Clinical evaluation of end caps in elastic stable intramedullary nailing of femoral and tibial shaft fractures in children

  • T. Slongo
  • L. Audigé
  • J. B. Hunter
  • S. M. Berger
Original Article



Elastic stable intramedullary nailing (ESIN) may be complicated by the loss of reduction following push out of the nails at the entry site in unstable femoral and tibial fractures, especially in older and heavier children and following technical failures. An end cap system addressing this complication was evaluated clinically.


In a retrospective case series, 49 femoral and five tibial fractures in 54 pediatric patients treated by ESIN and end caps were documented in two European tertiary centers. End caps were used to interlock standard ESIN nails. The results were evaluated regarding difficulties in the placement and removal of the end cap system, fracture stability and healing, and return to normal activities by analyzing patient charts and X-rays.


Fifty-three of 54 fractures were stabilized sufficiently with ESIN and end caps. Loss of reduction was observed in one patient, requiring additional surgery. Six complications were observed, five of which were not related to end caps. There were no significant leg length differences or varus/valgus deformities. A rotational difference of >10°–20° was found in one patient. Removal of the end caps and nails was rated as simple and uncomplicated in 35/37 cases.


End caps avoided postoperative instability in the majority of pediatric patients with lower limb shaft fractures, even in heavier, older patients and those with instable fracture types. End caps, however, will not compensate for operative technical insufficiency concerning reduction or nail placement. To maximize the stability of ESIN-instrumented unstable fractures, end caps require properly placed nails.


End cap system ESIN Femoral fracture Tibial fracture Pediatric 


  1. 1.
    Galano GJ, Vitale MA, Kessler MW, Hyman JE, Vitale MG. The most frequent traumatic orthopaedic injuries from a national pediatric inpatient population. J Pediatr Orthop. 2005;25(1):39–44.PubMedGoogle Scholar
  2. 2.
    Salem KH, Lindemann I, Keppler P. Flexible intramedullary nailing in pediatric lower limb fractures. J Pediatr Orthop. 2006;26(4):505–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Till H, Hüttl B, Knorr P, Dietz HG. Elastic stable intramedullary nailing (ESIN) provides good long-term results in pediatric long-bone fractures. Eur J Pediatr Surg. 2000;10(5):319–22.PubMedCrossRefGoogle Scholar
  4. 4.
    Anglen JO, Choi L. Treatment options in pediatric femoral shaft fractures. J Orthop Trauma. 2005;19(10):724–33.PubMedCrossRefGoogle Scholar
  5. 5.
    Kanlic E, Cruz M. Current concepts in pediatric femur fracture treatment. Orthopedics. 2007;30(12):1015–9.PubMedGoogle Scholar
  6. 6.
    Srivastava AK, Mehlman CT, Wall EJ, Do TT. Elastic stable intramedullary nailing of tibial shaft fractures in children. J Pediatr Orthop. 2008;28(2):152–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Setter KJ, Palomino KE. Pediatric tibia fractures: current concepts. Curr Opin Pediatr. 2006;18(1):30–5.PubMedGoogle Scholar
  8. 8.
    O’Brien T, Weisman DS, Ronchetti P, Piller CP, Maloney M. Flexible titanium nailing for the treatment of the unstable pediatric tibial fracture. J Pediatr Orthop. 2004;24(6):601–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Kubiak EN, Egol KA, Scher D, Wasserman B, Feldman D, Koval KJ. Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation? J Bone Joint Surg Am. 2005;87(8):1761–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Narayanan UG, Hyman JE, Wainwright AM, Rang M, Alman BA. Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them. J Pediatr Orthop. 2004;24(4):363–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Sink EL, Gralla J, Repine M. Complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types. J Pediatr Orthop. 2005;25(5):577–80.PubMedCrossRefGoogle Scholar
  12. 12.
    Slongo TF. Complications and failures of the ESIN technique. Injury. 2005;36(Suppl 1):A78–85.PubMedCrossRefGoogle Scholar
  13. 13.
    Wall EJ, Jain V, Vora V, Mehlman CT, Crawford AH. Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures. J Bone Joint Surg Am. 2008;90(6):1305–13.PubMedCrossRefGoogle Scholar
  14. 14.
    Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop. 2003;23(4):443–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Lascombes P, Haumont T, Journeau P. Use and abuse of flexible intramedullary nailing in children and adolescents. J Pediatr Orthop. 2006;26(6):827–34.PubMedCrossRefGoogle Scholar
  16. 16.
    Linhart WE, Roposch A. Elastic stable intramedullary nailing for unstable femoral fractures in children: preliminary results of a new method. J Trauma. 1999;47(2):372–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Dietz HG, Schmittenbecher PP, Slongo T, Wilkins KE. AO manual of fracture management. Elastic stable intramedullary nailing (ESIN) in children. Biomechanics. New York: Thieme; 2006. p. 7–8.Google Scholar
  18. 18.
    Slongo T. New pediatric products. End cap for elastic nails. AO Dev News. 2006;1(1):16–7.Google Scholar
  19. 19.
    Nectoux E, Giacomelli MC, Karger C, Gicquel P, Clavert J. Use of end caps in elastic stable intramedullary nailing of femoral and tibial unstable fractures in children: preliminary results in 11 fractures. J Child Orthop. 2008;2:309–14.PubMedCrossRefGoogle Scholar
  20. 20.
    Vierhout BP, Sleeboom C, Aronson DC, Van Walsum AD, Zijp G, Heij HA. Long-term outcome of elastic stable intramedullary fixation (ESIF) of femoral fractures in children. Eur J Pediatr Surg. 2006;16(6):432–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Ho CA, Skaggs DL, Tang CW, Kay RM. Use of flexible intramedullary nails in pediatric femur fractures. J Pediatr Orthop. 2006;26(4):497–504.PubMedCrossRefGoogle Scholar
  22. 22.
    Beaty JH, Austin SM, Warner WC, Canale ST, Nichols L. Interlocking intramedullary nailing of femoral-shaft fractures in adolescents: preliminary results and complications. J Pediatr Orthop. 1994;14(2):178–83.PubMedCrossRefGoogle Scholar
  23. 23.
    Schwieger K, Slongo T, Schneider E. News from the AO Research Institute (ARI). Performance of the end cap system. Biomechanical study of elastic stable intramedullary nailing (ESIN) in pediatric fractures. AO Dev News. 2006;1(1):28–9.Google Scholar
  24. 24.
    Bopst L, Reinberg O, Lutz N. Femur fracture in preschool children: experience with flexible intramedullary nailing in 72 children. J Pediatr Orthop. 2007;27(3):299–303.PubMedCrossRefGoogle Scholar
  25. 25.
    Flynn JM, Luedtke L, Ganley TJ, Pill SG. Titanium elastic nails for pediatric femur fractures: lessons from the learning curve. Am J Orthop. 2002;31(2):71–4.PubMedGoogle Scholar
  26. 26.
    Dietz HG, Schmittenbecher PP, Slongo T, Wilkins KE. AO manual of fracture management. Elastic stable intramedullary nailing (ESIN) in children. New York: Georg Thieme Verlag; 2006.Google Scholar
  27. 27.
    Hunter J, Slongo T, Schwieger K, Windolf M, Matthys R, Linke B, Clacert J, Reynolds R. Biomechanical investigations into improving the stability of elastic nails with screw-in end caps. Personal communication. 2008.Google Scholar
  28. 28.
    Morshed S, Humphrey M, Corrales LA, Millett M, Hoffinger SA. Retention of flexible intramedullary nails following treatment of pediatric femur fractures. Arch Orthop Trauma Surg. 2007;127(7):509–14.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • T. Slongo
    • 1
  • L. Audigé
    • 2
  • J. B. Hunter
    • 3
  • S. M. Berger
    • 1
  1. 1.Department of Pediatric SurgeryChildren’s Hospital, Inselspital, University of BerneBerneSwitzerland
  2. 2.AO Clinical Investigation and Documentation UnitDübendorfSwitzerland
  3. 3.Department of Orthopedic Surgery, Queen’s Medical CenterNottingham University HospitalsNottinghamUK

Personalised recommendations