Elastic Intramedullary Nailing of long bone fractures in children has become very popular. The recommended implant is the elastic titanium nail. The reported advantages include the elastic properties and superior instrumentation. However, the nails are quite expensive and the theoretical advantages need to be weighed against less expensive stainless steel kirschner wires. This study look a single surgeon’s experience using stainless steel kirschner wires rather than titanium nails in a hospital based in Saudi, Arabia.
The cohort consisted of 35 diaphyseal fractures in children between the ages of 2 and 16 years. The inclusion criteria were similar to other series including polytrauma patients, failed conservative management, and markedly displaced fractures. The fixation involved stainless steel kirschner wires of various diameters. The diameter was based upon the size of the measured canal. The sharp tip of the wire was cut off to prevent inadvertent penetration of the cortex. The tip of the nail was bent to an angle between 30-45° degrees. The wires were not pre-bent, but rather introduced straight. A single wire was used for stabilization of forearm fractures and two wires were placed for humerus fractures.
Of the 35 fractures, 11 involved the forearm bones and 3 of humerii, the rest involved the lower extremities. Fracture union was obtained in the forearm between 6-12 weeks, and the humerus between 6-10 weeks. There was some mild irritation of the pins but no major complications. The wires were routinely removed in the humerus between 10-12 weeks, and the forearm bone between 8-18 weeks. None of the children developed malunion or surrounding stiffness. Forearm fixation resulted in full return of pronation and supination.
Intramedullary devices have been used for a long time. The Rush nail was the forerunner of modern elastic nailing. The theoretical goals of titanium fixation are improved 3 point fixation and better properties for bone fixation. Micro-motion around the intramedullary device promotes external bridging callus. However, the theoretical basis for elastic titanium nailing has not been shown in the clinical setting. The experience of this study supports previous studies that suggest simple insertion of stainless steel kirschner wires can obtain similar results as titanium elastic nailing. The authors have not answered the question whether we need one or two bone fixation is necessary in forearm fractures, but do report good results with a single bone fixation. Comparison of prices indicates that this stainless steel kirschner wire is 92% cheaper than the Nancy nail, and 84% cheaper than a Synthes nail. In many developing companies use of these expensive nails is cost prohibited. The authors recommend consideration of kirschner wires rather than titanium elastic nailing, not just in developing companies but in modern countries to decrease the expense of health care.