Journal of Pediatric Orthopaedics - 2026-08-01 - Journal Article; Comparative Study
A Comparison of the Effectiveness of Different Fixation Strategies in Pediatric and Adolescent Subtrochanteric Femur Fractures.
Munshi MA, Siddabattula R, Najera Saltos D, Pereira DE, Cornaghie M, Hosseinzadeh P
Topics
Key Takeaway
Rigid nail fixation achieved 0% malalignment (>10°) at 3 months versus 31% for flexible nails and 33% for plating, though differences were not statistically significant (P=0.25) in this underpowered series of 31 pediatric subtrochanteric femur fractures.
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Summary
This study compared radiographic and functional outcomes of flexible nailing (48%), rigid nailing (32%), and plating (19%) for operatively managed pediatric subtrochanteric femur fractures (≤18 years, 2015–2023). At 6 weeks, malalignment >10° was significantly more common in the flexible nail group (P=0.046), but by 3 months malalignment rates were 31%, 33%, and 0% for flexible nail, plate, and rigid nail groups respectively with no statistically significant difference (P=0.25). PROMIS pain and mobility scores and radiographic healing rates did not differ across groups at any time point.
Key Limitation
The significant age disparity between treatment groups (mean 6 vs. 13 vs. 9 years) is a fatal confounder that makes implant-specific outcome attribution impossible, as age independently determines remodeling capacity and implant selection.
Original Abstract
INTRODUCTION
Subtrochanteric femur fractures account for 4% to 10% of all pediatric femur fractures. In adults, managing these fractures can be challenging due to loss of reduction and nonunion. Limited data exist on pediatric outcomes related to implant selection. This study evaluates the radiographic and functional outcomes of subtrochanteric femoral fracture fixation strategies.
METHODS
Patients ≤18 years old treated operatively for subtrochanteric femoral fractures, defined as fracture lines starting ≤10% of the femoral length distal to the lesser trochanter, between 2015 and 2023, were included. Medical records provided demographics, fracture characteristics, management, radiographic measurements, and outcomes. Radiographic healing was defined as bridging callus formation in 3 of 4 cortices. Angulation and displacement were measured at presentation and at follow-up visits. Complications, including painful hardware and malalignment (>10 degrees angulation in AP or lateral planes), were noted. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected.
RESULTS
We included 31 operatively managed subtrochanteric femur fractures with a median follow-up of 13.0 months (range: 0.6 to 127.0). Flexible nails were used in 48% of cases, rigid nails in 32%, and plating in 19%. Average ages were 6, 13, and 9 years, respectively ( P <0.001). Initial fracture translation and angulation were similar across treatment groups. At 6 weeks postoperatively, malalignment >10 degrees was most common in the flexible nail group ( P =0.046). Radiographic healing was not different across treatment methods. After 4 weeks postoperatively, PROMIS pain and mobility scores were similar across treatment groups ( P >0.05). At 3 months postoperatively, malalignment >10 degrees was present in 31% of flexible nail cases, 33% of plate cases, and 0% of rigid nail cases ( P =0.25).
CONCLUSIONS
Rigid nails, flexible nails, and plate fixation all result in radiographic healing and functional improvement in pediatric subtrochanteric femur fractures. Although flexible nails are associated with higher malalignment rates at 6 weeks, these rates were comparable across treatment groups by 3 months. Flexible nails remain a viable option in this population. Ultimately, the fixation strategy should be guided by patient-related factors rather than the subtrochanteric pattern alone.
LEVEL OF EVIDENCE
Level III-therapeutic studies; investigating the results of treatment.