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Flexible intramedullary nailing has become a popular method of fixation of pediatric femoral fractures. The authors analyzed their first 5-year experience with titanium elastic stable intra-medullary nailing, specifically to report the complications associated with this technique and to provide recommendations to avoid these complications. Seventy-eight children with 79 femoral fractures were treated by this method. Complications included pain/irritation at the insertion site (41), radiographic malunion (8), refracture (2), transient neurologic deficit (2), and superficial wound infection (2). Ten patients required reoperation prior to union. Malunion and/or loss of reduction requiring reoperation was strongly associated with the use of nails of mismatched diameters (odds ratio = 19.4) and comminution of more than 25% (odd ratio = 5.5). Pain at the insertion site was significantly associated with bent or prominent nail ends. Most complications are minor, and many are preventable. Surgeons should advance nail ends to lie against the supracondylar flare of the femur to avoid symptoms at the insertion site and should avoid implanting nails of two different diameters. Comminuted fractures should be monitored carefully and might benefit from additional immobilization.