Elastic Nails for Combined Femur and Tibia Fractures in a 13-Year-Old
Elastic nails alone are NOT recommended for this patient—you should use a combined approach of elastic intramedullary nails WITH external fixation to prevent the high refracture rates and alignment failures seen with elastic nails used in isolation. 1
Why Elastic Nails Alone Are Insufficient
The critical issue is that elastic nails used as standalone fixation have unacceptably high failure rates in pediatric patients with open physes, showing only 67.7% primary union and a 48.1% refracture rate. 1 This is particularly problematic in your 13-year-old patient who has BOTH femur and tibia fractures—the biomechanical demands are substantial, and length-unstable fractures require additional rotational and longitudinal stability that elastic nails cannot provide alone. 2
The Recommended Combined Approach
Combined external fixation with intramedullary elastic nails is the preferred method, achieving 84% consensus agreement among orthopedic specialists for preventing refractures and maintaining alignment while respecting growth plate integrity. 1 This technique:
- Provides the longitudinal stability needed for length-unstable fractures 2
- Maintains rotational control that elastic nails alone cannot achieve 2
- Allows the elastic nails to function as internal splints while the external fixator prevents shortening and malrotation 3, 2
Surgical Timing and Technique
Perform definitive osteosynthesis within 24 hours if your patient is hemodynamically stable, as early fixation reduces ARDS and fat embolism syndrome risk—particularly critical for combined femoral and tibial shaft fractures. 1, 4
For the surgical technique:
- Use elastic nails sized at 40% of canal width (yielding 80% canal fill with two nails) for both the femur and tibia 3
- Pre-bend the nails into a gentle C-shape to achieve three-point fixation at the fracture apex 3
- Insert nails through entry points that avoid the proximal tibial and distal femoral physes 3
- Apply unilateral external fixation to augment stability, planning for removal at 4 weeks once early callus formation provides additional stability 2
Weight-Bearing Protocol
Allow immediate weight-bearing as tolerated after stable combined fixation is achieved. 1 However, this applies specifically to the combined fixation approach—with elastic nails alone, weight-bearing must be restricted for several weeks until radiologic healing, particularly in comminuted or length-unstable fractures. 5
Critical Pitfalls to Avoid
- Never use fixed nails like Rush rods alone in pediatric patients with open physes—these have only 5% consensus agreement for use 1
- Do not bury the proximal nail tips beneath the cortex, as extraction will be extremely difficult 3
- Ensure nail ends do not contact the proximal tibial or distal femoral physes to prevent premature growth arrest 3
- Be vigilant for compartment syndrome in the immediate postoperative period, especially in patients >14 years old or >50 kg with high-energy injuries 3
Expected Outcomes
With the combined approach, expect:
- Mean time to union of approximately 7 weeks (compared to 18 weeks with external fixation alone) 6
- External fixator removal at 4 weeks with continued elastic nail support until full union 2
- Significantly better functional outcomes in pain, sports participation, and global function compared to external fixation alone 6