Flynn's Criteria Research Articles

A prospective randomised, controlled clinical trial comparing medial and lateral entry pinning with lateral entry pinning for percutaneous fixation of displaced extension type supracondylar fractures of the humerus in children

ObjectiveTo compare the efficacy of medial and lateral entry pinning with lateral entry pinning for percutaneous fixation of displaced (Gartland type II and type III) extension type supracondylar fractures of the humerus in children.MethodsThe study was a single center, prospective, randomized controlled clinical trial. Between October 2007 and September 2010, 160 patients who satisfy the inclusion and exclusion criterias were enrolled in the study, with 80 patients in each group. All the percutaneous pinning was done according to a uniform standardized technique. The patients were re-evaluated as outpatients at three weeks, six weeks and three months after the surgery. At three months follow-up visit, following informations were recorded as outcome measures: (i) Carrying angle (deg) (ii) passive range of elbow motion (deg) (iii) Flynn's criteria for grading, based on the loss of carrying angle and loss of total range of elbow motion. (iv) Baumann angle (deg) (v) Change in Baumann angle (deg) between the Intraoperative radiographs after the surgery and radiographs at three months follow-up visit (vi) loss of reduction grading, based on the change in the Baumann angle.ResultsThere were no significant differences between the two groups with regard to base-line characteristics, withdrawals and complication rate. At three months follow-up visit, patients were evaluated by recording the various outcome measures. There were no significant differences between the two groups with regard to the various outcome measures such as carrying angle, passive range of elbow motion, Flynn grading, Baumann angle, change in the Baumann angle and loss of reduction grading.ConclusionsIf a uniform standardized operative technique is followed in each method, then the result of both the percutaneous fixation methods will be same in terms of safety and efficacy.

SUPRACONDYLAR FRACTURE OF THE HUMERUS IN CHILDREN: FIXATION WITH TWO CROSSED KIRSCHNER WIRES

Objective: To analyze and present the surgical results from unstable supracondylar fractures of the humerus in children, treated by means of reduction and percutaneous fixation using two crossed Kirschner wires. Methods: A cross-sectional study was conducted on 20 children, taking into consideration sex, age at the time of the fracture, age at the time of the assessment, side affected, type and mechanism of trauma, postoperative complications and radiographic and clinic variables. Results: Ten fractures were observed in the left arm and ten in the right arm. The age at the time of the fracture ranged from 2 to 13 years (mean: 5.9 ± 2.48 years). Three fractures were classified as type II and 17 as type III. The length of follow-up ranged from four months to three years. Baumann's angle ranged from 69 to 100 (mean: 78.3) and cubitus varus was observed in four patients (values ranging from 84 to 100). According to the modified Flynn's criteria, 20 cases presented satisfactory outcomes: 17 excellent (85%), two good (10%) and one regular (5%). Two patients presented limited range of motion, two had paresthesia in the cubital region and one had transient neuropraxia of the ulnar nerve for six weeks. Conclusion: Percutaneous fixation with two crossed Kirschner wires leads to good results when carried out under direct viewing and with isolation of the ulnar nerve.

Fratura supracondiliana de úmero em crianças: fixação com dois fios de Kirschner cruzados

OBJETIVO: Analisar e apresentar os resultados de fraturas supracondilianas instáveis de úmero em crianças, tratadas cirurgicamente com redução e fixação percutânea com dois fios de Kirschner cruzados. MÉTODOS: Foi realizado estudo transversal com 20 crianças, considerando sexo, idade na época da fratura e no momento da análise, lateralidade, tipo e mecanismo de fratura, complicações pós-operatórias, variáveis radiográficas e clínicas. RESULTADOS: Observaram-se 10 fraturas à esquerda e 10 à direita. A idade na fratura variou de dois a 13 anos (média 5,9 anos ± 2,48). Três fraturas foram classificadas como tipo II e 17 do tipo III. O tempo de seguimento variou de quatro meses a três anos. O ângulo de Baumann variou de 69 a 100 (média 78,3), sendo observada a presença de cúbito varo em quatro pacientes (com valores variando de 84 a 100). Segundo os critérios de Flynn modificados, obtiveram-se 20 casos satisfatórios, 17 excelentes (85%), dois bons (10%) e um regular (5%). Dois pacientes apresentaram déficit da amplitude de movimento, dois parestesia no território cubital e uma criança apresentou neuropraxia transitória do nervo ulnar por seis semanas. CONCLUSÃO: A fixação percutânea com dois fios de Kirschner cruzados, quando realizada com visualização direta e isolamento do nervo ulnar, permite bons resultados.

Pediatric Femoral Shaft Fracture Management By Titanium Elastic Nailing; A Prospective Study Of 112 Patients

Objective – To assess the usefulness of TENS in treatment of pediatric femoral shaft fractures, which is one of most common pediatric major injuries encountered to orthopedic surgeon.Material and method – The study was conducted on 112 patients admitted at Govt. Medical College, Haldwani in the Department of Orthopedics from January 2007 to Januray 2012. We included patients of age group of 5 -15 years with fracture shafts of femurs excluding grade 3 compound fractures and pathological fractures. Patients were followed more than a year. Greater emphasis was given on complication analysis, major complications like limb length discrepancy, infection, angulations, and loss of knee movement were noted. Functional outcomes were analyzed according to Flynn criteria. In our prospective study by using Flynn criteria, 86 had excellent results, 24 had satisfactory results, and 2 had poor results.Discussion and conclusionTreatment of long bone fracture in pediatric age group by titanium elastic nail is broadly under acceptance. Technical ease, good functional outcome, preservation of epiphysis, low complications are very favorable point for TENS use for femoral shaft fracture. Encouraging reports and low complication from our study also supports exclusive use of TENS in pediatric femoral shaft fracture in age group 5-15 years.

Intramedullary nailing versus submuscular plating in adolescent femoral fracture

BackgroundFemoral fractures in adolescents usually need operative treatment, but the optimal method is unclear. The purpose of this study is to compare intramedullary nailing (IN) and submuscular plating (SP) in adolescent femoral fractures. Materials and methodsWe performed the prospective, comparison study of IN and SP in adolescent femoral shaft fractures at a mean age of 13.9 years (11–17.4). Twenty-two cases of IN and 23 cases of SP were followed for a minimum of 1 year. We compared radiological and clinical results, surgical parameters, and complications of two techniques. ResultsBony union was achieved in all cases except one case of IN. Time to union was similar in both groups. None showed mal-union over 10° or limb length discrepancy over 1cm. None of SP group and 2 in IN group experienced re-operation; one patient had deep infection with nonunion. The other patient sustained mal-rotation. Both patients healed after revision procedure. All patients showed excellent or satisfactory results of Flynn's criteria. The time to full-weight bearing was shorter in IN (IN: 57.3 days, SP: 89.2 days, p<0.05). In surgical parameters, operative time seemed shorter in IN (IN: 94.7min, SP: 104min, p=0.095), and fluoroscopy time was shorter in IN (IN: 58s, SP: 109s, p<0.05) than SP group. ConclusionAlthough both IN and SP yield good results and minimal complication in adolescent femoral fractures, IN may be advantageous in less need of fluoroscopy, technical easiness in reduction and early weight bearing.

Posterior bilaterotricipital approach for surgical treatment of children’s Gartland Type III supracondylar humeral fractures

Effects of posterior bilaterotricipital approach on the outcome of range of motion and carrying-angle of the elbow after open reduction and internal fixation of children’s Gartland Type III supracondylar humeral fractures were evaluated. Twenty-five patients (18 boys, 7 girls; mean age 11.2) with Gartland Type III supracondylar humeral fractures, who needed open reduction, were operated through posterior bilaterotricipital approach in our institution between the years 2000 and 2007. At the final follow-up examination, patients were questioned about pain, restriction in motion and satisfaction with the appearance of the elbow. Carrying-angles and flexion–extension arcs of the elbows were measured. Change in carrying-angle of the operated elbow was zero to 5° in 19 (76%), 6°–10° in four (16%) and 11°–15° in two (8%) patients. Fourteen (56%) patients lost less than 5°, eight (32%) lost 6°–10°, two (8%) lost 11°–15° and one (4%) lost more than 15° of movement in flexion–extension arc. According to Flynn criteria, excellent results were obtained in 12 (48%), good results in nine (36%), fair results in three (12%) and poor result in one (4%) of the patients at meanly 32.4 months follow-up. Satisfactory results can be obtained by using posterior bilaterotricipital approach for the surgical treatment of Gartland Type III supracondylar humeral fractures, which needed open reduction and internal fixation.

Closed reduction and percutaneous pinning of displaced supracondylar fractures of humerus in children with delayed presentation

Objective Supracondylar fractures of the humerus account for 60% of all the fractures around the pediatric elbow and even in developed countries 18% of patients undergo surgery 48 hours or longer following presentation in the hospital. Management guidelines are not clear yet for these patients who present late. The aim of this prospective study was to evaluate the clinical, radiological and functional outcome following closed reduction and percutaneous pinning of widely displaced supracondylar fractures of the humerus presenting 12 hours or more after injury. Methods We reviewed the functional and radiological results of closed reduction and percutaneous pinning using crossed K-wires in 40 patients with displaced extension type supracondylar fracture of the humerus (Gartland type III) with a delay of more than 12 hours in presentation. The average age of patients was 4.5 years and the mean delay in presentation was 17.55 hours. Results Closed reduction and percutaneous pinning was successful in 90% of patients. The mean follow up period was 15 months. The Baumann's angle was restored within 4 degrees of the unaffected side in all patients. Use of a small medial incision in patients with severe swelling helped us avoid ulnar nerve injury. Using Flynn's criteria, 38 patients (95%) had an excellent result. Two patients had mild myositis and both had a poor result. None of the patients developed cubitus varus. Conclusion Closed reduction and crossed pinning of displaced supracondylar fractures of humerus in children is a safe and effective method even with delayed presentation.

Gartland type III supracondylar humeral fractures

There is a lack of evidence to determine whether closed or open reduction results in better outcomes following Gartland type III supracondylar humeral fractures in children. One small randomized controlled trial (RCT) suggests that clinician-based outcomes (Flynn's criteria) may be slightly better following closed reduction. However, this needs to be weighed against the potential of a slight increase in iatrogenic ulnar nerve injury. A larger randomized trial is needed in order to better determine the benefits and harms of these two treatment options.

Does the technique of lateral cross-wiring (Dorgan’s technique) reduce iatrogenic ulnar nerve injury?

In this study we compared the results of patients with displaced supracondylar humeral fractures who had been treated with all lateral cross-wire and medio-lateral cross-wire fixation techniques. Only the 139 patients who were able to attend the final examination were included in the assessment. The patients were allocated retrospectively into two groups according to the pin configuration used. Group 1 comprised 75 patients, 60 male and 15 female, with a mean age of 7.5 years (range, 1.5-14 years). After closed reduction, fixation was achieved with crossed K-wires placed from the lateral condyle and lateral humerus towards the medial epicondyle. Care was taken so that the end of the K-wire passing from the lateral humerus did not protrude excessively at the level of the medial epicondyle. Group 2 comprised 64 patients, 54 males and ten females, with a mean age of 7.8 years (range, 2-13 years). After closed reduction, two cross-wires passed-one from medial and one from lateral. In group 1 there was no postoperative iatrogenic nerve damage whereas in group 2 iatrogenic ulnar nerve damage developed in six (9%) patients. On statistical evaluation, a significant difference was seen between the two groups. According to Flynn's criteria, there was no statistically significant difference between the two groups. In conclusion, the lateral cross-wire fixation technique may be a good choice in the treatment of paediatric supracondylar humerus fractures as it reduces the possibility of ulnar nerve damage and achieves the same level of stabilisation as medio-lateral fixation.

Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: A systematic review

There is no clear evidence in the actual literature regarding which of the surgical approaches could bring about the best functional, cosmetic, and radiological outcomes, as well as fewer complications, when an open reduction and pinning of a severely displaced supracondylar humerus fracture is performed. We, therefore, performed a systematic review of the English literature to investigate the existing evidence regarding this issue. A MEDLINE and EMBASE databases search was performed to identify articles that focused on the functional, cosmetic, and radiological outcomes, as well as post-surgical complications, regarding different surgical approaches used for open reduction and pinning in severely displaced supracondylar humerus fractures in children. One hundred and ninety-four articles were identified, of which seven were included for review. Data analysis included weighted means for all contingency tables and the Chi-square test. Standardized residues were studied when the Chi-square test was statistically significant. Statistical analyses were conducted using Stata 9.1/SE (StataCorp., College Station, TX) and P-values lower than 0.05 were considered to be statistically significant for all analyses. For functional outcome, a high frequency of excellent results was found within the lateral and medial approaches, and a high frequency of good results within the anterior approach. A high frequency of poor results was found within the posterior approach. For cosmetic outcome, there was a high frequency of fair results within the posterior and lateral approaches, and a high frequency of poor results within the posterior approach. No statistically significant difference regarding time to union, as well as complications, was found. Our results suggest that a combined antero-medial approach could be the method which allows the achievement of better functional and cosmetic outcome according to Flynn's criteria. Time to union, as well as post-surgical complications, should not be an issue regarding surgical approaches used for open reduction and pinning in these fractures.

Outcome of Gartland type II and type III supracondylar fractures treated by Blount’s technique

Background:According to some orthopedic surgeons, almost all supracondylar humerus fractures should be treated operatively by reduction and pinning. While according to others, closed reduction and immobolization should be used for Gartland type II and some type III fractures. However, the limit of this technique remains unclear. We present 74 patients with displaced extension-type supracondylar fractures treated by closed reduction and immobilization with a collar sling fixed to a cast around the wrist. The purpose of the study is to give a more precise limitation of this technique.Materials and Methods:Retrospective data acquisition of 74 patients with a Gartland type II or type III fractures treated by closed reduction and immobilization (Blount's technique) between January 2004 and December 2007 was done. The mean age was 6.3 years (range, 2–11). The mean time of follow-up was 6.5 months (range, 3–25). All open injuries and complex elbow fracture dislocations or T-condylar fractures were excluded from the study. All patients were evaluated with standardized anteroposterior and true lateral x-rays of the elbow, and Flynn criteria were used for functional assessment.Results:Gartland type II fractures had 94% good or excellent final results. Gartland type III fractures had 73% good or excellent final result. The Gartland type III outcome depended on the displacement. The fractures remained stable in 88% for the posterior displacement, and 58% for the posteromedial displacement. These displacements were mild. However, for the posterolaterally displaced fractures, only 36% were stable; 36% had a mild displacement and 27% had a major displacement.Conclusion:Pure posterior displacement is more stable than posteromedial displacement which is more stable than posterolaterally displaced fractures. This study suggests that Gartland type II and pure posterior or posteromedial displaced Gartland type III fractures can be treated by closed reduction and immobilization with success.

Closed reduction of the pediatric supracondylar humerus fractures: the “joystick” method

Our goal in this study was to propose an alternative closed reduction method to avoid open reduction in the management of pediatric supracondylar humerus fractures. A temporary Kirschner wire is inserted to the proximal part of the humerus to be used as a joystick to have a better control of the proximal fragment. Twenty-three patients with closed Gartland type III extension fractures were operated between 2003 and 2007. Mean age of the patients was 6.7 (4-10) years. Uninjured and fractured elbow's Bauman angles, lateral condylar angles, the carrying angles and ROM values were compared statistically according to independent samples t test. At a mean follow-up 96.73 weeks (53-150), clinical results using the Flynn criteria were excellent in 21 (91.3%), good in 1(4.35%), fair in 1 (4.35%) patient. These results suggest that the "joystick" reduction method is a reliable alternative when closed reduction itself is not successful.

Treatment of supracondylar fractures of the humerus in children through an anterior approach is a safe and effective method

In this prospective case series we evaluated the effectiveness and safety of using an anterior approach to paediatric supracondylar humerus fractures. We gathered data on 46 children that had a displaced supracondylar fracture of the humerus. All the patients had sustained a Gartland type III extension fracture that could not be reduced by closed means. Open reduction through an anterior approach was performed and two Kirschner wires were used to fix the fracture to the medial and lateral sides. Patients were recalled for follow-up and were evaluated using Flynn's radiological and clinical criteria. Loss of extension and flexion was noted by clinical assessment and carrying angle measured on radiograms. A follow-up examination performed in the 24th postoperative week showed that all fractures had healed; the patients' outcomes were rated as excellent or good according to Flynn's criteria. As a result the anterior approach for open reduction of paediatric supracondylar humeral fractures is a safe and reliable method with very good results.

Operative management of type III extension supracondylar fractures in children

The purpose of this study was to compare primarily open versus primarily closed surgical treatment of Gartland type III extension supracondylar fractures in children. Also the outcomes of different pinning techniques in open surgery were evaluated retrospectively. Eighty displaced type III extension supracondylar fractures treated consecutively at two different centres were included. The treatment protocol of one institute was primarily closed reduction and percutaneous cross-pinning (n = 43). The treatment protocol of the other institute was primarily open reduction and internal fixation (n = 37) with two lateral parallel pins (n = 11), cross pins (n = 11) and two lateral and one medial pin (n = 15) according to the stability and configuration of the fracture. According to Flynn's criteria the outcomes of the open and closed reduction groups were not statistically significant (P > 0.05). Although the outcomes of closed reduction showed no superiority over open reduction, it should be the first choice of treatment due to its low morbidity and short hospital stay.

Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures

The results of closed and open reduction via posterior approach with percutaneous pinning of posteromedial displaced supracondylar humerus fractures in children were evaluated. Fifty-five consecutive patients with Gartland type III fractures were reviewed. The mean follow-up period was 22 months (12-48 months). The closed reduction group consisted of 32 patients and the open reduction group with the posterior approach using the triceps-sparing method consisted of 23 patients. Both groups were stabilized with cross Kirschner wire fixation and followed the same protocol. In comparison with closed reduction, despite the fact that better bone alignment was obtained with open reduction, longer union time (7 vs. 5.8 weeks), significantly reduced range of motion of the elbow (12.3 degrees vs. 3.8 degrees), poorer functional outcomes and bad cosmetics because of hypertrophic scar tissue of the skin were found. The patients were analyzed according to their Bauman angle and Flynn criteria: good or excellent functional and cosmetic results were 91% in the closed reduction group but 52% in the open reduction group. On the basis of results of this study, closed reduction and percutaneous fixation of the posteromedial totally displaced fractures are preferable to open reduction with posterior approach.

Three Lateral Divergent or Parallel Pin Fixations for the Treatment of Displaced Supracondylar Humerus Fractures in Children

To evaluate the efficacy of lateral or parallel pin fixation using 3 smooth Kirschner wires (K-wires) or smooth Steinmann pins for the operative management of displaced supracondylar humeral fracture in a consecutive series of children. Sixty-one consecutive displaced or angled supracondylar humeral fractures (Gartland type II or III) in children (mean age, 5 years 6 months) treated by 2 orthopaedic surgeons between 2001 and 2004 according to the following protocol: close reduction under general anesthesia with fluoroscopic guidance and only lateral percutaneous pinning using 3 divergent or parallel Kirschner wires or Steinmann pins. Minimum 2 years' follow-up was done in all 61 patients (range, 2.0-3.3 years). Clinical assessment was obtained at final follow-up using Flynn criteria, and radiologic assessment was obtained using the Baumann and lateral humerocapitellar angles of both arms. Statistical analysis was performed by means of the Student t test (P < 0.05). The study group consisted of 61 patients, of whom 24 (39%) presented with Gartland type II fractures, and the remaining 37 (61%) presented with a type III fracture. A comparison of perioperative and final radiographs shows no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. Eight patients had preoperative nerve palsy. Five of these nerve injuries resolved immediately after surgery, and the other 3 resolved completely within 12 weeks of surgery. After an average of 28 months postoperation, 56 (91.8%) patients had achieved an excellent clinical result, and 5 (8.2%) achieved a good result. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a minor pin-track infection. Our series demonstrates that only 3 lateral divergent or parallel pin fixations are effective and safe for avoiding iatrogenic ulnar nerve injury and are appropriate treatment options for displaced or angled supracondylar humeral fractures in children. Therapeutic study, level III.

Correlation between posteromedial or posterolateral displacement and cubitus varus deformity in supracondylar humerus fractures in children

Cubitus varus deformity is one of the most common complications after displaced supracondylar humeral fractures in children. The purpose of this study was to evaluate the relationship between the fracture displacement and cubitus varus deformity in displaced supracondylar humerus fractures. Seventeen patients (11 males/6 females; mean age 7 years) with cubitus varus deformities occurring after Gartland type III posteromedial or posterolateral displaced supracondylar humerus fractures were evaluated with clinical and serial radiographic examinations. All patients had been treated surgically by open reduction through a medial approach and percutaneous cross-pinning. All fractures were reduced anatomically. Ten of the patients were operated within the first 24 h. The time interval between the initial injury and the surgical procedure for the remaining seven patients was 5.3 days on average (range 2-10 days). The carrying angle and range of motion of the elbow were measured throughout the follow-up period. The mean follow-up time was 3.7 years (range 2-12 years). Five patients with type III-B fractures had a mean carrying angle loss of 8.8 degrees (range 6-10 degrees ), whereas for the remaining 12 type III-A patients the mean loss was 15 degrees (range 6-29 degrees ) (P = 0.019). None of the patients in this study demonstrated limited elbow motion. According to the Flynn criteria, the results were good in five type III-B patients. There was no statistically significant relationship between the loss of carrying angle and the delay before the surgical procedure (P = 0.615 in type III-A, P = 0.096 in type III-B). The carrying angle loss was more significant in type III-A fractures compared with type III-B in this series. These results suggest that although anatomic reduction has been achieved by surgical treatment without loss of reduction, there is still a risk for cubitus varus deformity for type III-A fractures due to the initial compression of the medial column or, in other words, physeal injury.

Results of treatment of displaced supracondylar humeral fractures in children by percutaneous lateral cross-wiring technique

Seventy children with displaced type II and III supracondylar fractures of the humerus were managed with percutaneous lateral cross-wiring technique from January 2006 to January 2007. There were 54 boys and 16 girls with a mean age of 6.1 +/- 3.07 years. All patients were operated within 24 h after trauma using the Dorgans percutaneous lateral cross-wiring technique. Patients were followed up for a mean period of 6.1 +/- 2.6 months and assessed both radiologically for union; and functionally and cosmetically according to Flynn's criteria. All patients achieved solid union. Functionally, all patients achieved satisfactory results, while cosmetically, 91.4% of patients had satisfactory results and 8.6% had unsatisfactory results. The most frequently occurring complications were minor pin tract infection in six patients, deep infection in two patients, and 32 patients suffered excessive granulation tissue formation mostly around the proximal pin. There was no iatrogenic neurological injury either for the ulnar or for the radial nerves. The obtained results and minor complications reported signify this technique as a viable treatment method for displaced type II and III supracondylar fractures in children.

Underreduced Supracondylar Fracture of the Humerus in Children

Although supracondylar fractures of the humerus in children are common, the literature is sparse regarding acceptable limits of reduction of these fractures in the sagittal plane. We retrospectively reviewed 223 pediatric cases of supracondylar fractures of the elbow treated in our hospital between the years 1996 and 2000. In 30 patients, we found some degree of underreduction of the extension component of the fracture. Twenty-two of them were followed and evaluated at or close to skeletal maturity. The mean age at the time of fracture was 5.4 years, the mean follow-up was 8.2 years. Radiographic remodeling, range of elbow motion, and awareness of the patients to the functional limitation were evaluated. At final follow-up, 17 (77%) of the patients had radiographic abnormality of the humerocondylar angle (a difference of 5 degrees or more compared with the uninjured side). Eleven patients (50%) had limited elbow flexion, and 7 (31%) were aware of this deficit. Most of the underreductions occurred when reduction was attempted in the emergency department, when the angulation was not appreciated, and when the cast was applied without any reduction attempt. Patients who were left to heal with some degree of extension developed limited end-elbow flexion and were aware of it. Although only 3 patients felt minor subjective functional disability at the last follow-up, 10 patients had unsatisfactory results according to Flynn criteria for motion restriction. The treating surgeon must be aware of this possible outcome and be more demanding in the reduction of the extension component of the fracture. Otherwise, clinically significant limitation in elbow flexion may occur. Although the reduction of moderately displaced fractures may seem simple, it should be performed under general anesthesia and with radiographic control of reduction and pin placement.

Nail-assisted Percutaneous Plating of Pediatric Femoral Fractures

Traditional operative treatments for pediatric femoral shaft fractures may result in an unacceptable complication rate, especially in patients with complex fractures. Despite requiring the use of fluoroscopy and presenting some technical difficulty, minimally invasive percutaneous plating is an alternative operative method. We retrospectively reviewed 13 consecutive femoral fractures in children (mean age, 9 years) who were treated by a modified technique of percutaneous plating. Six of the fractures were comminuted. Nine children had associated injuries, including four with head trauma. The primary indication for use of percutaneous plating in this pediatric series was a complex fracture in which flexible nailing would be suboptimal. The results were evaluated by a modification of Flynn's criteria. All fractures united without bone grafts (mean, 11 weeks). No patients had residual radiographic angulations greater than 10 degrees or a leg-length discrepancy greater than 5 mm. All patients had excellent final outcomes. There were no major complications such as deep infection or refracture. The technique provided adequate stability for early functional treatment and predictable healing with maintenance of leg length and alignment. Provisional reduction and stabilization of complex pediatric femoral fractures can facilitate definitive percutaneous plating.