Femoral fractures in children are the commonest children's fracture requiring hospitalization. They consume disproportionate amounts of healthcare resource. Advances in operative management have resulted in improved clinical and health economic outcomes.This article describes 21st-century management of femoral fractures concentrating on recent advances. There is a clear trend to increased operative management in all femoral fractures with improved outcomes in the proximal femur and shaft. Crucially, advances in the treatment of both have led to a reduction in the rate of avascular necrosis of the femoral head.Units treating paediatric fractures need access to specialist surgeons and equipment to treat the full range of femoral fractures and improve outcomes.