Complications of Elastic Stable Intramedullary Nailing in Pediatric Fracture Management

Elastic stable intramedullary nailing (ESIN) for pediatric fracture management has gained increasing popularity since its introduction in the late 1970s. Relatively few modifications have been made to the original technique in the last forty years, which illustrates the sound biomechanical principles and simplicity of the technique. Jean-Paul Metaizeau, the originator of the technique, pointed out that poor results after ESIN were typically due to incorrect constructs, incorrect indications, and insufficient surgeon training1. The initial (1977 to 1980) indications for ESIN were limited to pediatric patients with multiple injuries or head trauma in whom cast or traction treatment was not practical. Later, its use was extended to all diaphyseal fractures of long bones in children. With widespread acceptance, the indications have been further expanded to metaphyseal fractures, comminuted fractures, pathologic fractures, and fractures of smaller bones (including clavicular, supracondylar humeral, and metacarpal fractures). ESIN was introduced in the United States in 19972. The literature is replete with reports of the clinical success of ESIN, but reports related to its complications are scarce. The aim of this manuscript was to review the common complications related to ESIN and provide technical pearls to manage and avoid complications. The principle of ESIN involves balanced nailing (i.e., use of two flexible nails of the same diameter to provide elasticity and stability in opposite directions at the fracture site). This principle is different from the principle of the Ender nail, which is based on maximal filling of the medullary canal3. To achieve balanced nailing when two nails are used, the apex of curvature of each nail should be at the fracture site. To achieve this, both nails should have the curvature of the letter “C” if they are inserted from opposite sides of the bone, or one nail should have …

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