Clinical Outcomes of Flexible Intramedullary Nailing for Pediatric Femoral Shaft Fractures

By: Dr. Rajdev Prasad Kushvaha, Dr. Rohit Gupta, Dr. Rahul Kumar (Narayani Hospital, Birgunj, Nepal) and Dr. Deepak Dutta (Bir Hospital, NAMS, Kathmandu, Nepal)

Target Readership: Orthopedic surgeons, pediatric specialists, and clinical practitioners

Key Terms: Elastic Stable Intramedullary Nailing (ESIN), Pediatric Femoral Shaft Fractures, Flynn’s Criteria, Stainless Steel Nails

Diaphyseal fractures of the femur account for approximately 1.6% of all pediatric skeletal trauma. While non-operative interventions—such as skeletal traction followed by hip spica casting—were long considered standard, prolonged immobilization frequently leads to complications, including joint stiffness, skin breakdown, psychological distress, and delayed functional independence.

In school-aged children and early adolescents (ages 6–14), modern pediatric orthopedics favors operative stabilization. A retrospective clinical study conducted at Narayani Hospital evaluates the safety, union rates, and functional outcomes of fluoroscopy-guided stainless steel flexible intramedullary nailing for displaced diaphyseal femur fractures.

Study Design & Patient Demographics

The study analyzed 30 pediatric patients aged 6 to 14 years presenting with acute, displaced femoral shaft fractures:

• Mean Patient Age: 9.5 years

• Primary Mechanism of Injury: Road Traffic Accidents (60%)

• Most Frequent Fracture Site: Middle-third / mid-diaphyseal junction (66.7%)

• Fixation Technique: Retrograde or antegrade stainless steel flexible intramedullary nailing under intraoperative fluoroscopic control

• Follow-up Protocol: Serial radiographic and clinical evaluations over a minimum duration of 6 months

• Outcome Scoring: Standardized according to Flynn’s Criteria

Key Clinical & Radiographic Findings

All 30 fractures progressed to complete radiographic union without non-union or delayed union requiring secondary bone grafting.

Technical Complications & Minor Sequelae

• Hardware Prominence: 5 patients experienced minor soft-tissue irritation at the nail entry site, which resolved following implant extraction after solid union.

• Limb Length Discrepancy (LLD): 3 patients developed mild, asymptomatic discrepancies averaging 0.5 cm, with none requiring corrective osteotomy or revision stabilization.

• Malalignment: No major rotational or angular deformities exceeding acceptable pediatric remodeling limits occurred.

Clinical Implications

Flexible intramedullary nailing acts as a minimally invasive, load-sharing biological internal splint that preserves the fracture hematoma, avoids physis damage, and avoids periosteal stripping:

1. High Success Profile: Achieving 100% satisfactory-to-excellent outcomes under Flynn’s criteria reinforces flexible nailing as a reliable standard for this age cohort.

2. Accelerated Recovery: Eliminates the burden of prolonged bed rest, pin-tract infections from traction, and spica-care complications.

3. Implant Selection: Stainless steel flexible nails deliver rigid biological alignment and rotational resistance when bent to the classic 3-point contact configuration, providing a cost-effective, readily available alternative in resource-constrained surgical centers.

While these findings affirm flexible intramedullary nailing as an optimal modality for pediatric diaphyseal femur fractures, larger prospective multicenter cohorts with extended skeletal-maturity follow-up will further validate long-term remodeling and leg-length symmetry.