Seventy-eight children, with 79 femoral fractures, treated with titanium elastic intramedullary nails were reviewed for complications.

Insertion site symptoms (41), malunion (8), refracture (2), transient neurological deficit (2), superficial wound infection (2), and reoperation prior to union (10).

Malunion/loss of reduction was increased with mismatched nails (p=0.02) and comminution (p=0.02). Insertion site symptoms were increased with nail ends that were bent (p=0.02), or > 10mm prominent (p=0.002). Nails remain implanted in 25 children without problems.

Nail ends should lie against the femur to avoid insertion site symptoms. Nails of different diameters should not be implanted. Comminuted fractures require close monitoring.