Flexible Nailing Research Articles

Tibial Shaft Fractures in Children and Adolescents.

* Tibial shaft fractures are common in the pediatric population.* Traditionally, the majority of pediatric tibial fractures have been managed nonoperatively, but surgical rates are increasing.* Management includes closed reduction and casting, flexible nailing, plate osteosynthesis, external fixation, and rigid intramedullary nailing.* Gustilo-Anderson grade-2 and 3 open pediatric tibial shaft fractures have higher complication rates than closed fractures.* The majority of pediatric tibial shaft fractures have excellent outcomes with an expectation for return to full activities.

Antegrade flexible intramedullary nailing through the greater trochanter in paediatric femur shaft fractures

Aims: To determine whether an antegrade approach, through the tip of the greater trochanter, in femoral shaft fractures in children, is safe, achieves adequate union and results in significant proximal femoral growth complications. Patients and methods: The case records and radiographs of 23 paediatric patients aged 7 to 12 years with femur shaft fractures managed with stainless steel antegrade flexible nailing were reviewed retrospectively. Pre-operative radiographs were reviewed for fracture pattern, level and comminution. Post-operative radiographs were reviewed to assess for union, alignment, osteonecrosis of the femoral head and epiphysiodesis of the greater trochanter. Morphological changes of the proximal femur were assessed by comparing the neck shaft angle and articulo-trochanteric distance with the opposite hip. Case records were reviewed for post-operative complications, patient-reported complaints and leg length discrepancy. Clinical outcomes were assessed with the criteria established by Flynn. Results: All patients achieved union, and none had evidence of osteonecrosis of the femoral head on follow-up. Three patients had malalignment and two patients had radiographic evidence of greater trochanteric epiphysiodesis. Two patients had morphological changes of the proximal femur, with one having an increased neck shaft angle and one an increased articulo-trochanteric distance. One patient had a leg length discrepancy of 2 cm. Fifteen patients had excellent clinical outcomes, five had satisfactory outcomes and three had poor outcomes according the criteria established by Flynn. Conclusion: Antegrade entry through the tip of the greater trochanter does not appear to compromise the blood supply to the femoral head or increase the risk of clinically significant morphological changes to the proximal femur. All patients achieved adequate union. Furthermore, antegrade insertion avoided skin problems and prominent nail complications around the knee seen with retrograde insertion. Level of evidence: Level 4

Biomechanical Analysis of Retrograde Flexible Intramedullary Nail Constructs in a Simulated Pediatric Femur Fracture Model

Various flexible intramedullary nail (FIMN) constructs for pediatric femur fractures are described; however, no biomechanical study has compared stability of medial-lateral entry versus all-lateral entry retrograde nailing. Our purpose is to compare the rotational and bending stiffness of 2 different FIMN constructs and 2 different materials in a simulated pediatric femur fracture model. Eighty adolescent-sized composite femurs were used to simulate transverse (40 femurs) and oblique (40 femurs) mid-diaphyseal fractures. Retrograde FIMN of the femurs was performed using either 3.5 mm titanium (Ti) or 3.5 mm stainless-steel (SS) flexible nails in 2 configurations: 2 "C"-shaped nails (CC) placed through medial and lateral entry sites or 1 "C"-shaped nail and 1 "S"-shaped nail (CS) placed through a single lateral entry site. Models were first tested in 10 cycles of axial rotation to ±1 N m of torque at a rate of 0.5 degrees/s under 36 kg of compression. Axial compression was performed and bending stiffness defined as the force required to achieve 10 degrees varus at the fracture site. No differences were noted in rotational stiffness comparing Ti and SS nails regardless of nail configuration or fracture pattern. Comparable rotational stability was found for CC and CS configurations with SS implants for both fracture patterns. The CS construct (0.60 N m/degree) was stiffer in rotation than the CC construct (0.41 N m/degree) with Ti implants in the transverse fracture model (P<0.005). SS nails provided greater bending stiffness than Ti nails in both oblique and transverse fracture patterns, regardless of nail construct. The all-lateral entry (CS) construct demonstrated statistically significant greater bending stiffness regardless of implant material or fracture pattern (P<0.03). An all-lateral entry (CS) FIMN construct demonstrated greater bending stiffness in both fracture patterns and materials. Ti and SS implants have comparable rotational stiffness in all fracture patterns and materials; however, SS nails were superior at resisting bending forces in both fracture patterns. CS nail configuration and SS implants demonstrated superior bending stiffness and rotational stiffness when compared with the more commonly used CC construct and Ti implants. NA (biomechanical study).

Atypical use of pediatric flexible nails in the treatment of diaphyseal fractures in adults.

Background and aim of the work:Elastic intramedullary nails are commonly used for the treatment of diaphyseal fractures in adolescents and children. The major advantages are the minimally invasive nature of the technique, the short operation time, and the preservation of the growth plate and periosteum thus allowing bone healing within a closed and intact biological environment. Elastic nails are rarely applied to the adult fractures.Methods:Five selected adult patients affected by diaphyseal fractures were treated using paediatric flexible nails T2 Kids (Stryker®, Mahwah, NJ, USA) as consequence of their poor clinical conditions, high risk of neurovascular injuries and skin/soft tissues problems. All patients were monthly clinically and radiographically evaluated after surgery until fracture healing.Results:Radiological and clinical outcomes were satisfying. All fractures healed after a mean period of 3 months. No losses of reduction as well as mobilization/breakage of implant were observed. Conclusions: Use of pediatric elastic nails is a valid surgical option in treatment of diaphyseal fractures in selected adult patients who request fast and minimally invasive surgery as consequence of precarious clinical or soft tissues conditions. (www.actabiomedica.it)

Submuscular plates versus flexible nails in preadolescent diaphyseal femur fractures.

:PurposeTo compare patient characteristics, operative time, estimated blood loss (EBL), postoperative length of hospital stay (LOS) and complications after insertion and removal of submuscular plates (SMPs) versus flexible nails (FNs) for paediatric diaphyseal femur fractures.MethodsWe reviewed records of 58 children (mean age, 7.7 years SD 2.0) with diaphyseal femur fractures who underwent treatment with SMPs (n = 30) or FNs (n = 28) from 2005 to 2017 (mean follow-up, 22 months SD 28). Patients with pathological fractures or musculoskeletal comorbidities were excluded. Alpha = 0.05.ResultsInsertion of FNs was associated with shorter operative time (ß = –24 mins) and less EBL (ß = –38 mL) (both, p < 0.001) compared with insertion of SMPs, after adjusting for fracture type and time from beginning of study period. Removal of FNs was also associated with shorter operative time (ß = –15 min) compared with removal of SMPs (p < 0.001). EBL during removal was similar between groups (p = 0.080). The FN group had a shorter LOS after insertion (ß = –0.2 d) compared with the SMP group (p = 0.032). Four patients treated with SMPs and three treated with FNs developed surgical site infections. Two patients treated with SMPs and seven treated with FNs experienced implant irritation that resolved with removal. No other complications occurred.ConclusionCompared with SMPs, FNs were associated with shorter operative time (for insertion and removal), less EBL (for insertion) and shorter post-insertion LOS in patients with diaphyseal femur fractures.Level of Evidence:III

A clinical study of surgical management of diaphyseal fractures of shaft of femur in children and adolescents using flexible nails

Aim and Objective: In this study 20 patients, aged 5 to 16 years, with fracture shaft of the femur were treated with retrograde flexible intramedullary nailing at Bapuji Hospital and Chigateri General Hospital, attached to J.J.M. Medical College in the period from September 2013 to September 2015.Materials and Methods: The study includes patients with femoral shaft fractures admitted and examined according to protocol. Associated injuries were noted. Clinical and radiological investigations were carried out and medical fitness for surgery to undergo flexible nailing fixation for the sustained fracture was taken.Patients were followed up at 1,2,3,6 months intervals till fracture union and once at 1 year after surgery. A minimum of 20 cases were studied without any sampling procedure.

Use of flexible intramedullary nailing in combination with an external fixator for a postoperative defect and pseudarthrosis of femur in a girl with osteogenesis imperfecta type VIII: a case report

Telescopic rodding has been developed in order to obtain long-lasting osteosynthesis in the growing long bones of children with osteogenesis imperfecta (OI). The major and still unsolved drawback of any telescopic rod or nail design is a lack of rotational stability and, currently, no telescopic system allows immediate weight-bearing. When these problems are associated with insufficient longitudinal bone stability and diminished healing capacity, the result can be unfavourable causing secondary bone fragment displacement, delayed or non-union. This article presents a case report of operative treatment in a 9-year-old girl affected with OI type VIII complicated with postoperative defect and pseudarthrosis of the femur causing functional impairment with loss of walking ability. A combination of intramedullary flexible nailing and minimal external fixation was applied for treatment of femoral defect-pseudarthrosis in a girl of 9 years with OI type VIII. Intramedullary and extramedullary nails with wrapping of titanium nickel mesh subperiosteally provided osteosynthesis and deformity correction of the tibia of a small intramedullary canal diameter. Upright standing and walking with progressive weight-bearing was started 4 days after surgery. There were no septic or vascular complications nor complications related to Ilizarov fixator. Radiographs demonstrated bone union in the femur 46 days after surgery. At the follow-up visit 9 months after fixator removal, clinical alignment remained excellent without any relapse of deformity. Bone remodelling with restitution of medullary canal was noted on lower limb radiographs. The patient was able to stand and walk without pain with an aide or walker. At the follow-up visit 17 months after fixator removal, there was no decrease in achieved functional abilities and the treatment outcome remained satisfactory. Use of an external fixator with intramedullary nailing for treatment of postoperative pseudarthrosis in patient with severe OI (recessive form of OI, type VIII) provides longitudinal, rotational and angular stability. Furthermore, this approach ensured early functional activity and walking with full weight-bearing, both favourable conditions for bone tissue regeneration. The external fixator was applied for a short period and only for additional stability and not for progressive deformity correction or other manipulation. In addition, the combination of intramedullary and extramedullary nailing and subperiosteal titanium nickel mesh seems to be promising for osteosynthesis in the deformity correction of bones with small diameter in children with OI.

Validity and responsiveness of the Nottingham clavicle score in clavicle shaft fractures treated with titanium elastic nailing

BackgroundThe Nottingham Clavicle Score (NCS) has been recently described for functional outcome assessment after injuries to clavicle and the Acromioclavicular joint. However; validity and responsiveness are context specific psychometric terms and the NCS has not been previously described in surgically treated clavicle shaft fractures. Aim of the present study was to investigate validity and responsiveness of the NCS in clavicle fractures treated with titanium flexible nailing. MethodsThis prospective study was undertaken on consecutively operated clavicle shaft fractures treated with titanium elastic nail from November 2013 to August 2016. Functional assessment using NCS was done at two and six months postoperatively. Construct validity was also evaluated by formulating the null hypothesis that there would be no difference in NCS at six months after open and closed reduction and in 15B1 and 15B2 fracture sub-types. The above two hypotheses were formulated based on previous studies that used Constant score and DASH score. Pre-specified hypothesis and results in accordance with the hypotheses suggest satisfactory construct validity. Responsiveness was evaluated using standardized response mean (SRM) and Effect size (ES). ES and SRM values ≥0.80 suggest satisfactory responsiveness. The proportion of patients having the least possible score of 0 points (floor effect) and the highest possible score of 100 points (ceiling effect) was evaluated at two and six months postoperatively. Floor and ceiling effect of <15% suggests satisfactory internal validity. ResultsThirty six consecutively operated patients were included in the study. The NCS at two months and six months was 69.6 ± 9.6 and 87.2 ± 7.1 respectively. The NCS at six months after fixation was 88.7 ± 4.8 in closed reduction cohort and 84.7 ± 9.4 in the open reduction cohort and this difference was not significant (p = 0.1). The NCS at six months after fixation was 85.3 ± 8.3 in 15B1 clavicular fractures and 89.7 ± 4.0 in 15B2 clavicular shaft fractures and this difference was also not significant (p = 0.07). All results pertaining to construct validity were in accordance with our hypothesis thereby suggesting that NCS demonstrates satisfactory construct validity. The ES and SRM were 1.8 and 2.6 respectively. NCS showed no ceiling (0%) or floor effect (0%) at two and six months postoperatively thereby suggesting adequate internal validity of the NCS. ConclusionNCS has satisfactory construct validity, internal validity and responsiveness in surgically treated clavicle shaft fractures with titanium elastic nailing.

Особенности ортопедического и соматического статуса у пациентов с несовершенным остеогенезом

Introduction Osteogenesis imperfecta (OI) is a group of rare and relatively diverse genetic disorders, characterized by frequent fractures, bone deformities, low bone mineral density and osteopenia. Frequent fractures, bone deformities, and nonunion are among orthopedic problems in OI patients. Varus deformity of the femoral neck, scoliosis, protrusion of the acetabulum, static deformities of the feet are considered separately. The main goal of surgical treatment of the limb deformities and fractures in OI patients is restoration and maintenance of their motor activity, autonomy and preservation of quality of life in severe OI types. The purpose of this study was to assess the deformities in the lower extremities and other accompanying orthopedic disorders, as well as the somatic status of patients with severe OI types (Sillence’s types III and IV) at the point of admission to operative orthopedic treatment. Material and methods Between 2003 and 2016, we examined 43 patients with severe OI (types III and IV) which were admitted for operative correction of deformities of the lower and upper extremities, nonunion, and varus deformity of the femoral neck. The average age at the time of admission was 14.4 ± 9.74 years (from 2 years 9 months to 46 years). Results Treatment of fractures was conservative in most cases; however, osteosynthesis with wires or flexible nails was used, followed by their removal in 4 patients; bone plates were applied in 4 patients; osteosynthesis with the Ilizarov apparatus was used in 3 cases, and intramedullary osteosynthesis with rigid rods in 4 patients. Regular administration of bisphosphonate preparations was conducted in 9 patients. Last dose of the drug was introduced at least 4 months before admission to surgical treatment. Thirteen patients had undergone reconstructive surgeries on the bones of lower extremities to correct the deformities. Conclusion Deformities of the lower limbs in patients with severe OI types are complex and multilevel, which implies the need for multilevel orthopedic interventions to correct them. High incidence of fractures and a complex nature of severe bone deformities result in the loss of the skills to move independently, or even its initial absence. Inadequate surgical interventions, untimely performed, non-telescopic nature of osteosynthesis, and absent bisphosphonate therapy contribute to the formation of additional orthopedic problems and aggravation of the loss of autonomy in such patients, which may complicate subsequent specific orthopedic surgical treatment.

“Bouquet technique” for displaced boxers fracture: Surgical technique and outcomes in143 consecutive cases

Background: Fifth metacarpal neck fractures, also known as Boxer’s fractures, commonly occur as a result of axial impact on a clenched fist. There is no agreement over the optimum management of undisplaced boxers fracture. We present the results of treatment by a Bouquet technique, described by Foucher in 143 consecutive cases of displaced fifth metacarpal neck fractures.Methods: We retrospectively reviewed our records for 143 consecutive cases of fifth metacarpal neck fractures treated with Bouquet technique. Clinical and radiological evaluation was done at 6 weeks, 12 weeks and 6 months. Total active motion of the fifth digit, radiography and complications if any were noted.Results: Of 143 cases, there were 113 cases with closed reduction and 30 with open reduction. Radiological union was achieved in 140 cases. Remaining 3 were lost to follow up. Good to excellent result was achieved in 95% cases. Seven cases developed bursitis at the K-wire entry site which required k-wire removal.Conclusion: The technique of flexible antegrade intramedulary nailing of fifth metacarpal neck fractures is simple, safe, soft tissue sparing, minimally invasive technique giving excellent functional and cosmetic results with minimal complications.

Dimensions of the Pediatric Femur: Anatomic Considerations for Flexible Nailing

Purpose: There is a paucity of studies evaluating the relationship between age and femoral dimensions. The current study sought to evaluate longitudinal and isthmic growth in the pediatric femur. This study also sought to determine the ability of pediatric femurs to accommodate flexible nails. We hypothesized that femoral length, isthmus width, and the ability to accommodate flexible nails would be closely correlated with chronological age. Methods: Consecutive patients with normal femurs and complete radiographs were included. We excluded patients with history of fracture, previous surgery, tumor, and dysplasia. AP and lateral femur radiographs were evaluated …

Dimensions of the Pediatric Femur: Anatomic Considerations for Flexible Nailing

Dimensions of the Pediatric Femur: Anatomic Considerations for Flexible Nailing

Flexible intramedullary nailing in pediatric femoral fractures, short term results at a secondary healthcare system

Background: Femoral fractures in children are among the most common fractures of long bones. The definitive treatment modalitiy remains controversial. Flexible intramedullary nailing has emerged as an accepted procedure for femoral fractures in school going children. We thus undertook a prospective study of paediatric femoral fractures treated with flexible titanium nailing at our centre which is a secondary health care. Material and Methods: Our study included 18 patients having femoral fractures treated with retrograde flexible intramedullary nailing. In our study we had males and females with right side and on left side. Patients were followed up for a mean period of 10 months. Results: Patients were followed up till their fractures healed or until the last followup visit. The mean length of follow-up was 10 months. All patients united uneventfully. Radiological union was evident in a mean time of 8.44 weeks ranging from 6 to 12 weeks. Three patients got limb lengthening of 1 – 1.5cm. Two patients got a varus angulation of less than 10o. There was no case of entry site irritation or any nerve palsy. One patient got a peculiar entry site medial localized cortical longitudinal fracture. There were 12 excellent and 6 satisfactory results using outcome criteria of Flynn et al for titanium elastic nail. Conclusion: Flexible nailing in pediatric femoral fractures yields excellent and satisfactory outcome with a relatively free from major complications.

All-endoscopic management of benign bone lesions; a case series of 26 cases with minimum of 2 years follow-up.

Purpose: Assessment of the functional and oncologic outcomes regarding endoscopic curettage of different benign bone tumor types within variable anatomic locations.Patients and methods: During the period between February 2012 and December 2016, 26 patients with symptomatic intra-osseous benign bony lesions were included. The age ranged from 3 up to 49 years (mean 20), of 14 females and 12 males. The follow-up duration ranged from 26 up to 58 months (mean 41). Functional scoring was done according to the Revised Musculoskeletal Tumour Society Rating Scale. Anatomic locations of the lesions included: 6 cases in the proximal tibia, 6 cases in the distal femur, 4 cases in the calcaneus, 3 cases in the proximal humerus, 3 cases in the distal tibia, 2 cases in the talus, 1 case in the proximal femur, and 1 case in the distal fibula. The procedure used 4 mm 30° scope for endoscopy, and high speed burrs 3.5–5 mm for extended curettage. Autogenous bone grafting was done in 5 cases, and adjuvant material (polymethylmethacrylate) was needed in 7 cases.Results: After exclusion of one case that was lost in the follow-up, the remaining 25 cases showed full functional recovery at a period of 8–12 weeks, and improved mean functional scores from 20.2 to 28.6/30 post-operatively, with p value <0.001 which was considered as a statistically significant result. The oncologic outcome showed 24 cases with adequate healing, while 1 case developed recurrence (aneurysmal bone cyst in the proximal tibia) for which, an open revision surgery was performed. Intra-operative fracture occurred in another case with aneurysmal bone cyst of the proximal femur, which was fixed by flexible nails with complete healing.Conclusion: Endoscopic curettage of different types of intra-osseous benign bony lesions proved to be an effective treatment modality with promising oncologic outcome, improved functional scores, and fast functional recovery.

Surgical management for tibial shaft fractures using flexible nailing in adult hypophosphatasia

Surgical management for tibial shaft fractures using flexible nailing in adult hypophosphatasia

Titanium Elastic Intramedullary Nailing in Paediatric Tibial Shaft Fractures

Introduction: Most of the pediatric tibial shaft fractures are treated non-operatively with close reduction and casting. Surgical indications include unstable fractures, open fracture, polytrauma patients, compartment syndrome or severe soft tissue injury. The purpose of this study was to assess the outcome of tibial shaft fracture fixation with titanium elastic intramedullary nails.Patients and methods: The average age of the patient was 11.3 years (range 6 to 15 years) and mean follow up was 14 months (range 6 to 26 months). Patient’s charts and radiographs were reviewed retrospectively. The outcomes were classified as excellent, satisfactory or poor according to Flynn’s criteria for flexible nail fixation.Results: All patients achieved union at a mean of 10.3 weeks (8 to 14 weeks). Full weight bearing was achieved at a mean of 9.2 weeks (8 to 14 weeks). At last follow-up, the result was excellent in 18 patients and satisfactory in 4 patients. Nineteen patients had less than 5-degree angulation and three patients had 5-10 degree angulation. The most common complication was irritation at nail entry site. Two cases had superficial wound infection at entry site and both healed with oral antibiotics and dressing changes.Summary: Elastic intramedullary nailing is a safe and reliable treatment method for pediatric tibial fractures. It provides stable fixation and allows rapid healing of fractures with minimal complications.

Flexible intramedullary nailing for femoral diaphyseal fractures in children

Background &amp; Objectives: Although various treatment options are available for the treatment of femoral diaphyesal fractures in children, the titanium flexible nailing has gained popularity because it is safe, easy procedure with rapid recovery and high success rate. The aim of this study was to evaluate the outcome of titanium elastic nails in treating paediatric femoral diaphyesal fractures at Patan Hospital.Materials &amp; Methods: There were 35 cases which were all fixed with titanium flexible intramedullary nail under image intensifier at the Patan hospital from January 2013 and December 2015. Patients were evaluated in follow-ups to observe the alignment of fracture, infection, delayed union, nonunion, limb length discrepancy, implant failure, range of movement of hip and knee joints, and time to unite the fracture. The final results were evaluated using criteria of titanium elastic nail (TEN) outcome score described by Flynn et al.Results: The mean age of the patients was 8.51 years. Among 35 patients (22 boys and 13 girls), there were 19 mid-shaft fractures, nine proximal third fractures and seven distal third fractures. Fracture patterns were transverse (22), oblique (10), spiral (2), and comminuted (2). The mean time for fracture union was 8.17 weeks radiologically whereas 9.83 weeks clinically. According to TEN outcome score, excellent and good results were in 28 cases (80%) and seven cases (20%) respectively.Conclusion: Flexible titanium nailing is a safe and satisfactory treatment for diaphyseal femoral fractures in children, because it provides rapid recovery, short rehabilitation and immobilization as well as very high union rate with few complications.

Pediatric humeral fracture fixed by a single retrograde titanium elastic nail

Introduction: Almost all pediatric humerus fractures are well managed with conservative treatment with higher percentage of union rate. However there are certain conditions where surgical intervention will be inevitable like humerus fracture associated with polytrauma compound fractures, those with head and unacceptable alignment. It is not only the stable fixation but also the alignment which is important and can be maintained even by a single pre-bent elastic or flexible intramedullary nailing. Methods: This was a retrospective study of 28 pediatric humeral fractures fixed with a single retrograde titanium elastic nail from 2012 to 2016. Time to unite the fracture along with other complications was noted. The functional outcomes were assessed according to Broberg and Morrey for elbow function and Disabilities of the Arm, Shoulder and Hand (DASH) score for shoulder function. Results: Average age of patients was 8.85 1.84 (range 6 to 12 years). Time to unite the fracture was 8.28 2.43 weeks (range 6 to 12 weeks). There were 1 case of malunion around 10 degrees, 1 case of nail migration, one case of superficial infection at the site of nail entry, one case of transient radial nerve palsy and one case of nail protrusion in our study. There were 24 (85.71%) cases of excellent and 4 (14.29%) cases of good results according to Broberg and Morrey functional scores. Conclusion: Fixation of pediatric humerus fractures with a single flexible nail reduces operative time, radiation exposure, cost of treatment, chances of iatrogenic supracondylar fracture and ulnar nerve injury without compromising the final outcomes.

Management of displaced midshaft clavicle fractures in adolescent patients using intramedullary flexible nails: A case series

IntroductionClavicle fractures are common injuries in adolescent patients. In this study we present our technique and results for treating non-comminuted displaced midshaft clavicle fractures using flexible intra medullary nails. MethodsA retrospective review of prospectively collected data using the electronic medical record was performed. Adolescent patients presenting to a level one pediatric trauma center with acute displaced non comminuted clavicular shaft fractures who were treated with intra medullary flexible nails were included in this study. ResultsSeven adolescent patients with non-comminuted displaced mid shaft clavicle fractures were treated with flexible nails over a period of five and half years with an average follow up time of 10 months. The average age was 14.6 years (range 14–16), and a 2mm nail was used in all cases. Closed reduction was obtained in five cases with only two cases needing open reduction to pass the nail. One patient had skin breakdown over the nail entry and had the nail removed in clinic two months after surgery, all other patients healed with no complication. Sports and full shoulder activity were allowed when radiographic healing was seen at an average 8 weeks. Implant removal was performed four of the seven patients. ConclusionFlexible intramedullary nailing is an effective minimally invasive method for the treatment of displaced midshaft clavicle fractures in the adolescent population. The surgeon should be aware that a 2mm nail is likely the optimal diameter, and the nail is difficult to pass beyond the lateral 2–3cm of the distal segment due to canal narrowing, but passage further than this is not necessary to achieve stability and union. Following these pearls will allow the surgeon to successfully perform the procedure.

Single incision pediatric flexible intramedullary tibial nailing

BackgroundThere has been a trend towards flexible intramedullary nailing for unstable tibial shaft fractures in the pediatric population, traditionally, utilizing a 2-incision technique with passage of one nail medially and one nail laterally. Our study aims to compare a single incision approach for flexible nailing of unstable tibial shaft fractures in pediatric patients to the traditional 2-incision approach. MethodsPatients were selected for operative fixation if they had a length unstable tibial shaft fracture confirmed by fluoroscopy. Exclusion criteria included length stable tibial fractures that could undergo nonoperative treatment. Single incision technique utilized the medial incision only. Patients were monitored in the hospital for one postoperative day and followed up at 4 week, 8 week, and 12 week marks. Radiographic analysis was performed to evaluate for malunion or nonunion. Operative times, infection rates and complications were recorded and analyzed. ResultsAll patients achieved complete fracture healing at the 12-week follow up. There were no delayed unions, nonunions or malunions in either treatment group. ConclusionsSingle medial incision for tibial flexible nails had equivalent outcomes with no difference in primary healing rate, malunion or nonunion rate when compared to the dual incision technique.