Dr. Herman recommends using 3.0 mm to 4.0 mm flexible titanium nails rather than stainless nails, which he says are stiffer and more difficult to pass through the intramedullary canal. “I tell my residents to use the largest two nails of equal diameter that they can pass safely—that’s about an 80 percent canal fill.”


Published 4/1/2012
Maureen Leahy

Flexible IM Nailing for Pediatric Tibial Fractures: Pearls and Pitfalls

Most tibial fractures in children can be successfully treated with closed reduction and cast immobilization. Surgery is indicated, however, when the fracture is irreducible, unstable, open with soft tissue injury, or associated with multiple injuries, according to Martin J. Herman, MD, of St. Christopher’s Hospital for Children in Philadelphia.

Surgical options include percutaneous pinning, external fixation, plating, and increasingly, flexible intramedullary (IM) nailing.

“Most of the orthopaedic surgeons in our practice now use flexible IM nails for surgical stabilization in this patient population. In my opinion, they are the best implants for tibia fracture fixation in children,” Dr. Herman said.

Speaking during the Pediatric Orthopaedic Society of North America Specialty Day, Dr. Herman shared pearls and pitfalls of using flexible IM nails to treat tibial fractures in children and adolescents.

Technical pearls
“The flexible IM nailing concept is simple,” said Dr. Herman, who credits French orthopaedic surgeons including Pierre Lascombes, MD, with developing the technique. “In the tibia, flexible IM nails work best for middle-third, length-stable fractures in patients with open tibial tubercles. When properly inserted, the flexible implants provide three-point fixation, creating a balanced suspension across the fracture site.”

Flexible IM nails can be used for stabilizing pediatric tibial fractures, particularly middle-third, length-stable fractures; inserted properly, the nails provide balanced suspension across the fracture site.

Courtesy of Martin J. Herman, MD


Before inserting the nails, he gently bends them so that the apex of each will be at the level of the fracture. “Sometimes I will make a tiny extra bend at the top of the nail to make it easier to pass, but most of the time the tibial nails will pass proximally without a problem,” he said. “It’s very important to avoid the physis and tubercle—I make my approach at least 2 cm distal to the physis and behind the tibial tubercle.”

Dr. Herman advances the nails under fluoroscopic guidance, being careful not to wind the nails around each other. He prefers to advance both nails to the fracture site sequentially, watching to make sure they don’t cross each other. The reduction can be fine-tuned, if necessary, by rotating the nails in and out of the plane. “However, if you do a large rotational correction on one side, the other side may angulate,” he cautioned.

When they are nearly embedded into the distal tibia, Dr. Herman taps the nails back, cuts them flush, and taps them into their final position. “After the nails are in, make sure that the reduction is satisfactory,” he said. If the fracture remains unstable after nailing, salvage options include changing the implant, stabilizing the fibula, placing short-term external fixation around the nails, or casting. “Many orthopaedic surgeons are shifting away from casting around flexible nails, but I will use a cast—it solves the problem of angulation,” he said.

Avoid pitfalls
Using flexible IM nailing to treat tibial fractures may not yield the same good results in older children who are approaching skeletal maturity as it does in younger children, according to Dr. Herman. Complications, he said, include malunion and delayed union. Although older children may benefit from the use of larger stainless steel nails, Dr. Herman prefers to use a locked IM nail for those patients with a nearly closed tubercle.

Flexible IM nails can be used in open tibial fractures but healing times will be longer, Dr. Herman added. “Open fractures take longer to heal regardless of the fracture grade or the age of the child,” he said. In addition to surgical fixation, open fracture management also involves aggressive irrigation and debridément, early soft- tissue coverage, and infection surveillance.

Finally, Dr. Herman stressed that flexible IM nails are not indicated for all fracture patterns of the tibia and, therefore, careful preoperative assessment is required. Less than ideal indications, he said, include fractures that are not length stable and fractures that are too distal or too proximal in the tibial shaft.

“If the fracture pattern isn’t suitable or you are unsure whether you can successfully treat the fracture with flexible IM nails, don’t try to. Choose another method, such as external fixation or plating,” he advised. “Once you understand the principles of flexible IM nails and can apply their use specifically to the tibia and avoid the pitfalls, you’ll find they are an excellent surgical solution for treating tibia fractures in children.”

Disclosures: Dr. Herman—Lanx Spine; Springer; Journal of Pediatric Orthopaedics

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

  • Although most pediatric tibia fractures can be treated with closed reduction and cast immobilization, some require surgical fixation.
  • Flexible IM nailing is a surgical option that achieves fracture stability by creating balanced suspension across the fracture site.
  • Flexible IM nails are not indicated for all pediatric fracture patterns of the tibia; locked IM nails are recommended for older children approaching skeletal maturity.
  • When used appropriately to treat pediatric tibia fractures, flexible IM nails produce excellent surgical results.