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Titanium Elastic Nails in the Treatment of Pediatric Femur Fractures- A Series of 11 cases

Chaudhary P, Karn N.K., Shrestha B.P, Khanal G.P, Maharjan R.

Department of orthopaedics,
B.P.Koirala Institute of Health sciences,
Dharan, Nepal

Address for Correspondence:

Pashupati Chaudhary
Assistant Professor
Department of Orthopaedics
B.P.Koirala Institute Of Health Sciences

Phone : 00977-25-525555-3164
E-mail :


This study aims to evaluate the efficacy of flexible intramedullary (IM) nails as a fixation device of paediatric femoral shaft fractures. A total of 11 children with 11closed fractures were treated by this method. The patients ranged in age from 6 to 12 years and the mean follow-up was 18 weeks. All patients had open femoral growth plates at the time of surgery. All fractures united and none of the patients needed re-operation. No major complications were recorded. After nail removal, all children had full range of hip and knee motion. At final follow-up, none of the children presented with clinical malalignment of the fractured limb. Maximum angulation that was calculated on the coronal plane was 5° into varus and on the sagittal plane 7°of anterior angulation (apex posteriorly). Leg-length discrepancy was assessed clinically and radiographically when needed.A Flexible nailing of diaphyseal fractures of the femur is a reliable method with a small learning curve and allows early mobilisation. Most of our minor complications were technique related and could be avoided1

J.Orthopaedics 2010;7(3)e6


Flexible nails; Femoral fractures; Childhood



Paediatric femoral fractures are treated by a variety of methods including traction, immediate spica cast, traction followed by spica cast, internal fixation with plate and screws, external fixation and intramedullary fixation. Orthopaedic surgeons remain divided about the optimal method of treatment for children's femoral fractures. The choice of treatment may be influenced by the age of the child, the level and pattern of the fracture and to a great extent, by regional, institutional or surgeons' preferences 2. A systematic review of the literature provides little evidence to support one method of treatment over another3. In general, outcomes tend to be uniformly good irrespective of the method of treatment.

Inclusion Criteria:

Age 6 to 12 years, open femoral physes; closed midshaft femur fracture; no concomitant injuries to either lower extremity; no history of injury to either femur; no history of asymmetric femoral malalignment; agree to participate in 18 weeks of follow up; informed consent1

Exclusion Criteria:

open midshaft femur fractures; other injuries to either lower extremity; a history of injury to either femur; unable to comply with 2 years of follow-up1

Elastic Stable Intramedullary Nailing
The technique of elastic stable intramedullary nailing, adapted from existing flexible rod systems, was first described by surgeons from Nancy, France4,5. Ligier et al reported the results of the Nancy experience5. The technique has become one of the most popular methods of fixation of paediatric femoral fractures in North America1. Excellent clinical results have been reported with this technique, which has been variously called "elastic stable intramedullary nailing", "flexible intramedullary nailing" or "Nancy nailing"6-9.

Perceived advantages of this technique include earlier mobilization and more rapid return to function than with nonoperative techniques, and less soft tissue disruption and smaller scars when compared with other surgical methods5.

Fig 1. Mid diaphyseal fracture

Principle of "Elastic Stability"
The flexible rod is initially bent or curved (plastically deformed). During intramedullary insertion, which is typically retrograde in the femur, the relatively straight medullary canal (compared with the contoured nail) forces the curved rod to straighten within the bone. This elastic deformation creates a bending moment within the long bone which will tend to angulate the fracture in the direction and the plane of the concavity of the curved rod, as the rod wants to return to its initial curved state. This moment is counteracted by a second rod of matched diameter and curve, which balances the first rod with an equal but opposite moment. The two intramedullary nails act complimentarily to stabilize the fracture. This biologic fixation is not rigid but sufficiently stable against angular, translational and torsional deforming forces and is associated with early formation of exuberant callus. Typically , no additional external immobilization is required. However, any significant imbalance in the magnitude or the direction of the moment created by the two nails will result in angulation of the fracture in the direction of the stronger nail.
The titanium nails have been distinguished from other flexible nail systems such as Ender nails, made of stainless steel. The latter are believed to be insufficiently elastic for children's fractures6.
Sometimes three or more flexible rods are inserted in order to better fill the medullary canal to enhance cortical contact, and provide more stable fixation. This constitutes a form of rigid intramedullary fixation, quite different from the Nancy nailing concept.


Fig 2. Proximal Long Spiral fracture

Elastic stable intramedullary nailing is ideally suited for mid-diaphyseal transverse, short oblique or short spiral fractures of the femur with minimal comminution, in children 6 to 12 years old who are being considered for operative stabilization (Fig. 1). The use of flexible nails can be extended to more proximal, even subtrochanteric fractures and some multifragmentary fractures by modifying the technique to take advantage of the principles outlined above (Fig. 2). The addition of external protection like a knee immobilizer can limit the overall motion of the lower extremity and reduce the deforming forces on the fracture in these situations10.



Fig 3:  Do not leave nail tips bent or prominent.

Fig: 4 Countering of nail at C-shaped configuration with apex at the fracture site

Fig: 5 Nail diameter should not exceed 40%  diameter of narrowest part of medullary cavity

Materials and Methods:

The material of this study consisted of 11 children with 11femoral shaft fractures treated by titanium elastic nail fixation at department of Orthopaedics, B.P.Koirala institute of health sciences, Dharan, Nepal. The age incidence in this series ranged from 6 years to 12 years (an average of 9 years),. 7 children (63.6%) were males and 5 (45.4%) were females. All the fractures in this series were recent closed fractures. The fracture pattern was transverse or short oblique in 9 cases and comminuted in two cases. All the fractures occupied the middle third of the femur.. The mechanism of injury included pedestrian vehicle accidents (60%), motor vehicle accidents (28%) and falls (12%). There were no associated injuries in this series. All the fractures in this series were treated by retrograde titanium elastic nail fixation using two nails of equal diameter for each fracture. The surgical technique was as follows: Under general anaesthesia, the child was positioned supine on a fracture table with a traction boot and traction was applied to the injured extremity followed by adjustment of the image intensifier (C-arm) for obtaining anteroposterior and lateral views for the injured femur intraoperatively. The nail diameter was determined on preoperative radiographs (Fig. 1). After sterilisation and draping of the injured extremity, the planned entry point for the nails were checked using image intensifier( 2-3 cm above distal femoral physis) then two TENS of equal diameter were inserted after proper countering and advance proximally to fracture site. Fracture were reduced closed and nails were advanced proximally one after another.


Fig:6 Pre-operative Photograph

Text Box:

Fig:7 Post-Operative photograph

Throughout the procedure, position of nails were checked by image and finally distal ends of nails were cut sothat they can flush into the femoral condyles. Any distraction at the fracture was checked and if any corrected by releasing traction.Out of 15 cases, two cases required open reduction. the nail diameter used in this series were 3mm in 10 cases, 2.5mm in 3 cases and 2mm in 2cases.Wound was closed and Above Knee POP slab was applied in all cases for 2 weeks i.e till suture removal. The patients was put on non weight bearing axillary crutch walking. The patients were followed up clinico-radiologically and look for fracture healing upto 3 months to sixy months.

Results :

The hospital stay ranged between 3 to 15 days, there was no post operative infection . All fractures united in 8 weeks to 12 weeks time. There were  limb length discrepancy in 5 cases which is less than 2 cm. There was no angulational and rotational deformity. there was no implant failure as well as migration of implant.In 2 cases there were irritation of skin at the implat insertion site. Implant was removed an average of 6 months(5-7 months). There were no voilation of cortex either medial or lateral in this series.The most common complications reported in this series are pain and skin irritation at the entry site associated with the prominence of the ends of the nails9. Nail ends should not be bent, as was originally recommended, but advanced so that they lie against the supracondylar flare of the femur in order to avoid symptoms at the insertion site. Use of nails of two different diameters is associated with a high rate of loss of reduction in the direction of the stronger rod9. Multifragmentary fractures might be better stabilized by alternative methods of fixation. If used in comminuted fractures, these should be monitored weekly for early loss of reduction, and they might benefit from some additional external immobilization
Although the originators of this technique recommended routine removal of the nails, there is no evidence that this is necessary in the absence of nail-related symptoms.

Discussion :

Paediatric femoral fractures are treated by a variety of methods including traction, immediate spica cast, traction followed by spica cast, internal fixation with plate and screws, external fixation and intramedullary fixation1. The indications for TENS for fixation of paediatric femoral shaft fractures are expanding as their advantages are realized and complications of other operative methods of stabilization are reported. Compression platings are associated with high incidence of refracture. External fixators are associated with pin tract infection, loss of reduction, refracture vafter removal of external fixator. rigid intramedullary nailing are associated with greater trochanter physis leading to growth arrest with subsequent coxa valga. It is also associated with damage to blood supply of femoral head leading to osteonecrosis of femoral head.These problems and complications are overcome by introduction of flexible intramedullary nailing(TENS) for treatment of paediatric femoral shaft fractures with following advantages2-3

·          Price are comparable and are available in different diameter

·          inserted without voilation of growth plate

·          Excellent purchase of nails in the bone due to dense medullary cavity of immature skeletal

·          Removal of nails are not associated withrefracture as they are load-sharing device

Our results are compatible with results of other series of TENS in terms of union, no implant failur,no refracture after implant removal, within acceptable limb length descrepancies


Elastic stable intramedullary nailing is an excellent method of managing most, but not all, paediatric femoral fractures that need operative stabilization1. It is by no means the only technique nor is there evidence yet that it is superior to other methods. Its advantages make it a valuable choice to consider in managing these fractures. Ultimately, the choice should reflect best evidence and also incorporate patient preferences2


  1. John A, Dimitios P, Charalampos K, Kristos P, George M., et al. Flexible intramedullary nailing in paediatric femoral shaft fractures. Clinical trials Volume 41, Issue 6, Pages 578-582
  2. Sanders J.O., Browne R.H., Mooney J.F., et al. Treatment of femoral fractures in children by pediatric orthopedists: Results of a 1998 survey. J Pediatr Orthop 2001;21:436-441.
  3. Wright J.G. The treatment of femoral shaft fractures in children: A systematic overview and critical appraisal of the literature. Can J Surg /J Chir Can 2000;43:180-189.
  4. Ligier J.N., Metaizeau J.P., Prévot J. Closed flexible medulary nailing in pediatric traumatology. Chir Pediatr 1983;24(6):383-5.
  5. Metaizeau J.P. L'osteosynthese chez l'enfant par embrochage centro medullaire elastique stable. Sauramps Medical, Montpellier 1988.
  6. Ligier J.N., Metaizeau J.P., Prévot J., Lascombes P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg [Br] 1988;70-B:74-7.
  7. Bar-On E., Sagiv S., Porat S. External fixation or flexible intramedullary nailing for femoral shaft fractures in children. J Bone Joint Surg. [Br] 1997;79-B: 975-8.
  8. Flynn J.M., Hresko T., Reynolds R.A.K., Blasier R.D., et al.. Titanium Elastic nails for Pediatric Femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4-8.
  9. Carey T.P., Galpin R.D. Flexible intramedullary nail fixation of pediatric femoral fractures. Clin Orthop 1996;332:110-118.
  10. Narayanan U.G., Hyman J.E., Wainwright A.M., Rang M., Alman B.A. The complications of elastic stable intramedullary nail fixation of paediatric femoral fractures, and how to avoid them. 2002. Submitted to J Pediatr Orthop.


This is a peer reviewed paper 

Please cite as: Pashupati Chaudhary: Titanium Elastic Nails in the Treatment of Pediatric Femur Fractures- A Series of 11 cases

J.Orthopaedics 2010;7(3)e6





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