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TRAUMATOLOGY Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 3  |  Page : 166-168
Treatment of long bone fractures in children by flexible titanium elastic nails

Paediatric Orthopaedic Surgeon, India

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Background: Elastic intra-medullary nailing is a new technique for treatment of various paediatric fractures. The use of these titanium nails is preferred over conventional stainless steel nails used in the past.
Method: Sixty patients with various long bone fractures underwent operative treatment with elastic intra-medullary nails. The mean age was ten years and the mean follow-up period was 28 months.
Results: All children achieved union in a mean time of 10 weeks. Few technical complications were seen earlier on in the series. Two cases developed infection which resolved with antibiotics. Insignificant limb length discrepancy was seen in 3 children, but this remains a potential problem which needs close follow-up until skeletal maturity.
Conclusion: Elastic intra-medullary nailing of long bone fracture is an excellent technique in the surgical treatment of long bone fracture in children. It is safe, less invasive and associated with fewer complications.

Keywords: Intramedullary nail; Elastic; Pediatric fractures.

How to cite this article:
Bhaskar A. Treatment of long bone fractures in children by flexible titanium elastic nails. Indian J Orthop 2005;39:166-8

How to cite this URL:
Bhaskar A. Treatment of long bone fractures in children by flexible titanium elastic nails. Indian J Orthop [serial online] 2005 [cited 2020 Mar 31];39:166-8. Available from:

   Introduction Top

Treatment of long bone fractures in children continues to improve as newer techniques evolve. Conservative treatment remains the mainstay, given the excellent remodelling ability of the immature bone in children [1] . However, unstable fractures of long bones require operative treatment to maintain alignment and preserve function [2] . Several options are available for operative treatment but with the development of flexible nail the treatment of long bone fractures, particularly femur has undergone a dramatic change [3] .

A number of other intra-medullary devices like the Rush nail or Ender's nails are available for treatment of paediatric fracture, but these have poor rotational stability and require multiple nails to achieve fracture stability [4] .

We highlight the initial experience, technical details, pitfalls and complications in the use to these flexible nails for all long bone fractures in children.

   Patients and Methods Top

A retrospective study of 60 children with various long bone fractures operated with elastic nails was performed. The study period was from 1998 -2001 inclusive and all case records and radiographs were analysed. There were 38 boys and 22 girls in the study. The mean age at the time of surgery was 10 years with a range from 6 years to 12 years. There were 33 femoral fractures, 6 tibial, 15 forearm, and 6 humeri fractures respectively. The injuries were due to falls, sporting accidents and vehicular impact. All injuries were closed and all fractures were initially splinted in casts. The decision for surgery was based on the adequacy of reduction and fracture instability.

All patients were operated under GA, using IITV (image intensifier television) for imaging the passage of nails and quality of reduction. The AO Synthes flexible nailing system was used in majority of cases. Pre-operative intravenous cefotaxime was used and 3 doses were given post-operatively.

In six cases an open reduction was required to achieve nail insertion. Post-operatively a plaster slab was used for the upper limbs for two weeks and a long knee splint was used for femur and tibial fractures. In 4 cases of femur fractures, 4 forearm fractures, and 3 tibial fractures supplementary casts were used to maintain rotational stability. Ambulation was allowed as healing progressed and majority of the children were able to partial weight bear by 3- 4 weeks.

Technique of nail insertion: The patient was positioned on a radiolucent table with access to the IITV. The bone was exposed with a longitudinal incision and the soft tissues spread in the same direction with help of blunt tip scissors. The periosteum was also incised longitudinally and the cortex exposed. With the help of sharp awl, the outer cortex was perforated and the awl angled to enter the medullary cavity. Care was taken to ensure that the entry point is in the middle of the width of the presenting cortex. With too anterior or posterior entry points the direction of nail insertion is altered. In femur, an anterior entry point can cause inadvertent penetration of the knee joint. In the humerus, two lateral entry points, one over the other are required to insert the nail. A medial entry portal requires exposure of ulnar nerve and care while leaving the nail end protruded.

Once the entry points were made, the nails were inserted with the curve tip into the medullary cavity. The nails were manually pushed with the help of a "T" insertion handle until resistance was met and then gently hammered with the curve tip sliding on the inner cortex. Once the nails reach the fracture ends, especially in the femur where both nails were inserted first up to the fracture site, then the fracture site was manipulated to allow reduction. An IITV here was very useful and can confirm reduction and correct passage of the nail.

The nails were inserted retrograde in the femur, humerus and ulna and antegrade in the radius and tibia. Nail sizing was crucial and was determined by measuring the width of the isthmus of the long bone, subtracting 20% for the magnification factor and dividing the remaining by two. Two nails of equal sizes appropriate for the width of the medullary cavity were selected. If nails of unequal sizes are used the torque imparted by the larger nail would be asymmetrical causing fracture angulation.

Once across the fracture site, the nails were inserted unto the metaphysis with the tips facing opposite directions to give good three-point purchase in the cancellous bone.

The nails were cut 1.5 cms long and bend to lie along the bony cortex to prevent skin and soft tissue impingement.

   Results Top

All fractures had uncomplicated union. The mean healing time was 10 weeks (range from 6 - - 16 weeks) depending on the type of long bone. In general the mean healing for femur and tibia was 12 weeks and 11 weeks respectively. The healing time for upper limb fractures was shorter: 8 weeks for forearm and 10 weeks for humerus fracture.

The mean follow-up period was 28 months (17 - - 48 months). We looked at the postoperative complications, healing time, rotational deformities, and limb length discrepancy, range of motion of adjacent joints and return to function.

Few complications were seen. There were two cases of superficial wound infection, one tibia and one femur. Both resolved with antibiotics. In three cases there was hardware prominence, two in femur and one radius. In all cases the implant was removed after fracture healing was observed. In two cases, there was loss of fracture position and a reoperation was required. In two femur fractures, an anterior entry point caused the nail to penetrate into the knee joint causing synovitis and pain. These resolved successfully after the nails were removed.

No obvious rotational deformities were present on clinical examination and all children recovered range of motion compatible with good function.

In 3 femur fractures there was overgrowth of the affected limb, but it was clinically insignificant. This needs further evaluation at skeletal maturity, as overgrowth may not correct with age.

   Discussion Top

Intramedullary fixation has always been the preferred treatment technique in long bone fractures, even in adults. The initial experience was with Kuntsher nails and Rush nails, but their use in children fractures was limited. Also these nails were rigid and difficult to insert through the metaphyses of children bones [5] . Enders nails were devised to overcome this problem but usually multiple Enders nail were required to achieve fracture stability [6] . The titanium flexible nail with its newer design and better material has an advantage over the older Enders type nail. Because of the inherent stiffness of titanium even 2 mm nails have adequate strength and elasticity compared to Kirschner wire or stainless steel pin of the same diameter [7] .

In a large series reported by Vrsansky, 308 fractures were treated by flexible nailing technique and all children had fracture union and reported satisfactory function. However, they cautioned that these nails should not be used in children under 5 years of age [8] . In a recent article, Barry and Paterson have described the role of titanium nails in paediatric fractures, with emphasis on technique in various long bones [9] .

Although in most cases the fracture can be manipulated and the nails inserted by closed technique, in six cases we encountered difficulty. A small incision was made at the fracture site to negotiate the nail into the intramedullary cavity. The healing time was not altered in these cases and there was no wound infection.

Careful placement of insertion point in the distal femur is important as an anterior entry point can cause the nail to migrate into the knee joint[10].

In the humerus, the pins were inserted from the lateral side in 3 cases, and both medial and lateral in 3 cases. It was felt that the exposure to locate the ulnar nerve would offset any advantages of closed nailing technique.

Limb length discrepancy is a problem especially after femoral fractures. It has been recommended to leave at least 1.5 cms overlap between fracture ends to prevent overgrowth. With end-to-end alignment with these nails, overgrowth remains a potential problem [11],[12] . These patients must be followed up until skeletal maturity.

Implant removal was undertaken when there were problems with the metal work. Routine metal removal of these implants is advocated and we recommend the metal work to be removed after nine months in children. Patients must be warned that implant removal may entail a bigger incision and can lead to unsightly scars.

We did not have a control group nor did we compare other methods of treatment. However, we feel that flexible nailing can have a place in the management of paediatric long bone fractures, which fail skilled conservative treatment. There are distinct advantages in terms of duration of hospital stay, fracture stability and early return to function. However, the surgeon must be well versed with the technique and limitation of these devices. With correct technique and attention to detail, some of the aforementioned complications can be avoided.

   References Top

1.McKibbin B. The biology of fracture healing in long bones. J Bone Joint Surg (Br). 1978; 60: 150-162  Back to cited text no. 1    
2. Nielsen AB, Simonsen O. Displaced forearm fractures in children treated with AO plates. Injury. 1984; 15: 393-396  Back to cited text no. 2    
3. Sanders JO, Browne RH, Mooney F et al. Treatment of femoral fractures in children by paediatric orthopaedists: Results of 1998 POSNA survey. J Pediatr Orthop. 2001; 21: 436-441.  Back to cited text no. 3    
4. Lee SS, Mahar AT, Newton PO. Ender nail fixation of paediatric femur fratures: a biomechanincal analysis. J Pediatr Orthop (Am). 2001; 21:442­445  Back to cited text no. 4    
5. Rush LV. Dynamic factors in medullary pinning of fractures. Am Surg 1951; 17: 803-808.  Back to cited text no. 5    
6. Ender J, Simon-Weidner R. Die Fixenrung der tronchanteren bruche mit runden elastischen condylennageln. Acta Chir Austr. 1970: 2-40  Back to cited text no. 6    
7. Metiazeau JP. Ostesynthese chez l'enfant; Techniques and indica­tions. J Pediatr Orthop. 1983; 69: 495-511  Back to cited text no. 7    
8. Vrsansky P, Bourdelat MD et al. Flexible stable intramedullary pinning technique in the treatment of pediatric fractures. J Pediatr Orthop. 2000; 1: 23-27  Back to cited text no. 8    
9. Barry M, Paterson JMH. Flexible intramedullary nails for fractures in children. J Bone Joint Surg (Br). 2004; 86: 947-953.  Back to cited text no. 9    
10. Rohde RS, Mendelson SA, Grudziak JS. Acute synovitis of the knee resulting from intra-articular knee penetration as a complication of flex­ible nailing of femoral fracture. J Pediatr Orthop. 2003; 23: 788-792  Back to cited text no. 10    
11. Corry IS, Nicol RO. Limb length after fracture of the femoral shaft in children. J Pediatr Orthop. 1995; 15: 217-219  Back to cited text no. 11    
12. Macnicol MF. Fracturs of the femur in children. J Bone Joint Surg (Br). 1997; 79: 891-892  Back to cited text no. 12    

Correspondence Address:
Atul Bhaskar
Apt 403, Bldg No 18, MHADA complex, Oshiwara, Andheri, Mumbai 4000 053
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5413.36715

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  [Figure - 1], [Figure - 2], [Figure - 3]

This article has been cited by
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