The document discusses the history and development of elastic stable intramedullary nailing (ESIN) for fractures in children. It describes early techniques using rigid pins and wires, and the development of the modern ESIN method in the 1980s using pre-bent titanium nails inserted from opposite sides of the bone for axial, lateral, and rotational stability. Key aspects of ESIN technique are outlined, including nail sizing, insertion points, pre-bending, and final positioning to stabilize fractures while minimizing soft tissue injury and allowing callus formation. Risks and special considerations for different bone fractures are also mentioned.

1. Dr (Major) Parthasarathy S
Pg Resident,MS Orthopaedics
Stanley Medical College,Chennai
Ref : Rockwood & Wilkin’s fractures in children 8th
edition
The elements of fracture fixation 3rd
edition

2.  Primary definitive fracture care
 Thick periosteum
 Biological healing
 Minimal soft tissue insult
 Callus promoting micro movements
 Maintains length,rotation,alignment

3.  In the mid-19th century,rigid ivory pins were
used
 Intramedullary fixation was typified by the
Küntscher nail
 difficulties encountered in trying to avoid the physes.

4.  The Rush nail
 forerunner of modern elastic intramedullary fixation
 three-point fixation
 slightly flexible
 pre-bent
 rotational stability was poor
 flexibility was insufficient

5.  Hackethal Marchetti
 bundles of thinner wires which filled the medullary cavity
 Stabilisation achieved by splaying the ends of the wires
 Ender
 safely inserted into the metaphysis

6.  In the early 1980s, surgeons in Nancy,France
 Developed an elastic stable intramedullary nail based
on a theoretical concept by Firica.
 elasticity and stability combined in one construct
 two pre-tensioned nails inserted from opposite sides
of the bone
 Metazieau, Ligier et al were able to show that
titanium nails which were accurately contoured and
properly inserted could impart excellent axial and
lateral stability to diaphyseal fractures in long bones.
 Rotational stability weakest point of the technique

7.  Young’s/elastic/tensile modulus-object’s
resistance to being deformed elastically
 Young’s modulus=stress/strain
 Stress-forcing causing deformation/area
 Strain-change in length

11.  Precurved-3 times the narrowest diameter of
bone
 Maximum curvature in fracture zone
 2 nails inserted often
 Opposite to each other
 4 properties
 Flexural,axial,rotational,transitional stability

13.  3 point fixation
 Entry point
 Fracture zone
 Far end in dense metaphyseal area

16.  Intraarticular fracture
 Complex fracture particularly in connection
with overweight & age >15

17.  1.5mm -300mm long
 2-4mm – 440mm long
 End caps

18.  Position –supine
 Reduce fracture – F tool

19.  Nail size
 30-40% of isthmus diameter
 Identical nail chosen to avoid valgus/varus
deformity

20.  Insertion point
 2.5-3 cm proximal to distal epiphyeal plate
 One finger breadth above upper pole of patella
 Avoid joint capsule & epiphysis

21.  Skin incision
 Open medullary cavity
 Bone awl/drill bit

22.  Prebend nail

23.  Insert nail and advanse

25.  The tip should reach metaphysis
 The nail’s second crossover should
be after crossing # site

26.  Trim nails

27.  Final positioning

29.  Monolateral insertion
 Anterolateral in subtrochanteric area
 Prebend nail ‘S’ shape

32.  Closed unstable #
 Irreducible #
 Polytrauma
 Always descending technique
 Medial & lateral of tibial tuberosity
 Nail tip curved posteriorely-antecurvation

36.  2/3rd
of medullary isthmus nail size
 Radius
 Ascending technique
 2cm proximal to distal epiphyseal plate
 Superficial radial nerve

37.  Ulna
 Descending technique
 2cm distal to apophyseal
plate
 Olecranon apophysis

38.  Tips point towards each other
 Oval bracing of interosseous membrane

40.  Do not prebend

42.  Monolateral
 Prox humerus/shaft

44.  Monolateral
 Distal #
 Attachment point of deltoid

46.  Pain at insertion site(most common)
 Nail tip irritation
 Skin infection
 Implant failure
 Unacceptable angulation
 Malrotation