Femoral shaft fractures in young children are commonly treated with closed reduction and spica casting; however, there is increasing literature and interest focusing on internal fixation. This study aims to assess trends in the management of femoral shaft fractures in patients under the age of 6. This is a retrospective study utilizing the Pediatric Health Information System (PHIS) database. We queried for patients aged 1 to 6 years who had an isolated, closed femoral shaft fracture from October 2015 to December 2020. ICD10 procedure codes were used to determine treatment of the injury. Descriptive statistics and tests of trend were utilized in the analysis of this study. We identified 4608 patients with a femoral shaft fracture during the study period. The majority of patients were treated with spica casting (n=3398, 73.7%), followed by intramedullary fixation (n=600, 13.0%) and plate osteosynthesis (n=449, 9.7%). In this cohort, 3236 patients were between the ages of 1-3 years, and 1372 patients were between the ages of 4-6 years. There was a significant difference in management between these two age groups with lower rates of spica casting in older patients (92.1% vs. 30.5%) and higher rates of intramedullary fixation (37.3% vs. 2.7%) and plate osteosynthesis (28.2% vs. 1.9%) (p<0.01). There was a significant correlation with increasing rates of intramedullary fixation and plate osteosynthesis from 2016 to 2020 (p=0.03 and 0.01, respectively), and a decrease in rate of spica casting over time (p=0.04). Femur fractures in young children are treated with spica casting, intramedullary nails, and plate osteosynthesis. There is a significant change in management over time, and children between the ages of 4 and 6 are more likely to be treated with intramedullary nails compared to younger children. Additional studies are needed to understand these trends as well as justify the increase in rates of intramedullary nails and plate osteosynthesis in young children. Level III; Retrospective Cohort Comparison using Large Database •Historically, spica casting was the gold standard for femur fracture treatment in younger patients.•There has been recent interest in the utilization of internal fixation for treatment of femur fractures in young children.•The use of intramedullary nails and plate osteosynthesis in young patients with femur fractures has increased by 34% and 25%, respectively, from 2015 to 2020.•Spica casting has remained the main treatment option for patients aged 1-3.•Intramedullary nails and plate osteosynthesis have been used increasingly over time for patients aged 4-6.