fat embolization syndrome in patients with concurrent chest trauma (p < 0.0001). In head-injured patients, discharge Glasgow Coma Scale score was highest in the group fixed within 24 hours. Timing of operative fixation did not affect mortality. CONCLUSION: Our data show that early femur fracture fixation (< 24 hours) is associated with an improved outcome, even in patients with coexistent head and/or chest trauma. Fixation of femur fractures at 2 to 5 days was associated with a significant increase in pulmonary complications, particularly with concomitant head or chest trauma, and length of stay. Chest and head trauma are not contraindications to early fixation with reamed intramedullary nailing.     

Hip spica versus Rush pins for management of femoral diaphyseal fractures in children

Background:Femoral fractures are common in children between 2 and 12 years of age and 75% of the lesions affect the femoral shaft. Traction followed by a plaster cast is universally accepted as conservative treatment. We compared primary hip spica with closed reduction and fixation with retrogradely passed crossed Rush pins for diaphyseal femur fracture in children. The hypothesis was that Rush pin might provide better treatment with good clinical results in comparison with primary hip spica.Results:Mean duration of fracture union was 15 weeks in group A and 12 weeks in group B. Mean duration of weight bearing 14 weeks in group and 7 weeks in group B. Mean hospital stay was 4 days in group A and 8 days in group B. Mean followup period in group A was 16 months and group B was 17 months. Complications such as angulation, shortening, infection were compared.Conclusions:Closed reduction and internal fixation with crossed Rush pins was superior in terms of early weight bearing and restoration of normal anatomy.     

Ipsilateral femoral neck and shaft fractures. Report of two cases using an alternate technique

A technique for ipsilateral femoral neck and shaft fracture using the sliding compression hip screw with plate combined with trochanteric antegrade Ender nailing of the femur was applied in two cases. Ender nails can be passed without difficulty past a compression hip screw and the bicortical plating screws. The hip and femur can be fixed internally through a single approach in a single position. Sliding compression hip screw devices can provide excellent preliminary stable femoral neck fixation. Blood supply to the femoral head is not disturbed while the femoral intramedullary fixation is performed. Antegrade Ender nailing avoids the common knee complications associated with other retrograde techniques. Decreased operative time, less blood loss, less technical difficulty, and early mobilization are important factors in the multiple-injured patient. Femoral intramedullary fixation may require open reduction, circlerage to ensure stability, and maintenance of alignment in case of significant comminution to allow early crutch ambulation. This mode of fixation may be advantageous for selected cases.     

Pediatric femoral fractures: a systematic review of 2422 cases

BACKGROUND: The incidence of femoral fractures in children comprise 20 per 100,000 yearly in the United States and Europe. The treatment of femoral shaft fractures in the pediatric population remains controversial. The child's age often directs the management. Nonoperative treatment options include functional treatment for the very young, Pavlic harness, skin or skeletal traction, and spica casting. Operative treatment options include closed reduction and external fixation, open reduction and internal plate fixation, closed reduction and minimally invasive plate osteosynthesis (MIPO), and closed reduction and intramedullary nailing with either flexible or rigid nails. The effect of operative versus nonoperative treatment has been the focus of several comparative studies. OBJECTIVE: To determine the effect of different treatment options on the rate of union, malunion, leg-length discrepancy (LLD), complications, and outcome after femoral shaft fractures in children.     

弹性髓内钉治疗儿童股骨干骨折35例经验及文献综述

目的探讨弹性髓内钉治疗儿童股骨干骨折的效果并文献综述。方法 2007月7月至2014年6月,采用弹性髓内钉治疗儿童股骨干骨折35例,男28例,女7例,年龄5~13岁,平均年龄9.2岁,评估手术时间、术中出血量、住院时间、负重时间,骨折愈合时间及疗效评估。结果手术平均持续65 min(45~95 min),平均失血量为70 mL,平均住院8天(6~14天)。本组病例术后随访6~20个月,平均约14个月。所以患者均获得一期愈合,愈合时间6~9周,平均愈合时间约7.5周。无术后感染、骨不连、断钉、骨骺损伤等并发症发生。其中2例有钉尾激惹导致膝部皮肤轻度疼痛,在内固定取出疼痛消失。术后一年测量发现15例肢体不等长情况,其中3例患肢短缩,12例患肢延长,但均在1.5 cm内,对患者的行走无明显影响,并在随后的随访中发现肢体不等长现象得到纠正。按Flynnetal治疗评价标准测定,治疗效果痊愈31例,良好4例。结论弹性髓内钉治疗稳定性儿童股骨干骨折,具有手术时间短、失血量少、创伤小等优点。     

Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients

BACKGROUND: From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. Fifty-nine (4 percent) of those fractures were treated with early external fixation followed by planned conversion to intramedullary nail fixation. This two-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or who required expedient femoral fixation followed by repair of an ipsilateral vascular injury. The purpose of the current investigation was to determine whether this protocol is an appropriate alternative for the management of fractures of the femur in patients who are poor candidates for immediate intramedullary nailing. METHODS: Fifty-four multiply injured patients with a total of fifty-nine fractures of the shaft of the femur treated with external fixation followed by planned conversion to intramedullary nail fixation were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis. RESULTS: The average Injury Severity Score for the fifty-four patients was 29 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15). Most patients (forty-four) had additional orthopaedic injuries (average, three; range, zero to eight), and associated injuries such as severe brain injury, solid-organ rupture, chest trauma, and aortic tears were common. Forty fractures were closed, and nineteen fractures were open. According to the system of Gustilo and Anderson, three of the open fractures were type II, eight were type IIIA, and eight were type IIIC. Intramedullary nailing was delayed secondary to medical instability in forty-six patients and secondary to vascular injury in eight. All fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first twenty-four hours after the injury; the average duration of the procedure was thirty minutes. The duration of external fixation averaged seven days (range, one to forty-nine days) before the fixation with the static interlocked intramedullary nail. Forty-nine of the nailing procedures were antegrade, and ten were retrograde. For fifty-five of the fifty-nine fractures, the external fixation was converted to intramedullary nail fixation in a one-stage procedure. The other four fractures were associated with draining pin sites, and skeletal traction to allow pin-site healing was used for an average of ten days (range, eight to fifteen days) after fixator removal and before intramedullary nailing. Follow-up averaged twelve months (range, six to eighty-seven months). Of the fifty-eight fractures available for follow-up until union, fifty-six (97 percent) healed within six months. There were three major complications: one patient died from a pulmonary embolism before union, one patient had a refractory infected nonunion, and one patient had a nonunion with nail failure, which was successfully treated with retrograde exchange nailing. The infection rate was 1.7 percent. Four other patients required a minor reoperation: two were managed with manipulation under anesthesia because of knee stiffness, and two underwent derotation and relocking of the nail because of rotational malalignment. The rate of unplanned reoperations was 11 percent. The average range of motion of the knee was 107 degrees (range, 60 to 140 degrees). CONCLUSIONS: We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.     

Is external fixation in pediatric femoral fractures a risk factor for refracture?

The aim of this study was to investigate whether external fixation is a risk factor for refracture by comparing the outcomes of children who received three different forms of treatment of femoral fractures. One hundred ninety-two patients treated for femoral fracture between 1990 and 1999 who underwent final examination were assessed. One hundred were treated with hip spica casting after traction, 57 with closed reduction and external fixation, and 35 with open reduction and external fixation. Morbidity results such as time to union, length of hospital stay, refracture, and wire site infection were statistically evaluated. Patients undergoing open reduction had a greater time to union and length of hospital stay and a higher refracture rate. The difference was statistically significant. Wire site infection occurred in all three groups; there was no statistically significant difference between groups. The authors concluded that external fixation is not a risk factor for refracture in the treatment of pediatric closed femoral diaphyseal fractures, and that it may be used with ease in clinics with shortages of personnel and space.     

Intramedullary locked nailing in the treatment of proximal femoral fractures]

INTRODUCTION: The aim of the study is evaluation of results of operative treatment the proximal femoral fractures with intramedullary locked nailing. MATERIAL AND METHOD: In years 1996-2004 44 patients were treated because of proximal femoral fractures with closed reduction and stabilization with intramedullary locked nailing. There were 15 women and 29 men in average age 60 years (18-95 years). There were 2 femoral neck fractures and 42 peritrochanteric fractures. The fracture of femoral shaft in 2 patients accompanied the fracture of proximal part of femur. The morphology of fractures was estimated according to AO classification. Clinical results were evaluated with Harris hip score (HHS). RESULTS: The average follow up is 8 months (from 6 to 24 months). There was good reduction of 27 fractures on postoperative radiograms. The average 15 degrees of varus lack of reduction was noted in 17 peritrochanteric fractures (from l0 to 35 degrees). There were mainly 31.A.3 unstable fractures according to AO classification. 3 patients died during three postoperative months from causes not connected with operative treatment. 39 fractures united in the period from 10 to 16 weeks. Delayed union--after 6 months occurred in 2 persons. Fatigue fracture of intramedullary rods occurred to both of this patients. The average Harris Hip Score was 86 points (from 70 to 100 points) after union of fractures. CONCLUSIONS: (1) The use of intramedullary locked nailing in the treatment of fractures of proximal part of femur leads to union without additional immobilization. (2) Closed intramedullary locked nailing in the treatment of unstable intertrochanteric fractures is connected with the risk of varus malalignment of fragments, which does not delay union, but decreases functional outcome. (3) Proper operative technique decreases the number of intra- and postoperative complications.     

Close reduction and intramedullary flexible titanium nails fixation of femoral shaft fractures in children under 5 years of age

We retrospectively reviewed 13 cases of diaphyseal femoral fractures treated with close reduction and intramedullary flexible titanium nails, in children aged 3-5 years. The mean follow-up time was 11.5 months (range 3-29). No cases of nonunion or malunion were noted. Minor complications were observed in two children. Loss of initially restored femoral lengthening had occurred in one child, with nail protrusion and related focal cellulites. Mild postoperative leg-length discrepancy occurred in another child. The healed fractures usually exhibited abundant callus, which allowed an early ambulation. Although the operative approach to simple diaphyseal fractures of the femur at such a young age is not routinely recommended, it can be a valuable option as an initial treatment, or when a conventional treatment with a spica cast has failed. In our group of patients, the parents chose this type of treatment as an alternative to the conventional spica cast.     

Mortality after reamed intramedullary nailing of bilateral femur fractures

We performed retrospective review of 743 patients treated with reamed intramedullary nailing of a femoral shaft fracture was done to assess the clinical impact of bilateral femur fractures on the mortality, hospital stay, and length of intensive care treatment in patients with blunt trauma. Unilateral injuries occurred in 689 patients and bilateral injuries occurred in 54 patients. Mortality in patients with bilateral femur fractures was 5.6% compared with 1.5% in patients with unilateral femur fractures. The two groups were analyzed using multiple linear regression and logistic regression with age and Injury Severity Scores as covariants to allow for comparison of similarly injured groups as predicted by the Injury Severity Scores. Bilateral femur fractures still were associated with a significantly higher mortality, longer length of stay in the hospital, and longer length of stay in the intensive care unit. As expected, when analyzed separately, patients with bilateral femur fractures had significantly higher Injury Severity Scores, longer lengths of stay in the intensive care unit, and longer lengths of stay in the hospital. Patients with bilateral femur fractures have an increased mortality when compared with patients with unilateral femur fractures after controlling for Injury Severity Score and age. When used alone, the Injury Severity Score underestimates the contribution of a second femur fracture.     

Diaphyseal femoral fractures in children: should we change the present mode of treatment?

Three hundred thirty-nine diaphyseal fractures of the femur in 327 children were studied retrospectively. There were 196 boys and 131 girls, with a mean age of 5.59 years (range, 1 day-14 years). The majority of the children were < 6 years of age. In 67.8% of the children, the fracture was caused by a road traffic accident. Seventy-seven of the children had associated injuries. The minimum hospital stay was 15 days, and the maximum was 42 days (mean, 32.6 days). The most common site of fracture was at the middle third (N = 206), and 133 were the transverse type. The mode of treatment was balance skin traction in 146, skeletal traction in 72, hip spica in 22, internal fixation in 16, and external fixators in 5. The average follow up was 7.8 years. Complications were few. Our experience indicates that with a conservative mode of treatment, there is no risk of overgrowth, and a rotational malalignment of up to 20 degrees corrects during growth. We believe that diaphyseal fractures of the femur in children can be safely managed nonoperatively and economically, contrary to the present advocacy of operative treatment. The operative mode of treatment should be used in selected cases.