Outcomes and complications of elastic stable intramedullary nailing for forearm fractures in children

This prospective study investigated medium-term outcomes for 51 children treated from 1997 to 2001 for displaced diaphyseal forearm fractures with elastic stable intramedullary nailing. Forty-three patients included achieved excellent/good functional results at an average follow-up of 38 months. Four patients required open fracture-manipulation at surgery. Complications included eight cases of soft-tissue irritation at nail-insertion site (three required shortening procedures), two temporary radial nerve branch injuries, four minimal rotational mobility deficits, one 10 degrees elbow extension deficit after splinting, and five small keloid scars. All patients were pain-free, without limitations in activities for daily life or sport/play activities by 12 months after hardware removal. Elastic stable intramedullary nailing is appropriate therapy for these injuries.     

Nancy nail versus intramedullary-wire fixation of paediatric forearm fractures

Intramedullary nailing provides effective fracture fixation with satisfactory functional outcome without the risks associated with plating. Unfortunately, elastic stable intramedullary nailing devices are not always available in every hospital. We have examined the outcome of 23 children who underwent intramedullary fracture fixation of one or both forearm diaphyseal fractures in our department. We have compared the outcome of intramedullary Nancy nailing with the use of standard, available K-wires to achieve intramedullary fixation. We have assessed, over a 12-month period, rates of union (100% in both groups), function of the forearm and complication rates. We have found no significant increase in the rates or severity of complications when using K-wires compared with Nancy nails. Both groups had equal excellent functional outcome. We advocate that if elastic stable intramedullary nailing devices are unavailable, a K-wire can be used to achieve three-point compression of a paediatric forearm diaphyseal fracture.     

前臂交锁髓内钉治疗尺桡骨粉碎骨折的临床研究

目的探讨应用前臂交锁髓内钉治疗尺桡骨粉碎性骨折的可行性及其疗效。方法应用前臂交锁髓内钉采用切开或闭合复位技术治疗尺桡骨粉碎性骨折18例,男15例,女3例;年龄32～63岁,平均42岁。骨折按AO分型,A 1型4例,A 2型1例,A 3型2例,B 2型1例,B 3型3例,C 2型3例,C 3型4例。手术均在伤后1周内进行。结果所有病例术后随访8～10个月,骨折愈合时间8～16周,平均12周。所有患者均未发生骨不连、术后感染及桡神经深支损伤病例;术后有2例前臂旋转功能恢复欠佳,1例骨折延迟愈合,其余患者功能恢复满意。根据B erton评定标准进行评价,优10例,良5例,可2例,差1例,优良率为83.3%。结论应用前臂交锁髓内钉技术治疗尺桡骨骨折,具有手术创伤小、固定牢靠、骨折愈合率高、功能恢复快等优点,是治疗前臂骨折较理想的手术方法,尤其适用于多段骨折、粉碎性骨折。     

Comparison of intramedullary nailing to plating for both-bone forearm fractures in older children

BACKGROUND: When operative stabilization of forearm fractures in older children is necessary, the optimal method of fixation is controversial. This study compared the radiographic and functional outcomes of intramedullary nailing to plating of forearm fractures in children between 10 and 16 years of age. METHODS: Thirty-one patients who underwent operative fixation of midshaft radius and ulna fractures were divided into nailing and plating groups and were compared retrospectively according to perioperative data and patient outcome measures (fracture union at 3 and 6 months, loss of forearm rotation, restoration of radial bow magnitude and location, and complication rates). RESULTS: The nailing group had 19 patients, with a mean age of 12.5 years (range, 10-14.6 years), and the plating group had 12, with a mean age of 14.5 years (range, 11.9-16 years). Groups were similar for sex, arm injured, fracture location, Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association classification, and number of open fractures. Duration of surgery and tourniquet use were significantly shorter in the nailing group (P = 0.037 and 0.001, respectively). No differences were found between the groups for fracture union at 3 or 6 months. At latest follow-up, radial bow magnitude was similar for the 2 groups and restored to normal in both. Radial bow location in the nailing group was significantly different from the reported normal values (P = 0.001). Despite this, there was no difference in loss of forearm rotation between groups. Complication rates were also similar between groups, with 1 ulna nonunion, 1 compartment syndrome, and 2 refractures in the nailing group and 1 radius and ulna nonunion, 1 broken plate, and 2 refractures in the plating group. CONCLUSIONS AND SIGNIFICANCE: Based on similar functional and radiographic outcomes, nailing of length-stable forearm fractures remains an equally effective method of fixation in skeletally immature patients 10 to 16 years of age when compared with plating and is our treatment of choice. LEVEL OF EVIDENCE: Therapeutic level III--retrospective comparative study.     

弹性髓内钉去弹性化治疗儿童桡骨干远段骨折

目的 应用弹性髓内钉去弹性化技术治疗儿童桡骨干远段骨折,观察临床疗效、放射学结果 及预后功能情况.方法 自2006至2008年,应用闭合复位、弹性髓内钉去弹性化技术治疗儿童桡骨干远段骨折18例,男13例,女5例;年龄5～15岁,平均9岁8个月.所有病例均为闭合性骨折,从受伤到接受手术治疗的时间为1～9d.骨折部位均位于桡骨干远段1/3,15例合并同侧尺骨骨折,另外3例为单纯桡骨骨折.复位方式均为"C"型臂X线机透视下闭合复位.术后常规长臂功能位石膏管型固定3～周.结果 最短随访时间12个月,平均骨折完全愈合时间为5个月(3～7个月).术后骨折对位正位平均93.2%±5.9%,侧位平均95.7%±7.1%;术后成角正位平均2.7°±1.5°,侧位平均1.4°±1.2°.94%(17/18)的患儿最终恢复了完全的前臂旋转功能,1例患儿存在10°以内的前臂旋转受限,随着随访时间延长,逐步好转中.并发症包括1例患儿出现髓内钉钉尾软组织激惹症状,1例患儿进钉部位手术瘢痕皮肤敏感.结论 弹性髓内钉去弹性化技术对于治疗儿童桡骨干远段骨折是一种有效、安全且方便可行的方法 .     

三种内固定方式治疗大龄儿童尺桡骨双骨折的前瞻性对比研究

目的 对应用尺骨加压钢板与桡骨弹性髓内钉、双弹性髓内钉、双钢板三种不同内固定方式治疗大龄(10～16岁)儿童尺桡骨双骨折的疗效进行对比分析.方法 对2004年2月-2008年6月收治的45例手法复位失败或不稳定型的大龄儿童尺桡骨双骨折进行前瞻性随机对照研究.分为尺骨加压钢板与桡骨弹性髓内钉固定组(A组)、双弹性髓内钉固定组(B组)、双钢板固定组(C组)3组,每组15例.分别对3组患者术中及住院期间的各项指标,术后的影像学结果、临床疗效结果及并发症进行对比分析.结果 三组相比,A、B两组手术时间相对较短、术中出血量较少,与C组相比差异均有统计学意义,而A、B两组之间差异无统计学意义;B组术中上止血带时间最短,A组次之,C组最长,三组间两两比较差异均有统计学意义;A、B、C三组在术后5d疼痛评分两两比较,差异均无统计学意义.A组3个月骨折愈合率高于B组,差异有统计学意义;而B组与C组、A组与C组间差异均无统计学意义.三组在术后6个月骨折愈合率比较差异无统计学意义.在前臂旋转受限及并发症发生率上,A组最低,B组次之,C组最高,但三组间两两比较差异无统计学意义.结论 从手术创伤、骨折愈合率、临床疗效及并发症等方面进行综合比较,采用尺骨加压钢板与桡骨弹性髓内钉的内固定方式有优越性,是治疗大龄儿童尺桡骨双骨折的一种有效方法.而双弹性髓内钉内固定具有更能体现微创化、二期取出内固定方便的优点.     

Radius-only intramedullary nailing for both-bones diaphyseal forearm fractures in children

Both-bones diaphyseal forearm fractures are common injuries in the paediatric age group and are potentially unstable. Both-bones intramedullary nailing for these fractures is a minimally invasive procedure that maintains alignment, and promotes rapid bony healing. Good results have also been shown with single-bone fixation. We report our experience in treating these common injuries with radius-only intramedullary nailing in 29 children. The clinical notes and radiographs were reviewed retrospectively. There were 9 girls and 20 boys; the mean age at the time of operation was 9 years (range: 5 to 17 years). Closed reduction was achieved in 21 patients, while eight patients required open reduction. Mean duration of follow-up was 6.8 months (range: 4 to 12 months). All fractures achieved clinical and radiological union at 6-8 weeks. Radius-only intramedullary nailing is a sufficient and effective option in treating both bones paediatric forearm displaced unstable type AO 22-A3 fractures, with excellent functional outcome and union rates.     

Delayed healing of forearm shaft fractures in children after intramedullary nailing

BACKGROUND: In displaced and unstable forearm shaft fractures, elastic stable intramedullary nailing represents the current treatment of choice. Delayed healing has been observed in single cases, but the incidence of healing disturbances remains unclear. METHODS: Retrospective analysis of all patients with forearm shaft fractures and open epiphyseal plates, treated with elastic stable intramedullary nailing between 2000 and 2004 in 5 pediatric trauma units, was conducted. Evaluation of cases with insufficient consolidation 90 days after osteosynthesis was performed. RESULTS: Ten (1.9%) of 532 cases showed delayed healing. Mean age (12.3 years), part of open fractures (30%), and part of open reductions (60%) were clearly higher than in a nonselected collective; the ulna was concerned in 70%. One refracture, 1 local soft tissue infection, and 1 small sequestration were found. In 5 children, nails were extracted with (2x) or without (3x) local surgical intervention. In the other 5 children, the nails were left in place. All fractures healed within 13 months posttrauma without relevant functional restrictions. CONCLUSIONS: Delayed healing is possible especially in open fractures or open reduced fractures of the ulna in older children, but healing takes place up to 13 months. Therefore, no change of treatment principles is necessary. Protection of ulna periost has to remain in the center of surgical focus. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.     

两种方法治疗大龄儿童肱骨外科颈骨折的疗效比较

目的观察大龄儿童移位型肱骨外科颈骨折经闭合复位逆向弹性髓内针内固定以及克氏针内固定两种不同手术方法的临床疗效对比。 方法回顾性分析十堰市人民医院创伤骨科从2016年5月至2018年12月2.5年间符合纳入标准的手术内固定治疗的儿童及青少年移位型肱骨外科颈骨折45例患者，按照内固定方法分为两组：逆向弹性髓内针内固定23例(弹性髓内针组)；闭合复位克氏针内固定22例(克氏针组)。采用t检验或卡方检验分析骨折愈合时间，肩关节功能评分、并发症个数及优良率。 结果所有病例骨折均达到良好愈合，骨折愈合时间为(8.0±2.1)周。术后6周两组功能评分弹性髓内针组优于克氏针组(t＝5.295，P<0.05)；术后3个月功能评分无明显差异(P>0.05)。88.9%患者肩关节功能均达到了优良效果，两组优良率无明显差异(X²＝0，P>0.05)。弹性髓内针组有1例出现桡神经挫伤，2例出现弹性髓内针穿出；4例出现复位再丢失。但克氏针内固定组出现了克氏针松动、脱落4例；骨折复位丢失3例；无血管神经损伤并发症。 结论采用逆向弹性髓内针及克氏针内固定治疗儿童移位型肱骨外科颈骨折，都是微创、有效的治疗方法，值得临床推广运用。术者应选择熟悉的手术方法避免并发症。     

A critical analysis of postoperative complications of antebrachium ten-nailing in 35 children

Background: Unstable antebrachium diaphyseal fractures in children are nowadays increasingly treated operatively by elastic intramedullary nailing. Aim: Aim of the study was to critically assess both radiological and functional outcome of antebrachium fractures treated by titanium elastic nail (TEN) in a pediatric cohort. Material and Methods: This retrospective study investigated 75 consecutive children, who were treated for antebrachium shaft fractures at Tampere University Hospital during the time period from January 2001 to December 2005. All the fractures were classified according to OTA. Thirty-five children (mean age 12.3 years) were treated by TEN-nailing. Twenty four of the forearm fractures were instable, five were open, five were re-fractures and one had ulnar nerve deficit. In all but one patient both forearm bones were fractured. Twelve (34%) operations were managed by closed reduction, open reduction was needed in 23 (66%) patients. In 29 cases both bones were fixed with TEN-nail. In the four patients with re-fracture in both ulna and radius only the radius was TEN-nailed. In one case radius was fixed with TEN-nail and ulna with K-wire and in another case radius was fixed with TEN-nail and ulna with plate. Fracture pattern, mode of reduction, surgical approach, short- and long-term complications and outcome were recorded. Results: Twenty three (66%) patients achieved healing of the fractures without any limitation in range of motion. Twelve patients with postoperative complication were followed up 31-74 (median of 54) months. Eleven (31%) patients had minor postoperative complications and one (0,3%) patient had a Volkmann's ischemic contracture. Five of complicated patients had more than one problem. Immediate post-operative problems were noted in these five patients. At follow-up visits four patients complained of ulnar nail discomfort, two had neural symptoms. Additionally, three children suffered from re-fractures. Discussion: Despite various minor complications, TEN-nailing is considered suitable treatment for unstable forearm shaft fractures. Most of the problems were related to poor technical performance in nailing.     

Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation?

BACKGROUND: Operative treatment of tibial fractures in children requires implants that do not violate open physes while maintaining tibial length and alignment. Both elastic stable intramedullary nails and external fixation can be utilized. We retrospectively reviewed our experience with these two techniques to determine if one is superior to the other. METHODS: We retrospectively reviewed the operative records and trauma registries of three institutions within our hospital system and identified thirty-five consecutive patients with open physes who had undergone operative treatment of a tibial fracture between April 1997 and June 2004. Four patients were excluded because they had been managed with locked intramedullary nails or with pins and plaster. Of the thirty-one remaining patients, sixteen had been managed with elastic stable intramedullary nails and fifteen had been managed with unilateral external fixation. The clinical and radiographic outcomes were compared. The functional outcomes were compared with use of the Pediatric Outcomes Data Collection Instrument. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment also were compared. RESULTS: Thirty-one patients with thirty-one operatively treated tibial fractures were available for evaluation. Fifteen patients had been managed with external fixation. Seven of these patients had a closed fracture, and eight had an open fracture. There were seven healing complications in this group, including two delayed unions, three nonunions, and two malunions. Sixteen patients had been managed with elastic stable intramedullary nailing. Eleven patients had a closed fracture, and five had an open fracture. The mean time to union for the intramedullary nailing group (seven weeks) was significantly shorter than that for the external fixation group (eighteen weeks) (p < 0.01). The functional outcomes for the intramedullary nailing group were significantly better than those for the external fixation group in the categories of pain, happiness, sports, and global function (the mean of the mean scores of the first four categories) (p < 0.01 for these comparisons). CONCLUSIONS: When surgical stabilization of tibial fractures in children is indicated, we believe that the preferred method of fixation is with elastic stable intramedullary nailing.     

Pre‐bent elastic stable intramedullary nail fixation for distal radial shaft fractures in children

Objective: To investigate the functional and radiographic outcomes of pre‐bent elastic stable intramedullary nail in treatment of distal radial shaft fractures in children. Methods: From January 2006 to December 2008, 18 children with distal radial shaft fracture were treated by close reduction and internal fixation with a pre‐bent elastic stable intramedullary nail. The age range was from 5 years to 15 years, with an average of 9 years and 8 months. The minimum follow‐up was 12 months. Results: All fractures maintained good alignment postoperatively, and 94.4% (17/18) of the patients regained a full range of rotation of the forearm. One patient has limitation of rotation to less than 10°, this had improved by final follow‐up. Complications included soft tissue irritation at the site of nail insertion in one patient and transient scar hypersensitivity in another. Conclusion: Fixation with a pre‐bent elastic stable intramedullary nail is an effective, safe and convenient method for treating distal radial shaft fractures in children.     

闭合复位弹性髓内钉固定术与切开复位克氏针固定术治疗儿童桡骨颈骨折疗效比较

目的通过与切开复位克氏针固定术比较,分析闭合复位弹性髓内钉固定术治疗O’BrienⅢ型儿童桡骨颈骨折的疗效。方法 2007年11月-2010年11月,收治31例O’BrienⅢ型桡骨颈骨折患儿,其中18例采用闭合复位弹性髓内钉固定术治疗(闭合复位组),13例采用切开复位克氏针固定术治疗(切开复位组)。两组患儿性别、年龄、病程、骨折分型等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。结果术后两组患儿切口均Ⅰ期愈合。31例均获随访,随访时间1～2年,平均1.5年。闭合复位组2例发生伸直受限;切开复位组6例发生屈、伸或旋前功能受限。末次随访时,闭合复位组肘关节屈、伸、旋前、旋后活动度与健侧比较,差异均无统计学意义(P>0.05);切开复位组除旋后活动度与健侧相似(P>0.05)外,屈、伸、旋前活动度均小于健侧,差异均有统计学意义(P<0.05)。肘关节功能根据Metaizeau等的标准评定,闭合复位组获优16例,良2例;切开复位组获优4例,良4例,一般3例,差2例;组间比较差异有统计学意义(Z=3.435,P=0.001)。X线片复查示,术后内固定物取出前两组骨折均解剖复位;取出后切开复位组4例发生骨折再移位,闭合复位组无骨折再移位。随访期间均无桡骨头骺缺血性坏死改变。结论与切开复位克氏针固定术比较,闭合复位弹性髓内钉固定术治疗O’BrienⅢ型儿童桡骨颈骨折具有微创、手术操作简便、固定牢固、允许术后早期活动、并发症少等优点,是一种较好的治疗方法。     

Flexible intramedullary nailing of displaced diaphyseal forearm fractures in children

INTRODUCTION: This study analyses the results of 50 displaced diaphyseal forearm fractures in children treated with flexible intramedullary nailing. METHODS: Between 1999 and 2002 we treated 50 children aged between 5 and 15 years, with diaphyseal fractures of the forearm using Flexible intramedullary nailing (FIN). Both bones were fractures in 45 patients, radius only in 4 and ulna only in 1. The indications for fixation were instability (26), re-displacement (20), and open fractures (4). RESULTS: 24 patients were reduced closed, followed by nailing, while 26 fractures required open reduction of either one bone(16 cases) or both bones(10 cases) prior to nailing. Bony union of all fractures was achieved by an average of 7 weeks (range 6 weeks to 4 months) with one delayed union. Pronation was restricted by an average of 20 degrees in 9 patients. Two patients developed post operative compartment syndrome requiring fasciotomy. Three patients were lost to follow-up. INTERPRETATION: FIN led to early bony union with acceptable bony alignment in all 47 patients available at final follow-up. We therefore recommend FIN for the treatment of unstable diaphyseal forearm fractures in children.     

Nancy nailing of diaphyseal forearm fractures. Single bone fixation for fractures of both bones

We identified 25 children (10 girls and 15 boys) who had been treated with single bone intramedullary fixation for diaphyseal fractures of both forearm bones. Their mean age was 10.75 years (4.6 to 15.9). All had a good functional outcome. We conclude that in selected children, single bone intramedullary nailing is a suitable method of treatment for diaphyseal fractures of both bones of the forearm.     

Erfahrungen mit der elastisch stabilen intramedullären Nagelung (ESIN) diaphysärer Frakturen im Kindesalter

The aim of this prospective clinical controlled trial was to investigate the early and midterm results of shaft fractures in children treated with elastic stable intramedullary nailing (ESIN). From January 1997 to December 2001, elastic stable intramedullary nailing was carried out on 112 children with 118 diaphyseal fractures. The mean age was 7.7 years. There were 51 fractures of the lower arm, 46 femoral fractures, 14 of the lower leg, and 7 of the humerus. A total of 92 children have been followed up for more than 12 months. The mean time of follow-up was 38 months.The mean time of fluoroscopy was 2.2 min. Open reduction was necessary in 3.4 %. In children with injuries of the lower extremity, full weight bearing was achieved after a mean period of 9.3 days. In 1.8% of the children, reoperation was necessary within the first 10 days after the operation. In 3.6 % there was painful skin irritation due to the protruding end of a nail. No infection or delayed union was observed. Implant removal was done after a mean time of 5.6 months. There was no rotational or angular deformity of more than 5 degrees in children with isolated fractures of the lower extremity. Mean lengthening of the injured leg was 2.4 mm. In three children who had fractures of the upper extremity, a deficit in range of motion of the adjacent joints was detected. The current results show that intramedullary fixation of displaced diaphyseal fractures in children with a flexible titanium nail is a safe, minimally invasive surgical technique producing excellent functional and cosmetic results.     

Forearm fractures in children. Single bone fixation with elastic stable intramedullary nailing in 20 cases

We present our experience with elastic stable intramedullary nailing (ESIN) used in the single bone fixation of both bones forearm fractures in children. From May 2002 to July 2004, 20 children (14 boys and 6 girls), median age of 10 years (range 6–15 years) were treated with ESIN for 16 closed and 4 grade I open forearm fractures. All patients were reviewed clinically at a median follow-up of 20 months (range 6–30 months). All fractures were radiologically united at a median of 6.7 weeks (6–9 weeks). The median operating time was 35 min (range 25–60 min). The median hospital stay was 2 days (range 1–3 days). Removal of the nails was undertaken in all 20 children at a median of 19 weeks (range 16–24 weeks) post-operatively. At follow-up, a full range of elbow and wrist movements were found in all cases. There was no clinically significant rotational deformity in any case. ESIN seems to be a safe method in the treatment of single bone fixation of both bones forearm fractures in children between 6 and 15 years of age.     

Zweizeitige bilaterale Klavikulafraktur

In this case report we present treatment strategies and the functional and cosmetic outcome in a case of midclavicular fractures. A 20-year-old patient suffered from nearly identical fractures of the left and right clavicle with a time interval of 2 years following snowboard falls. The first fracture was treated conservatively leading to an unsatisfactory course and result. This was the reason why 2 years later the contralateral fracture was treated by intramedullary nailing using an elastic titanium nail. The functional and cosmetic outcome of this treatment was excellent. In cases of clavicular fractures elastic stable intramedullary nailing (ESIN) is a minimally invasive technique leading to fast analgesia resulting in a high level of mobility and ultimately a pleased patient. If the indication is right, intramedullary nailing can be a helpful operation technique which complements the already established procedures (conservative and plate osteosynthesis) in cases of dislocated clavicular fractures.     

应用前臂带锁髓内钉治疗尺桡骨骨折初步疗效分析

目的 探讨髓内钉固定系统治疗尺、桡骨骨折的临床疗效. 方法自2003年lO月至2007年3月收治并获得随访的尺、桡骨骨折患者共94例,其中尺骨骨折35例,桡骨骨折38例,尺、桡骨双骨折21例,均为闭合性骨折.所有患者均采用闭合复位或小切口有限切开复位髓内钉内固定术,术前若伴有上、下尺桡关节脱位的病例则行石膏单托前臂旋后位固定3周,否则术后早期功能锻炼.结果 所有患者随访9～26个月,平均13.5个月,术后骨折全部愈合,愈合时间8～14周,平均10.2周.并发症:术中骨质劈裂2例,桡神经浅支挫伤1例,骨桥连接1例,无血管、肌腱损伤、骨髓炎、不愈合、内固定失败病例,并发症发生率4.2%.术后半年Anderson功能评价:优68例,良22例,可4例,总优良率95.7%.肘关节屈伸丧失0.150,平均5.5°,前臂旋前丧失0～35°,平均14.2°,旋后丧失0～50°,平均18°. 结论髓内钉用于尺、桡骨骨折的治疗有其独特的优势,特别是对于骨质疏松、多段、粉碎骨折,具有疗效满意、创伤小、并发症少的特点,但在l临床应用中需要掌握一定的熟练技术及指征.     

Unstable pediatric femoral and forearm shaft fractures. Comparison between conservative treatment and stable intramedullary nailing

Elastic intramedullary nailing represents a new surgical concept in the treatment of unstable shaft fractures in children. The present case control study wanted to examine the superiority of intramedullary nailing in comparison to conservative therapeutic concepts which had been applied so far. 13 children with forearm fractures who were treated initially by conservative measures were compared to 13 other children who received a primary intramedullary nailing. With femoral fractures, 12 children were included in each group. In each patient pair age, type and localisation of the fracture were comparable. During the observation period (until the termination of final therapeutic measures or until the third year after injury) we examined clinical variables and subjective findings. Both therapeutic concepts led to comparably good functional results. Also subjective judgement of the therapeutic success did not differ between groups. However, with intramedullary nailing of shaft fractures of the femur the mean hospital length of stay (7.0 +/- 3.5 days) was significantly shorter than with initial conservative treatment (36.5 +/- 2.2 days, P < 0.05). Irrespective of the localisation of the fracture intramedullary nailing required significantly less x-ray examinations during the observation period. These results suggest intramedullary nailing to be the procedure of choice to treat unstable forearm and femoral fractures in children.