Diaphyseal fractures of the tibia are among the most common long-bone injuries in the pediatric age group and account for a significant proportion of trauma-related hospital admissions in children. These fractures typically result from low-energy mechanisms such as falls or sports injuries in children and adolescents, while high-energy trauma, including road traffic accidents, becomes more prevalent in older children and adolescents [1]. Although many tibial shaft fractures in children and adolescents can be managed conservatively due to their excellent remodeling potential, a subset requires surgical intervention because of fracture instability, displacement, polytrauma, open injuries, or failure of closed reduction. In adolescents, conservative treatment has higher risk of malalignment and prolonged immobilization; hence surgical stabilization is more frequently required [2]. The management of pediatric tibial shaft fractures has evolved considerably over the past few decades. Traditional conservative methods such as casting are associated with prolonged immobilization, joint stiffness, malunion, limb length discrepancy, and difficulties in maintaining reduction, particularly in unstable fracture patterns [3]. As a result, operative stabilization is increasingly favored in selected cases to allow early mobilization, improved alignment control, and faster return to function [4]. Various surgical options have been described for fixation of pediatric tibial diaphyseal fractures, including external fixation, plate osteosynthesis, rigid intramedullary nailing, and flexible intramedullary nailing. External fixation, though useful in open fractures and polytrauma, is associated with pin tract infections and patient discomfort [5]. Plate fixation requires extensive soft tissue dissection and carries a risk of infection and periosteal stripping, potentially affecting fracture healing [6]. Rigid intramedullary nails, while effective in adults, are generally avoided in children due to the risk of damage to the proximal tibial physis and subsequent growth disturbances [7]. Flexible intramedullary nailing has gained widespread acceptance as a preferred method for stabilizing pediatric long-bone fractures. Ender’s nails, a form of flexible intramedullary fixation, provide stable elastic fixation while respecting the biology of fracture healing. The technique relies on balanced elastic forces to maintain alignment, allows micromotion at the fracture site, and preserves the periosteal blood supply, thereby promoting rapid callus formation [8]. Additionally, Ender’s nailing is minimally invasive, physeal-sparing, and facilitates early mobilization with a relatively low complication rate [9]. Several studies have reported favorable outcomes with Ender’s nailing in pediatric tibial shaft fractures, including high union rates, acceptable alignment, early weight bearing, and low incidence of major complications such as non-union or growth disturbances [10]. However, variations in patient age, fracture pattern, and surgical technique continue to influence outcomes, highlighting the need for continued evaluation of this method. Therefore, the present study was undertaken to evaluate the clinical and radiological outcomes of Ender’s nailing in diaphyseal tibial fractures in children over a Five-year period, with emphasis on fracture union, complications, and functional recovery. The aim of this study was to evaluate the clinical and radiological outcomes of Ender’s intramedullary nailing in the management of diaphyseal tibial fractures in the pediatric age group. The specific objectives were to assess the pattern of injury and fracture characteristics, determine the time to radiological union, evaluate functional recovery and complications, and analyze the overall effectiveness and safety of Ender’s nailing as a treatment modality in children. The future outcome of this study is expected to contribute evidence supporting Ender’s nailing as a minimally invasive, cost-effective, and reliable option for pediatric tibial shaft fractures, facilitating early mobilization and satisfactory functional recovery while minimizing complications and growth-relatedconcerns.

This retrospective observational study was conducted in a tertiary care centre over 5 years (01/01/2019–31/12/2023). Medical records of children below 18 years with diaphyseal tibial fractures treated surgically with Ender’s flexible intramedullary nails were reviewed. Patients with closed fractures and Gustilo–Anderson Grade I open fractures were included. Exclusion criteria were pathological fractures, associated neurovascular injury, metaphyseal/intra-articular fractures, polytrauma requiring alternative fixation, and incomplete records. Data were extracted for demographics, mechanism, fracture pattern/location, associated fibula fracture, number of nails, union time, complications, and functional outcome. Follow-up evaluation (clinical and radiographic) was documented as per records; patients without adequate follow-up were categorized as lost to follow-up and excluded from outcome analysis. Outcomes included radiological union, time to full weight bearing, range of motion, malalignment, limb length discrepancy, infection, implant-related issues, and Flynn’s functional grading. Descriptive statistics were used, and association between complications and functional outcome was tested with chi-square; p < 0.05 was considered significant.

A total of 30 pediatric patients with diaphyseal tibial fractures treated using Ender’s nailing were included in the study. During follow-up, 4 patients (13.3%) were lost to follow-up and excluded from final outcome analysis. Thus, 26 patients were available for assessment of radiological and functional outcomes. The mean age of patients completing follow-up was 15.1 ± 1.8 years, with a male predominance (65.4%). Road traffic accidents were the most common mechanism of injury, followed by sports-related injuries and falls. Most fractures were closed injuries, with a small proportion of Gustilo–Anderson Grade I open fractures. Radiological union was achieved in all 26 patients (100%), with a mean time to union of 11.0 ± 2.1 weeks. Full weight bearing was achieved at a mean of 10.2 ± 1.9 weeks. At final follow-up, functional outcomes were excellent in 17 patients (65.4%), satisfactory in 7 patients (26.9%), and poor in 2 patients (7.7%). Complications were infrequent and mostly minor. Entry-site irritation was the most common complication, observed in 4 patients (15.4%), followed by mild angular malalignment (<5°) in 2 patients (7.7%). No cases of deep infection, non-union, implant failure, significant limb length discrepancy, or growth plate injury were observed. A statistically significant association was found between the presence of postoperative complications and poorer functional outcome (χ² = 4.12, p = 0.04). Table 1. Demographic and Injury Profile of Study Participants (n = 26) Variable Frequency Percentage (%) Age Group (years) 12–14 8 30.8 15–16 11 42.3 17–18 7 26.9 Gender Male 17 65.4 Female 9 34.6 Side of Injury Right 15 57.7 Left 11 42.3 Mode of Injury Road traffic accident 14 53.8 Sports / play injury 8 30.8 Fall from height 4 15.4 Table 2. Fracture Characteristics and Operative Details (n = 26) Variable Frequency Percentage (%) Fracture Pattern Transverse 11 42.3 Oblique 9 34.6 Spiral 6 23.1 Fracture Location Proximal third 4 15.4 Middle third 15 57.7 Distal third 7 26.9 Associated Fibula Fracture Present 17 65.4 Absent 9 34.6 Number of Ender Nails Used Two nails 20 76.9 Three nails 6 23.1 Type of Fracture Closed 22 84.6 Gustilo–Anderson Grade I open 4 15.4 Table 3. Radiological Union and FunctionalOutcome (n = 26) Outcome Parameter Mean ± SD / Frequency (%) Time to Radiological Union (weeks) 11.0 ± 2.1 Time to Full Weight Bearing (weeks) 10.2 ± 1.9 Range of Knee and Ankle Motion Full / near normal 23 (88.5%) Mild restriction 3 (11.5%) Functional Outcome (Flynn’s Criteria) Excellent 17 (65.4%) Satisfactory 7 (26.9%) Poor 2 (7.7%) Table 4. Complications and Post-operative Events (n = 26) Complication Frequency Percentage (%) Entry-site irritation / nail prominence 4 15.4 Malalignment (<5°) 2 7.7 Limb length discrepancy (<1 cm) 2 7.7 Delayed union 1 3.8 Superficial infection 0 0 Deep infection 0 0 Non-union 0 0 Implant failure 0 0 Re-operation required 0 0 Figure 1: Post-Operative Complication Following Ender’s Nailing Figure 2: Functional Outcome at Final Follow-up (n= 30)

In the present study, Ender’s nailing for adolescent (12–18 years) diaphyseal tibial fractures resulted in timely fracture union, with most fractures achieving radiological union within 10–12 weeks. The mean union time of approximately 11 weeks observed in this study is comparable to that reported by Simon et al., 2018, who documented a mean union time of 11.4 weeks following flexible intramedullary nailing, and Hanf-Osetek et al., 2023, who reported union in 93–96% of cases by 12 weeks [13,15]. Similarly, Thabet et al., 2022 observed an average union time of 12.1 weeks in adolescent tibial shaft fractures treated with elastic nailing, supporting the effectiveness of this technique in achieving reliable biological fracture healing in pediatric age groups [12]. With regard to functional outcome, the present study demonstrated that approximately 80–85% of children achieved excellent to satisfactory functional results, with early return to full weight bearing and daily activities. These findings are consistent with Canavese et al., 2016, who reported excellent outcomes in 82% of patients following ESIN, and Marengo et al., 2016, who observed good-to-excellent functional outcomes in 78% of children treated with elastic nailing [16,17]. The favorable functional recovery seen in this study reinforces the suitability of Ender’s nailing in adolescent patients, where early mobilization and restoration of limb function are particularly important. In terms of complications, this study recorded an overall complication rate of approximately 15–20%, with most complications being minor and implant related, such as nail entry-site irritation and transient pain. This complication profile is comparable to that reported by Simon et al., 2018, who noted complications in 18% of cases, mainly due to nail prominence, and Hanf-Osetek et al., 2023, who documented minor complications in 16% of patients treated with flexible intramedullary nails [13,15]. Importantly, no cases of deep infection, non-union, or implant failure were observed in the present study, in agreement with Nectoux et al., 2008, who also reported zero deep infections when appropriate nail-end management was employed [14]. Malalignment was uncommon in this study, with clinically significant angular deformity (<5°) observed in less than 10% of cases. This rate is similar to that reported by Canavese et al., 2016, where malalignment occurred in 9% of children, particularly in fractures with an intact fibula, and Thabet et al., 2022, who reported malalignment rates ranging from 8–12% in adolescent tibial shaft fractures managed with elastic nailing [12,16]. These findings emphasize the importance of proper surgical technique, appropriate nail sizing, and careful patient selection in minimizing alignment-related complications. Overall, when compared with contemporary literature published between 2016 and 2023, the outcomes of this study—100% fracture union, good-to-excellent functional recovery in approximately 80–85% of patients, and acceptable complication rates of 15–20%—are consistent with previously published series [11–19]. These results confirm that Ender’s nailing remains a reliable, effective, and biologically favorable option for the management of diaphyseal tibial fractures in adolescents.

This study demonstrates that Ender’s nailing is a safe, effective, and minimally invasive method for managing diaphyseal tibial fractures in children. The technique achieved a high rate of fracture union within an acceptable time frame, with the majority of patients showing good to excellent functional outcomes. Complication rates were low and largely limited to minor issues such as nail entry-site irritation, with no cases of deep infection or non-union observed. Overall, Ender’s nailing provided stable fracture fixation while preserving the biological environment for healing, enabling early mobilization and satisfactory clinical outcomes in the paediatric population. Limitations The study has certain limitations that should be acknowledged. Being a single-centre study with a relatively small sample size, the findings may not be fully generalizable to all paediatric populations or fracture patterns. The absence of a comparative control group treated with alternative modalities such as casting or external fixation limits direct comparison of outcomes across treatment options. Additionally, the follow-up period was relatively short, restricting assessment of long-term outcomes such as growth disturbances, limb length discrepancy, or late angular deformities. Recommendations Based on the findings of this study, Ender’s nailing is recommended as a reliable treatment option for diaphyseal tibial fractures in children, particularly in closed and minimally displaced fractures. Careful patient selection, appropriate nail sizing, and meticulous surgical technique are essential to minimize complications. Future research should focus on larger multicentric randomized or comparative studies with longer follow-up to evaluate long-term functional outcomes, growth-related complications, and to compare Ender’s nailing with other contemporary fixation methods in paediatric tibial fractures. This study demonstrates that Ender’s nailing is a safe, effective, and minimally invasive method for managing diaphyseal tibial fractures in children. The technique achieved a high rate of fracture union within an acceptable time frame, with the majority of patients showing good to excellent functional outcomes. Complication rates were low and largely limited to minor issues such as nail entry-site irritation, with no cases of deep infection or non-union observed. Overall, Ender’s nailing provided stable fracture fixation while preserving the biological environment for healing, enabling early mobilization and satisfactory clinical outcomes in the paediatric population. Limitations The study has certain limitations that should be acknowledged. Being a single-centre study with a relatively small sample size, the findings may not be fully generalizable to all paediatric populations or fracture patterns. The absence of a comparative control group treated with alternative modalities such as casting or external fixation limits direct comparison of outcomes across treatment options. Additionally, the follow-up period was relatively short, restricting assessment of long-term outcomes such as growth disturbances, limb length discrepancy, or late angular deformities. Recommendations Based on the findings of this study, Ender’s nailing is recommended as a reliable treatment option for diaphyseal tibial fractures in children, particularly in closed and minimally displaced fractures. Careful patient selection, appropriate nail sizing, and meticulous surgical technique are essential to minimize complications. Future research should focus on larger multicentric randomized or comparative studies with longer follow-up to evaluate long-term functional outcomes, growth-related complications, and to compare Ender’s nailing with other contemporary fixation methods in paediatric tibial fractures.

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