Surgical Science, 2010, 1, 15-19
doi:10.4236/ss.2010.11003 Published Online July 2010 (
Copyright © 2010 SciRes. SS
Titanium Elastic Nails for Pediatric Femur Fracture s:
Clinical and Radiological Study
Nishikant Kumar*, Laljee Chaudhary
Department of Ort h opaedics, Dar b ha n ga me di cal C ol l ege a nd Hospital, L aheriasar ai , Bi har, India
Received May 16, 2010; accepted July 14, 2010
Background: Management of femoral diaphyseal fractures in the age group 6-16 years is controversial.
There has been a resurgence worldwide for operative fixation. Material and methods: Twenty children (15
boys, 5 girls) aged 6-16 years with femoral diaphyseal fractures (20 fractures, one in each) were stabilized
with Titanium Elastic Nail (TEN). Patients underwent surgery within ten days of their injury. The results
were evaluated using Flynn’s Scoring Criteria.Two nails were used in each fracture. Results: All 20 patients
were available for evaluation and follow up for a mean duration of 24 months (15-32 months). Radiological
union in all cases was achieved in a mean time of 8 weeks. Full weight bearing was possible in a mean time
of 10 weeks (8-12 weeks). The results were excellent in 14 patients (70%) and successful in 6 patients (30%).
Few complications that occurred were infection (in 2 cases), knee joint stiffness(in 4 cases), angulation less
than 10 degrees( in 4 cases), shortening less than 10 mm(in 4 cases). Conclusion: Intramedullary fixation by
TEN is an effective treatment of fracture of femur in properly selected patients of the 6-16 years age group.
Keywords: Children, Intramedullary Fixation, Titanium Elastic Nail, Femoral Fracture, Diaphysis
1. Introduction
Femoral shaft fracture is an incapacitating injury in chil-
dren [1,2]. The treatment has traditionally been age re-
lated, influenced by the type of injury, associated injuries
and the location and type of fracture.
The aim of fracture treatment is not only anatomical
realignment, but also restoration of muscle and joint
function as close as possible to the normal. Psychological
recovery is accelerated by early resumption of functional
activity, which encourages healing of fracture, mainte-
nance of normal circulation, preservation of tone of the
muscles and restoration of the movements of the joints.
The aim therefore is early mobilization by early use of
the injured part without movement at the fracture site.
Because of rapid healing and spontaneous correction
of angulations most of femoral shaft fractures in children
younger than six years of age can be treated conserva-
tively. Above six years of age all such fractures when
treated non-operatively could have loss of reduction,
malunion, intolerance and complication associated with
plaster. Near the end of skeletal maturity accurate reduc-
tion is necessary as angular deformity is no longer cor-
rectable by growth. In skeletally mature adolescents, use
of an antegrade solid locked intramedullary nail has be-
come the standard of treatment.
In patients between 6-16 years of age there has been a
tendency towards operative approach. Titanium Elastic
Nailing (TEN) which is variously known as elastic stable
intramedullary nailing (ESIN), has become the choice of
stabilization in pediatric long bone fractures, particularly
the femoral shaft fracture. The present study is aimed at
the evaluation of intramedullay fixation with TEN in
children with femoral fractures. Until recently skeletal
traction and application of a cast was the preferred
method of treatment of diaphyseal femoral fractures in
children and young adolescent. The device would exploit
a child’s dense metaphyseal bone, rapid healing and abil-
ity to remodel without risking damage to the epiphysis or
the blood supply to the capital femoral epiphysis.
2. Material and Methods
Twenty children (15 boys and 5 girls) in the age group of
6-16 years (average 10.8 years) with femoral shaft frac-
ture were stabilized with TEN from April 2007 to Octo-
ber 2009. The predominant mode of injury was due to
fall from height (50%). Right-sided involvement was
seen in 13 cas es (65%) and left side in 7 cases (35%).
Mid-diaphyseal fracture of femur was found in 70% of
cases and subtrochanteric fracture in 30% cases. About
50% of the patients underwent surgery within 10 days of
their injury. The surgery had been carried out in the De-
partment of Orthopaedics, Darbhanga Medical College &
Hospital, Laheriasarai, Darbhanga, Bihar, India.
Nail comes in five diameters from 2.5 mm to 4.5 mm
in a fixed length. The nails are colour coded for identifi-
cation. The nails (Figure 1) are straight except for a bent
tip. Special instruments include radiolucent reduction
tool, nail holder, nail bender, Insertion device, nail ex-
tractor, wice grip and a nail impactor were used.
All the patients treated with TENs had skin/skeletal
traction for approximately 1 week. As is the policy of our
institution the traction pin (4.76 mm threaded Steinmann
Pin) was inserted in the operating room under local an-
aesthesia. The Pin was inserted in the region of tibial
tuberosity anterolateral to posteromedial plane. Some
patients were stabilised with skin traction. Compound
fractures were primarily thoroughly debrided and upper
tibial skeletal traction applied. The injured limb was put
on a Bohler’s-Brawn splint and adequate weight applied.
This is essen tial to minimize pain, muscle spasm and
shortening. Appropriate tetanus prophylaxis, antibiotics
and analgesics were instituted. In the period of rest and
resuscitation, the patient was properly investigated and
examined. As soon as the patient became fit for anaes-
thesia and surgery he/she was posted for fixation of
femoral shaft fractures with TEN. Good preoperative
X-ray (Figure 2) of the injured femur was used to esti-
mate the nail diameter and to develop an approach to
supplement fixation and plan the incision.
Half an hour before operation 1 ampoule of atropine
was given intramuscularly. Intravenous line was setup.
Prophylactic antibiotic 1 gm ceftriaxone was given in-
travenously. 1 ampule perinorm was given intramuscu-
larly. General/spinal (above 14 years) anaesthesia was
given with full aseptic and antiseptic precautions on an
image intensifier (IITV) compatible operation table.
As soon as anaesthesia was effective, the patient was
placed supine and upper tibial skeletal traction pin was
removed with aseptic and antiseptic precaution. The pa-
tient was placed on radiolucent fracture table. The limb
was prepared and draped to give access to the entire fe-
mur and knee joint and to permit manual manipulation of
Figure 1. TEN with different length and diameter.
Figure 2. Preoperative x-ray of femur (AP and Lat view).
the thigh. The image intensifier was placed so that one
could get antero-posterior and lateral view of the femoral
shaft. The monitor was placed in such a way that surgeon
could have clear vision when inserting the nail and re-
ducing the fracture.
The selection of the insertion point for the nails was
medial and lateral at the top of the flare of the medial and
lateral condyles so that after insertion they would tend to
bind against the flare of the condyles. If the nails are
inserted too low, they will tend to backout, which is a
troublesome complication. In addition, the insertion
should be posterior to mid line of the shaft so that if the
nails backout, they will be less likely to enter the syno-
vial pouch.
A 5mm incision was made on the lateral side of the leg
extending about two finger breadth above the superior
pole of the Patella. (The superior pole of the patella lies
slightly above the level of the physis). A guide wire for
6.5 mm cannulated screw was passed at 45 degrees
angulation at the level of the superior pole of the patella.
Over this a drill hole was made with the cannulated drill
bit. Using a curved bone awl, the hole is extended
cephalad to elongate the hole and avoid cracking of the
cortex when the rod is inserted. The medial entry hole
was similarly elongated using a curved bone awl in
cephalad direction. The diameter of nail should be 2/5 of
the internal diameter of t he medullary canal (Nail di-
ameter = 0.4 x Canal diameter).
Ideally, the lateral nail should extend to the level of
the greater trochanter and the medial nail into the femo-
ral neck. The amount of prebending should be equal for
both the nails. (The amount of bending should be three
times the inner diameter of the shaft).Both the nails were
inserted through the entry holes one after another and
were driven upto the fracture site. The reduction was
helped by the use of F-tool which is a radiolucent device.
The arms of the F-tool were readjusted depending on the
fracture configuration and bulk of thigh viewing with the
image intensifier. This nail was advanced about 2 cm and
Copyright © 2010 SciRes. SS
then rotated. At this point, it was advanced further by
rotating this nail. Further reduction of the fracture was
accomplished and then the second nail was advanced.
The traction was released and both nails were ad-
vanced to their full length. Rotational and angular mal-
reductions were checked and if present the same was
corrected by partially withdrawing the nails, correcting
the deformity and reinserting the nails. When the nail
was at its final position, it was marked with a pen or
clamp about 10 to 20 mm from the insertion hole. The
nails were cut at the marked level and advanced so that
they lay against the supracondylar flare of the femur in
order to avoid complications at the insertion site.
A knee immobilizer or controlled motion brace should
be used for additional support. The patients were advised
to perform movements at the knee joint and three point
touch down exercise the day after surgery under the
guidance of a physiotherapist. When early callus forma-
tion is observed, weight bearing can be increased. Exter-
nal support can be discontinued when radiographic heal-
ing is co mplete. It is important that the patients bear
weight because this provides the motion at the fracture
site that leads to early callus formation. In all cases post-
operative x-rays antero-posterior and lateral views were
taken. In the post-operative period parenteral antibiotics
were continued for 5 days and then oral antibiotics were
given till stitch removal. Along with antibiotics, haema-
tinics, serratiopeptidase, Calcium, multivitamins were
given. Stitches were removed on the 12th post-operative
day. After removal of stitch by 13th to 14th day post-op-
erative patients were discharged.
Patients underwent regular follow up in the out patient
department for clinical and radiological evaluation in the
immediate post-operative period (Figure 3), at 4 weeks,
8 weeks (Figure 4), 12 weeks (Figure 5), 24 weeks, 35
weeks or till the publication of this series, whichever was
3. Results
The median duration of the surgery was 80 min (60-120
min). All 20 patients were available for evaluation after a
mean of 24 months (15-32 months) of follow-up. All pa-
tients were encoura ged to do hip and knee nonweight
bearing exercises from first post-operative day. Weight
bearing was allowed according to the fracture geography
and fixation. At the end of 1st post operative week all pa-
tients were made ambulatory on crutches allowing weight
bearing according to the quality of fixation. By 8th week
all the patients were bearing weight with only 2 patients
with touch-down weight bearing. Out of 20 cases, 2 cases
complained of pain and irritation of skin at the entry site,
associated with the prominence of the ends of the nails.
Out of 20 cases, 10 mm (1 cm) shortening was ob-
served in 4 cases. These were among the earlier cases of
the series and with comminuted fractures. Out of 20 pa-
tients, 3 patients showed 10 degree or less angulation in
the lateral plane and one patient had an eight degree
angulation in the anteroposterior plane. No broken nails
were observed in any of the 20 cases. Out of 20 cases, 2
opening the entry site. These patients had to undergo knee
physiotherapy again and regained movements at the knee.
No re-fracture was observed in the 2 cases that underwent
Figure 3. Immediate postoperative x-ray of femur (AP and
Lat view).
Figure 4. 8th week postoperative x-ray of femur (AP and Lat
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Figure 5. 12th week postoperative x-ray of femur (AP and
Lat view).
nail removal.
4. Discussion
In the present series TEN was used as a mode of fixation
in different types of femoral fractures in children between
ages 6 to 16 years. 20 cases were treated and evaluated
radiologically, clinically and functionally for the efficacy
of TEN.In our series results were excellent in all 20 cases.
Heinrich et al. (1994) reported that 22% of their patients
had an extension over 5 mm, and 11% had a shortening
under 5 mm. In a study comparing several methods in-
cluding TEN the maximum shortening was observed in
the early casting group followed by external fixator group
where as lengthening was observed only in the external
fixator group. In our study only 4 cases showed 1 cm
shortening which was clinically indiscernible. Herndon et
al. (1989) reported that malunion developed in seven of
24 patients who were treated with traction while no
malunion was observed in 21 children who were treated
using TEN.
In a study comparing anterograde versus retrograde
TEN by Galpin et al. [6] it was reported that 35 out of 37
patients had excellent improvement in terms of angular
deformity. We had angulation less than 10 degree towards
varus/valgus or antero/posterior only in 4 patients (20%).
In our series union progressed satisfactorily in all 20
cases. At the end of 8 weeks, 14 cases showed fair to
good callus formation while 6 cases had minimal callus
formation. No bone grafting was required in any of the
cases. No significant malunion was observed in any of the
20 patients.
Flynn et al. (2002) found TEN advantageous over
hip-spica in treatment of femoral shaft fractures in chil-
dren. Buechsenschuetz et al. [7] documented TEN to be
superior in terms of union, scar formation and overal l
patient satisfaction when compared to traction and casting.
Ligier et al. [8] treated 123 femoral shaft fractures with
TEN. All fractures united with excellent long term out-
come. Similarly Narayanan et al. (2004) found TEN to be
a very promising modality of fracture management in
children. In our series of 20 cases, in 2 cases implants
were removed after complete union.
In the present series, by the time stitches were removed
all 20 cases could do straight leg raising exercises. At the
end of study period 15 patients (75%) could do full range
of motion at knee joint.
All patients were encouraged to do hip and knee non-
weight bearing exercises from first post-operative day. At
the end of 1st postoperative week all patients were made
ambulatory on crutches, allowing weight bearing accord-
ing to the quality of fixation.
Flynn et al. (2002) used a knee fixating device to con-
trol the pain, to support quadriceps and to prevent the end
of nail causing any soft tissue irritation in the knee until
the callus tissue appears (4-6 weeks). The patients were
able to walk on day 9 on an average with the help of
equipment and at week 8.5 on average without the
equipment. In our series patients were made ambulatory
on crutches after 1st postoperative week. Partial weight
bearing was allowed at 6 weeks (range 4-8 weeks) and
full weight bearing was allowed at 10 weeks (Range 8-12
The results of th e present series are c omparable to
those of the other series on management of femoral shaft
fracture in children. It has definite advantages over the
other conventional implants that have been used in the
management of pediatric fractures. Notable advantages
of this technique are early union due to repeated micro-
motion at fracture site, early mobilization, early weight
bearing, scar acceptance, easy manipulation involved in
implant removal and high patient satisfaction rate. Be-
sides these, unlike other implants TEN does not endanger
either the epiphysis or the blood supply to femoral head.
The excellent biocompatibility and elasticity of titanium
have further enhanced the virtues of TEN. High grade of
elasticity of titanium limits the degree and permanence
of deformation that the nail undergoes during insertion.
More importantly elasticity promotes callus formation by
limiting stress shielding.
Table 1 shows important aspects of this study like age
and sex of the patients, nature and mode of injury, speci-
fications of nail used, follow up results and duration,
surgical complications like intraoperative blood loss and
The biomechanical principle of TEN is based on the
symmetrical bracing action of two elastic nails inserted
into the metaphysis, each of which bears against the in-
ner bone at three points. This biomechanics helps in achie-
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Table 1.
Time for union
S.No. Name
Type of
Side of
dia. ROM 4
1 MP 8 M RTA MD R Closed100-200 2.5 mmFR + ++ ++++++
2 RS 11 M HGT MD R Closed< 100 ml2.5 mmFR + ++ ++++++
3 NK 13 M ASLT MD L Closed100-200 2.5 mmFR + ++ ++++++
4 PK 12 F RTA ST R Open 100-200 2.5 mm0-100º- + ++ ++
5 GH 14 M HGT MD L Closed< 100 ml3 mm FR + ++ ++++++
6 KP 9 M ASLT MD L Closed< 100 ml2.5 mmFR + + ++ +++
7 ST 11 M HGT MD R Open 200-300 2.5 mmFR + ++ ++++++
8 RD 14 F ASLT ST R Open < 100 ml3 mm 0-120º+ ++ ++++++
9 AK 12 M HGT MD R Closed100-200 2.5 mmFR - + + ++
10 UP 13 M HGT MD R Closed< 100 ml3 mm FR + ++ ++++++
11 BS 10 F RTA ST L Closed100-200 2.5 mmFR + ++ ++++++
12 DNP 11 F HGT MD R Open 200-300 2.5 mm0-120º+ ++ ++ +++
13 BP 11 M HGT MD R Closed< 100 ml2.5 mmFR ++ +++ ++++++
14 NP 15 M RTA SY L Open 100-200 3 mm FR + ++ ++++++
15 WA 16 M HGT MD R Closed< 100 ml3.5 mmFR + + ++ +++
16 SKG 10 M HGT ST L Open 100-200 2.5 mm0-100º+ ++ ++++++
17 VD 16 M HGT MD L Closed< 100 ml3.5 mmFR + + ++ ++
18 SL 15 M RTA ST R Closed< 100 ml3 mm FR + ++ ++++++
19 AP 8 M ASLT MD R Open 200-300 2.5 mm0-120º- + ++ ++
20 GLY 16 F RTA MD R Closed100-200 3 mm FR ++ +++ ++++++
M = Male; F = Female; RTA = Road Traffic Accident; HGT = Height; ASLT = Assault; MD = Mid diaphyseal; ST = Subtrochanteric; R = Right; L=
Left; ROM = Range of Motion; FR = Full Range; + = Little amount callus seen; ++ = Fair amount callus seen; +++ = Good amount of callus seen; - =
No visible callus seen.
ving a high grade of stability i.e. flexural stability, axial
stability, translational stability and rotational stability.
5. Conclusions
The intramedullary fixation by TEN is a method of
choice due to its distinct advantages over other conven-
tional modalities. Easy manoeuvering, excellent outcome,
lower incidence of complications and easier postopera-
tive maintenance have made TEN the most prudent,
practical and successful intervention in the management
of femoral shaft fractures of patients between 6 and 16
years of age.
6. References
[1] J. M. Flynn, D. Skaggs, P. D. Sponseller, T J. Ganley, R.
M. Kay and K. K. Leitch, “ The Operative Management
of Pediatric Fractures of the Lower Extremity,” The
Journal of Bone and Joint Surgery, Vol. 84, No. 12, 2002,
[2] M. Heybelly, H. H. Muratli, L. Celeb, S. Gulcek and A.
Bicimoglu, “The Results of Intramedullary Fixation with
Titanium Elastic Nails in Children with Fem oral Frac-
ture,” Acta Orthop Traumatol Turc, Vol. 38, No. 3, 2004,
[3] S. L. Buckley, “Current Trends in the Treatment of
Femoral Shaft Fractures in Children and Adolescents,”
Clinical Orthopaedics, Vol. 338, 1997, pp. 60-73.
[4] J. R. Kasser and J. H. Beaty, “Femoral Shaft Fractures,”
In: J. H. Beaty, J. R. Kasser, Eds., Reckwood and Wilkins
‘Fracture in Children”, 5th Edition, Lippincott Williams
and Wilkins, Philadelphia, 2001, pp. 941-980.
[5] J. M. Flynn, T. Hresko, R. A. Reynolds, R. D. Blasier, R.
Davidson and J. Kasser, “Titanium Elastic Nails for Pe-
diatric Femur Fractures: A Multicenter Study of Early
Results with Analysis of Complications,” Journal of Pe-
diatric Orthopaedics, Vol. 21, No. 1, 2001, pp. 4-8.
[6] R. D. Galpin, R. B. Willis and N. Sabano, “Intrame-
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[7] K. E. Buechsenschuetz, C. T. Mehlman, K. J. Shaw, A. H.
Crawford and F. B. Immerman, “Femoral Shaft Fractures
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Elastic Stable Intramedullary Nailing,” The Journal of
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[8] J. N. Ligier, J. P. Metaizeau, J. Prevot and P. Lascombes
“Elastic Stable Intramedullary Nailing of Femoral Shaft
Fractures in Children,” The Journal of Bone and Joint
Surgery [Br], Vol. 70, No. 1, 1988, pp. 74-77.