Pediatric femoral shaft fractures present many challenging patient care decisions. Nonoperative treatment approaches still dominate care of the youngest age groups while surgical intervention is commonplace in virtually all older children. Treatment is determined primarily by patient age as modified by clinical factors including mechanism of injury, weight, and skeletal maturity. Infants can be successfully treated by placement into a Pavlik harness, whereas children younger than 5 years are most commonly treated by early reduction and spica cast immobilization. Children aged up to 11 years are most commonly treated by flexible intramedullary nailing, whereas older children and adolescents, particularly with length unstable fractures should be treated with more rigid fixation such as lateral entry locked nails or submuscular plating.