Submuscular Plating, Titanium Elastic Nailing, and External Fixation for Pediatric Femoral Shaft Fractures: A Comparative Systematic Review and Meta-Analysis

Pediatric femoral shaft fractures are commonly treated with titanium elastic nailing (TENS), submuscular plating (SMP), or external fixation (EF), but the optimal fixation strategy remains controversial. This systematic review and meta-analysis compared perioperative metrics, union, complications, and functional outcomes between SMP, TENS, and EF in skeletally immature patients. A comprehensive search of PubMed, Scopus, Web of Science, Embase, and Google Scholar (up to November 2025) identified comparative studies of diaphyseal pediatric femoral shaft fractures treated with at least two of these modalities. Thirteen studies involving 759 fractures were included: 410 managed with TENS, 246 with submuscular or locking plates, and 89 with EF, plus a small hybrid intramedullary external construct subgroup. Data were pooled using fixed- or random-effects models to calculate standardized mean differences and odds ratios with 95% confidence intervals, and methodological quality was assessed using the Downs and Black checklist. TENS was associated with significantly shorter operative time and lower blood loss than SMP, while hospital stay and time to union were broadly similar. SMP, however, achieved a higher proportion of excellent Flynn functional outcomes and markedly fewer soft-tissue irritation symptoms related to hardware prominence, with no clear differences in infection, unplanned reoperation, implant removal, or radiation exposure. Compared with EF, TENS provided faster or equivalent radiographic union, substantially lower surgical-site and pin-tract infection rates, fewer pin-site problems, and a trend toward reduced refracture after frame or implant removal while maintaining reliable limb alignment and function. Heterogeneity ranged from low to high across outcomes, but no meaningful publication bias was detected. Overall, TENS appears to be an efficient, low-morbidity option for most length-stable pediatric femoral shaft fractures; SMP offers superior stability and functional outcomes in heavier children and length-unstable patterns; and EF should be reserved for severe open injuries, polytrauma, or damage-control scenarios rather than routine femoral shaft fracture management.