Medical Professional Publications

Submuscular Plating Leads to Better Outcomes for Some Young Patients With Diaphyseal Femur Fractures

Columbus, OH — January 2017

While the ideal surgical technique for stabilization of pediatric diaphyseal femur fractures is still debated, the Department of Orthopaedics at Nationwide Children’s Hospital continues to find that submuscular plating is often the best option for skeletally immature children.

A November 2016 study on the subject from Nationwide Children’s surgeons and researchers, published in Orthopedics, generally demonstrated better outcomes after plating than after flexible or rigid intramedullary nailing. This builds on findings from a 2013 study showing submuscular plating was an effective option for skeletally immature pediatric patients.

“This has become our go-to surgery, our surgery of choice, for a child of about 5 years to 12 years of age with a length unstable femur fracture,” says Kevin E. Klingele, MD, senior author of the study and chief of Orthopaedics at Nationwide Children’s. “We still treat every child individually, and it’s not a technique we use on all patients. We consider submuscular plating first for this population, however, before we consider others.”

The most recent study analyzed the records of 196 skeletally immature children 8 years of age and older treated at Nationwide Children’s for diaphyseal femur fractures. Submuscular plating was used in 35 cases, flexible retrograde intramedullary nailing in 61 and rigid antegrade intramedullary nailing with trochanteric entry point in 100.

Time to union after surgery was significantly less for the submuscular plating patients than for either of the nailing groups; the mean was six weeks for plating, eight weeks for flexible nailing and 11 weeks for rigid nailing. The plating group also had a significantly shorter time to full weight bearing (mean seven weeks vs. nine weeks for rigid nailing and 12 weeks for flexible nailing).

Even with the new study’s findings, intramedullary nailing may still be the most appropriate option in many cases, says Dr. Klingele, who is also a clinical assistant professor of Orthopedics at The Ohio State University College of Medicine.

Skeletally immature children with low bone density, or those with neuromuscular conditions that affect bone, likely would have better weight-bearing with a device inside the femur instead of a plate outside of it. Children 4 years and younger are still most often treated with immediate casting; older children with closed growth plates are treated as adults would be.

But for many active children with open plates, the study shows that with “submuscular plating, we can avoid some complications and speed recovery compared to other techniques,” Dr. Klingele says.


Sutphen SA, Mendoza JD, Mundy AC, Yang JG, Beebe AC, Samora WP 3rd, Klingele KE.  Pediatric diaphyseal femur fractures: submuscular plating compared with intramedullary nailing. Orthopedics. 2016 Nov 1; 39(6):353-358.

Samora WP, Guerriero M, Willis L, Klingele KE. Submuscular bridge plating for length-unstable, pediatric femur fractures. Journal of Pediatric Orthopedics. 2013 Dec;33(8):797-802.

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