Introduction
Traumatic injuries of the bones are the leading causes of fractures in children and adolescents. The fracture most commonly occurs in the shaft of the long bones. A shaft is the diaphysis or midsection of a long bone. Some of the common long bones in the body include the upper arm bone, forearm bone, thigh bone, and shinbone. Elastic stable intramedullary nailing (ESIN) or titanium elastic nail system (TENS) is the latest minimally invasive surgical technique employed for the treatment of pediatric fractures. Due to the minimally invasive nature of the procedure, ESIN offers several benefits such as a small incision, minimal muscle trauma, quick recovery, and safe and excellent stability without the need for plaster cast immobilization.
Types of Long Bone Fractures
Some of the common types of long bone fractures include:
- Transverse fracture: In this type of fracture, the break occurs as a straight, horizontal line going across the bone shaft.
- Oblique fracture: In this type, the break occurs as an angled line across the bone shaft.
- Comminuted fracture: A severe type of fracture where the bone breaks into 3 or more pieces.
- Spiral fracture: A type of fracture caused by a twisting force with a fracture line that encircles the bone.
- Open fracture: This is also known as a compound fracture and causes serious damage to the surrounding soft tissue structures as the bone fragments to protrude out through the skin to the external air exposing the fracture site.
- Stress fracture: Also called a hairline fracture, this fracture appears as small thin cracks in the bone and occurs due to overuse or wear and tear.
Indications for Elastic Nailing
Elastic intramedullary nailing is primarily indicated for the management of metaphyseal and diaphyseal fractures of long bones in children. In general, the use of elastic nailing depends upon factors such as:
- Age of the patient
- Location of the fracture
- Type of fracture.
- Bone condition of the patient
Preparation for Elastic Nailing
Preoperative preparation for elastic nailing may commonly involve the following:
- Your doctor will review the patient’s medical history and perform a thorough examination.
- The patient should refrain from medications such as blood thinners, aspirin, or anti-inflammatory drugs for a week or two prior to surgery.
- You will be asked if the patient has allergies to medications, anesthesia, or latex.
- You should inform your doctor of any medications, vitamins, or supplements that the patient is taking.
- The patient should not consume any solids or liquids at least 8 hours prior to surgery.
Procedure of Elastic Nailing
Although the elastic nailing technique is employed for treating all types of long bone fractures, lower leg femoral shaft fracture is explained in detail below along with a note on upper arm forearm fracture to give a general idea of the procedure.
Elastic Nailing of the Femur:
- General or regional anesthesia is administered for the procedure.
- After adequately sterilizing the surgical area, your surgeon makes an incision over the outside of the femur.
- The supporting structures around the bone are gently moved out of the way to prepare the surface of the femur for placement of the nails.
- A cut is made above and below the femur and 2 pre-bent elastic titanium nails are inserted with a special insertion device inside the intramedullary canal of the bone passing across the fracture site.
- The nail tips are aligned in such a manner that they diverge from each other.
- The ends of the nails are bent slightly upwards to facilitate subsequent removal of the implant after fracture healing.
- All surrounding tissues and structures are restored to their normal anatomic position.
- The incisions are closed with sutures and sterile dressings are applied.
Elastic Nailing of the Forearm:
- Your forearm is the section of the arm between the elbow and the wrist. It is made up of 2 bones called the radius and the ulna. The radius is the bone located on the thumb side of the forearm and the ulna is the bone located on the little finger side of the forearm.
- Elastic nailing of the forearm is recommended when the fractured bone ends of the forearm are unstable and cannot be aligned or if both the radius and ulna are fractured. This minimally invasive procedure involves passing elastic nails or rods through the central or medullary canal of the fractured bones. The nails are bent and inserted through a small incision near either end of the bone without damaging the growth plates. The nails have properties of flexibility and stability and once in place help align and stabilize the fracture fragments.
Postoperative care
In general, postoperative care and recovery involve the following:
- A compression bandage is applied to the operated area for several days to facilitate healing.
- Mobilization exercises without weight-bearing are encouraged after a week with support and assistance.
- Partial weight-bearing is encouraged in 4 to 6 weeks’ time and full weight-bearing in 6 to 8 weeks’ time.
- Medications are provided as needed to manage pain, swelling, infection, and other issues.
- Instructions on surgical site care are provided prior to discharge.
- A physical therapy regimen may be ordered for strengthening.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications of Elastic nailing
Elastic nailing for fractures is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:
- Pain
- Infection
- Nail irritation
- Neurapraxia
- Improper healing of the fracture
- Non-healing of the fracture
- Delayed healing of the fracture
- Loss of alignment
Summary
Children are prone to injuries and fractures as they are curious to explore their environment and engage in sports activities. Elastic intramedullary nailing is a new state-of-the-art minimally invasive technique that offers a high degree of safety and stability. It helps children recover quickly and get back to sports and other physically demanding activities, without cosmetic or functional deficiencies.
