Flexible intramedullary nailing (elastic nailing, TENS/Nancy nailing) is a minimally invasive technique to stabilise long bone fractures in children using flexible titanium or steel nails inserted through small incisions near the ends of the bone.
Two small incisions are made near the end of the fractured bone (away from the growth plate). Two pre-bent flexible nails are inserted and advanced up the canal, crossing at the fracture site to provide three-point fixation. The fracture is reduced under X-ray guidance. The nail ends are cut short and left protruding slightly under the skin for later removal. The operation takes 30–60 minutes.
Flexible nailing is the preferred fixation method for displaced long bone fractures in children aged approximately 5–14 years — particularly femoral shaft fractures, tibial shaft fractures, and forearm fractures. It provides stable fixation while respecting the growth plates.
Casting alone (for undisplaced or minimally displaced fractures), traction (rarely used now), and hip spica casting (for younger children with femoral fractures).
Standard pre-assessment. Surgery usually within 24–48 hours of injury.
Stable fracture fixation allowing early mobilisation. High healing rates in children. The nails are removed after fracture healing (usually at three to six months), allowing the bone to remodel normally.
The protruding nail ends may cause discomfort under the skin.
From nail ends near the entry point.
Nails are routinely removed under anaesthesia at three to six months.
The nails may back out.
Healing with some angulation or shortening. Remodelling usually corrects this in children.
Pin site or wound infection.
Very rare with careful technique.
Rare but requires urgent treatment.
General anaesthesia.
Children recover remarkably quickly. Crutches for four to six weeks for lower limb fractures. Sling for two to four weeks for forearm fractures. Most children return to full activity by six to eight weeks. Nail removal at three to six months (a short general anaesthetic procedure).
X-rays at two weeks, six weeks, and before nail removal.
Flexible nails respect the growth plates, require minimal incisions, and allow the bone to heal with some controlled micromotion, which stimulates healing. They are removed after healing, unlike plates which may be left permanently.
Yes, flexible nails are routinely removed at three to six months once the fracture has healed. This is a short procedure under general anaesthesia.