• Users Online: 61
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 21-26

Use of flexible intramedullary nailing in treating diaphyseal fractures of long bone of lower limb in children

Department of Orthopaedics, Jhalawar Medical College and SRG Hospital, Jhalawar, Rajasthan, India

Date of Web Publication19-Aug-2019

Correspondence Address:
Dr. Sanjay Kumar Ghilley
Room No. 308, PG Boys Hostel, Jhalawar Medical College, Jhalawar - 326 001, Rajasthan
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_5_19

Rights and Permissions

Background: Management of diaphyseal fractures of long bones of the lower limb in the age group of preschool to early teenage has multiple methods of treatment ranging from conservative management to internal fixation using open/closed reduction methods. Objective: The study was performed to know the potential of using principles of intramedullary nailing in treating diaphyseal fractures of long bones of the lower limb in preschool to early teenage population. Materials and Methods: Patients with diaphyseal long bones fractures of tibia and femur in between the age group ranging from 5 to 14 years were treated by closed reduction and internal fixation using titanium elastic nailing system (TENS) nail. The results were evaluated on the basis of radiological signs of union and Flynn's criteria. The average time after which surgery was done is 2 days. Results: Of 14 patients, eight patients had diaphyseal femur fracture and remaining six had diaphyseal tibia fracture treated by TENS nailing.Thirteen patients achieved union in a mean time of 8 weeks with full-weight-bearing in around 10 weeks. The average time duration of hospital stay was 6 days and follow-up period was up to 24 weeks. Conclusion: The use of flexible intramedullary nailing in properly selected patients in the preschool to early teenage population is an effective method of treating diaphyseal fractures of long bones of the lower limb.

Keywords: Diaphyseal fractures, flexible intramedullary nailing, titanium elastic nailing system

How to cite this article:
Ghilley SK, Meena MK, Jhanwar P, Jain HK. Use of flexible intramedullary nailing in treating diaphyseal fractures of long bone of lower limb in children. J Orthop Traumatol Rehabil 2019;11:21-6

How to cite this URL:
Ghilley SK, Meena MK, Jhanwar P, Jain HK. Use of flexible intramedullary nailing in treating diaphyseal fractures of long bone of lower limb in children. J Orthop Traumatol Rehabil [serial online] 2019 [cited 2020 Sep 21];11:21-6. Available from: http://www.jotr.in/text.asp?2019/11/1/21/264733

  Introduction Top

Femoral and tibial fractures are common long-bone injuries in children. The injuries are more common in boys, especially during the toddler years and early adolescence.[1],[2] The mechanism of injury varies from simple falls to high-energy trauma.[3]

In the past, for management of pediatric lower extremity fractures, use of traction alone or hip spica cast for fracture femur and for fracture tibia groin to toe slab followed by groin to toe cast slab followed by GT cast Conservative treatment necessitates a long stay in the hospital for traction and subsequent immobilization in an uncomfortable cast and this treatment is not well-tolerated, especially in adolescence.[4]

In the recent past, the trend of management of femoral and tibial fractures in children is being shifted toward the operative side.[5],[6],[7] By the operative treatment, complications such as rotational malalignment, nonunion, and malunion are low in addition to reduce cost as compared to nonoperative treatment.[8],[9]

The aim of the treatment of diaphyseal fracture of long bones of the lower limb in children is to stabilize the fracture, to control the length and alignment, to promote the bone healing, and to minimize the morbidity and complications in the child and family.

Titanium elastic nailing, also known as elastic stable intramedullary nailing, has become the choice of stabilization in pediatric long-bone fractures.[10],[11]

Titanium elastic nailing system (TENS) is an ideal fixation device for pediatric femur fracture due to the ease of use, and it functions as an internal splint providing three-point fixation.[10],[11]

The advantages of flexible intramedullary nails as a fixation device include closed insertion of the device, with preservation of the fracture hematoma and minimal risk of fracture site infection. No reaming is required and as such the endosteal blood supply is preserved. The devices provide three-point fixation. The advantage of this technique includes early union due to repeated micromotion at fracture site, early mobilization, early weight-bearing, scar acceptance, easy implant removal, and high patient satisfaction rate.[10],[12],[13],[14]

  Materials and Methods Top

In our study, 14 patients between the age group of 5 and 14 years having closed diaphyseal fracture of femur and tibia were included in the study. Exclusion criteria include metaphyseal fractures with/without the involvement of epiphysis, pathological fractures, compound fracture, and parents not willing for surgery. Children suffering from epilepsy, heart diseases, and bleeding diathesis were excluded from our study.

After informed consent and routine preoperative workup, surgery was performed under general/spinal anesthesia with the patient on a fracture table in the supine position for femur fracture and on the regular operating table for tibia fracture.

The diameter of the individual nail was selected as per Flynn et al's formula (Diameter of nail = Width of the narrowest point of the medullary canal on Anteroposterior and Lateral view × 0.4 mm) and intraoperative assessment. The diameter of the nail was chosen and hence that each nail occupies at least 33%–40% of the medullary cavity.


The usual procedure for TENS nailing of diaphyseal fracture of femur and tibia under image intensifier guidance was performed. Nails were inserted from proximal to distal for tibia and from distal to proximal for the femur.

Site is selected under image intensifier just proximal/distal to the growth plate. Make 1 cm small longitudinal incision on the lateral and medial aspect to expose bone, with the help of sharp awl, the entry was made through the cortex to obtain access to the medullary cavity [Figure 1]. Care was taken to ensure that the growth plate was not breached while making the entry point. Nails were bent before insertion, so that apex of both nail rest at the fracture site and were inserted using T-handle. Once fracture site was reached, the fracture was manipulated under image intensifier guidance to obtain reduction and nails were passed further up to metaphysis and adequate three-point fixation was ensured with the tip of nails facing in opposite directions.
Figure 1: Insertion of titanium elastic nailing system nail for fracture shaft of femur

Click here to view

After that entry wound stitched and dressing done. In all six cases of tibia, in which fracture pattern was spiral or oblique, we applied above knee slab. Moreover, in femur fracture cases, we applied thigh spica in four cases, and in remaining four cases, we applied bandage only.

All patients received intravenous (i.v.) antibiotic 1 h before the surgery and on the postoperative day until patient discharge. The patient discharged with 5 days oral antibiotic and analgesics.

Postoperative protocol

Patients are in the supine position with operated leg elevated on a pillow, stitched removed on day 10, partial weight-bearing was started by 6 weeks depending on fracture configuration and callus response. Full-weight-bearing was started by 8–10 weeks depending on the radiological sign of union. Follow-up was done at 4, 8, 12, and 24 weeks, and each follow-up patients are assessed clinically, radiologically, and complications were noted. Two cases are taken here one for fracture femur and one for fracture tibia. There follow up are shown here as case 1 for fracture femur [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6] and case 2 for fracture tibia [Figure 7], [Figure 8], [Figure 9], [Figure 10].
Figure 2: Pre op x-ray

Click here to view
Figure 3: Post op x-ray

Click here to view
Figure 4: 4 week follow up

Click here to view
Figure 5: 12 week follow up

Click here to view
Figure 6: 24 week follow up

Click here to view
Figure 7: Pre op x-ray

Click here to view
Figure 8: Post op x-ray

Click here to view
Figure 9: 4 week follow up

Click here to view
Figure 10: 22 week follow up

Click here to view

  Results Top

In our study, there were nine boys (64%) and five girls (36%) [Graph 1]. The minimum age was 5 years, and the maximum age was 14 years. Majority of cases (8) were between 6 and 10 years. The major cause of fracture was a road traffic accident in eight cases (60%) followed by fall from height in four cases (28%) [Figure 11].

Figure 11: Mode of injury

Click here to view

Of 14 cases, there were eight cases (57%) of femur fractures and six cases (43%) of tibia fractures [Graph 2]. Out of 14 cases,10 cases (71%) were of right side. Majority of patients, i.e., six cases (44%) had transverse fracture pattern followed by short oblique pattern two cases (15%) and long oblique three cases (22%) [Figure 12].

Figure 12: Fracture pattern

Click here to view

All patients were prepared and operated as early as possible once the general condition was stable and the patient was fit for surgery. In this study, 11 cases (80%) of patients were operated on the next day of admission, and the average duration of hospital stay was 5–6 days with 5 days of i.v. antibiotic and patient discharge with oral antibiotics. Follow-up was done on 4, 8, 12, and 24 weeks.

Partial weight-bearing was started when the patient is pain-free and radiological callus seen in 11 cases (80%) on 6 weeks postoperative; in three cases (20%), delayed weight-bearing (8 weeks) was done.

Full-weight-bearing was started in 11 cases (78%) at 8 weeks postoperatively and in remaining 3 case (22%) cases, it was started at 10 weeks.

All patients had full range of motion of proximal and distal joints.

Case 1

A 9 year old boys with fracture shaft of femur operated with tens nail [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6].


In our study, at 24 weeks follow-up, On basis of flynn's scoring criteria we found that 11(78%) patients had no limb length discrepancy, shortening 1–2 cm was noted in three cases (22%) [Table 1], all were femur fracture of oblique type and during follow-up, 5 (35%) patients complaint of pain over operated nail ends entry site, for which implant had to remove at 16 weeks, otherwise all patient were advised for removal of nail minimum of 1 year after good healing of fracture.
Table 1: Showing the results of flynn's scoring criteria

Click here to view

Case 2

A 8 year old female with fracture shaft of tibia operated with tens nail [Figure 7], [Figure 8], [Figure 9], [Figure 10].

  Discussion Top

TENS works on the principle of symmetric bracing action of two elastic nails having the same modulus of elasticity, which causes three-point fixation and gives rotational, axial, transational, and bending stability by counteracting the distraction and compression forces working on diaphysis of the long bone.

Until recently, conservative treatment was the preferred method for the treatment of diaphyseal fractures in children and young adolescents. However, to avoid the effects of prolonged immobilization to reduce the loss of school days and for better nursing care, the operative approach has been gaining popularity for the past two decades.

The external fixator provides good stability and early mobilization but it is associated with the risk of pin tract infections, and it takes a longer time for weight-bearing.[15],[16]

Interlocking nail is ideal for skeletally matured children. Reports of avascular necrosis of femoral head and coxa valga have been reported with interlocking nail when attempted in skeletally immature patients.[17],[18]

Titanium elastic nail seems advantageous over other surgical methods, particularly in this age group because it is simple, is a load-sharing internal splint that does not violate the physis, allows early mobilization and maintains alignment. Micromotion conferred by the elasticity of the fixation promotes faster external bridging callus formation. The periosteum is not disturbed and being a closed procedure, there is no disturbance of the fracture hematoma and thereby less risk of infection.

Flynn et al. found TEN advantageous over hip spica in the treatment of femoral shaft fractures in children.[19]

Buechsenschuetz et al. documented titanium nail superior in terms of union, scar acceptance and overall patient satisfaction compared to traction and casting.[8]

Ligier et al. treated 123 femoral shaft fractures with elastic stable intramedullary nail. All fractures united. Thirteen children developed entry site irritation.[20]

Narayanan et al. found good outcome in 79 femoral fractures stabilized with TENS.[13] The most common complication of titanium elastic nail is entry site irritation and pain.[13],[21]

  Conclusion Top

Flexible elastic nail is simple, reliable, and effective method for the management of lower-extremity long-bone fractures in the pediatric age group, especially in transverse and short oblique fracture as it takes short operative time, minimal blood loss, small operative scar, shorter hospital stay, early mobilization, and minimum complications.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hedlund R, Lindgren U. The incidence of femoral shaft fractures in children and adolescents. J Pediatr Orthop 1986;6:47-50.  Back to cited text no. 1
Flynn JM, Skaggs DL. Femoral shaft fractures. In: Kasser J, Beaty J, editors. Rockwood and Wilkins' Fractures in Children. Ch. 22. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 809-15.  Back to cited text no. 2
Bridgman S, Wilson R. Epidemiology of femoral fractures in children in the West Midlands region of England 1991 to 2001. J Bone Joint Surg Br 2004;86:1152-7.  Back to cited text no. 3
Metaizeau JP. Stable elastic intramedullary nailing for fractures of the femur in children. J Bone Joint Surg Br 2004;86:954-7.  Back to cited text no. 4
Hosalkar HS, Pandya NK, Cho RH, Glaser DA, Moor MA, Herman MJ. Intramedullary nailing of pediatric femoral shaft fracture. J Am Acad Orthop Surg 2011;19:472-81.  Back to cited text no. 5
McCartney D, Hinton A, Heinrich SD. Operative stabilization of pediatric femur fractures. Orthop Clin North Am 1994;25:635-50.  Back to cited text no. 6
Sponseller PD. Surgical management of pediatric femoral fractures. Instr Course Lect 2002;51:361-5.  Back to cited text no. 7
Buechsenschuetz KE, Mehlman CT, Shaw KJ, Crawford AH, Immerman EB. Femoral shaft fractures in children: Traction and casting versus elastic stable intramedullary nailing. J Trauma 2002;53:914-21.  Back to cited text no. 8
Kołecka E, Niedzielski KR, Lipczyk Z, Flont P. Treatment of the femoral, tibia and humeral shaft fractures in children with the use of intramedullary nailing or external fixation, a long term study. Chir Narzadow Ruchu Ortop Pol 2009;74:139-44.  Back to cited text no. 9
Bhaskar A. Treatment of long bone fractures in children by flexible titanium nails. Indian J Orthop 2005;39:166-8.  Back to cited text no. 10
  [Full text]  
Sanders JO, Browne RH, Mooney JF, Raney EM, Horn BD, Anderson DJ, et al. Treatment of femoral fractures in children by pediatric orthopedists: Results of a 1998 survey. J Pediatr Orthop 2001;21:436-41.  Back to cited text no. 11
Flynn JM, Skaggs D, Sponseller PD, Ganley TJ, Kay RM, Leitch KK. The operative management of pediatric fractures of the lower extremity. The Journal of bone and joint surgery. American 2002;84:2288-300.  Back to cited text no. 12
Narayanan UG, Hyman JE, Wainwright AM, Rang M, Alman BA. Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them. J Pediatr Orthop 2004;24:363-9.  Back to cited text no. 13
Hunter JB. The principles of elastic stable intramedullary nailing in children. Injury 2005;36 Suppl 1:A20-4.  Back to cited text no. 14
Aronson J, Tursky EA. External fixation of femur fractures in children. J Pediatr Orthop 1992;12:157-63.  Back to cited text no. 15
Krettek C, Haas N, Walker J, Tscherne H. Treatment of femoral shaft fractures in children by external fixation. Injury 1991;22:263-6.  Back to cited text no. 16
Beaty JH, Austin SM, Warner WC, Canale ST, Nichols L. Interlocking intramedullary nailing of femoral-shaft fractures in adolescents: Preliminary results and complications. J Pediatr Orthop 1994;14:178-83.  Back to cited text no. 17
Letts M, Jarvis J, Lawton L, Davidson D. Complications of rigid intramedullary rodding of femoral shaft fractures in children. J Trauma 2002;52:504-16.  Back to cited text no. 18
Flynn JM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, et al. Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am 2004;86-A:770-7.  Back to cited text no. 19
Ligier JN, Metaizeau JP, Prévot J, Lascombes P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-7.  Back to cited text no. 20
Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J. Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4-8.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]

  [Table 1]

This article has been cited by
1 Outcome of Surgically Managed Diaphyseal Fractures in Children- A Prospective Study
Sridhar Maryada Reddy,Nareshkumar Satyanarayan Dhaniwala
Journal of Evolution of Medical and Dental Sciences. 2020; 9(07): 393
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded114    
    Comments [Add]    
    Cited by others 1    

Recommend this journal