Andrea Garcia-Ortiz

The Effects of Titanium Elastic Nails on Children and Adults with Humeral Fractures

Titanium elastic nails have become the new cornerstone for orthopedic surgeons to treat

patients with major limb fractures. The nails are made out of titanium or stainless surgical steel

(DePuy Synthes, 2017). They range from 1.5 mm to 4.0 mm in diameter and 300 mm to 400 mm

in length (DePuy Synthes, 2017). The nails are malleable, but the stainless steel nails are

significantly harder to shape when compared to the nails made out of titanium alloy (DePuy

Synthes, 2017). The nails are inserted into the medullary canal of the bone from an antegrade or

retrograde entry point to create a three point fixation that supports proper bone alignment (DePuy

Synthes, 2017). The common use of elastic nails are to treat humeral and femoral fractures in

children and adults (DePuy Synthes, 2017).

This paper consists of recovery outcomes of patients with humeral fractures because they

consist of 3-5 % of all fractures and are found in both children and adults (Weatherford, 2017).

Humeral fractures can be found in the proximal, middle, or distal third of the long bone

(Weatherford, 2017). The most common fracture patterns of humeral fractures are spiral,

transverse or comminuted (Weatherford, 2017). With the rise of elastic nails to treat diaphyseal

fractures, patients need to be informed of the benefits and risks of the technique. The benefits

and risks of surgical techniques can differ greatly depending on age of the patient (The Royal

Children’s Hospital Melbourne [RCHM], n.d.). Adult’s and children’s bone physiology and

structure contrast greatly and determine how effective a surgical technique is on bone union

(RCHM, n.d.).

The topic of elastic nails to treat diaphyseal fractures fascinates me due to my love of the

human skeletal system. My main love for bones resides in their ability to heal and support the
human body. I want to one day become an orthopedic surgeon who specializes in long bones

such as the femur and humerus. In my future profession, I must be constantly informed on all the

new surgical techniques used in my field. I must also be able to perform and describe each

technique to my future patients and offer them alternative solutions if they decide not to go ahead

with my first recommendations.

The first step taken by all surgeons when creating a clinical plan for their patient is to

consider their age and bone physiology (RCHM, n.d.). Unsurprisingly, as human bodies age, so

do their bones. A child’s skeleton is comprised of a mixture of cartilage and ossified bone

(RCHM, n.d.). Unlike adults, children also have multiple segments of bone specialized solely for

bone growth (RCHM, n.d.). The physis or growth plate and epiphysis act as ossification centers

for growing children (RCHM, n.d.). Growth plates are often hard to see on traditional x-rays

(Gupta, 2017), because this specialized bone segment is radiolucent (RCHM, n.d.). Surgeons

must take special care when treating humeral fractures to avoid growth plate damage (RCHM,

n.d.). As a child ages, their bones begin to ossify and turn into the hard material most people

recognize (RCHM, n.d.).

A common childhood fracture type is the “greenstick” fracture, named after the result of

snapping a freshly cut tree branch (Gupta, 2015). Like the tree branch, greenstick fractures do

not break through the entire bone, allowing flexible unossified cartilage to remain intact (Gupta,

2015). Children have a distinct advantage over adults with similar fractures because their bodies

are constantly in the process of ossification (RCHM, n.d.). Adult skeletons are fully ossified and

lack the bendable give allowed by cartilage (RCHM, n.d.). Complete bone fractures are common

in adults and require more complex methods of treatment (Gupta, 2017).

 To compare the effects of titanium elastic nails on both children and adults they must

both share the same fracture type. Although more uncommon in children, complete fractures can

still occur and resemble the fractures of their adult counterparts (Gupta, 2017). None of the

fractures in the research articles used in this essay are greenstick, due to the inability of adults to

experience such fractures.

Titanium elastic nails are pieces of equipment that resemble electrical wire and allow

orthopedic surgeons to realign fractures. The nails are flexible and can be bent to fix each patient

individually (DePuy Synthes, 2017). The nail may be contoured manually or with the assistance

of specialized tools (DePuy Synthes, 2017). The length and diameter of the nails can also be

modified (DePuy Synthes, 2017). The nails are chosen based off of the measurement of the

patient’s medullary canal at their narrowest diameter and multiplying by 0.4 percent (DePuy

Synthes, 2017). Common nail diameters for humeral fractures in adults and children range from

2.5 mm to 3.5 mm (DePuy Synthes, 2017). Prior to titanium elastic nails, surgeons lacked

flexible equipment that allowed internal medullary fixation that not only smoothly realigned

bones, but also preserved the body’s natural healing process (Upadhyay & Lil, 2017). The nails

realign fractured bones using internal fixation which causes tension within the bone (DePuy

Synthes, 2017). As the internal tension builds the bones shift back into place, allowing the body

to continue to ossify and heal the fracture without the probability of misalignment (DePuy

Synthes, 2017).

Due to the differences between children and adult bones, several alterations must be

made to accompany the needs of each patient. Thinner nails are chosen when operating on

children and special care is to taken to avoid damaging growth plates (Wang, Shao, & Yang,

2014). Adults do not have growth plates, and therefore do not require as much specialized care
during nail insertion (RCHM, n.d.). Both children and adults require two nails to provide proper

support and fixation (DePuy Synthes, 2017).

The risks and outcomes associated with titanium elastic nails vary. The primary areas that

surgeons must monitor are union rates, hospital stay lengths, healing time, and iatrogenic

complications (Upadhyay & Lil, 2017). Union rates allow surgeons to determine how well a

bone has rejoined. “Nonunion of humeral shaft fractures is defined as a fracture with no evidence

of healing six weeks after the injury” (Verma et al., 2017, p. 22). In a fracture study where adults

with humeral fractures were treated with titanium elastic nails, the union rates were a hundred

percent (Upadhyay & Lil, 2017). They exceeded previous data that predicted a higher percentage

of nonunion (Upadhyay & Lil, 2017). The union rates of a similar study with children was also

perfect (Wang et al., 2014).

Hospital stay length is often used as an indicator of the effectiveness of a surgical

technique. Long durations in a hospital are expensive and diminish the cost effect value of a

surgical technique. Surgeons must be able to ensure their patients that a proposed procedure will

allow them to leave the hospital as quickly as possible. In the study on adults, the average length

of stay was four days (Upadhyay & Lil, 2017). The similar child study did not record the average

length of stay (Wang et al., 2014). The duration of time passed until a fracture fully ossifies is

one of the most important factors used when considering a surgical technique. Children

historically heal significantly faster than adults with similar fractures (Gupta, 2017). Patients

want to be healed as soon as possible. In today’s fast paced environment, fractures can be a huge

hindrance on modern life. Adults treated with titanium elastic nails experienced an average

healing period of 15 weeks (Upadhyay & Lil, 2017), while children experienced an average

healing period of 11 weeks (Wang et al., 2014).

 Iatrogenic complications are the final hurdle all surgeons must overcome when

evaluating a technique. Iatrogenic complications are any complications that resulted from a

patient’s stay at a hospital (Upadhyay & Lil, 2017). They can occur as a result of surgical errors

such as not properly dressing the postoperative incision marks (Verma et al., 2017). Iatrogenic

complications can hinder a patient’s overall recovery. In the adult study, there were no cases of

iatrogenic complications aside from a few cases that experienced shoulder stiffness (Upadhyay &

Lil, 2017). In the child study, there were also no iatrogenic complications (Wang et al., 2014).

Although titanium elastic nails provide great patient outcomes, the technique is very

limited. Titanium nails are advised only for fractures that consist of only two pieces (DePuy

Synthes, 2017). Fracture types that consist of several fracture points are not recommended to be

treated by titanium elastic nails (Verma et al., 2017). The nails require a fairly intact medullary

canal to function properly and guarantee proper bone union (DePuy Synthes, 2017). Studies that

used titanium elastic nails to treat humeral fractures excluded complex fractures from their study,

possibly increasing their union rates. The studies also were specific to hospitals outside of the

United States of America, where regulations on surgical techniques vary. The study sizes were

nominal with many studying less than fifty patients. The studies also utilized varied sources to

obtain their overall review of the nails’ effectiveness. One study used the Disabilities of the Arm

Shoulder and Hand questionnaire to determine fracture recovery (Verma et al., 2017), while

another used the NEER shoulder score (Wang et al., 2014).

Titanium elastic nails provide a unique and innovative way to realign fractures while still

preserving surrounding tissue biology (DePuy Synthes, 2017). The nails had an exceptional

union rate and was free of iatrogenic complications. The articles used provided clear and concise

information that was easy to follow and report. The articles, however, lacked a large sample size.
There are also no studies done in the United States regarding the technique of using titanium

elastic nails. In the future, I would like to see titanium elastic nails be available to patients with

more severe fracture types. The information provided in the articles used in this essay have a

solid foundation but require a larger and broader sample size in order to determine any definitive

conclusions about the effectiveness of titanium elastic nails.

 References

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Gupta, R. C. (2015). Broken bones. Retrieved from http://m.kidshealth.org/en/parents/b-

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The Royal Children’s Hospital Melbourne. (n.d.). Anatomic differences: Child vs. adult.

Retrieved from https://www.rch.org.au/fracture-

education/anatomy/Anatomic_differences_child_vs_adult/

Upadhyay, A. S., & Lil, N. A. (2017). Use of titanium elastic nails in the adult diaphyseal

humerus fractures. Malaysian Orthopaedic Journal, 11(2), 53-59.

doi:10.5704/MOJ.1707.019

Verma, A., Kushwaha, S. S., Khan, Y. A., Mohammed, F., Shekhar, S., & Goyal, A. (2017).

Clinical outcome of treatment of diaphyseal fractures of humerus treated by titanium

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RC01–RC04. doi:10.7860/JCDR/2017/26449.9812

Wang, X., Shao, J., & Yang, X. (2014). Closed/open reduction and titanium elastic nails for

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Weatherford, B. (2017). Humeral shaft fractures. Retrieved from

http://www.orthobullets.com/trauma/1016/humeral-shaft-fractures