What is titanium elastic nail?

Elastically stabilized intramedullary nails (ESINs) are a common method for surgical stabilization of long bone fractures in children. It is widely used to treat unstable fractures of the radius, ulna, femur, and occasionally the tibia and humerus. It is also used to treat pathological fractures of long bones in children. ESIN provides closed fracture fixation without opening the fracture site, three-point stability, and preservation of length and rotation in transverse, short oblique fractures. As a load-sharing implant, it allows early movement of the limb. Typically, elastically stable intramedullary nails are removed after fracture healing.

Femoral fractures

The indications of ESIN in femoral fractures are: age between 4 and 14 years and femoral fractures within multiple trauma .

The patient is positioned on the orthopedic traction table, and the size of the boot is adapted to the size of the child’s leg. The fluoroscope is required for obtaining antero-posterior (AP) and latero-lateral (LL) views of the affected thigh and is placed so as to allow the visualization of the femur from hip to knee level. The obtaining of reduction is checked in both the AP and LL views, and rotation is also verified .

Choice of the nails The nail diameter should observe the general rule for choosing the nails. The following classification may be used as an alternative variant, which is correlated with the child’s age:

- 6–8 years: 3 mm diameter;

- 9–11 years: 3.5 mm diameter;

- 12–14 years: 4 mm diameter.

The length of the nails is equal to the distance from the distal growth cartilage to the greater trochanter growth cartilage .

Diaphyseal fractures

The proximal and middle third In the case of diaphyseal fractures in the proximal and middle third, the C-shaped approach, with the nails inserted retrograde through the distal metaphysis, is chosen. In the case of proximal fractures, the proximal tip of the nails is bent, while for mid-diaphyseal fractures, the middle of the nail is curved. At the end of the operation, in the case of transverse fractures, the fragments are impacted in order to avoid residual distraction, which can be responsible for the unequal length of the lower limbs. In the case of oblique or comminuted fractures, the distal tip is bent and impacted into the bone to avoid the telescoping of the fragments and the migration of the nails.

The natural tendency of these fractures is to induce a 5–10 mm shortening immediately postoperatively, which will be compensated by the stimulation of growth during the consolidation of the fracture .

Tibial fractures

Positioning and preparation of the patient The patient is positioned on the orthopedic table in order to facilitate reduction. The presence of the fluoroscope is mandatory for intraoperative control. The operative field must include the knee .

Insertion of the nails 

The elastic nails are always inserted antegrade into the proximal metaphysis, at antero-lateral and anteromedial locations .

The nail diameter varies between 2.5 and 4 mm, depending on the patient’s age. The use of the hammer for advancing the nails is allowed but should be used with caution.

The quality of the reduction is ensured by the nail diameter and the degree of bending.

The nails should not be impacted into the cancellous bone of the distal metaphysis before reduction is perfect; otherwise, correction procedures may destabilize osteosynthesis.

Before impaction, the rotation of fragments is checked and, in the case of the presence of residual varus deformity, this is corrected by the excessive bending of a nail. At the end of the operation, traction is relaxed and the fragments are impacted.

In the case of comminuted fractures, the proximal tips of the nails that are left outside the bone are bent at 90° and impacted into the cortical bone to prevent the telescoping of fragments.

Humeral fractures

The indications of ESIN in humeral fractures vary depending on the fracture site: the proximal metaphysis or the diaphysis. In the fractures of the surgical neck of the humerus, ESIN is indicated because it reduces the period of immobilization required in the case of conservative treatment .

In the case of diaphyseal fractures, the use of elastic nails is indicated regardless the presence radial nerve lesions.

Insertion of the nails The nails are inserted using the retrograde method. The insertion points are found on the lateral margin of the supracondylar area, having a postero-lateral direction and proximal inclination . The entry points are prepared using a drill because the cortical bone in this area is very hard. The diameter of the nails varies between 2.5 and 3.5 mm, and they are bent identically. The nails are inserted by vertical manual pressure and rotating movements. If the fracture in the proximal metaphyseal area cannot be adequately reduced, the 1800 rotation of the nails facilitates this reduction. If, however, reduction is impossible, a Kirschner guide-wire is placed in the proximal fragment before open reduction. In the case of oblique diaphyseal fractures, it is important to avoid the nails leaving the medullary canal and migrating posteriorly into the radial nerve sulcus. After both nails have crossed the fracture site, they are impacted into the cancellous bone of the proximal metaphysis.

Forearm fractures

Orthopedic treatment in forearm fractures is accepted, but the allowed limits of spontaneously remodeled angulation are well known. If these limits are exceeded or in the case of orthopedic treatment failure, closed reduction and ESIN are indicated in forearm fractures .

Operative technique The patient is positioned in dorsal decubitus, with the affected forearm on the radiotransparent table.

The diameter of the nails used varies between 2.5 and 3 mm. The ulnar nail is almost straight, while the radial nail has a marked bending in order to restore the pronatory curve of the radius.

Fixation usually starts with the bone that is easier to reduce. For the radius, the entry point is found in the distal metaphysis, above the distal growth cartilage, between the tendons of the long and short extensors of the thumb. The cortical bone is exposed through a small incision and a hole is drilled, which is enlarged by circular movements. The nail is inserted into the medullary canal up to the fracture site. Fracture reduction is performed and the nail is advanced into the proximal fragment under fluoroscopic control .

A similar procedure is carried out for the ulna, using the antegrade technique, with the entry point on the medial margin of the olecranon.

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