Fractures of the growing bone require fixation techniques, which preclude any injury to the growth plate regions. This requirement is perfectly met for shaft fractures by Elastic Stable Intramedullary Nails (ESIN) which are positioned between both metaphyseal regions. The rate of operative fracture treatment in children has increased considerably after the introduction of suitable implants. A variety of ESIN has been developed during the past decades. All nails are made from (pre)bendable material (stainless steel or titanium alloy) and have a curved tip. Nail diameters of 1.5, 2.0, 2.5, 3.0, 3.5 and 4.0 mm are available. Once introduced, 3-point fixation results in an elastic stable construct. Most fixations will need two nails per bone and do not provide rigid fixation. Rapid bone healing in children overcomes this period of relative instability within a few weeks.

The currently most advanced instrumentarium is the DePuy Synthes ESIN instrumentarium^® that has a specific T- shaped handle, a specific clamp for nail removal and a cutting device that produces dull clean nail ends which do not irritate the surrounding soft tissues. The advantages of this instrumentarium are particularly evident in difficult fracture patterns and in the introduction of nails with a large diameter (>3 mm). For a simple forearm shaft fractures however, any T-hand piece and a standard nail cutter may be sufficient.

To increase stability of the bone-implant construct, different systems for interlocking of the nails were suggested. One of the earliest locking devices was a screw which was placed through a hole in the nail end. This technique however required special nails manufactured in different length. Alternatively, indirect locking is possible by the so-called miss the nail technique where a screw is placed between two nails at their crossing in the medullary canal. More recently, special end caps were introduced that can be applied to any standard ESIN, independent of its length and diameter [1]. A hollow titanium cap is placed over the nail end and screwed into the cortical bone to avoid backing out of the nail. This technique requires very exact shortening of the nail to 0.5–1 cm above the cortical surface. This interlocking is especially useful in lower extremity fractures of older, heavier children.

While 4 mm ESIN with end caps may be stable enough even for highly unstable fracture types in the femur up to an age of about 14 years or up to a weight of 50 kg, more stability is needed in adolescents. For this age group, adult femur nails may be too thick to fit into the medullary canal. Therefore, the adolescent lateral femur nail (ALFN, DePuy Synthes^®) was introduced [2]. Application and operative technique for this nail is expected to gain higher acceptance with (adult) orthopedic surgeons than among pediatric surgeons. Reports of the use of this nail are rather scarce until now since the implant is suitable only for a narrow age group.

A 1–2 cm long incision is made at the medial aspect of the clavicle, 1 cm lateral to the sternoclavicular joint. A 2 mm ESIN nail is inserted with slight rotatory movements from medial to lateral after closed reduction of the fracture. Limited open reduction is performed when attempts to closed reduction are unsuccessful. Intraoperative image intensification control assures that there is no perforation of the nail out of the clavicle in any direction. In order to avoid soft tissue irritation at the nail end or nail migration, it is recommended to impact the nail tip firmly into the lateral clavicle and to use an end cap. Postoperatively, mobilization as tolerated is allowed. Abduction above 90° and weight bearing are avoided until fracture healing. Control radiolographs are taken after 4 weeks. Uneventful bone healing can also be assumed by the presence of pressure-indolent callus. ESIN removal is usually possible after 4 months.

A monolateral, ascending technique is mostly chosen in fractures of the proximal humerus and the humeral shaft. Alternatively, a bilateral, radial and ulnar approach may be used. The ulnar approach bears the risk of damaging the ulnar nerve. When using a monolateral approach, a 3–4 cm incision is made 1 cm proximal to the lateral epicondyle. The anterior aspect of the distal, lateral humerus should be exposed to visualise the nail insertion points. The position of the radial nerve has to be taken into account, so that the insertion points are not chosen too cranial. Two elastic nails are always inserted. The largest possible nail diameter should be selected. The minimal nail diameter is one third of the diameter of the medullary canal at the isthmus. One elastic nail has to be prebent in an S-shape, the other in a standard C-shape. The tip of the S-shaped nail should reach the surgical neck medially; the tip of the C-shaped nail should be directed towards the greater tubercle. Great care must be taken to avoid perforation of the cortex by any nail tip. Rotational alignment must be controlled during placement of the nail. It is recommended to proceed with the medial S-shaped nail first. The lateral nail should be advanced subsequently. The apex of the bending of both nails should be at the fracture level (Fig. 24.2a–c). In case of unstable or comminuted fractures, the use of end caps is recommended.

When a radial and ulnar approach is used, both nails are prebent in C-shape. The same recommendations as depicted above are followed (Fig. 24.3a–c).

In case of antegrade nailing, the entry portals of both nails are situated at the proximal lateral humerus below the insertion of the deltoid muscle. The end points of both nails are the medial and lateral condyles respectively.

Pure epiphyseal separations represent one-third, fracture-separations two-thirds of all radial neck fractures in infancy. Because of the large correction potential, relatively large malpositions can be treated without reduction. In children younger than 10 years, tilting of 45° is considered acceptable, whereas in older children 20° of tilting is the limit. Functional therapy should be started as early as possible and the time for immobilisation should be kept as short as needed for pain therapy. There is a risk of post-traumatic necrosis and deformation of the radial head because the radial head epiphysis receives its blood supply from distal only. In case the malposition of the radial head exceeds the above mentioned limits, surgical reduction and fixation is indicated. An attempt to closed reduction by direct manipulation of the radial head should be done first in order not to endanger its blood supply. Closed reduction can also be tried with the help of an elastic nail, which is introduced retrograde through the distal radial styloid process. If several attempts are not successful, a limited open reduction is inevitable. The reduced head can finally be fixed with this retrograde elastic nail [8, 9].

The child is lying in a supine position in the operation room and the arm is placed on a radiolucent side table. The nail’s diameter is 2 or 2.5 mm. A longitudinal skin incision is made over the styloid process. An open dissection is recommended to protect the tendons and superficial branch of the radial nerve. The nail’s insertion point is located about 1–2 cm proximal to the growth plate. An entry portal is created very carefully with the help of an awl. The nail’s tip is pushed forward to the radial head under fluoroscopic control. In cases of severe tilting, direct pressure on the radial head can be applied by the operator’s thumb. If unsuccessful, a K-wire is used percutaneously to reduce the head. The curved tip of the elastic nail can also be used as a reduction aid. By rotating this tip, the dislocated head is brought into its anatomical position. After reduction, the elastic nail is pushed further into the radial head. The stability of the retention should be controlled under fluoroscopy (Fig. 24.4a–c).

Isolated dislocations of the radial head are extremely rare after trauma. Usually, there is an accompanying pathology of the ulna, known as Monteggia lesion. A dislocation of the radial head can easily be missed if there is only a slight bowing of the ulna. With reduction of the ulna fracture or correction of the bowing, reduction of the radial head is easily obtained. The ulna is stabilized with an antegrade ESIN (Fig. 24.5a–f). The operation is performed in supine position and the arm placed on a radiolucent side table. The entry point of the nail is located about 2 cm distal to the proximal apophysis. Therefore, a 3 cm longitudinal incision is made at the dorsoradial side of the proximal ulna. The diameter of the nail is 2 or 2.5 mm, similar as in elastic nailing of the radius [10].

The child is lying in a supine position in the operation room and the arm is placed on a radiolucent side table. The diameter of both nails is 2 or 2.5 mm. Closed reduction is attempted. The percutaneous use of pointed reduction forceps, which are attached to each fracture fragment, may be helpful. Open reduction is necessary if muscles or tendons are intercalated between the fracture fragments.

Since closed reduction of the ulna is mostly easier, ulna nailing is done first. The entry point of the ulnar nail is located about 2 cm distal to the proximal apophysis. Therefore, a 3 cm longitudinal incision is made at the dorsoradial side of the proximal ulna. The nail is advanced to the fracture and passed beyond under fluoroscopic control. For radial nailing, a longitudinal skin incision is made over the styloid process. An open dissection is recommended to protect the tendons and superficial branch of the radial nerve. The nail’s insertion point is located about 1–2 cm proximal to the growth plate. The nail’s tip is pushed forward to the fracture and passes the fracture gap under fluoroscopic control. Both nails should have an as long as possible trajectory in the medullary canal. Any cortical perforation should be avoided or corrected.

In all above mentioned procedures, the nail ends are bent slightly in a direction opposite to the cortical surface, which is easily performed with the beveled impactor. The nails are subsequently cut near to the cortical surface, using the special cutting device, to avoid damage to the surrounding soft tissues, skin irritation or skin perforation. The nail ends remaining outside of the bone should be long enough to enable unproblematic metal removal.

Most shaft fractures of the femur, even long spiral fractures or comminuted multiple segment fractures, can be stabilized adequately with ESIN to allow for healing in anatomical position.