Purpose: Fractures of the femoral diaphysis are common injuries in the paediatric population. Rigid, locked, intramedullary nailing allows for early mobilization, but is usually reserved for older children and adolescents. Avascular necrosis (AVN) of the femoral head is a rare but serious complication of this technique. The entry site of the nail has been speculated to have an effect on this risk. Different nail entry sites have been used and include the piraformis fossa, tip of the greater trochanter, and the lateral greater trochanter. The purpose of this study is to complete a review of the literature to determine the effects of nail entry site on the risk of proximal femoral AVN.

Method: The English medical literature (Pubmed, Embase, Cochrane database, and relevant articles from the bibliographies) was searched and 1277 articles were identified. Articles were excluded if they were case reports, if they did not examine long term complications, or if the insertion location could not be determined. Patients treated using each insertion site were combined together for analysis to determine the overall AVN and complication rate for each site.

Results: From the 1277 articles identified, 19 articles met the inclusion criteria. The piraformis fossa treatment group included 239 patients and had an AVN rate of 2%. The tip of the greater trochanter treatment group included 139 patients and had an AVN rate of 1.4%. The lateral greater trochanter treatment group included 80 patients and had no reported cases of AVN. Other complications included length discrepancy, heterotrophic ossification, and changes in proximal femoral morphology (articular trochanteric distance, neck shaft angle, trochanter to trochanter distance, and femoral neck diameter).

Conclusion: Based on the current literature, the lateral greater trochanteric entry site for rigid, locked intra-medullary nailing has a lower risk of AVN as compared to the piraformis fossa and the tip of the greater trochanter entry sites.