BACKGROUND: The optimal surgical strategy for length-unstable pediatric femoral shaft fractures remains debated. This study compared clinical and radiologic outcomes between submuscular biological plating (SBP) and flexible intramedullary nailing augmented with external fixation (FIMN/EF). METHODS: In this prospective, randomized trial, 32 children (5 to 14 years) with unstable femoral fractures (AO/OTA 32-D/5.1 or 32-D/5.2) were allocated to SBP (n=16) or FIMN/EF (n=16). Primary outcomes included operative time, fluoroscopy time, time to union, complications, and knee range of motion (ROM). Secondary outcomes included alignment, limb length discrepancy, functional scores (Flynn criteria), and implant removal characteristics. RESULTS: The SBP group demonstrated shorter operative time than the FIMN/EF group (mean: 73.1 vs. 88.8 min, P=0.002) and reduced fluoroscopy time (mean: 51.9 vs. 74.1 s, P0.05). Knee flexion at final follow-up was greater in the SBP group (mean: 108.1 vs. 100.6 degrees, P=0.015). Complication rates and limb length discrepancies (≤10 mm) were similar in both groups, with no statistically significant difference. Functional outcomes were excellent or good in most patients in both groups. CONCLUSIONS: Both SBP and FIMN/EF appear to be effective treatment options for selected length-unstable pediatric femoral shaft fractures. SBP offers shorter surgery, reduced radiation exposure, and better early knee ROM, whereas FIMN/EF provides easier implant removal. Technique selection should be based on patient factors, fracture pattern, surgeon experience, and family preference.
Elkholy et al. (Mon,) studied this question.