Titanium Elastic Nails Versus Spica Cast in Pediatric Femoral Shaft Fractures: A Systematic Review and Meta-analysis of 1012 Patients



1 Department of Trauma and Orthopaedics, Faculty of Medicine, Suez Canal University, Egypt Ashford and St Peters NHS Trust, Chertsey, UK

2 Faculty of Medicine, Zagazig University, El-Sharkia, Egypt

3 Faculty of Medicine, Al Azhar University, Cairo, Egypt

4 Warwick University Hospitals, Warwick, UK

5 Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse, Zurich, Switzerland Department of Orthopaedics and Traumatology, Paracelsus Medical University, Muellner Hauptstrasse, Salzburg, Austria

6 Wrightington Hospital Appley Bridge, UK

7 Ashford and St Peters NHS Trust, Chertsey, UK

8 Epsom and St Helier NHS Trust, Carshalton, UK


Background: There is a general consensus on the management of femoral fractures in children younger than two years and adolescents older than sixteen years. The best treatment for patients younger than sixteen years of age is still debatable. Titanium Elastic Nails (TEN), is widely used with some evidence, nonetheless, we undertook a systematic meta-analysis to assess the efficacy of TEN compared to Spica cast for the management of femoral shaft fracture in children aged between 2 to 16 years old.
Methods: A computer literature search of PubMed, Scopus, Web of Science, CINAHL and Cochrane Central was conducted using relevant keywords. We included clinical trials and observational studies that compared TEN versus Spica cast; Records were screened for eligible studies and data were extracted and synthesized using Review Manager version 5.3 for Windows. Our search found 573 unique articles. After screening the abstract and relevant full text, 12 studies with a total of 1012 patients were suitab le for the final analysis
Results: In terms terms of union (in weeks), the reported effect sizes favoured the TEN group in two included studies only. Moreover, the overall standardized mean difference in sagittal (SMD -0.48, 95% CI [-0.70 to -0.26], P<0.001) and coronal angulations (SMD -0.66, 95% CI [-1.00 to -0.31], P<0.001) favored TEN fixation in management of femoral fractures younger than 16 years. The reported length of hospital stay was not consistent across studies. The overall risk ratio of malalignment (RR=0.39, 95% CI [0.27 to 0.57], P<0.001) favored the TEN as well as walking independently. Based on our analysis, TEN treatment is superior to traction and hip spica for femoral fractures in patients younger than 16 years old.
Conclusion: Based on our analysis we recommend the use of TEN fixation in management of pediatric femoral fractures in patients younger than 16 years.
Level of evidence: II


Main Subjects

1. Bahuaud C, Beneteau M, Dorr MF. [Treatment of
fractures of the femoral diaphysis in children]. Soins
Chir. 1993(150-151):36-42.
2. Rewers A, Hedegaard H, Lezotte D, Meng K, Battan
FK, Emery K, et al. Childhood femur fractures,
associated injuries, and sociodemographic risk
factors: a population-based study. Pediatrics.
3. Sanzarello I, Calamoneri E, D’Andrea L, Rosa MA.
Algorithm for the management of femoral shaft
fractures in children. Musculoskeletal surgery.
4. Rodriguez-Merchan EC, Moraleda L, Gomez-Cardero
P. Injuries associated with femoral shaft fractures
with special emphasis on occult injuries. Arch Bone Jt
Surg. 2013; 1(2):59-63.
5. Dalton HJ, Slovis T, Helfer RE, Comstock J, Scheurer
S, Riolo S. Undiagnosed abuse in children younger
than 3 years with femoral fracture. American
journal of diseases of children (1960). 1990;144(8):
6. Hinton RY, Lincoln A, Crockett MM, Sponseller P, Smith
G. Fractures of the femoral shaft in children. Incidence,
mechanisms, and sociodemographic risk factors. The
Journal of bone and joint surgery American volume.
7. Flynn JM, Schwend RM. Management of pediatric
femoral shaft fractures. The Journal of the
American Academy of Orthopaedic Surgeons.
8. Sanders JO, Browne RH, Mooney JF, Raney EM, Horn
BD, Anderson DJ, et al. Treatment of femoral fractures
in children by pediatric orthopedists: results of
a 1998 survey. Journal of pediatric orthopedics.
9. Aslani H, Tabrizi A, Sadighi A, Mirbolook AR.
Treatment of pediatric open femoral fractures with
external fixator versus flexible intramedullary nails.
Arch Bone Jt Surg. 2013; 1(2):64-7.
10. Andalib A, Sheikhbahaei E, Andalib Z, Tahririan
MA. Effectiveness of minimally invasive plate
osteosynthesis (MIPO) on comminuted tibial
or femoral fractures. Arch Bone Jt Surg. 2017;
11. Buckley SL. Current trends in the treatment of
femoral shaft fractures in children and adolescents.
Clinical orthopaedics and related research.
12. Buehler KC, Thompson JD, Sponseller PD, Black BE,
Buckley SL, Griffin PP. A prospective study of early
spica casting outcomes in the treatment of femoral
shaft fractures in children. Journal of pediatric
orthopedics. 1995;15(1):30-5.
13. Curtis JF, Killian JT, Alonso JE. Improved treatment
of femoral shaft fractures in children utilizing the
pontoon spica cast: a long-term follow-up. Journal of
pediatric orthopedics. 1995;15(1):36-40.
14. Miller ME, Bramlett KW, Kissell EU, Niemann KM.
Improved treatment of femoral shaft fractures in
children. The “pontoon” 90-90 spica cast. Clinical
orthopaedics and related research. 1987(219):
15. Rasool MN, Govender S, Naidoo KS. Treatment of
femoral shaft fractures in children by early spica
casting. S Afr Med J. 1989;76(3):96-9.
16. Al-Habdan I. Diaphyseal femoral fractures in children:
should we change the present mode of treatment? Int
Surg. 2004;89(4):236-9.
17. Krettek C, Haas N, Walker J, Tscherne H. Treatment
of femoral shaft fractures in children by external
fixation. Injury. 1991;22(4):263-6.
18. Aronson J, Tursky EA. External fixation of femur
fractures in children. Journal of pediatric orthopedics.
19. Kirschenbaum D, Albert MC, Robertson WW, Jr.,
Davidson RS. Complex femur fractures in children:
treatment with external fixation. Journal of pediatric
orthopedics. 1990;10(5):588-91.
20. Mostafa MM, Hassan MG, Gaballa MA. Treatment of
femoral shaft fractures in children and adolescents.
The Journal of trauma. 2001;51(6):1182-8.
21. Kregor PJ, Song KM, Routt ML, Jr., Sangeorzan BJ,
Liddell RM, Hansen ST, Jr. Plate fixation of femoral
shaft fractures in multiply injured children. The
Journal of bone and joint surgery American volume.
22. Beaty JH, Austin SM, Warner WC, Canale ST, Nichols
L. Interlocking intramedullary nailing of femoralshaft
fractures in adolescents: preliminary results
and complications. Journal of pediatric orthopedics.
23. Beaty JH. Operative treatment of femoral shaft
fractures in children and adolescents. Clinical
orthopaedics and related research. 2005(434):114-
24. Buford D, Jr., Christensen K, Weatherall P.
Intramedullary nailing of femoral fractures in
adolescents. Clinical orthopaedics and related
research. 1998(350):85-9.
25. Momberger N, Stevens P, Smith J, Santora S, Scott
S, Anderson J. Intramedullary nailing of femoral
fractures in adolescents. Journal of pediatric
orthopedics. 2000;20(4):482-4.
26. Galpin RD, Willis RB, Sabano N. Intramedullary nailing
of pediatric femoral fractures. Journal of pediatric
orthopedics. 1994;14(2):184-9.
27. Keeler KA, Dart B, Luhmann SJ, Schoenecker
PL, Ortman MR, Dobbs MB, et al. Antegrade
intramedullary nailing of pediatric femoral fractures
using an interlocking pediatric femoral nail and a 
lateral trochanteric entry point. Journal of pediatric
orthopedics. 2009;29(4):345-51.
28. Lee MC. Luau Limbo and the Age for Rigid Nailing
of Pediatric Femoral Fractures: How Low Can
You Go? Commentary on an article by Samuel N.
Crosby Jr., MD, et al.: “Twenty-Year Experience
with Rigid Intramedullary Nailing of Femoral Shaft
Fractures in Skeletally Immature Patients”. The
Journal of bone and joint surgery American volume.
29. Allar BG, Hedequist DJ, Miller PE, Glotzbecker
MP, Spencer SA, Shore BJ. Treatment outcomes
after insufficiency femoral diaphyseal fractures in
nonambulatory children. J Pediatr Orthop B. 2016.
30. Cosma D, Vasilescu DE. Elastic Stable Intramedullary
Nailing for Fractures in Children - Specific
Applications. Clujul Med. 2014;87(3):147-51.
31. Kaiser SP, Holland T, Baidoo PK, Coughlin RC, Konadu
P, Awariyah D, et al. An observational cohort study of
the adoption of elastic stable intramedullary nailing
for the treatment of pediatric femur fractures in
Kumasi, Ghana. World J Surg. 2014;38(11):2818-24.
32. Till H, Huttl B, Knorr P, Dietz HG. Elastic stable
intramedullary nailing (ESIN) provides good longterm
results in pediatric long-bone fractures. Eur J
Pediatr Surg. 2000;10(5):319-22.
33. Ligier JN, Metaizeau JP, Prevot J, Lascombes P. Elastic
stable intramedullary nailing of femoral shaft
fractures in children. The Journal of bone and joint
surgery British volume. 1988;70(1):74-7.
34. Heinrich SD, Drvaric DM, Darr K, MacEwen GD.
The operative stabilization of pediatric diaphyseal
femur fractures with flexible intramedullary nails: a
prospective analysis. Journal of pediatric orthopedics.
35. Flynn JM, Luedtke LM, Ganley TJ, Dawson J, Davidson
RS, Dormans JP, et al. Comparison of titanium elastic
nails with traction and a spica cast to treat femoral
fractures in children. J Bone Joint Surg Am. 2004;86-
36. Stang A. Critical evaluation of the Newcastle-
Ottawa scale for the assessment of the quality of
nonrandomized studies in meta-analyses. Eur J
Epidemiol. 2010;25(9):603-5.
37. Altman DG, Bland JM. Standard deviations and
standard errors. Bmj. 2005;331(7521):903.
38. DerSimonian R, Laird N. Meta-analysis in clinical trials
revisited. Contemporary clinical trials. 2015;45(Pt
39. Higgins JP, Thompson SG. Quantifying heterogeneity
in a meta-analysis. Statistics in medicine.
40. Higgins JP, Thompson SG, Deeks JJ, Altman DG.
Measuring inconsistency in meta-analyses. Bmj.
41. Terrin N, Schmid CH, Lau J, Olkin I. Adjusting for
publication bias in the presence of heterogeneity. Stat
Med. 2003;22(13):2113-26.
42. Heffernan MJ, Gordon JE, Sabatini CS, Keeler KA,
Lehmann CL, O’Donnell JC, et al. Treatment of femur
fractures in young children: a multicenter comparison
of flexible intramedullary nails to spica casting in
young children aged 2 to 6 years. Journal of pediatric
orthopedics. 2015;35(2):126-9.
43. Assaghir Y. The safety of titanium elastic nailing
in preschool femur fractures: a retrospective
comparative study with spica cast. J Pediatr Orthop B.
44. Saseendar S, Menon J, Patro DK. Treatment of femoral
fractures in children: is titanium elastic nailing an
improvement over hip spica casting? J Child Orthop.
45. Shemshaki HR, Mousavi H, Salehi G, Eshaghi MA.
Titanium elastic nailing versus hip spica cast in
treatment of femoral-shaft fractures in children. J
Orthop Traumatol. 2011;12(1):45-8.
46. Soleimanpour J, Ganjpour J, Rouhani S, Goldust M.
Comparison of titanium elastic nails with traction
and spica cast in treatment of children’s femoral shaft
fractures. Pakistan journal of biological sciences :
PJBS. 2013;16(8):391-5.
47. Sela Y, Hershkovich O, Sher-Lurie N, Schindler
A, Givon U. Pediatric femoral shaft fractures:
treatment strategies according to age--13 years
of experience in one medical center. J Orthop Surg
Res. 2013;8:23.
48. Say F, Gurler D, Inkaya E, Yener K, Bulbul M.
Which treatment option for paediatric femoral
fractures in school-aged children: elastic nail or
spica casting? European journal of orthopaedic
surgery & traumatology : orthopedie traumatologie.
49. Buechsenschuetz KE, Mehlman CT, Shaw KJ, Crawford
AH, Immerman EB. Femoral shaft fractures in
children: traction and casting versus elastic stable
intramedullary nailing. The Journal of trauma.
50. Nascimento FP, Santili C, Akkari M, Waisberg G,
Braga Sdos R, Fucs PM. Flexible intramedullary
nails with traction versus plaster cast for treating
femoral shaft fractures in children: comparative
retrospective study. Sao Paulo Med J. 2013;131(1):
51. Clinkscales CM, Peterson HA. Isolated closed
diaphyseal fractures of the femur in children:
comparison of effectiveness and cost of several
treatment methods. Orthopedics. 1997; 20(12):
52. Hsu AR, Diaz HM, Penaranda NR, Cui HD, Evangelista
RH, Rinsky L, et al. Dynamic skeletal traction spica
casts for paediatric femoral fractures in a resourcelimited
setting. Int Orthop. 2009;33(3):765-71.
53. Kasser JR. Femur fractures in children. Instructional
course lectures. 1992;41:403-8.
54. Benum P, Ertresvag K, Hoiseth K. Torsion deformities
after traction treatment of femoral fractures
in children. Acta orthopaedica Scandinavica.
55. Karn MA, Ragiel CA. The psychologic effects of
immobilization on the pediatric orthopaedic
patient (continuing education credit). Orthop Nurs.