Intramedullary Nailing Of Unstable Pediatric Tibial Diaphyseal Fractures. Should we always use two Nails?

Background: Tibial shaft fractures are one of the most common skeletal injuries in children. Surgical fixation is warranted in fractures with an unstable configuration. Recently, titanium elastic nailing (TEN) has been advocated for tibial shaft fractures. Standard technique of TEN fixation in tibial shaft fractures includes insertion of 2 pre-bended nails to achieve stability of the fracture and optimal alignment of the tibia. The purpose of this study was to evaluate the results of treatment in patients that were treated in our institution by a single nail fixation and casting.
Methods: From June 2011 until August 2015 we treated 17 male patients with unstable diaphyseal fractures of the tibia. Average age was 8 years ( range 4-13 years). Eight fractures were in the middle third of the tibia, 5 in the distal third and 4 fractures were between the middle and the distal thirds. One pre-bended TEN of various diameters was introduced under fluoroscopic guidance and final alignment was achieved using cast molding. All fractures underwent closed reduction. All patients were followed at least until union, and radiological follow-up lasted until at least 6 months after operation.n
Results: Mean follow-up was 8 months. All patients achieved complete union at an average of 6 weeks after operation (range 4-9 weeks). Alignment was excellent in 16 patients and one patient had minimal mechanical axis deviation.
Conclusion: Based on our preliminary experience with a single TEN fixation, we believe that this technique might be useful in many pediatric tibial fractures. A single nail was stable enough, and with cast fixation this technique could achieve excellent alignment in most cases.