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Year : 2017  |  Volume : 6  |  Issue : 1  |  Page : 1-5

Flexible intramedullary nail is still a cost-effective, minimally invasive treatment for stable tibial diaphyseal fracture - A large scale study

Department of Orthopaedics , Sanjeevani Institute of Medical Sciences, Kanhangad, Kerala, India

Date of Web Publication2-Feb-2018

Correspondence Address:
Dr. K R Gowtham
Sanjeevani Institute of Medical Sciences, Kanhangad - 671 531, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajt.ajt_4_17

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Background: Many times, we come across patients who ask for conservative line of treatment either because of lower socioeconomic status or many people are unable to stay in the hospital for various reasons. Being orthopedicians, mere treatment of fracture should not be our only aim. Our aim also should be to treat patient as a whole. In country like India, especially in rural set-up, economy plays a major role. Hence, we conducted a study to evaluate the cost-effectiveness of flexible unreamed nailing, using Ender nails for the most common long bone fracture, i.e., tibia.
Materials and Methods: Nearly 590 patients with diaphyseal fractures were fixed with Ender nails from September 2002 to September 2016. The mean age of the patients was 39 years (range 18–65 years). Inclusion criteria were closed fractures and type 1 compound fractures with relative stable configuration. Exclusion criteria were long oblique and spiral fractures; type 2 and type 3 open fractures. Two Ender nails of 4.5 mm each were passed across the fracture site into the distal fragment. The mean follow-up was 16 months.
Results: Average time to fracture union was 11 weeks (range 8–14 weeks). Average peri-operative blood loss was <10 ml and operative time was about 20 min. Average radiation exposure was six shoots. Range of knee movement achieved in most of the cases was >120°.
Conclusions: Ender nailing in cases of tibial diaphyseal fractures could achieve reliable fracture stability, better union with least complications. Advantage of low-cost intramedullary device, its easy removal, and less hospital stay makes this even more attractive for the poor patients.

Keywords: Diaphyseal fracture, Ender nails, minimally invasive, tibia

How to cite this article:
Gowtham K R, Nambiar M R. Flexible intramedullary nail is still a cost-effective, minimally invasive treatment for stable tibial diaphyseal fracture - A large scale study. Afr J Trauma 2017;6:1-5

How to cite this URL:
Gowtham K R, Nambiar M R. Flexible intramedullary nail is still a cost-effective, minimally invasive treatment for stable tibial diaphyseal fracture - A large scale study. Afr J Trauma [serial online] 2017 [cited 2023 Sep 23];6:1-5. Available from: https://www.afrjtrauma.com/text.asp?2017/6/1/1/224639

  Introduction Top

Stabilizing tibial diaphyseal fractures with an intramedullary implant is now generally accepted treatment with emphasis on closed, locked intramedullary nailing by various authors.[1],[2],[3],[4],[5],[6],[7] However, up to 79% of patients need complementary procedures for certain complications.[8],[9] Pain in the knee is a frequent complication in 22%–71% of the cases,[10],[11] and breaking of screw or implant in unreamed locked nails occurs in up to 52% of cases with early weight-bearing.[12] The main limitation to conventional reamed nailing is the patient's pulmonary condition and the risk of ARDS, besides fear of large areas of endosteal avascularity.[1],[2] It has resulted in emphasis being shifted to unreamed solid nails. Moreover, there are many reports recommending dynamization of a statically locked nail, 8–10 weeks after the surgical procedure to promote union of fracture.[3],[4],[5] Dynamic intramedullary fracture fixation using Ender's nails appears to closely meet the objective of achieving osteosynthesis with very minimal surgical trauma, less blood loss, less surgical time, less radiation, and hospitalization time.[13] The present study evaluates the authors' experience of Ender nails in treating a large series of tibial diaphyseal fractures.

  Materials and Methods Top

It is a prospective trial conducted between September 2002 and September 2016. Nearly 590 tibial diaphyseal fractures were stabilized using two Ender nails.

Inclusion criteria

Patients aged 18–65 years, closed and type 1 open fractures with relatively stable configuration, having transverse or short oblique fracture line, or with unicortical comminution were included in the study.

Exclusion criteria

Long oblique and spiral fractures, type 2 and type 3 open fractures, patients who lost for follow-up were excluded in the study.

In our study, 402 (68%) were male and 188 (32%) were female. All patients were treated within 2 days of the fracture. The clinical and radiological assessment was done in all cases. A detailed informed consent was taken from each patient. The mean follow-up was 16 months (range 12–36 months).

Procedure and postoperative protocol

Appropriate nail length was ascertained by trial placements of nail over the limb. Two stab wounds of 1.5 cm each, one medial and the other lateral to the tuberosity of the tibia, were made [Figure 1]. Two bone orifices were perforated with a broach [Figure 2], one in each tibial condyle about 3 cm from the articular surface, so as to allow the introduction of Ender pin to fill the space of the medullary canal at its narrowest part. The fractures were reduced with manual traction, and the nails were advanced into the distal fragment and positioned about 2 cm above the ankle joint with fanning of distal ends [Figure 3]a and [Figure 3]b. Wounds were closed with one or two sutures [Figure 4], followed by immobilization with below knee slab for better pain relief and soft tissue healing.
Figure 1: Two stab wounds of 1–1.5 cm each, one medial and the other lateral to the tuberosity of the tibia

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Figure 2: Two bone orifices were perforated with a broach

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Figure 3: (a) Comminuted fracture tibia. (b) Two nails were advanced into the distal fragment and positioned about 2 cm above the ankle joint with fanning of distal ends

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Figure 4: Wounds were closed with one or two sutures

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Knee bending and quadriceps strengthening exercises were encouraged from the first postoperative day. Nonweight-bearing ambulation was permitted in patients by the 1st or 2nd postoperative day and discharged on the 3rd or 4th day. The patient was called for follow-up at the end of 4 weeks, assessed clinically and radiologically. Partial weight-bearing was initiated after the removal of slab at the same time. It was gradually progressed to full weight-bearing over a period of 3–5 weeks. Successive reviews were done at 6-week intervals, during which limb length discrepancy and knee range of motion and union were assessed.

  Results Top

The evaluation of the results at the end of 1 year of follow-up was based on the criteria defined by Johner and Wruhs,[14] which include deformities; union rate; neurovascular disturbances; knee, ankle, and subtalar joint mobility; and pain, gait, and effort capacity. Four groups were defined as follows: excellent, good, fair, and poor [Table 1].
Table 1: Result of the study

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Studied were shortening, rotational, and angulations in the sagittal and frontal planes. The first two were measured clinically and the last in verification radiographs. Malunion was defined as varus or valgus deformity >5°, antecurvation or recurvation deformity >10°, rotational deformity >10°, and shortening >1 cm.[14]


Criterion adopted was the presence of at least 3 healed cortices seen in 2 radiographs (AP and lateral), in addition to the absence of pain and mobility at the fracture point.[7]


Range of movements in knee, ankle, and subtalar joint was observed during a physical examination performed at each follow-up and was expressed as a percentage in comparison to the normal side.


Pain was evaluated at the end of 1 year of follow-up and was classified as absent; occasional when it was infrequent, unpredictable, and not requiring analgesics; moderate when it always occurred when the patient performed some action (such as climbing stairs) or required the use of analgesics; and severe when it occurred even at rest.


One year after surgery was identified as normal or altered. When altered, this parameter was separated into small limp when perceptible only during a detailed clinical examination of gait and large limp when easily noted when the patient entered the clinic.


The ability to use the leg with effort after 1 year of follow-up was considered normal or altered. When normal, the patient was able to climb stairs normally, and when altered, this parameter was divided into limited when unable to climb stairs, very limited when unable to walk at least 100 meters, and impossible when unable to walk without assistance.

The average operative time was 20 min (15–35) and average peri-operative blood loss was <10 ml. Average radiation exposures six C-arm shoots (4–10). Radiological evidence of callus appeared in most cases by 5–7 weeks. Sound bony union was seen in average time of 12 weeks (10–16 weeks) [Figure 5]. Shortening of 1 cm was observed in 24 patients. In 18 patients, there was migration of the nails resulting in knee pain. Among that, only the cases did require nail removal. No case of infection was seen.
Figure 5: Sound bony union was seen in average time of 12 weeks (10–16 weeks)

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  Discussion Top

In this study, there were larger number of middle-aged patients (average age 39 years), males (402), and traffic accident victims (365). These findings are in accordance with the majority of studies related to tibial diaphyseal fractures.[1],[4]

Migration of Ender pins when used in treating tibial fractures is an infrequent occurrence, with a rate of <3.1%.[15] Only three cases in our study required surgery to remove the implants for these reasons.

The evaluation criteria used were those of Johner and Wruhs [14] because they included both clinical aspects, such as pain, ability to walk and to perform heavy activities, joint mobility, and radiographic aspects such as union and deformities.

In this study, about 85% of results were good or excellent. The credit of the fracture stability was attributed to proper fanning of the nail ends, which brings about six point fixations and prevents rotation. Patients classified as fair or poor, theoretically, could improve in terms of pain and gait with continued treatment, resulting in an improved evaluation.

Among the various modes of treatment of tibial shaft fractures, internal fixation has become the mainstay of treatment, with emphasis largely on intramedullary fixations. Concept of interlocking nail has further widened the indications of intramedullary fixation to include fractures approaching the ends of tibia. Reports in literature indicating adverse effects of reaming like increased incidence of pulmonary complications and disruption of vascular supply of inner two-third of cortex have resulted in increased popularity of unreamed nails for fixation of such fractures.[1],[2]

Flexible unreamed intramedullary nails have long been used to manage diaphyseal fractures of long bones. These nails rely on six-point fixation in the medullary canal and provide favorable mechanical conditions [Figure 6] as the forces are evenly distributed along the entire length of nails.[7],[8] As the fixation by these nails is not rigid, therefore, some amount dynamic micromotion occurs between the two fragments which, in turn, stimulates fracture healing. However, these nails do not ensure sufficient longitudinal stability in grossly comminuted or long oblique fractures with resultant shortening.[5],[6],[7],[16]
Figure 6: These nails rely on six-point fixation in the medullary canal and provide favorable mechanical conditions

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The rationale behind not using fracture table includes ease of set-up, the ability to perform multiple procedures with single positioning of the patient, and elimination of the morbidity associated with its use.

Operative time in Ender's nailing ranged from 15 to 25 min.[13],[11],[15] On the other hand, reported operative time for plating is 1.7–2.6 h and 1.5 h for closed intramedullary IL nailing of tibia.[4],[5],[17] The procedure can be done without blood loss, thus obviating the need of blood transfusion and its possible complications.

However, the method has its limitation in that it cannot be used in unstable comminuted fractures on account of its relatively poor longitudinal stability. Higher number of nails provides better stability because of better nail-cortical contact besides decreasing the chances of stress fracture of the nails. Moreover, using more number of nails with both medial and lateral portals ensures better rotational and angular stabilization of the fracture, thereby permitting early weight-bearing.[11] As Ender's nails are flexible, weight-bearing leads to axial micromotion at the fracture site, thereby stimulating the external callus formation,[6] and early partial weight-bearing by 1–4 weeks can be allowed without any complications of bending or breaking of nails.[6],[11] In our study, however, allowed full weight-bearing only at 10–12 weeks.

  Conclusions Top

Closed intramedullary fixation using Ender's nails is a simple, safe, and more effective method of treating tibial diaphyseal fracture of relatively stable configuration. This quick and atraumatic method has an additional advantage of low cost in poor patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Court-Brown CM, Christie J, McQueen MM. Closed intramedullary tibial nailing. Its use in closed and type I open fractures. J Bone Joint Surg Br 1990;72:605-11.  Back to cited text no. 1
Hooper GJ, Keddell RG, Penny ID. Conservative management or closed nailing for tibial shaft fractures. A randomised prospective trial. J Bone Joint Surg Br 1991;73:83-5.  Back to cited text no. 2
Alho A, Benterud JG, Høgevold HE, Ekeland A, Strømsøe K. Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures. Clin Orthop Relat Res 1992;277:243-50.  Back to cited text no. 3
Whittle AP, Russell TA, Taylor JC, Lavelle DG. Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming. J Bone Joint Surg Am 1992;74:1162-71.  Back to cited text no. 4
Gregory P, Sanders R. The treatment of closed, unstable tibial shaft fractures with unreamed interlocking nails. Clin Orthop Relat Res 1995;315:48-55.  Back to cited text no. 5
Bone LB, Sucato D, Stegemann PM, Rohrbacher BJ. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients. J Bone Joint Surg Am 1997;79:1336-41.  Back to cited text no. 6
Karladani AH, Granhed H, Edshage B, Jerre R, Styf J. Displaced tibial shaft fractures: A prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients. Acta Orthop Scand 2000;71:160-7.  Back to cited text no. 7
Riemer BL, DiChristina DG, Cooper A, Sagiv S, Butterfield SL, Burke CJ 3rd, et al. Nonreamed nailing of tibial diaphyseal fractures in blunt polytrauma patients. J Orthop Trauma 1995;9:66-75.  Back to cited text no. 8
Koval KJ, Clapper MF, Brumback RJ, Ellison PS Jr., Poka A, Bathon GH, et al. Complications of reamed intramedullary nailing of the tibia. J Orthop Trauma 1991;5:184-9.  Back to cited text no. 9
Court-Brown CM, Gustilo T, Shaw AD. Knee pain after intramedullary tibial nailing: Its incidence, etiology, and outcome. J Orthop Trauma 1997;11:103-5.  Back to cited text no. 10
Toivanen JA, Väistö O, Kannus P, Latvala K, Honkonen SE, Järvinen MJ. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft. A prospective, randomized study comparing two different nail-insertion techniques. J Bone Joint Surg Am 2002;84:580-5.  Back to cited text no. 11
Court-Brown CM, Will E, Christie J, McQueen MM. Reamed or unreamed nailing for closed tibial fractures. A prospective study in Tscherne C1 fractures. J Bone Joint Surg Br 1996;78:580-3.  Back to cited text no. 12
Merianos P, Cambouridis P, Smyrnis P. The treatment of 143 tibial shaft fractures by Ender's nailing and early weight-bearing. J Bone Joint Surg Br 1985;67:576-80.  Back to cited text no. 13
Johner R, Wruhs O. Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop Relat Res 1983;178:7-25.  Back to cited text no. 14
Abramowitz A, Wetzler MJ, Levy AS, Whitelaw GP. Treatment of open tibial fractures with Ender rods. Clin Orthop Relat Res 1993;293:246-55.  Back to cited text no. 15
Chiu FY, Lo WH, Chen CM, Chen TH, Huang CK. Treatment of unstable tibial fractures with interlocking nail versus Ender nail: A prospective evaluation. Zhonghua Yi Xue Za Zhi (Taipei) 1996;57:124-33.  Back to cited text no. 16
Keating JF, O'Brien PJ, Blachut PA, Meek RN, Broekhuyse HM. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am 1997;79:334-41.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1]


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