The document discusses the titanium elastic nailing system (TENS) used to treat fractures in children. TENS involves the use of flexible titanium nails inserted into the medullary canal. It is primarily used for diaphyseal and metaphyseal fractures in children ages 3-15. The appropriate use of TENS depends on considering the child's age as well as the type and location of the fracture. TENS provides stability while allowing bending and early ambulation.

1. TITANIUM ELASTIC NAILING SYSTEM
Dr.PONNILAVAN

2. • In early 1980 , flexible stable intramedullary nailing using
titanium was developed in an University in Nancy, France
( hence called Nancy Nail) ( Depuy)

5. • TENS is used primarily for the management of
diaphyseal & metaphyseal fractures in
children.
- Whether the TENS is indicated or not depends
upon the age of the patient & the type & site
of the fracture.
• All three factors must be considered
together.

6. • Age
• Age limit depends on the biological development of the child.
• Experience has shown that the lower limit is 3–4 years and the
upper limit 13–15 years.

7. • Type of fracture
– Transverse fractures
– Short oblique or transverse fractures with broken-off wedges
– Long oblique fractures with the possibility of cortical support
– Spiral fractures
– Multi-fragment and bifocal fractures
– Pathological fractures with juvenile bone cysts

8. • Fracture site
– femur: diaphyseal
– distal femur: metaphyseal
– femur: subtrochanteric
– lower leg: diaphyseal
– lower leg: distal metaphyseal
– humerus: diaphyseal and subcapital
– humerus: supracondylar
– radius and ulna: shaft
– radius: neck

9. • Other possible special indications:
– humerus and forearm in adults
– polytrauma in combination with craniocerebral trauma, even
outside the age range specified above
– prophylactic stabilization with juvenile bone cysts
– osteogenesis imperfecta

10. • Contraindications
– intraarticular fractures
– complex femoral fractures, particularly in connection with
overweight (50–60 kg) and/or age (15–16 years)

11. Nail size 30 to 40% of isthmus diameter
Choose nails with identical diameter to avoid varus/ Valgus malpositioning
Each nail diameter chosen is 0.4 times the diameter of the medullary canal.

13. FART stability

14. Pre-bend nails

15. • Vertex of arch should be located at the level of # zone.
• Pre-bend both nails in exactly the same way.
• Pressure applied internally can be increased by prebending the nails to a
smaller diameter, thus shifting the nail crossover points more towards the
metaphyses.
• This can increase the stability in complex fractures.

16. • TENS serve as load sharing devices
• Flexible enough to allow bending and avoid the need to cross the physis
during their insertion.
• Relatively small incisions confer a cosmetic advantage to the traditional
plating techniques.
• These nails are easy to remove, and allow for early ambulation (48–72
hours).

17. Ascending technique
• FEMUR - standard
• Radius
• Proximal humerus#
• Do not prebend for radial head/neck #

18. Descending technique
• Tibia
• Ulna
• Femur
• Distal humerus #
• ( TUFdh)

21. • THANK YOU