Injury, Int. J.
Care Injured (2005) 36, S-A20—S-A24
The principles of elastic stable intramedullary nailing
in children
James B. Hunter
Consultant Trauma and Paediatric Orthopedic Surgeon, Queen’s Medical Centre, Nottingham, UK
KEYWORDS: Summary1 Elastic nailing is the foremost method of surgically stabilizing chil-
Children; fractures; dren’s long bone fractures. This article traces the history of the method, sum-
nailing. marizes the scientific basis, both biological and biomechanical, and assesses the
broad indications.
History
Elastic nailing for children in the form currently
recognized as ESIN (elastic stable intramedullary
nailing) or in the original French ECMES (enbrocage
centro medullaire elastique stable) was first per-
formed on a child with Vitamin D resistant rickets
in Nancy, France in 1977. In that case, realignment
osteotomies were being stabilized and the technique
spread fairly rapidly in that unit to the stabilization
of long bones, mostly in multiple trauma. The idea
of using relatively low diameter intramedullary rods
to stabilize long bone fractures, in particular those
of the femoral shaft, was of course not new. Rush
reflected on 30 years’ use of his pins in 1968 and the
German school had been using condylocephalic nail-
ing of intertrochanteric fractures since 1950 [19].
In 1970, Ender described the nailing of trochanter-
ic fractures using three pins that were smaller and
more flexible than the previously described devices
inserted through the medial femoral condyle and
spread out in the femoral neck [1]. After a period
of popularity, this rather unstable method of tro-
chanteric fracture fixation fell out of favour for its
lack of length and rotational control [12]. These
Ender nails, however, were also used to stabilize
femoral shaft fractures and, in the United States,
Pankovich wrote a series of papers commending
their use for this indication as well as pointing out
1 Abstracts in German, French, Italian, Spanish, Japanese,
and Russian are printed at the end of this supplement.
0020–1383/$ — see front matter ß 2004 Published by Elsevier Ltd.
doi:10.1016/j.injury.2004.12.009
the limitations and complications that arose [2, 16,
17]. Because of the shape of the Ender nails and
their insertion from both medial and lateral femoral
condyles, they elastically braced the fracture with
double 3-point fixation very similarly to the ESIN cur-
rently practised in paediatric fracture management.
The failures encountered by adult trauma surgeons
in the use of this technique can be minimized by
confining the method to paediatric fractures, which
have rather different characteristics [4, 5, 11].
Prevot, the professor in Nancy at the time of the
development of elastic nailing, wrote that several
factors had proven important in the development of
the technique [14].
1. Dissatisfaction of children aged greater than six
or seven with the prolonged conservative man-
agement of femoral shaft fractures.
2. Difficulties with schooling and psychological
problems associated with being out of circulation
for six weeks or more.
3. Prevot’s personal conviction that open reduc-
tion and plate fixation was an unsuitable and
unphysiological method for fracture fixation in
a growing bone.
4. The advent of co-workers with the vision and
drive to create a fracture stabilization system
particular to children.
5. Technological advances to permit such develop-
ment—mainly (a) materials with a suitable tensile
strength and modulus of elasticity and (b) modern
image intensification with low pulse dosage and
a memory.