Elastic intramedullary nails versus submuscular locked plates in treatment of pediatric length stable femoral shaft fractures: A prospective, randomized clinical trial

Objectives: Diaphyseal femoral fractures are frequently encountered in children aged 6–14 years and remain a management challenge. The optimal fixation strategy for length-stable fracture patterns in this age group remains debated, particularly regarding the relative benefits of elastic intramedullary nailing (EIN) versus submuscular locked plating (SLP). The objective of this study was to compare functional and radiological outcomes following fixation of pediatric length-stable femoral shaft fractures using EIN or SLP. Methods: A prospective randomized clinical trial, 40 children aged 6–14 years with length-stable femoral shaft fractures were enrolled and randomly assigned to either EIN ( n = 20) or SLP ( n = 20). Perioperative parameters, time to radiographic union, time to full weight-bearing, complication rates, knee range of motion (ROM), and functional outcomes at 6 months, as assessed using the Flynn scoring system, were evaluated. Results: Forty patients were analyzed (20 EIN, 20 SLP). The SLP group demonstrated significantly longer operative time (58.45 ± 7.25 min versus 52.80 ± 7.07 min; p = 0.017) and greater intraoperative blood loss (73.75 ± 8.41 cc versus 13.65 ± 2.08 cc; p = 0.001) compared with EIN. No significant differences were observed in radiographic union time or time to weight-bearing. Full knee ROM at 6 months was achieved in all SLP patients but in only 80% of the EIN group ( p = 0.035). Excellent Flynn scores were more common in the SLP cohort (90% versus 65%; p = 0.048). Conclusions: Although EIN was associated with shorter operative time and lower blood loss, SLP demonstrated superior early functional outcomes, including better knee ROM recovery and higher rates of excellent Flynn scores, suggesting a functional advantage in pediatric length-stable femoral shaft fractures.