Elastic stable intramedullary nailing (ESIN) for pediatric fracture management has gained increasing popularity since its introduction in the late 1970s. Relatively few modifications have been made to the original technique in the last forty years, which illustrates the sound biomechanical principles and simplicity of the technique. Jean-Paul Metaizeau, the originator of the technique, pointed out that poor results after ESIN were typically due to incorrect constructs, incorrect indications, and insufficient surgeon training1. The initial (1977 to 1980) indications for ESIN were limited to pediatric patients with multiple injuries or head trauma in whom cast or traction treatment was not practical. Later, its use was extended to all diaphyseal fractures of long bones in children. With widespread acceptance, the indications have been further expanded to metaphyseal fractures, comminuted fractures, pathologic fractures, and fractures of smaller bones (including clavicular, supracondylar humeral, and metacarpal fractures). ESIN was introduced in the United States in 19972. The literature is replete with reports of the clinical success of ESIN, but reports related to its complications are scarce. The aim of this manuscript was to review the common complications related to ESIN and provide technical pearls to manage and avoid complications.
The principle of ESIN involves balanced nailing (i.e., use of two flexible nails of the same diameter to provide elasticity and stability in opposite directions at the fracture site). This principle is different from the principle of the Ender nail, which is based on maximal filling of the medullary canal3. To achieve balanced nailing when two nails are used, the apex of curvature of each nail should be at the fracture site. To achieve this, both nails should have the curvature of the letter “C” if they are inserted from opposite sides of the bone, or one nail should have the curvature of the letter “C” and the other should have the curvature of the letter “S” if they are inserted from the same side (Fig. 1)4. When two nails are used, each should be 40% of the narrowest diameter of the canal1,5,6. When a single nail is used, the nail should be two-thirds of the narrowest canal diameter.
ESIN was used in 573 pediatric patients (175 female and 398 male) at our institution between 2005 and 2011. It was used for 223 fractures of the femur, 240 fractures of the radius and ulna, eighty-seven fractures of the tibia, and twenty-three fractures of the humerus. The mean age (and standard deviation) was 8.1 ± 2.9 years (range, two to sixteen years) for ESIN of the femur, 11 ± 2.9 years (range, four to seventeen years) for ESIN of the radius and ulna, 12.1 ± 2.3 years (range, four to sixteen years) for ESIN of the tibia, and 12.8 ± 3.9 years (range, six to seventeen years) for ESIN of the humerus. Our previous experience (1997 to 2005) related to ESIN of the femur and tibia has been reported7,8. All patients were followed until fracture union. On the basis of a review of the literature and our experience, we provide recommendations to avoid and manage complications of ESIN.
The most commonly reported complication related to ESIN involves nail prominence and irritation at the nail entry site. Nail prominence can lead to more serious complications such as skin breakdown, superficial or deep infection, effusion at the adjacent joint and stiffness due to soft-tissue irritation, bursitis, reoperation to perform nail trimming or nail advancement, and early implant removal with the subsequent risk of refracture. The worst complication is osteomyelitis, which can extend to the diaphysis1. The prevalence of nail irritation has been reported to be 3% to 52%, with the femur being the most commonly affected site (Table I). The earlier recommendations by the originators of the ESIN technique to bend the nail ends or leave them prominent for easy removal have been modified.
For femoral ESIN, Luhmann et al.9 recommended that ≤25 mm of the nail end should protrude from the cortex, and Narayanan et al.10 recommended that unbent nail ends should lie closely opposed to the metaphyseal flare. For tibial ESIN, Sankar et al.11 recommended that ≤1.5 cm of the nail should be outside the bone, the nail should lie parallel to the proximal tibial metaphysis, and there should be no bend to the portion of the nail outside the cortex. Postoperative immobilization of the knee joint has been recommended to prevent soft tissues from rubbing over the nail ends11,12, although we agree with Luhmann et al.9 that irritation by the nail tip is not associated with early knee motion.
Recommendation
Leave approximately 1 to 2 cm of the nail outside the medullary canal, with the nail ends flush with and parallel to the metaphysis (Fig. 2). Typically, the nail should end at approximately the level of the physis. The nail should not be bent at the end. Modified nail cutters prevent oblique nail cuts and sharp edges. Nail removal can be easily performed with the help of needle-nose pliers. Possible treatments for prominent nails include early removal, trimming of the nail end, advancement of the nail, exchange nailing, or observation.
Inability to achieve reduction of the fracture or loss of reduction after ESIN can lead to fracture malunion. Angular malunion and limb-length discrepancy are relatively common, whereas rotational malunion is uncommon13. The reported rate of angular malunion after femoral ESIN varies from 0%12 to 16%14, whereas the rate after tibial ESIN varies from 0%15 to 21%8 (Table II). After femoral ESIN, minor (<1 cm) overgrowth is more common than shortening, especially in children less than ten years of age12,14,16. The various factors implicated in malunion are age and body weight, fracture pattern, and nail size and material.
For femoral fractures, it is recommended that ESIN should not be used in older, heavier patients. Moroz et al.17 reported an age of more than eleven years to be a predictor of poor outcome, whereas Ho et al.14 reported an increased complication rate in children over ten years of age. An upper weight limit of 4917 or 5018 kg has been recommended by some authors. Others have found no direct correlation between excessive body weight and malunion7,9. Luhmann et al.9, however, concluded that a combination of increased body weight and smaller nail diameter would lead to increased sagittal angulation postoperatively9. Sagan et al. recommended that at least one nail be inserted with its tip directed anteriorly to prevent procurvatum, which is the most common sagittal-plane malunion19.
Ideally, ESIN should be used for length-stable (transverse or short oblique) fractures6,20. Narayanan et al.10 reported more complications, including malunion, when elastic nails were used in fractures with fragmentation of >25% of the shaft diameter. Similarly, Ho et al.14 reported a 12% rate of unplanned revision surgery after treatment of unstable fracture patterns compared with 5% for stable fractures. However, other studies have shown no association between fracture pattern and malunion7,9. Moroz et al.17 reported an 18% malunion rate of fractures of the distal third of the femur compared with 9% in both the midshaft and the proximal part of the femur.
The biomechanical principles of ESIN should be followed to prevent malunion. Mismatched nail size10, inappropriate nail size6,9,21, and nail material7,22 have all been implicated as causes of femoral malunion. We recommend use of stainless steel elastic nails for lower-extremity long-bone fractures, especially in older, heavier patients or patients with a length-unstable fracture. If titanium nails are used, their diameter must be larger than the corresponding stainless steel nails23.
Although malunion is uncommon in tibial fractures24, Goodwin et al.25 reported on two patients with angular deformity of ≥10°. Tibial ESIN is technically challenging because of the eccentric location of the tibia in the leg musculature and its triangular cross section, which makes it prone to recurvatum deformity since the nails are aligned with their convexity and tension directed in a posterior direction1,26. In such instances, the nail tips should be pointing in a posterior direction to counteract the recurvatum force. For isolated tibial fractures, Lascombes et al.27 recommended that the nail tip be in a valgus orientation to counteract the varus force of an intact fibula. A body weight of >49 kg does not appear to be an important predictor of malunion in tibial fractures11.
Malunion after ESIN of forearm fractures in children is uncommon. A number of studies have reported minor (<15°) loss of forearm rotation after ESIN, without radiographic evidence of malunion27-29. Loss of the normal radial bow because of insufficient fracture reduction or insufficient prebending of the radial nail can cause loss of forearm rotation. To maintain the interosseous space, the tips of both the ulnar and radial nails should be facing each other and toward the interosseous space.
The rate of clinically important malunion requiring a repeat reduction or other procedure has been low after ESIN12,17. Adjunctive postoperative support, such as a brace or cast, is recommended for unstable fractures9,14,17. If loss of reduction and angular deformity are recognized early in the postoperative period, before fracture-healing, the principle of balanced nailing can be exploited by removal of the nail responsible for the deformity (Fig. 3). Sankar et al.11 reported on two patients with angular deformity after tibial ESIN who were treated with closed reduction with the nails retained. After the fracture heals, a corrective osteotomy may be required for a symptomatic malunion if remodeling of the deformity is not expected with growth (Fig. 4). If collapse at the fracture site resulting in shortening is recognized early in the postoperative period, it can be managed with a cast, traction, exchange nailing with larger nails, external fixation, or plate fixation (Fig. 5). Since limb-length discrepancy can improve with growth, it is recommended that any limb equalization procedure be delayed16. Ligier et al.12 reported on two patients with >2 cm of lengthening who were treated with distal femoral epiphysiodesis. Malunion of the radius and ulna with substantial loss of forearm rotation and functional deficits should be treated with an osteotomy, realignment, and plate fixation.
Recommendation
For the femur, we routinely use ESIN for length-unstable fractures, fractures in older and heavier children, and proximal (subtrochanteric) or distal (metaphyseal) fractures. We prefer stainless steel nails, postoperative immobilization, and a delay in weight-bearing until early callus is seen on radiographs.
For forearm fractures, we verify full supination and pronation at the end of the procedure and then immobilize the upper extremity for three to four weeks. For malunited fractures, we recommend observation if more than two years of growth is remaining and remodeling is expected4. In rare cases of symptomatic malunion, osteotomy should be performed.
Another complication associated with ESIN of forearm shaft fractures is extensor tendon injury, usually involving the extensor pollicis longus tendon. This complication is related to the entry site selection, specifically the choice between the floor of the first dorsal compartment and the so-called bare area between the second and third dorsal compartments; the latter choice places the extensor pollicis longus tendon at greater risk because of its proximity. This complication is not unique to ESIN, as it has also been reported in the setting of closed distal radial fractures and after closed reduction and Kirschner wire fixation remote to the extensor pollicis longus30,31. However, a steadily increasing number of extensor pollicis longus tendon injuries have been reported since the initial report by Ponet and Jawish in 198932.
Cullen et al.33 used a dorsal entry point to the radius, in the region of the Lister tubercle, in eleven patients and reported that one twelve-year-old girl sustained “extensor pollicis longus tendon entrapment.” Other authors have documented the same phenomenon in both acute and delayed scenarios30,34-38. Schmittenbecher39 reported six cases of extensor tendon injury after dorsal-entry nailing of the radius in 143 patients. Cumming et al.40 criticized the dorsal entry point to the radius as being implicated in extensor pollicis longus tendon rupture requiring surgical repair and stated, “All our complications occurred by insertion through either a dorsal approach or through a stab incision.”40 We have had three cases of extensor pollicis longus tendon rupture after a dorsal approach, and we treated these with tendon transfer. We have also had one case of a partial tear of extensor carpi radialis brevis, which we treated conservatively. If a dorsal approach is desired, then the nail should be bent and cut so that its tip remains outside the extensor compartment and just below the skin5,39. Avoiding positioning the nail flush to the distal surface of the radius should prevent the extensor tendons from rubbing against the sharp nail tip (Fig. 6).
The radial approach to the distal aspect of the radius, although safer, has also been associated with complications. Injury to the superficial branch of the radial nerve has been reported with a radially located entry site27. Fernandez et al.41 reported on fifteen patients with superficial radial nerve deficit (eight following radial nail insertion and seven following radial nail removal). The hypoesthesia resolved in thirteen cases and diminished but persisted in the other two cases. An injury to the radial artery at the wrist has been reported after inadvertent use of an awl during the radial approach1.
The relatively high-amplitude extensor pollicis longus (third dorsal compartment tendon) appears to be at substantially higher risk than the relatively low-amplitude first and second dorsal compartment tendons; thus, an entry point closer to the first dorsal compartment would appear to be desirable during a radial approach to the radius. Both the originators of ESIN and long-term users recommend that an entry point near the first dorsal compartment be used in such an approach1,42.
Recommendation
For a radial entry to the radius, a 2-cm longitudinal incision should be made over the first dorsal compartment of the wrist, followed by blunt dissection and retraction of the superficial radial nerve and tendons dorsally. The awl should be directed from a volar-radial to a dorsal-ulnar direction. Percutaneous insertion of nails through this entry site is not recommended. We have encountered occasional transient neurapraxia of the superficial radial nerve without permanent deficit.
Delayed union (no callus at twelve weeks) and nonunion (no osseous healing at six months) are uncommon after ESIN of long bones in children. However, a severe, direct injury to the tibia in an adolescent could result in delayed union or nonunion, even if ESIN is used (Fig. 7). If the fibula is intact or heals quickly, ESIN of the tibia could result in slight distraction at the fracture site and resultant hypertrophic nonunion26,27, which can be treated with either a 1-cm fibular resection or rigid intramedullary tibial nailing. Infection after ESIN of an open tibial fracture can lead to delayed union or nonunion. Srivastava et al.8 reported five delayed unions and two nonunions in a series of sixteen children with open tibial shaft fractures treated with ESIN.
Delayed union and nonunion after ESIN of forearm fractures have been reported at a rate of 0% to 4%27,41,43-45. They most commonly occur in the mid-diaphysis of the ulna, although they have been reported in the radius as well45. They are almost always associated with open fractures or with the need for open reduction at the time of surgery41,43. In the largest series of 553 forearm fractures treated with ESIN, Fernandez et al.43 reported that fourteen children had delayed union and seven children had ulnar nonunion. Ogonda et al.46 hypothesized that antegrade nailing of the ulna causes distraction at the fracture as the rigid curved tip of the nail is forced through the narrow distal end of the ulna. Wright and Glowczewskie47 described a watershed zone in the mid-diaphysis of the ulna that is of importance when the periosteal blood flow is disrupted following an open fracture or open reduction. The delayed union may take over a year to fully consolidate45. Treatment of a nonunion is indicated for persistent pain or deformity and frequently involves removal of the elastic nail and plate fixation or exchange nailing with or without bone-grafting.
For femoral fractures, Ho et al.14 reported on two patients with nonunion after ESIN. One patient was treated with open reduction and internal fixation with bone-grafting, and the other was treated with a retrograde intramedullary nail. Similarly, Luhmann et al.9 reported one case of hypertrophic nonunion of a closed femoral fracture after ESIN with two 2-mm nails; revision at six months involved exchange nailing using two 3.5-mm nails. The authors cited inadequate stabilization by thin nails as the cause of the nonunion.
Recommendation
Since tibial and ulnar fractures are more prone to delayed union or nonunion, every possible attempt should be made to treat these fractures in a closed manner and preserve the vascularity of the bone ends. For the ulna, a relatively straight nail is used. If the optimal size is between two available nail sizes, the smaller size should be chosen to prevent distraction at the fracture site. Forceful impaction of the nail can cause iatrogenic comminution, physeal injury (Fig. 8), or incarceration of the nail in the diaphysis. We recommend postoperative immobilization until callus is seen on radiographs. For delayed union, a bone stimulator can be used. For nonunion, we recommend protecting the fracture using adjunctive support and waiting for at least a year before surgical treatment of the nonunion is considered.
The need for routine removal of elastic nails after fracture-healing in children is controversial. Common reasons cited to support routine removal include avoidance of (1) difficulty in performing future orthopaedic procedures, (2) difficulty in obtaining good-quality images, (3) bone weakness and fracture associated with stress-shielding and stress risers (Fig. 9), and (4) nail irritation or prominence1,48,49. The arguments against their removal include (1) difficulty in removal; (2) the time and cost of removal; (3) the need for a second operation; and (4) potential complications during the removal procedure, including incomplete removal, fracture, and infection48,49. In one series50, seven (7%) of ninety-six patients who underwent removal of elastic nails had complications, including two patients with refracture, two with pain, two with superficial infection, and one with wound dehiscence.
Lascombes et al.27 recommended removal of nails at three to four months after fracture fixation of all long bones except those in the forearm. In their series of eighty-five forearm fractures treated with ESIN, the nails were removed at 4.25 months after the initial surgery in the first fifty patients, but because three cases of refracture occurred, they recommended nail removal between ten months and one year after the initial surgery. Similarly, Gorter et al.50 reported forearm refractures in patients who had elastic nails removed between two and four months after injury. Fernandez et al.41 reported on fourteen patients who sustained refractures with the nail in place and an additional thirteen patients who sustained refractures after nail removal at between six and eight months; the overall refracture rate was 5% (twenty-seven of 553). In addition to preventing refracture, retention of the intramedullary nail in cases of delayed union or nonunion would help to stabilize the fracture until healing has been completed or definitive treatment has been performed4.
Refracture after ESIN of other bones occurs at a similarly low rate10,51. The treatment of refracture with nails in situ is controversial. Closed reduction has been performed with the elastic nails in place by rebending the nail39,52, but subsequent biomechanical studies have shown that this significantly weakens the nail52, and a case report has illustrated that rebending can lead to nail breakage53. Other treatment options include exchange nailing or open reduction and internal fixation.
Recommendation
Nails should be removed only after circumferential callus and complete obliteration of fracture line are confirmed on radiographs. After removal of nails from the forearm, we recommend continued protection with a cast or brace for six to eight weeks. When permanent implantation of elastic nails is desired (as in neuromuscular diseases, osteogenesis imperfecta, or pathologic fractures), the nail ends are cut short and the nails are recessed into the bone. Continued patient growth may necessitate an exchange nailing procedure if the nail migrates away from the physis and protrudes from the diaphysis, causing implant-related problems.
Yuan et al.54 noted an increased risk of compartment syndrome after ESIN of pediatric forearm fractures. The authors noted that patients with longer operative times and greater use of fluoroscopy were at higher risk of developing compartment syndrome, likely because multiple attempts at fracture reduction and multiple passes with the nails caused increased soft-tissue injury. If compartment syndrome is diagnosed after conservative management, then ESIN at the time of fasciotomy assists with fracture stabilization and wound management25. If compartment syndrome is diagnosed after ESIN, the nails should protect against fracture displacement during and after fasciotomy1. In addition to forearm fractures, compartment syndrome has been reported after treatment of femoral and tibial fractures with ESIN6,11.
Recommendation
Excessive manipulation of the fracture site should be avoided. We follow the “ten-minute rule.” If we are unable to navigate the nails across the fracture site in ten minutes, open reduction is considered4. If open reduction is performed for forearm and tibial fractures, a prophylactic fasciotomy is performed. Postoperatively, we recommend routine hospital admission and vigilant monitoring after ESIN in children. The patients are discharged to home only after pain is adequately controlled.
Improper surgical technique, including forceful nail insertion or difficult fracture reduction, can cause iatrogenic comminution at the fracture site, leading to fracture instability that requires an intraoperative change in the treatment plan (Fig. 10). Luhmann et al.9 reported fracture comminution during nail insertion in a patient with a distal femoral fracture; the nails had to be removed during surgery, and plate stabilization was performed. Stainless steel nails have been implicated in causing iatrogenic comminution more often than titanium nails because of the greater inherent rigidity1. Schmittenbecher et al.55 reported on six patients with iatrogenic comminution at the fracture site, with the comminution occurring during antegrade nailing of the radius in four of the six cases.
During retrograde femoral ESIN, the nail tip can perforate the calcar posteriorly because of procurvatum of the femoral shaft and anteversion of the femoral neck26,55. Such perforation of the cortex and protrusion of the nail can make the construct unstable. Narayanan et al.10 reported one case of delayed sciatic neurapraxia secondary to nail protrusion through the femoral neck. The nail tip can also perforate the cortex opposite the nail entry site (Fig. 11). Insufficient curvature or forcible nail insertion is frequently the cause of such perforation. Rathjen et al.22 reported splintering at the nail entry site during femoral nail insertion in thirty of eighty-one patients, but none needed additional treatment. Another form of technical error is the failure to catch the proximal or distal fragment during nail insertion26,41; this can be avoided by use of orthogonal fluoroscopic views (Fig. 12).
Recommendation
During nail contouring, we recommend an increased bend at the tip of the nail to help it slide around the opposite cortex without perforation and through the fracture site. If the nail does not advance, it should be withdrawn, rotated, and reinserted. If it still does not advance, then a smaller-sized nail should be selected. Iatrogenic fracture comminution is frequently caused by the nail tip. Thus, the nail should be rotated to keep the tip pointing away from the long bone spikes. For comminuted or subtrochanteric fractures, the nails should be inserted into the femoral neck. When a nail is advanced into the femoral neck, it should be rotated anteriorly to account for femoral anteversion, and lateral fluoroscopic imaging should be performed to assess its final position.
ESIN is a reliable stabilization method for long-bone fractures in children, provided that the important biomechanical principles of ESIN are respected. These principles are more important in older and heavier children, especially in the case of fractures in weight-bearing bones. ESIN is predominantly used for stabilization of diaphyseal femoral fractures and unstable radial and ulnar fractures in children. It is less commonly used for diaphyseal tibial and humeral fractures. When indications for ESIN are expanded, modifications of the existing technique and strict vigilance are required. Patients and their families must be adequately counseled preoperatively about potential complications related to ESIN.
Note: The authors thank Mary Pam Pfiester, PA, and Emily Eismann, MS, for their assistance with the development of this manuscript.
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 Jan-Feb;21(
1):4-8.[CrossRef]
Ender
HG. [Treatment of per- and subtrochanteric fractures in old age using elastic nails]. Hefte Unfallheilkd.
1975;(
121):67-71. .
Parikh
SN;
Wells
L;
Mehlman
CT;
Scherl
SA. Management of fractures in adolescents. J Bone Joint Surg Am.
2010 Dec 15;92(
18):2947-58.
Dietz
HG;
Schmittenbecher
PP;
Slongo
T;
Wilkins
KE, ; 2006.
Sink
EL;
Gralla
J;
Repine
M. Complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types. J Pediatr Orthop.
2005 Sep-Oct;25(
5):577-80.[CrossRef]
Wall
EJ;
Jain
V;
Vora
V;
Mehlman
CT;
Crawford
AH. Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures. J Bone Joint Surg Am.
2008 Jun;90(
6):1305-13.[CrossRef]
Srivastava
AK;
Mehlman
CT;
Wall
EJ;
Do
TT. Elastic stable intramedullary nailing of tibial shaft fractures in children. J Pediatr Orthop.
2008 Mar;28(
2):152-8.[CrossRef]
Luhmann
SJ;
Schootman
M;
Schoenecker
PL;
Dobbs
MB;
Gordon
JE. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop.
2003 Jul-Aug;23(
4):443-7.
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 Jul-Aug;24(
4):363-9.[CrossRef]
Sankar
WN;
Jones
KJ;
David Horn
B;
Wells
L. Titanium elastic nails for pediatric tibial shaft fractures. J Child Orthop.
2007 Nov;1(
5):281-6. .[CrossRef]
Ligier
JN;
Metaizeau
JP;
Prévot
J;
Lascombes
P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br.
1988 Jan;70(
1):74-7.
Houshian
S;
Gøthgen
CB;
Pedersen
NW;
Harving
S. Femoral shaft fractures in children: elastic stable intramedullary nailing in 31 cases. Acta Orthop Scand.
2004 Jun;75(
3):249-51.[CrossRef]
Ho
CA;
Skaggs
DL;
Tang
CW;
Kay
RM. Use of flexible intramedullary nails in pediatric femur fractures. J Pediatr Orthop.
2006 Jul-Aug;26(
4):497-504.[CrossRef]
Gordon
JE;
Gregush
RV;
Schoenecker
PL;
Dobbs
MB;
Luhmann
SJ. Complications after titanium elastic nailing of pediatric tibial fractures. J Pediatr Orthop.
2007 Jun;27(
4):442-6.[CrossRef]
Gogi
N;
Khan
SA;
Varshney
MK. Limb length discrepancy following titanium elastic nailing in paediatric femoral shaft fractures. Acta Orthop Belg.
2006 Apr;72(
2):154-8.
Moroz
LA;
Launay
F;
Kocher
MS;
Newton
PO;
Frick
SL;
Sponseller
PD;
Flynn
JM. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br.
2006 Oct;88(
10):1361-6.
Weiss
JM;
Choi
P;
Ghatan
C;
Skaggs
DL;
Kay
RM. Complications with flexible nailing of femur fractures more than double with child obesity and weight >50 kg. J Child Orthop.
2009 Feb;3(
1):53-8. .[CrossRef]
Sagan
ML;
Datta
JC;
Olney
BW;
Lansford
TJ;
McIff
TE. Residual deformity after treatment of pediatric femur fractures with flexible titanium nails. J Pediatr Orthop.
2010 Oct-Nov;30(
7):638-43.[CrossRef]
Sink
EL;
Faro
F;
Polousky
J;
Flynn
K;
Gralla
J. Decreased complications of pediatric femur fractures with a change in management. J Pediatr Orthop.
2010 Oct-Nov;30(
7):633-7.[CrossRef]
Flynn
JM;
Luedtke
L;
Ganley
TJ;
Pill
SG. Titanium elastic nails for pediatric femur fractures: lessons from the learning curve. Am J Orthop (Belle Mead NJ).
2002 Feb;31(
2):71-4.
Rathjen
KE;
Riccio
AI;
De La Garza
D. Stainless steel flexible intramedullary fixation of unstable femoral shaft fractures in children. J Pediatr Orthop.
2007 Jun;27(
4):432-41.[CrossRef]
Metaizeau
JP. Stable elastic intramedullary nailing for fractures of the femur in children. J Bone Joint Surg Br.
2004 Sep;86(
7):954-7.[CrossRef]
O’Brien
T;
Weisman
DS;
Ronchetti
P;
Piller
CP;
Maloney
M. Flexible titanium nailing for the treatment of the unstable pediatric tibial fracture. J Pediatr Orthop.
2004 Nov-Dec;24(
6):601-9.[CrossRef]
Goodwin
RC;
Gaynor
T;
Mahar
A;
Oka
R;
Lalonde
FD. Intramedullary flexible nail fixation of unstable pediatric tibial diaphyseal fractures. J Pediatr Orthop.
2005 Sep-Oct;25(
5):570-6.[CrossRef]
Slongo
TF. Complications and failures of the ESIN technique. Injury.
2005 Feb;36
Suppl 1:A78-85.[CrossRef]
Lascombes
P;
Prevot
J;
Ligier
JN;
Metaizeau
JP;
Poncelet
T. Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases. J Pediatr Orthop.
1990 Mar-Apr;10(
2):167-71.
Garg
NK;
Ballal
MS;
Malek
IA;
Webster
RA;
Bruce
CE. Use of elastic stable intramedullary nailing for treating unstable forearm fractures in children. J Trauma.
2008 Jul;65(
1):109-15.[CrossRef]
Kanellopoulos
AD;
Yiannakopoulos
CK;
Soucacos
PN. Flexible intramedullary nailing of pediatric unstable forearm fractures. Am J Orthop (Belle Mead NJ).
2005 Sep;34(
9):420-4.
Kay
RM;
Khounganian
GS;
Stevanovic
M. Late extensor pollicis longus rupture following displaced distal radius and ulna fractures in a child. J Orthop Trauma.
2004 Jan;18(
1):53-6.[CrossRef]
Hirasawa
Y;
Katsumi
Y;
Akiyoshi
T;
Tamai
K;
Tokioka
T. Clinical and microangiographic studies on rupture of the E.P.L. tendon after distal radial fractures. J Hand Surg Br.
1990 Feb;15(
1):51-7.[CrossRef]
Ponet
M;
Jawish
R. [Stable flexible nailing of fractures of both bones of the forearm in children]. Chir Pediatr.
1989;30(
2):117-20. .[PubMed]
Cullen
MC;
Roy
DR;
Giza
E;
Crawford
AH. Complications of intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop.
1998 Jan-Feb;18(
1):14-21.
Kravel
T;
Sher-Lurie
N;
Ganel
A. Extensor pollicis longus rupture after fixation of radius and ulna fracture with titanium elastic nail (TEN) in a Child: a case report. J Trauma.
2007 Nov;63(
5):1169-70.[CrossRef]
Griffet
J;
el Hayek
T;
Baby
M. Intramedullary nailing of forearm fractures in children. J Pediatr Orthop B.
1999 Apr;8(
2):88-9.
Pugh
DM;
Galpin
RD;
Carey
TP. Intramedullary Steinmann pin fixation of forearm fractures in children. Long-term results. Clin Orthop Relat Res.
2000 Jul;(
376):39-48.
Stahl
S;
Calif
E;
Eidelman
M. Delayed rupture of the extensor pollicis longus tendon following intramedullary nailing of a radial fracture in a child. J Hand Surg Eur Vol.
2007 Feb;32(
1):67-8. .[CrossRef]
Sproule
JA;
Roche
SJ;
Murthy
EG. Attritional rupture of extensor pollicis longus: a rare complication following elastic stable intramedullary nailing of a paediatric radial fracture. Hand Surg.
2011;16(
1):69-72.[CrossRef][PubMed]
Schmittenbecher
PP. State-of-the-art treatment of forearm shaft fractures. Injury.
2005 Feb;36
Suppl 1:A25-34.[CrossRef]
Cumming
D;
Mfula
N;
Jones
JW. Paediatric forearm fractures: the increasing use of elastic stable intra-medullary nails. Int Orthop.
2008 Jun;32(
3):421-3. .[CrossRef]
Fernandez
FF;
Langendörfer
M;
Wirth
T;
Eberhardt
O. Failures and complications in intramedullary nailing of children’s forearm fractures. J Child Orthop.
2010 Apr;4(
2):159-67. .[CrossRef]
Mehlman
CT. Intramedullary fixation of forearm shaft fractures. : Wiesel
SW, . Operative techniques in orthopaedic surgery. Philadelphia: Lippincott Williams & Wilkins; 2010. p 1026-34.
Fernandez
FF;
Eberhardt
O;
Langendörfer
M;
Wirth
T. Nonunion of forearm shaft fractures in children after intramedullary nailing. J Pediatr Orthop B.
2009 Nov;18(
6):289-95.[CrossRef]
Fernandez
FF;
Egenolf
M;
Carsten
C;
Holz
F;
Schneider
S;
Wentzensen
A. Unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing. Injury.
2005 Oct;36(
10):1210-6. .[CrossRef]
Schmittenbecher
PP;
Fitze
G;
Gödeke
J;
Kraus
R;
Schneidmüller
D. Delayed healing of forearm shaft fractures in children after intramedullary nailing. J Pediatr Orthop.
2008 Apr-May;28(
3):303-6.[CrossRef]
Ogonda
L;
Wong-Chung
J;
Wray
R;
Canavan
B. Delayed union and non-union of the ulna following intramedullary nailing in children. J Pediatr Orthop B.
2004 Sep;13(
5):330-3.[CrossRef]
Wright
TW;
Glowczewskie
F. Vascular anatomy of the ulna. J Hand Surg Am.
1998 Sep;23(
5):800-4.[CrossRef]
Busam
ML;
Esther
RJ;
Obremskey
WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg.
2006 Feb;14(
2):113-20.
Peterson
HA. Metallic implant removal in children. J Pediatr Orthop.
2005 Jan-Feb;25(
1):107-15.
Gorter
EA;
Vos
DI;
Sier
CF;
Schipper
IB. Implant removal associated complications in children with limb fractures due to trauma. Eur J Trauma Emerg Surg.
2011 Dec;37(
6):623-627. .[CrossRef]
Baldwin
K;
Hsu
JE;
Wenger
DR;
Hosalkar
HS. Treatment of femur fractures in school-aged children using elastic stable intramedullary nailing: a systematic review. J Pediatr Orthop B.
2011 Sep;20(
5):303-8.[CrossRef]
Muensterer
OJ;
Regauer
MP. Closed reduction of forearm refractures with flexible intramedullary nails in situ. J Bone Joint Surg Am.
2003 Nov;85-A(
11):2152-5.
Mittal
R;
Hafez
MA;
Templeton
PA. “Failure” of forearm intramedullary elastic nails. Injury.
2004 Dec;35(
12):1319-21.[CrossRef]
Yuan
PS;
Pring
ME;
Gaynor
TP;
Mubarak
SJ;
Newton
PO. Compartment syndrome following intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop.
2004 Jul-Aug;24(
4):370-5.[CrossRef]
Schmittenbecher
PP;
Dietz
HG;
Linhart
WE;
Slongo
T. Complications and problems in intramedullary nailing of children’s fractures. Eur J Trauma.
2000;26:287-93.[CrossRef]
Lieber
J;
Joeris
A;
Knorr
P;
Schalamon
J;
Schmittenbecher
PP. ESIN in forearm fractures. Euro J Trauma.
2005;31:3-11.[CrossRef]
Furlan
D;
Pogorelić
Z;
Biočić
M;
Jurić
I;
Budimir
D;
Todorić
J;
Šušnjar
T;
Todorić
D;
Meštrović
J;
Milunović
KP. Elastic stable intramedullary nailing for pediatric long bone fractures: experience with 175 fractures. Scand J Surg.
2011;100(
3):208-15.[PubMed]
Salem
KH;
Lindemann
I;
Keppler
P. Flexible intramedullary nailing in pediatric lower limb fractures. J Pediatr Orthop.
2006 Jul-Aug;26(
4):505-9.[CrossRef]
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.