Journal of Pediatric Orthopaedics - 2026-05-04 - Journal Article
Submuscular Biological Plating Versus Flexible Nailing With External Fixation for Treating Unstable Pediatric Femoral Fractures.
Elkholy MN, Frahat A, Arafa A, Morrah A
Topics
Key Takeaway
For length-unstable pediatric femoral shaft fractures, SBP reduced operative time by 15.7 minutes and fluoroscopy time by 22.2 seconds versus FIMN/EF, with superior knee flexion at final follow-up (108.1° vs. 100.6°).
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Summary
This RCT asked whether SBP or FIMN/EF produces superior outcomes in children aged 5–14 with AO/OTA 32-D/5.1 or 32-D/5.2 length-unstable femoral shaft fractures. Sixteen patients per arm were randomized; SBP yielded shorter operative time (73.1 vs. 88.8 min, P=0.002), less fluoroscopy (51.9 vs. 74.1 s, P<0.001), and greater knee flexion at final follow-up (108.1° vs. 100.6°, P=0.015). Time to union, complication rates, limb length discrepancy (≤10 mm), and Flynn criteria functional scores were equivalent between groups.
Key Limitation
The sample size of 32 patients is insufficient to detect differences in low-frequency but high-stakes outcomes such as physeal injury, malunion requiring reoperation, or infection.
Original Abstract
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, P <0.001). Time to radiologic union was comparable between groups ( P >0.05). 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.