Ender Nails Research Articles

Distal locking in femoral intramedullary nailing system: Is one cross screw sufficient?

Introduction: The indications for intramedullary nail fixation of fractures of the femoral shaft have been greatly expanded by techniques of interlocking nailing. However, distal locking screw fixation remains the most technically demanding and problematic portion of the procedure and maybe responsible for as much as one-half of the exposure of the surgeon’s hands to radiation during the procedure. Objective: This biomechanical study was undertaken to compare the stability of using one distal locking cross screw versus two cross screws in femoral fractures fixed with intramedullary nailing (IMN) system. Materials: A composite model made from a stainless steel IMN (12 mm × 1 mm) was connected to a load cell (Instron machine). Axial forces upto 2 kN (3 times body weight) was applied or until a maximum displacement of 1 mm was reached. The distal locking end of the intramedullary nail was secured with stainless steel cylinders of different dimensions 50 mm × 5 mm, 75 mm × 5 mm and 100 mm × 3 mm to represent the proximal femoral diaphysis, diaphyseo-metaphyseal junction and distal femoral metaphyseal respectively. The distal locking end of the intramedullary nail was attached to the cylinder with a dedicated single or two rods (5 mm diameter), made from stainless steel, to represent the distal locking cross screw. Results: In the 50 mm cylinder, the mean stiffness (±standard deviation) of the system using either single or two screws were similar i.e. 3298 ± 144 N/mm. But in the 75 mm and 100 mm cylinders, the mean stiffness of the fracture model with two distal locking cross screws fixation was 2.059 ± 96 N/mm and 0.816 ± 122 N/mm and with single distal locking cross screw fixation were 0.643 ± 142 N/mm and 0.289 ± 88 N/mm respectively. Conclusion: Single distal locking cross screw fixation provide poorer fracture stability compared to two distal locking cross screws when used to fix distal femoral metaphyseal fractures.

Biomechanical Comparison of Tibial Nail Stability in a Proximal Third Fracture: Do Screw Quantity and Locked, Interlocking Screws Make a Difference?

This study compared the fatigue life of nailed proximal third tibial fractures stabilized with either three or four proximal screws using commercially available nails with both locked (through threaded holes or end caps) and nonlocked proximal interlocking screw configurations. Eight paired and two independent tibiae of known bone mineral density were acquired, divided into three groups, and implanted with three different commercially available nails (n = 6/group). Nails were all 10 mm in diameter and individually sized for length. Individual tibiae from a given pair received different nails. Based on nail design, Nail A received four proximal screws (three that lock into the nail), whereas Nails B and C each received three proximal nonlocking screws. Standard end caps were used with all nails. As a result of its design, in Nail B, the most proximal interlocking screw was "locked" by the nail end cap. All nails used two distal screws. After implantation, an unstable proximal third fracture was created and specimens were tested with combined axial and torsional loads of 40 to 400 N and 0.11 to 1.1 Nm for 500,000 cycles or until failure. The fatigue life of Group A was significantly greater than either Groups B or C (P < 0.001 in both cases) with a mean cycle to failure of 392,977 versus 86,476 and 64,595 cycles for Nails B and C, respectively. Fatigue life of Group A was greater or equivalent to all contralateral tibiae; Group B outlasted all contralateral Group C limbs and the Group C constructs did not outlast any contralateral limbs. Bone mineral density correlated positively and significantly with fatigue life across all three groups (P < 0.001). In this study, proximal segment stability was improved with a greater quantity of screws and with locked interlocking screws.

Modifizierte Technik zur Entfernung von Oberschenkelnägeln

The indication of implant removal of intramedullary nails is a subject of much discussion. The main concern is the increased morbidity of the preparation of the proximal nail end which can cause postoperative discomfort. The aim of the present study was to develop a soft-tissue protecting extraction technique and to evaluate it in comparison to the standard procedure. With the modified technique the proximal end of the nail is preparated by a guidewire and the standard reamer used for implantation. This allows a soft-tissue protection with reduced morbidity, especially in patients with ossification. The outcome was assessed 4-20 weeks postoperatively and the operation times compared with those of 10 patients operated with the conventional technique. From 5/09 to 12/10 we treated 9 patients with the mentioned technique. The operation time was reduced from a mean of 74.8 minutes to 32.0 minutes. Eight of nine patients had reduced or no discomfort postoperatively. Eight of nine patients stated that they had a benefit from the operation. The modified operation technique is capable of reducing operation time and morbidity in the implant removal of intramedullary nails.

The use of Ender nail in intertrochanteric fractures supported with external fixation

Intramedullary Ender nailing in intertrochanteric fractures was very popular in the past. However, this method has fallen in favor over time, due to complications. The purpose of this study was to evaluate results with this method and possible ways to prevent these complications, including the use of unilateral fixators to support the Ender nails. This technique (Ender nailing and external fixator) was used in 39 patients (17 M/22 F, mean age: 71.4 years). The preoperative mean American Society of Anesthesiologists (ASA) score was 1.84 (range: 1-4) for all the patients. AO/OTA classification of fractures was used. In our surgery, we used an external fixator to support the intramedullary nails. All patients were evaluated with Parker-Palmer mobility score and with the Harris hip score. The follow-up period was 29.2 months (20-56). Two patients experienced nail migration in the knees, two patients had varus deformation with a reduction in length of 2 cm, and seven patients developed pin-track infection. The average Harris score and Parker-Palmer score of the 14 patients who presented for their last follow-up examination were 64 and 6.8, respectively. This method demonstrated several advantages, in that it allows the patient to put weight on the extremity after a shorter period of time and enables the fracture to heal rapidly without any serious complications.

Comparison of the results of treatment of humeral shaft fractures by different methods

The aim of this study was to compare the functional results of non-operative and different operative techniques of managing humeral shaft fractures. The average follow-up was one year after the trauma in 61 patients with united fracture, where the initial method of treatment was the definitive one. The patients were divided into four groups: 22 were treated with hanging cast, 20 with intramedullary nails, 10 with dynamic-compressive plates and screws and 9 with external fixators. We estimated the presence of bone union by radiographic and clinical evaluation and compared the results with Constant and Mayo scores. The etiology of injuries was falls and traffic accidents in 87% of cases. The hanging cast group had the most of elbow contractures and insufficient results of functional scales. The plating group had lower average values of scores than nails, especially considering the elbow function. Among subgroups, the locked intramedullary nails had better results than Ender nails. The most complicated cases treated with Ilizarov and Mitković's external fixators had good results, especially in the treatment of open humeral shaft fractures; however, the rehabilitation period was longer. The best average functional results were recorded in the nailing group because of rigid fixation, solid callus formation and return to everyday activities in the shortest time.

ATTRITIONAL RUPTURE OF EXTENSOR POLLICIS LONGUS: A RARE COMPLICATION FOLLOWING ELASTIC STABLE INTRAMEDULLARY NAILING OF A PAEDIATRIC RADIAL FRACTURE

Elastic stable intramedullary nail fixation has become established as an acceptable method of treatment for diaphyseal fractures of both forearm bones in the paediatric population. It is considered safe, minimally invasive and does not compromise physeal growth. We report a case of delayed rupture of extensor pollicis longus due to attrition over the sharp edges of a protruding nail end after elastic stable intramedullary nailing of a paediatric radial diaphyseal fracture.

Comprehensive global evolution of intramedullary nailing of diaphyseal fractures

The treatment of midshaft fractures of the long bones has significantly evolved in the last 150 years. This paper will trace the timeline and evaluate the treatment of these fractures which has evolved through from the sixteenth century. The first and second world wars had amputation as the surgery of choice until the development of the Kuntsher Nail (1939) for femoral shaft fractures. Then followed interlocking nails, Ender nails, the telescoping nail and lastly the elastic intramedullary nails used in childhood and adolescents (1). It will also touch on the development of interlocking nails for other long bones; the humerus, tibia and the forearm bones and most recently intramedullary nails for small bones of the hand and feet. This paper touches on the historical reasons for the different techniques and how they have improved patient outcome. To the early surgeons, stabilization of diaphyseal fractures was difficult more so in open fractures and dilemma was which way to go – Amputation by the radical surgeons or conservative treatment to save the limbs. At that time the surgeons had only the above two options. During the American Civil War, Smith’s anterior splint was used but led to ulcerations and malunion and was not popular. It was clumsy with the leg suspended from the ceiling and traction obtained by moving the bed forwards/backwards. The next was Hodgers Cradle splint which was a wire splint suspension device to ensure complete extension of the limb and prevent contractures. Then followed the famous Thomas

Intramedullary Nailing for Diaphyseal Forearm Fractures in Children after Failed Conservative Treatment

To evaluate treatment outcomes after intramedullary nailing using Ender nails for diaphyseal forearm fractures. 11 male and 9 female patients aged 6 to 15 (mean, 12) years underwent intramedullary nailing using Ender nails plus cast immobilisation for fractures of both the radius and ulna after conservative treatment had failed. After a mean follow-up of 24 (range, 12-30) months, results were excellent in 14 patients, good in 5, and fair in one. None was poor. The mean operating time was 36 minutes. The mean time to bone union was 10 (range, 7-12) weeks. The mean time in the cast was 6 (range, 4-11) weeks. The mean time to implant removal was 8 (range, 6-10) months. All patients regained a full range of elbow movement, except in one who had limited supination and pronation (<20 degrees) due to a degree of malrotation. Two patients had pain owing to nail protrusion. One patient had a superficial infection. One patient had transient neurapraxia. Intramedullary nailing using Ender nails plus cast immobilisation is effective for diaphyseal forearm fractures in children after conservative treatment has failed.

Preliminary effect of proximal femoral nail antirotation on emergency treatment of senile patients with inter-trochanteric fracture

Objective To retrospectively analyse the clinical outcome of emergency treatment of senile intertrochanteric fractures with proximal femoral nail antirotation (PFNA). Methods From September 2008 to March 2009, 35 senile patients with intertrochanteric fracture, aged from 65 to 92 years with an average age of 76.5 years, were treated with PFNA within 24 hours after injury. There were 10 type I fractures, 19 type II and 6 type III according to upgraded Evans-Jensen classification system. All patients were complicated with osteoporosis, and 19 patients had preexisting internal medical diseases. According to the rating scale of disease severity by the American Society of Anesthesiologists (ASA), there were 9 grade I, 14 grade II, 8 grade III, and 4 grade IV. Results The duration for operation ranged from 45 to 73 minutes with an average of 57.6 minutes. The volume of blood loss during operation ranged from 50 to 120 ml with an average of 77.5 ml. Patients could ambulate 2–4 days after operation (mean 3.5 days). Hospital stay was 4–7 days (mean 5.3 days). Full weight bearing time was 10–14 weeks (mean 12.8 weeks). During hospitalization period, there was no regional or deep infection, hypostatic pneumonia, urinary tract infection and bedsore except for 2 cases of urine retention. All cases were followed up with an average period of 12.3 months, and bone healing achieved within 15–18 weeks (mean 16.6 weeks). No complications such as delayed union, coxa vara or coxa valga, screw breakage or backout occurred and only 2 cases had trochanter bursitis because of thin body and overlong end of the antirotated nail. According to the Harris grading scale, the results were defined as excellent in 21 cases, good in 9 cases and fair in 5 cases, with the excellent and good rates of 85.7%. Conclusion The emergency treatment of senile inter-trochanteric fracture with proximal femoral nail antirotation has the advantages of minimal invasion, easy manipulation, less blood loss, shorter length of stay, less complications, and the preliminary clinical effect is satisfactory.

Intertrochanteric fractures in elderly high risk patients treated with Ender nails and compression screw.

Background:Ender and Simon Weidner popularized the concept of closed condylocephlic nailing for intertrochanteric fractures in 1970. The clinical experience of authors revealed that Ender nailing alone cannot provide secure fixation in elderly patients with osteoporosis. Hence we conducted a study to evaluate the efficacy of a combined fixation procedure using Ender nails and a cannulated compression screw for intertrochanteric fractures.Materials and Methods:76 patients with intertrochanteric fractures were treated using intramedullary Ender nails and cannulated compression screw from January 2004 to December 2007. The mean age of the patients was 80 years (range 70-105 years).Using the Evan’s system of classification 49 were stable and 27 unstable fractures. Inclusion criteria was high risk elderly patients (age > 70 years) with intertrochanteric fracture. The exclusion criteria included patients with pressure sores over the trochanteric region. Many patients had pre-existing co-morbidities like diabetes mellitus, hypertension, COPD, ischemic heart disease, CVA and coronary artery bypass surgery. The two Ender nails of 4.5mm each were passed across the fracture site into the proximal neck. This was reinforced with a 6.5 mm cannulated compression screw passed from the sub trochanteric region, across the fracture into the head.Results:The mean follow-up was 14 months (range 9-19 months) Average time to fracture union was 10 weeks (range 6-16 weeks). The mean knee ROM was 130° (± 5°). There was no case of nail penetration into hip joint. In five cases with advanced osteoporosis there was minimal migration of Ender nails distally.Conclusions:The Ender nailing combined with compression screw fixation in cases of intertrochanteric fractures in high risk elderly patients could achieve reliable fracture stability with minimal complications.

Easy insertion of the gamma nail's end cap

Instrumentation for the Gamma 3 Trochanteric Nail 180 (Stryker, UK) facilitates a minimally invasive approach. However, insertion of the end cap can be difficult through a small incision. The end cap can fall off the screwdriver and is sometimes lost in the soft tissues for some minutes. We have found that by re-inserting the ball-tipped wire into the top of the nail, the end cap can be easily threaded over the wire and pushed down to engage the nail. It is then screwed home. This simple technique, which is not previously reported,1 avoids multiple insertion attempts and saves operative time. Figure 1 Secure insertion of the end cap over the guide wire.

Closed reduction and internal fixation of fractures of the shaft of the femur by the Titanium Elastic Nailing System in children.

Femoral shaft fractures account for 1.6% of all bony injuries in children, usually caused by assault or fall during normal play. Common methods of treatment include, traction followed by hip spika, dynamic compression plate, external fixator, and IM nailing. Though the fracture union is rapid in children chances of mal union still exists. Taking this into view, we did this study.Materials and methods-A series of 25 patients with femoral shaft fracture with ages between 6 to 14 years were treated from May 2007 to August 2008 is reviewed. Patients were treated with TENS. Male to female ratio was 2.6:1.mode of injury was RTA in 80%.open fractures were excluded from the study.60% were transverse, 24%short oblique, 16% had short spiral. Flynn et al, criteria was used while evaluating final result.Results-Average hospital stay was 9 days post operative.Average duration of callus formation was 3.5 weeks.Average duration of fracture union was 8.5 weeks.Two cases had over growth of 5 and 4mm respectively.One had shortening of 2cm.Conclusion-TENS is a safe and satisfactory mode of treatment and is relatively easy to perform. It avoids the chances of pin tract infections and long scars. Long term immobilization leading to fracture disease or spika immobilization is avoided. INTRODUCTION Femoral shaft fractures account for 1.6% of all bony injuries in children. Male female ratio being 2.6:1.These fractures have bimodal age distribution with peak at 2 and 17 years. Fractures are mostly caused by fall during play (30%) or abuse. Low velocity trauma leads to transverse fractures and high speed causes comminuted or segmental fractures . In recent past Traction and or Hip spika was the standard treatment of all femoral fractures , which involved long duration of treatment. More recently variety of therapeutic alternatives such as flexible intramedullary nails like Enders nail and TENS have become available to decrease morbidity, increase convenience and decrease cost of care. Fractures are classified asTransverse, spiral or oblique 1.

Elderly patient's mortality and morbidity following trochanteric fracture. A hundred cases prospective study

Trochanteric fractures are a major source of mortality, morbidity and functional impairment in the elderly. Morbidity is closely related to the degree of instability and comminution and is substantially influenced by the quality of reduction and internal fixation. Advanced age and associated co-morbidities are two decisive factors of mortality secondary to trochanteric fracture.This prospective study examined the epidemiological profile of trochanteric fractures and assessed mortality and morbidity with the aim of establishing management guidelines and improving prevention strategies.One hundred patients were included; 60% were male. Mean age was 76 years (range, 60-96 yrs). One, or more than one, co-morbidities were present in 68% of cases. The fractures were caused by a simple fall in 90% of cases. Fractures were classified according to the criteria of Ramadier and the ones of Ender. Sixty-five percent of these fractures were unstable. A dynamic hip screw was systematically used as the standard means of internal fixation.Anatomic and functional results were analyzed in 82 patients (18 had died within the first year following fracture occurrence). Mean follow-up period was 24 months (range, 12-36 months). Bone healing was achieved in 96% of cases. There were numerous postoperative complications (four cases of thromboembolism, fourteen immobility-related complications, two infections, six secondary displacement combined to loss of fixation, four non-unions, and nine malunions). At 2 years follow-up, 28 patients had died. Mortality was strongly correlated with older age (over 90 years), associated co-morbidity and fracture instability. Good functional outcomes (72%) correlated with younger age (60-74 years), fracture stability, adequate reduction and internal fixation.In stable trochanteric fractures, osteosynthesis by dynamic screw-plate is more effective than alternative techniques (blade-plate, nail-plate, Ender nail or even trochanteric nail). In unstable trochanteric fractures, delayed weight-bearing should be preferred to avoid mechanical complications. In fractures that are unstable or extend far below the lesser trochanter, trochanteric nailing is indicated since providing enhanced stability, but sometimes at the cost of insufficient reduction. The treatment objective should be the complete resumption of weight-bearing as early as possible with the fewest possible complications. Prevention consists in detecting and treating osteoporosis and countering the causes of falls in elderly subjects (muscular reinforcement and correction of neurosensory deficit).Level III: Prospective diagnostic study.

Hip arthroplasty for failed treatment of proximal femoral fractures.

Failed treatment of an intertrochanteric fracture typically leads to profound functional disability and pain. Salvage treatment with hip arthroplasty may be considered. The aim of this study was to evaluate the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture. Twenty-one patients were treated in our hospital with hip arthroplasty for failed treatment of intertrochanteric hip fracture. There were sixteen women and five men with a mean age of 75.8 years (range 61-85 years). Fourteen patients had failure of a previous nail fixation procedure, five had failure of a plate fixation, one of hip screws fixation and one of Ender nail fixation. In 19 out of 21 patients we performed a total hip arthroplasty-14 cases used modular implants with long-stems and five cases used a standard straight stem. In 2 of 21 cases we used a bipolar hemiarthroplasty. A statistically significant improvement was found comparing pre and postoperative conditions (p < 0.05). Our experience confirms that total hip arthroplasty is a satisfactory salvage procedure after failed treatment of an intertrochanteric fracture in elderly patients with few serious orthopaedic complications and acceptable clinical outcomes.

AO titanium elastic nail combined with autologous hone marrow injection for treatment of simple bone cysts of the long bones in children

Objective To study the effects and advantages of the treatment for simple bone cysts of the long bones in children with AO titanium elastic nail and autologous bone marrow injection. Methods Eighteen patients with a simple bone cyst at humerus or femur were managed with AO titanium elastic in-tramedullary nail combined with autologous bone marrow injection. There were eleven boys and seven girls in total, with the mean age of 8.1 years, ranged from 6 to 12 years. Twelve cysts was located in the proximal end of humerus, five in the proximal end of femur and one in the middle part of the shaft of femur. Twelve cysts were active and six inactive according to Neer standard. Radiographic evaluation was performed three, six, twelve and eighteen months after operation during the 11 to 23 months follow-up by taking anteroposteri-or and lateral X-ray pictures. Then we measured residual radiolucent areas on X-ray pictures and did statistic research with group comparison. Results Six cysts (33.3%) healed completely, and twelve (66.7%) healed with residual radiolucent areas which were visible on X-ray pictures 3 to 6 months after operation. Residual radiolucent areas on X-ray pictures gradually reduced during the different phases and it has statistical signif-icance by group comparison. There was no recurrence or major complication except for one patient with mild irritation of skin caused by the end of the nail up to now. Conclusion The treatment for simple bone cysts of the long bones in children combined with AO titanium elastic nail and autologous bone marrow injection not only has satisfactory healing rate but also can provide early stability to the long bones, and accelerate the healing of cysts which allows early mobilization and thus obviates the long-term need for a plaster cast and decreases the prevalence of the most common complication: a pathological fracture. Key words: Titanium; Bone cysts; Bone Screws; Bone marrow transplantation; Child

大腿骨転子部骨折に対する Ender 法の術後成績

大腿骨転子部骨折に対する Ender 法の術後成績

Iatrogenic Radial Nerve Palsy After Operative Management of Humeral Shaft Fractures

It is generally agreed that a period of observation is appropriate for primary radial nerve palsy associated with humeral shaft fractures. There is no consensus, however, with regard to secondary radial nerve palsy, particularly when it is iatrogenic. Most texts state that surgical exploration is indicated for nerve palsy that occurs after fracture manipulation, but our experience suggests that it is not necessary for radial nerve palsy developing after operative management of humeral shaft fractures. A total of 707 humerus shaft fractures were treated operatively at our two hospitals over a 10-year period. Of these, 30 patients sustained iatrogenic radial nerve palsy. Another 16 cases were referred to us with adequate documentation from other institutions. No recognized intraoperative injuries to the radial nerve were recorded in any case. Of the 46 patients, 21 were female and 25 were male. The median age was 40 years (range, 19-75 years). A total of 39 patients had been treated with dynamic compression plates, 3 with a rigid interlocking intramedullary nail, and 4 with Ender nails. All fractures were diaphyseal, at the middle or distal third level. At the discretion of the surgeon, five cases were surgically explored. In all five cases the radial nerve was in continuity and no macroscopic lesions were noted. All cases eventually recovered grade 4 of 5 muscle strength or better. The median time to the beginning of clinical recovery was 16 weeks (range, 5-30 weeks). The timing and pattern of radial nerve recovery in this situation was similar to that seen in primary radial nerve palsy. There appears to be no advantage to early exploration of the radial nerve. In the absence of obviously misplaced instrumentation or fracture displacement, we treat it like a primary palsy and recommend observation for a minimum of 4 months before exploration.

Treatment of Fractures Of the shaft of the femur in children by Ender`s nails: A prospective study

We did a prospective study of 20 cases on treatment of fracture shaft of femur in children by Ender's nail. The average duration of hospital stay was 9 days. Femoral shaft fractures in children can be operatively treated with excellent results and a decreased complication rate. Operation results in shorter hospitalization which has psychological, social, educational, and economic advantages over conservative treatment.

Treatment of Long Bone Osteomyelitis With a Mechanically Stable Intramedullar Antibiotic Dispenser: Nineteen Consecutive Cases With a Minimum of 12 Months Follow-Up

Antibiotic cement beads are the most common system of local antibiotic delivery. Unfortunately, bead strings do not give mechanical support to the fracture site, stability being fundamental in osteomyelitis treatment. Local treatment associated with bone stability should improve the results in posttraumatic osteomyelitis. The objective of this article is to present our experience in the treatment of long bone osteomyelitis using an intramedullary, mechanically stable antibiotic dispenser. We present a retrospective review of a consecutive series of patients with a long bone osteomyelitis treated using an intramedullary, mechanically stable antibiotic dispenser. The dispenser used with a T-95 chest tube filled with poly(methyl methacrylate) + antibiotic (vancomycin, gentamycin, or both, tobramycin or imipenem; depending on culture results) and with a metal center (Ender nail). Fifteen patients were men and three were women, with an average age of 37 years (range, 18-52 years). In four cases, treatment involved the femur and in 15 the tibia. Positive cultures were obtained from each patient. Methicillin-resistant Staphylococcus aureus was isolated in 17 cases. The intramedullary dispenser was removed between 6 and 76 weeks after surgery. Success was defined as negative cultures after dispenser removal. Follow-up period was between 10 and 54 months. Negative cultures were obtained from intramedullary reaming after dispenser removal in all but one patient who could not finish treatment because of local intolerance to antibiotic treatment. None of the 17 patients presented an infection recurrence. The combination of local antibiotic treatment with bone segment stability showed acceptable results in our short series of patients. Further investigation on locked intramedullary antibiotic dispensers providing improved stability will help us learn about this difficult clinical scenario.

Comparison of Flexible Intramedullary Nailing with External Fixation in Pediatric Femoral Shaft Fractures

Purpose: This study compared the results of external fixation with those of flexible intramedullary nailing using Ender nails in pediatric femoral shaft fractures. Materials and Methods: Twenty-eight children with pediatric femoral shaft fractures were enrolled in the study. The children's ages ranged from 6 to 11 years, and the average period of follow-up was 27.2 months. Fifteen patients underwent flexible intramedullary nailing (FIN) using Ender nails and thirteen patients underwent external fixation (EF). The outcomes were assessed based on the clinical and radiology findings. Results: The healing time averaged 9.8 weeks in the FIN group and 11.2 weeks in the EF group. In the FIN group, one patient suffered pin migration. In the EF group, three patients had a pin site infection, one patient had refracture after removing the external fixator and one patient had pin breakage 8 weeks after surgery. The broken pin was removed and the condition was stabilized with internal fixation using a plate. Conclusion: Flexible intramedullary nailing with Ender nails is an effective treatment option for treating femoral shaft fractures in children because it has fewer complications than external fixation does.