Caleb Foster
Flexible elastic nails are used in the treatment of femoral shaft fractures in children. The nails are made of titanium or stainless steel and are inserted into the medullary canal to fill 40% of the canal at the level of the isthimus. The choice between titanium and stainless steel elastic nails remains debated due to inconsistent findings. Titanium elastic nails have a higher malunion rate but greater axial compression stiffness than stainless steel nails. The average time for nail removal is 11 months postoperatively, with an average hospital stay of 5.1 days and a mean follow-up of 7.16 years.
| Characteristics | Values |
|---|---|
| Application | Pediatric femoral shaft fractures |
| Types | Titanium elastic nails, Stainless steel elastic nails |
| Time to fracture union | TENS: 93.8±60.5 days, SSENS: 82.2±40.0 days |
| Average hospital stay | 5.1 (3-9) days |
| Average operative time | 37 (range 25-110) minutes |
| Average age at final follow-up | 15.5 years (10-21 years) |
| Average follow-up | 7.16 years (5.0-8.6 years) |
| Complications | Malunion, knee stiffness, angular or rotational deformities |
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What You'll Learn
- Titanium elastic nails are used to treat femoral shaft fractures in children
- Flexible intramedullary nails are an accepted procedure for paediatric femoral fractures
- Titanium elastic nails are cut close to the bone, leaving 1.5-2 cm protruding for easy removal
- Titanium elastic nails have a higher malunion rate than stainless steel elastic nails
- Flexible intramedullary nails offer advantages such as minimal invasiveness and short hospital stays
Titanium elastic nails are used to treat femoral shaft fractures in children
Femoral shaft fractures are an incapacitating pediatric injury. The treatment has traditionally been age-related, influenced by the type of injury, associated injuries, and the location and type of fracture. Elastic nailing is a popular choice for the fixation of femoral shaft fractures in children. Titanium elastic nails (TEN) are one such option for treating femoral shaft fractures in children.
The use of titanium elastic nails for treating femoral shaft fractures in children has been found to be advantageous over hip spica in terms of union, scar acceptance, and overall patient satisfaction. A study by Ligier et al. treated 123 femoral shaft fractures with elastic stable intramedullary nails, and all fractures united. Another study by Buechsenschuetz et al. documented titanium nails superior in terms of union, scar acceptance, and overall patient satisfaction compared to traction and casting.
The duration of time that titanium elastic nails have to stay in is not clearly defined in the sources. However, one study reported a mean follow-up of 26 months (ranging from 14 to 36 months) for 22 patients who underwent titanium elastic nailing for femoral diaphyseal fractures. The radiological union was achieved in a mean time of 8.7 weeks, and full weight-bearing was possible in a mean time of 8.8 weeks. The mean duration of the hospital stay was 9.8 days.
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Flexible intramedullary nails are an accepted procedure for paediatric femoral fractures
Flexible intramedullary nails are an accepted procedure for treating paediatric femoral fractures. Femoral shaft fractures are among the most common diaphyseal fractures in childhood, and flexible intramedullary nailing has emerged as a standard treatment option. This procedure is suitable for all patients with femoral shaft fractures and open physis.
The use of flexible intramedullary nails in paediatric femoral fractures has been studied extensively, with reports of excellent results. However, opinions among orthopaedic surgeons remain divided regarding its usefulness and the best material for nails. Titanium elastic nails and stainless steel nails are commonly used, with titanium nails being the recommended treatment for patients aged 4-12 years and weighing less than 50 kg. The National Institute for Clinical Excellence in the UK suggests the Titanium Elastic Nailing System (TENS) for this age and weight group.
The procedure involves inserting two pre-bent flexible nails across the fracture in a retrograde fashion. The nails are inserted about 2 cm proximal to the distal femoral physis from the medial and lateral sides. The medial nail is directed within 2 cm of the proximal femoral capital physis, while the lateral nail is inserted about 1 cm from the greater trochanteric physis. The nails are bent and cut close to the bone, leaving 1.5-2 cm protruding for easy removal.
Flexible intramedullary nailing offers several advantages over traditional treatments, such as closed reduction in plaster spica cast, which can cause physical and psychological stress for the patient and their family. It also provides an alternative to external fixation and plate osteosynthesis, which may require a second surgery for implant removal. Flexible intramedullary nails allow for closed reduction without the need for a traction table, reducing soft tissue injury.
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Titanium elastic nails are cut close to the bone, leaving 1.5-2 cm protruding for easy removal
Titanium elastic nails are a popular choice for treating femoral shaft fractures in children. They are flexible and less invasive, leading to shorter hospital stays and earlier mobilisation. The elastic stable intramedullary nails (ESIN) are widely accepted for length-stable femoral fracture patterns as they avoid femoral head osteonecrosis and premature greater trochanteric epiphysiodesis.
The choice between titanium and stainless steel elastic nails remains a subject of debate. While titanium nails offer greater axial compression stiffness, some studies suggest that stainless steel nails have a lower malunion rate. However, there is no significant difference in bone healing, fracture stability, or complication rates between the two types of nails. The decision should be based on individual circumstances and the specific needs of each patient.
The average time for nail removal is around 11 months, but this can vary depending on the patient's recovery and healing process. The nails can be safely removed once the fracture has healed and the patient has achieved radiographic union, which typically occurs within 6 to 18 weeks after surgery.
In summary, titanium elastic nails cut close to the bone with a small portion protruding facilitate a straightforward removal process while minimising any discomfort or irritation for the patient. The decision to use titanium or stainless steel nails depends on various factors, and healthcare professionals carefully monitor each patient's progress to determine the appropriate timing for nail removal.
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Titanium elastic nails have a higher malunion rate than stainless steel elastic nails
Flexible elastic nails are used in the treatment of femoral shaft fractures in children. The elastic stable intramedullary nails (ESIN) have been distinguished from other flexible nail systems such as Ender nails, which are not sufficiently elastic for children's fractures. The elastic nailing offers advantages such as minimal invasiveness, short hospital stays, early mobilization, and fewer complications.
While titanium elastic nails have emerged as an effective treatment for diaphyseal femoral fractures in children aged 6 to 16, the choice between titanium and stainless steel elastic nails remains debated due to inconsistent findings. Wall et al. found that the titanium elastic nailing system's malunion rate was four times higher than that of stainless steel elastic nails. However, other studies have found no significant difference in bone healing, fracture mechanical stability, or complication rates between the two systems.
The average time to fracture union for titanium elastic nails was 93.8±60.5 days, while for stainless steel elastic nails, it was 82.2±40.0 days. The average hospital stay for patients with titanium elastic nails was 5.1 (3-9) days. Nails are typically removed at an average of 11 months postoperatively.
The inconclusive nature of the research highlights the need for further investigation to properly evaluate which nail system is more appropriate for pediatric patients.
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Flexible intramedullary nails offer advantages such as minimal invasiveness and short hospital stays
Flexible intramedullary nails are an accepted procedure for treating paediatric femoral fractures. Flexible nails are also used to treat forearm fractures in adolescents. Flexible intramedullary nailing was introduced for femoral fractures in 1982 by the Nancy group in France. The technique is adapted from existing flexible rodding techniques.
Flexible intramedullary nails offer advantages such as minimal invasiveness, short hospital stays, early mobilisation, and fewer complications. They also provide equivalent outcomes with decreased operative time and blood loss during surgery, and lower hospitalisation costs compared to plating techniques. The blood loss for elastic stable intramedullary nails (ESIN) averaged 18 mL, compared with 163 mL for plating. Hospital stays for patients averaged 5.1 days. The average time for inserting expandable intramedullary nails is as short as 35 minutes.
Elastic nails are made of titanium or stainless steel. Titanium nails have a greater axial compression stiffness than stainless steel nails. However, the choice between titanium elastic nailing (TENS) and stainless steel elastic nailing (SSENS) remains debated due to inconsistent findings. For instance, the malunion rate for TENS was found to be four times higher than SSENS.
In addition to the above advantages, flexible intramedullary nails avoid femoral head osteonecrosis and premature greater trochanteric epiphysiodesis secondary to rigid intramedullary techniques. They also prevent pin-related complications. Novel intramedullary nail designs include expandable nails, which avoid the need for interlocking screws, and carbon fibre nails, which have superior biomechanical properties.
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Frequently asked questions
Flexible elastic nails are usually removed at an average of 11 months post-operation.
Flexible elastic nails are made of either titanium or stainless steel.
Flexible elastic nails are used to treat femoral shaft fractures in children.
Flexible elastic nails offer advantages such as minimal invasiveness, short hospital stays, early mobilization, and fewer complications.
Yes, alternatives to flexible elastic nails include external fixation, plate osteosynthesis, and rigid intramedullary nailing. However, these alternatives may have more complications and may require a second surgery for implant removal.
