Pavlik harness

<6 months

Ensure parents understand residual displacement will remodel

Proximal and middle third

Distal fractures,

>6 months

Avoids skin irritation from spica cast

If > 20° angulation deformities reliant on remodeling

Immediate spica casting

6 months–5 years

Close follow-up first 3 weeks, cast wedging to correct angulation deformity

Low energy, isolated fractures. Where telescope test results in less than 30 mm shortening

Multiple trauma,

Obesity

Simple, proven history

Prolonged immobilization. Assessment of soft tissues and Skin loss

Loss reduction

Traction and casting

6 months–5 years

5–10 years low energy

Traction pin inserted medial to lateral 90°–90° traction. Hip spica when no fracture site tenderness and radiographic evidence of callus (2-weeks) Traction weight 0.5 kg per year of life

Where shortening unacceptable for immediate casting. In increasing age or higher energy

Obesity

Floating knee

Head injury

Polytrauma

Distal fractures

Non-invasive.

Prolonged hospital stay. Outdated with internal fixation techniques

Flexible nailing

5–12

Nail diameter 40% isthmus femur. Use nails of the same diameter

Transverse, short oblique fractures

Very proximal or very distal spiral fracture. Length unstable

>49 kg

Early mobilization, avoids physis, reduced re-fracture.

Skin tip irritation, malunion/shortening in unstable fractures, proximal or distal fracture may require limited weight bearing or bracing

External fixation

5–16

Release TFL to allow knee movement

Severely injured, large soft tissue defect, wide area fracture comminution. If nailing or plating contraindicated

If amenable to nailing

Minimally invasive, quick, early weight bearing

Refracture following removal, pin site infection, knee stiffness, family and schooling stigma with frame. Delayed union. Construct too rigid for callus formation but reduction not stable enough for primary bone healing

Compression plating

5–16